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The decade of the 1970s

The year 1970 was a critical one for the health transition in Costa Rica. The National Health System was established to provide health coverage of the total Costa Rican population, and to control the most common infectious diseases, and eliminate child malnutrition. In the early 1970s, the Ministry of Health did exhaustive research with a view of assessing the population's health status, the availability and productivity of the existing human and physical resources, and the degree of integration and coordination of the health services. Thus, the Ministry of Health established the premises for the provision of health services (see Table 2) and, after having made a national health diagnosis, formulated the National Health Plan for the decade 1971-1980. For the purpose of achieving the new objectives, the Ministry also proceeded to make several important political decisions that are discussed later.

According to our own classification of the development of Health Sector institutions, the fourth stage started in 1970 with the formulation of a National Health Plan.

TABLE 2. Premises for the Provision of Health Services

• Health care is a right of the population and the government has the responsibility to organize it properly.

• Health services should be integrated and cover disease prevention, cure, and rehabilitation.

• Health services should be organized according to regions and sectors in order to expand health coverage and improve the supply of local health care.

• Priority should be assigned to good outpatient health care provided in a well-organized outpatient clinic.

• Training of human resources at the professional, technical, and auxiliary level should be widely promoted, as well as ongoing education, in-service training, and research on medical and administrative problems.

• Service costs should be in agreement with the economic capabilities of the country.

Although several institutions participated in the preparation of the National Health Plan, the Ministry of Health and the Costa Rican Social Security Institute assumed a greater responsibility. As already mentioned, the goals of the Plan were to provide health services to the Costa Rican population as a whole through the reorganization of the health sector and the establishment of a National Health System, to facilitate the eradication or control of common infectious diseases and the drastic reduction of malnutrition. Some of the specific goals established by the Plan were the following:

• To increase life expectancy by eight years.
• To decrease infant mortality by 50%.
• To decrease the prevalence of endemic goiter to less than 10%.
• To supply potable water to 100% of the urban population and 70% of the rural population.

A number of political decisions had to be made in order to achieve the stated specific goals of the Plan, as well as its general ends. Thus, several remarkable laws were passed and a rural health program was created.

We now discuss the main characteristics of these laws.

Principal Legal Measures

• Law No. 5349 on the Transfer of Hospitals to the Costa Rican Social Security Institute: its purpose was to universalize Social Security, and thereby ensure that all the people enjoyed medical services of good quality.

• Law No. 5395, also known as General Law on Health. It replaced the 1949 Health Code and clearly defined the relationships among the government, individuals, and businesses. It incorporated a series of compulsory principles concerning individual and community health, oriented towards the achievement of the best possible health status. It made the Ministry of Health responsible for the definition of national policies on planning, coordination, and control of health-related public and private activities.

• Law No. 5412 or Organic Law of the Ministry. It decreed that from then on, the Ministry should be called the Ministry of Health. It provided for the internal restructuring of its agencies. The Directorate General of Health and the Directorate General of Assistance became a single unit under the name Directorate General of Health. The Technical Council for Medical-Social Assistance was attached to the Minister's Office, and its functions were limited to collecting and distributing funds allocated to care for patients insured by the government (until then known as indigents). Advisory bodies, such as the National Health Council and the Sectoral Planning Unit, were also created at this time.

An important additional component of the National Health Plan was the creation of the Rural Health Program and the substantial strengthening of programs for environmental sanitation, clean drinking water, immunizations, and nutrition.

Reorganization of the Social Security Institute

As we have already seen, several important decisions were required to reorganize the Health Sector according to the National Health Plan. The most important element relating to the Social Security Institute was the transferral, according to Law No. 5349, to the Costa Rican Social Security Institute of all hospitals managed by Boards and Foundations for Social Protection. Article 2 of this Law refers to the compulsory care to be provided by the Costa Rican Social Security Institute, at the government's expense, to persons without insurance and unable to pay for medical services, a group known as Persons Insured by the government.

