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Final reflections

From the 1970 experiences, we learned that in spite of economic limitations, progress was possible in the health field and time should not be wasted. In 1986, when I was appointed Minister of Health, we started to work hard on the following aspects:

Ministry of Health

• Health policy
• Health promotion
• Prevention of diseases and eradication of malnutrition and some infections
• Integration of Primary Health Care
• Definition of health areas
• Decentralization
• Community participation
• Emphasis on the most vulnerable groups
• Development of technical and administrative subsystems
• Management
• Automation
• Training and education at a distance
• Research
• Coordination and cooperation versus confrontation
• Paradigm of the chronic diseases
• Health education
• Publications
• Stimulation of staff (recognition)
• Physical infrastructure
• Environmental sanitation
• Intelligence on epidemiology

National Health System

• Coordination with the Costa Rican Social Security Institute
• Universal coverage
• Decentralization
• New forms of medical care
• Joint programming
• Integration of facilities and certain services
• Development of local health systems
• Aqueducts and sewage systems
• Labor and accident medicine
• Transformation of compulsory social services
• Involvement of the private sector
• Increased involvement of the municipalities
• Increased involvement of the communities

National Health Council

Executive Secretariat:

• Medium- and long-term planning
• Budget
• Monitoring and assessment
• Political guidance
• Matching of regions and provinces
• Rationalization
• Regulation and deregulation

Working Areas

• Politics
• Administration
• Finances
• Scientific knowledge
• Data processing
• Law
• Sociology

I feel that since the 1980s, the following elements have contributed the most to improving the work of the Ministry of Health:

• The clear message of dedication conveyed to the health staff.

• The permanent and strong support given to primary health care programs.

• The decentralization of functions and authority of primary health care programs, with their integration at the local level; the strengthening of epidemiological surveillance, prenatal care, and environmental sanitation.

• Efficient budgetary outlays that allocate the limited monetary resources to the most needy counties, communities, and families.

I also sought the widest possible consensus on my ideas, concepts, and strategies and always took the initiative and accept full responsibility for my own actions.

Although academically trained and specialized staff are desirable, it is possible to achieve health advances without them. The Ministry of Health, nevertheless, was able to improve the figures on infectious problems and malnutrition substantially, to expand health coverage and the protection provided to mothers and children, and to ameliorate basic environmental sanitation and personal hygiene.

Contrary to what has been frequently stated, the contribution of pressure groups and labor organizations was very limited. Furthermore, the measures that have overcome the great national health problems of Costa Rica tended to meet with opposition from these groups. Similarly community participation, although, contributing more positively, has been weak and intermittent.

Defining clear policies, identifying the obstacles to achieving them, utilizing communication media to reach all personnel frequently with encouraging messages, and systematically monitoring key activities are all valuable means of mobilizing health works and the public in general and developing in them a mystique and faith that these efforts are worthwhile. When people are convinced that they have the strength to move forward and destroy enemies of health in their daily life, a Pygmalion-like phenomenon occurs. When people believe that it is impossible to advance, a generalized feeling of defeat, sterility of thought, and paralysis are immediately produced.

The accumulated heuristic experience of 20 years of thought and participation in practically all levels in the field of health have led me to formulate general theories of health that explain the evolution of health in Costa Rica. These range from the scientific advances that support the great change in whatever area of human health that are the result of changes in the interpretation of global reality, abandoning interpretations that proved erroneous and substituting others more valid in a process of continual formulation and reformulation.

Based on these concepts, we have recognized and described three stages in the last 50 years that explain the reasons and causes of the improvement in the health of Costa Ricans over this period. The capacity to change one approach to another was the key to making possible what appeared to be impossible. During the 1986 to 1989 period the goals for reducing infant mortality were first established (Table 3) and the necessary interventions to achieve these goals were identified (Table 4). Similar strategies were formulated for interventions to reduce mortality in children 1-4 years of age (Table 5). Similarly, for the prevention of malnutrition, infectious diseases, and chronic diseases analyses were done of the causes, the specific problems and desirable strategies. These included developing a philosophical basis and analyzing psychological attitudes to overcome. To change one paradigm for another is the key to making possible what seems impossible.

TABLE 3. Goals for the Improvement of Infant Health (1986-1990 Costa Rican Government)

• Decrease child mortality to 14/1,000

• Reduce undesired pregnancies by 50%

• Reduce endogamy by 50%

• Provide prenatal care to 100% of pregnant women

• Detect 100% of the high-risk pregnancies and refer them to a specialized center

• Improve quality of birth

• Decrease cesarean sections by 20%

• Decrease prematurity and low birth weight by 30%

• Decrease neonatal hypoxia by 50%

• Decrease incidence of hyaline membrane disease by 90%

• Decrease intracranial hemorrhages by 50%

• Decrease congenital malformations by 20%

• Monitor growth and development in 100% of the child population (use of Childrens' Health ID)

TABLE 4. Strategies and Interventions Identified to Achieve These Goals

• Improvement of family integration

• Promotion of optimal age for pregnancy

• Promotion of optimal birth spacing

• Universal prenatal care and classification of birth risks

• High-quality institutional birth

• Transportation system for the sick newborn

• Enrollment at home of the newborn into health programs

• Growth and development surveillance (Childrens' Health ID)

• Breast-feeding, iron supplements, and appropriate diets

• Introduction of new vaccines

• Primary and secondary health care of good quality and accessible to all. Excellent tertiary health care. Early detection of health problems

• Organization and active participation of the community

• Basic environmental sanitation

• Emphasis on eradication or control of infectious diseases and prevention or control of perinatal disorders and congenital malformations

• Educational health package promoting the elimination of certain harmful habits, as well as chronic disease and accident prevention

• Suitable housing

TABLE 5 Interventions to Reduce Mortality of Children 1 to 4 Years of Age

• Control of infectious diseases

• Eradication of severe intestinal parasites

• Appropriate nutrition to improve growth and development

• Control of accidents and poisonings

• Early detection of changes and illness

• Early stimulation of learning

• Prevention of abuse

• Establishment of kindergartens and child care centers

• Environmental safety

• Good quality primary and secondary education accessible to all. Availability of excellent tertiary education

• Introduction of a health education package that includes elimination of undesirable habits and prevention of chronic disease

• Introduction of new vaccine


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