Article 6 of Law No. 5349 states that all health care actions related to preventive medicine that are not legally assigned to the Costa Rican Social Security Institute come under the responsibility of the Ministry of Health.

Article 7 states that all revenues or income of any kind received by institutions of the Ministry of Health, the Boards of Social Protection, or the Foundations are to be transferred to the Costa Rican Social Security Institute, with the provision that if the funds are insufficient, the government will establish specific revenues for the complete payment of the health care provided to its insured persons.

Article 8 of the same Law declared that it is national policy and supercedes all prior legal provisions insofar as these are opposed to it.

Law No. 5541 complements Law No. 5349 and defines the working conditions of people employed in centers that would be transferred to the Costa Rican Social Security Institute.

Other essential actions required by the Costa Rican Social Security Institute with a view to structural readjustment and internal organization were based on the following:

• Executive Decree No. 6919, dated April 4, 1977, established the National Committee on Human Resources, whose main goal was to determine the need for medical professionals in the coming years.

• The 1979 Executive Decree No. 10653-P-OP ordered the division of the national territory into five regions for the purpose of investigating and planning socioeconomic development.

• The Board of Directors of the Costa Rican Social Security Institute, on June 7, 1978, agreed on the internal organic restructuring of the medical services it provided, including measures of decentralization to the Regional Health Directorates.

• The 1978 Executive Decree No. 9283-P created the System for Administrative Reforms as a component of the National Planning System for the fundamental purpose of achieving efficiency and productivity in the Public Administration.

• The 1979 Executive Decree No. 109157P-OP created the Subsystem for Regional and Urban Planning and Coordination to orient and coordinate governmental actions at the regional level and to balance the development of the different regions.

The above-mentioned Subsystem is part of the National Planning System.

On July 15, 1978, the Board of Directors of the Costa Rican Social Security Institute created the Coordinating Council for Medical Services and resolved to divide the national territory into five program regions, matching the regionalization process referred to in Executive Decree No. 10653-P-OP. The regions thus created were Northwestern, Western, Eastern, Central, Northern Huetar, Chorotega (Dry Pacific), Alantic Huetar, and Brunca (South Pacific).

The coordinating council initiated decentralized regional administration of coverage and collection of fees. Geographically this coincided with the regionalized medical services.

Political Context

During the 1969 political campaign, José Figueres, the presidential candidate running for the National Liberation Party, proposed to expedite the social and economic development of the country and stressed that it was possible to eradicate extreme poverty in Costa Rica. When he became President of the Republic in May 1970, he and his cabinet immediately started to work towards his promised goals. President Figueres succeeded in motivating several of his collaborators and a substantial sector of the population; at the same time, he gave hope to the most needy sectors.

Figueres, probably aware that this would be his last chance to serve the country as President (he had been Chief of State in 1948-1949 and President in 1954-1958), decided to use his power and experience to give impetus to momentous transformations, particularly those with social content. The opposing political party (Conservative) and the Communist Party were rather skeptical about Figueres' statements, which they considered sometimes to be extravagant. In general terms, however, the President's thoughts were truly reformist, with a social democratic ideology adapted to the environment.

The group heading the Health Sector, imbued with the President's reformist ideas, knew that it had the President's total trust and support. Thus, it approached child health problems seriously and rapidly, since children were the most vulnerable and affected population group.

The Health Sector group set two general objectives:

• To break down economic barriers to universal medical care.

• To eradicate and control common infectious diseases, since they constituted another powerful barrier on the road to better health status.

A prerequisite to President Figueres' idea of eradicating extreme poverty was the establishment of mechanisms to improve gross national product redistribution and to increase production.

The first objective took the form of two institutions: the Mixed Institute for Social Assistance (IMAS) and the 1971 Social Development and Family Allowance Fund.

The Mixed Institute for Social Assistance created by Law No. 4760, dated May 8, 1971, had the following goals:

• To formulate and implement a national policy for social and human promotion among the most needy sectors of Costa Rican society.

• To lessen or eliminate the causes and effects of poverty.

• To transform social stimulation programs into a means to obtain, in the shortest possible time, the incorporation of marginal human groups into the economic and social activities of the country.

• To prepare the indigent sectors, in an appropriate and rapid manner, so that they can improve their capability to do remunerative work.

• To attend to the needs of social groups or persons who should be provided with means of subsistence when they lack these.

• To obtain the participation of the private sectors, as well as public, national, and foreign institutions specialized in these tasks, in the creation and development of all kinds of systems and programs oriented towards improving the cultural, social, and economic conditions of groups affected by poverty, and obtaining maximum participation of the groups themselves.

• To coordinate the national programs of the public and private sectors that have similar goals to those expressed in this law.

The main source of financing for IMAS is the 0. 5% monthly surcharge on ordinary and extraordinary wages and salaries paid by all enterprises registered with the National Institute of Learning, the Social Security Institute, or the Popular Bank.

Law Number 5662, the Law for Social Development and Family Allowances, was published in La Gaceta on December 18, 1971. It created a special fund, and a specific Directorate General to manage it, for GNP redistribution purposes, to foster social development and family allowances. Even though the fund was actually discussed during the Figueres government, it was created by President Daniel Oduber, who was in office from May 1974 to May 1978.

The objective of the Social Development and Family Allowances Fund was to promote and complete socioeconomic programs and services favoring low-income persons and families. This fund was managed by institutions such as the Ministry of Health (nutrition programs managed by School Committees and by local education and nutrition centers), the Mixed Institute for Social Assistance, the National Foundation for Children, the National Nutrition Clinic, the Institute for Agrarian Development, first known as the Institute of Land and Settlements, and the National Institute of Learning.

Twenty percent of the fund is used for capital formation, which finances the Noncontributory Pension program for a basic number of persons not entitled to benefits of contributory plans of the Costa Rican Social Security Institute either because they have not paid or because they have not completed the required number of contributions. The law specifies that this money be remitted to the Costa Rican Social Security Institute, which administers the Noncontributory Pension program along with the Disabled, Elderly, and Death initiative.

The fund also gives loans either in cash or as family allowances to low-income workers with handicapped children or children under 18 years of age, or children between 18 and 25 years of age, as long as they study at an institution of higher learning.

The fund is derived from the Reform to the Sales Tax Law No. 3914 dated July 17, 1967, and its amendments, as well as from a 5% surcharge on the total amount of wages and salaries paid monthly by public and private employers, with legally specified exceptions. The exceptional fact that in Costa Rica the same political party, the National Liberation Party (social democratic), won two consecutive elections allowed the momentous reform in the social sector to continue eight years after its inception in 1970. This time frame allowed the reform's goals to be achieved and the political and technical process to be perfected. It was then followed by the ambitious project contained in the National Health Plan.

When he became President in 1978, President Oduber endorsed the programs started in 1970 by energetically strengthening them vigorously with political support and financial resources.

In addition to President Oduber's strong leadership, the dramatic results achieved in the health field in such a short amount of-time probably contributed to the political will needed to maintain reformation of the health sector for eight consecutive years. In view of the deep-rooted assumption in our country that health improvements require long latency periods, it was an unexpected and most important finding to have concrete results after a few years. Through this experience we became aware that political sponsorship is important in the initial phases of the program, but it was the impressive results that provided a fundamental feedback and served to stimulate and activate both the health staff end the population, giving them a certain degree of vital autonomy within the framework of the existing natural interdependency. After many years of disappointment and apathy, the staff accelerated health progress with positive and enthusiastic attitudes.

The Role Played by Pressure Groups

During the 1970s, particularly in the first part of the decade, the different Costa Rican pressure groups played a very limited role in the life of the country. Although associations for community development were aware of their immediate needs, they did not have a clear idea of actions to be implemented in order to satisfy those needs. This explains, on the one hand, their surprise and astonishment at the different initiatives started by the Ministry of Health and, on the other hand, their timid support of health initiatives.

The professional associations were belligerent in opposing the Ministry of Health. Arguing that the utilization of auxiliary staff to expand health service coverage was an attempt on the lives of those receiving these services, they clearly stated their opposition to the Rural Health Program. These associations defended the principle that health care should be in the hands of fully qualified physicians and nurses. Unfortunately, at that time they were not aware that a health system reaching all inhabitants implies the development of primary health care which operates with auxiliary staff, guided by defined standards and under professional supervision.

Even the Costa Rican Association of Public Health Specialists expressed its total disagreement with the Rural Health Program. Nevertheless, the firmness of the Ministry of Health in promoting the changes and its repeated explanations of the program in conferences, round tables, and bulletins neutralized the statements of the opposing groups. The activities were first implemented in San Ramón, headed by Dr. Juan Guillermo Ortiz, and in zones affected by malaria. The health staff was especially trained to assume their new tasks, which targeted health problems considered to be a priority as of that moment.

Another important decision, which started heated discussions, was the reorganization of hospital management. It implied the transfer of all hospitals to the Costa Rican Social Security Institute and, therefore, the elimination of Boards and Foundations for Social Protection. The members of these organizations and some media opposed the decision, arguing that Social Security universalization was uncontrollable and, hence, could overlook the indigents. High-ranking officials from the Costa Rican Social Security Institute, aware that this attitude could ruin their institution, were very much concerned.

Law No. 2738 of 1961 established the compulsory universalization of Social Security within a time frame no longer than 10 years. Several Costa Rican Social Security officials interpreted this law as implying universalization of obligatory insurance only, i.e., covering wage earners and not the non-wage-earning population. After many discussions and negotiations, the Ministry of Health and the Costa Rican Social Security Institute reached an agreement in which representatives of the Legislative Assembly from the National Liberation Party and the Second Vice President of the Republic, Dr. Manuel Aguilar Bonilla, participated.

Another hindrance to the project was the opposition stated by highest authorities of the Pan American Health Organization, who exerted tremendous pressure on the Minister of Health and the President of the Republic to withdraw the law. Both the President and the Minister listened to all arguments against the project but, nevertheless, supported the national technicians who implemented it. As of 1974, President Oduber, VicePresident Dr. Carlos Manuel Castillo, and the Minister of Health developed the Family Allowances Program quickly. Furthermore, in the health sector they gave a significant momentum to the reform project, which allowed the active participation of organized communities, particularly in the rural areas. The population changed its traditional demand for education services to a demand for health services, once it discovered the feasibility of obtaining them in the short term and at a reasonable cost.

Within the health sector, other outstanding laws were passed during this agitated period: Laws No. 4750, 5395, and 5412. Law No. 4750, dated March 30, 1971, made Social Security contributions, calculated over total individual remunerations, compulsory. Law No. 5395, dated November 24, 1973, the General Health Law, replaced the 1949 Sanitary Code. Law No. 5412, dated January 18, 1974, the Organic Law of the Ministry of Health, reorganized and updated the Ministry, thus providing it with the necessary conditions to play a leading role in the health sector. These three laws were not as controversial as others discussed before.

In retrospect, it is worth noting that throughout this major health reform, a traditionally Costa Rican trait was illustrated: to change progressively with the goal of achieving well-being for all of the population, but acting within the legal framework and seeking consensus through conviction rather than though force or brutal actions.

It is pleasing to note that the health reform led to dramatic improvements in the health status of the population in such a short time, an achievement that previously had been considered absolutely impossible.

The decade of the 1980s

In 1980, only 10 years after initiation of the Figueres health reforms, the general mortality rate in Costa Rica dropped to 4.1/1,000 and infant mortality had fallen to 20/1,000. Morbidity and mortality were associated with chronic diseases in adults as well as in children. It was generally felt, at this time, that the country had reached its limit of achievement in the health area.

At this time, one of the most severe economic crises of the century hit the country: the Costa Rican colon was devalued by 600%, inflation increased by 100%, foreign exchange reserves were exhausted, unemployment reached 10%, and the fiscal deficit was 14% of the gross domestic product.

The First Part of the 1980s

The future for the health sector seemed ominous. People started to note the deterioration of key sanitary and medical assistance programs. All international experts visiting Costa Rica agreed that the country would not be able to maintain the health services intact; therefore, morbidity and mortality, particularly due to infectious disease and nutritional deficiencies, would increase.

During the second part of the 1970s, the country's health outlays reached the impressive figure of 10% of the gross domestic product, dropping to 7% in the first part of the 1980s. Thus investments, machinery, and common supplies were drastically curtailed.

The economic crisis suddenly impoverished a vast sector of the population. At the same time, it substantially decreased budgets financing operating costs of different public health, environmental, and preventive medicine programs.

A great fear arose among the people, because it seemed as though the gains achieved during the 1970s would be lost, and infectious diseases and malnutrition - problems of misery and underdevelopment - would ravage the country once more. Common health supplies became scarce; health service users and health staff started complaining about the management of the institutions providing health services.

The economic and financial crisis was compounded by a severe problem of immigration from the Central American countries, mainly made up of indigents, illiterates, and sick people. The very poor population of the country increased not only as a result of the underlying economic problem but also because of the large number of indigent immigrants. Health problems that had been eliminated or controlled in Costa Rica returned to the country with the immigrants, thus worsening the general situation.

There was an increase in the incidence of malaria, tuberculosis, scabies, malnutrition, some parasitic diseases, and certain vaccine preventable infections. A slight increase in the mortality rates associated with some of these conditions was also observed.

The large negative impact on health in Latin America, predicted by some national and international groups because of the economic crisis, did not occur in Costa Rica because of the success achieved by a health infrastructure and health services, that was accessible to all of its people, developed during the 1970s. Even though it suffered some deterioration it functioned well during the crisis and served the population with limited resources from a real catastrophe that would have incited disorder in the country. This tested the National Health System and demonstrated its value.

In the mid-1980s, the country reacted vigorously and partially solved its economic problems. Tranquillity replaced fear, and trust was reborn. A structural adjustment program stimulated exports. The health sector intensified its actions directed toward protection of the most needy and improvement of the coordination among institutions of the health system.

Impact on Health

It is noteworthy that the turmoil of the early 1980s was not significantly reflected in infant mortality which rates remained stationary. In 1982, however, coinciding with the economic crisis, infant mortality rates due to diarrhea showed a slight transient increase, which disappeared the following year.

In summary, the economic crisis had only a minimal impact on the health situation in Costa Rica, and this was rapidly corrected. In fact, the immediate and effective reaction of the health sector solved a problem that could have become a serious obstacle to the country's development. This response demonstrated the capacity of the National Health System and the capacity of its three basic levels, and its different institutions.

On the other hand, there is no doubt that communities and individuals were organized better and contributed directly to minimizing the predicted negative impact on the health sector. As discussed in the following, the crisis was actually helpful, because it allowed the implementation of clear and decisive adjustments which, in spite of budgetary curtailments, rapidly led to a strong positive impact despite the budget cuts. Throughout the last decade, there was no correlation between per capita income and infant mortality.

The Later Part of the 1980s

The economic crisis taught us the need to review and transform the structure and functioning of the public sector to make it more solid, efficient, and modern. It brought into the open problems of scale, competence, and technical weakness, as well as the organizational obsolescence of several institutions and concepts. Through the crisis, we became aware that the government had to become smaller and more efficient, and improve its management of resources and knowledge. The theory of systems, including the principle of complementarily between the public and private sectors, also gained ground.

After having overcome the results of the earthquake during the early 1980s, we committed ourselves to the restructuring and consolidation of a universal decentralized National Health System, based on primary health care programs, with marked involvement of the organized community. Several decrees and resolutions firmly established a truly integrated system of health services which did away with the contradictions and mistaken interpretations of the past. The new health system also opened the door to a deluge of innovations which greatly improved the quantity and quality of the health services, in spite of budgetary curtailments.

The experiences of the latter part of the 1980s showed the presence of three actors in the crisis: economic depression, massive immigration of Central Americans, and an obsolete government structure needing changes. To change it, we realized that the public sector could achieve more with less money, and that broad unifying bridges between the private and public sectors should be built. The only responsible response could be deep reflection followed by obstinate actions to renew the National Health System to make it more dynamic.

As the crisis began, the people who had never believed in Costa Rica from the beginning now loudly proclaimed that at last the country would sink. Their ominous predictions were mere wishful thinking. Those of us who believed in Costa Rica, however, always contended that the crisis gave us an opportunity to review, change, and improve our country. History proved us right.

From 1986 to 1989, child mortality decreased by a further 25%, and severe malnutrition practically disappeared. The country remained free of poliomyelitis, diphtheria, human rabies, yellow fever, and dengue. Other conditions, such as xerophthalmia, scurvy, and pellagra, were no longer considered public health problems; maternal mortality, immunopreventable diseases, deaths related to food-borne disease, and the health problems aggravated by the massive immigration of Central Americans decreased by more than 50%. Moreover, between 1986 and 1989, deaths caused by traffic accidents decreased by 16%, and those caused by drowning decreased by 50%.

Child growth and development continued to improve; it was observed that 18- and 20-year-old young adults had increased in height. As compared to 1966 height data, men increased by 6 cm and women by 4.5 cm.

As a natural consequence of these changes, the Costa Rican general mortality rate dropped to 3.7/1,000, among the lowest in the world, and life expectancy increased to 76 years.

The Political Context

In the first part of the 1980s, the main struggle of the Costa Rican government was to save the National Health System and to protect the health status of the population in the severe economic crisis that affected the country. In the late 1980s, however, the main objective was to return to progress.

From the beginning, the idea of restructuring on pragmatic rather than ideological bases prevailed. In the public sector, the principles of efficiency, rationality, prioritization and complementarily, as well as the need to reduce the size of the government reached the National Health System.

During the 1985 political campaign, the desire for new qualitative progress on two fronts developed at the governmental level:

• Internationally, there was an effort to contribute to the Central American peace process in order to obtain the stability needed for development.

• Nationally, there was a commitment to modernizing the productive and social structures of the country, including the government; to improve the standard of living of the population groups most affected by recession (employment and housing); and to strengthening a process of participatory democracy.

As of 1986, the following fundamental objectives were established:

• Regarding public health, to improve the quality of the environment and to eradicate some parasitic disorders, and as many other infectious diseases as possible, and malnutrition. In preventive medicine, to consider the problems of women, children, and young adults, as well as the occupational health of adults as a priority; and to strengthen the programs for the elderly. Special attention was directed to the "Dental Health for Everyone" project.

• Regarding medical care, to foster the decentralization process of hospitals and clinics and to promote the participation of health staff, their organizations, and the communities themselves. Furthermore, to make a maximum effort to humanize the health services for the patient and to expand the program in mixed medicine.

• Regarding the Disabled, Elderly, and Death plan of the Costa Rican Social Security Institute, to generalize its benefits through appropriate financial provisions, following similar administrative steps as those taken for the Illness and Maternity Program. To establish an overall National Institute for Social Security, with the participation of all relevant institutions, and to support and foster policies on health for everyone on a more solid footing.

On the other hand, a National Health Policy was defined on the following terms:

• Health for everyone as a social goal and national and international commitment.

• The development of the National Health System and all of the institutions making up the Health Sector.

• The strengthening of the infrastructure of the health services.

• The consolidation of prior health gains; the tackling of new health problems and the implementation of new approaches within the framework of integrated care for the population.

• The participation of the community in all activities pertaining to the Health Service System.

• Give priority to providing health services to the:

• Prevention and control of communicable diseases.
• Prevention and control of chronic diseases.
• Mother and child health.
• Environmental health.
• Disaster and emergency preparations.
• Development of physical infrastructure.


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