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3. Development and characteristics of health and nutrition services for urban and rural communities of Costa Rica

Background information on community outreach programs
Methodological characteristics of the Costa Rican health programs
Nutrition programs
Impact of the programs on the health of children living in rural areas

Dr. William Vargas


Most countries in the world have set themselves the goal of expanding health services to all their people. However, few have achieved this goal or shown any substantial progress. There is no question that Costa Rica belongs to these few privileged countries. In the early half of the 1970s, Costa Rica had developed health services in the cities, but did not have any in the rural areas. At that time, not even 20% of the rural population had access to minimal health services. By the end of that decade, however, health services covered more than 90% of the country's population, and all health indicators improved significantly nationwide.

During this period, approximately 400 health posts were established in rural zones. In the urban areas, health centers oriented their activities toward the identification of priority and high-risk areas - called Community Health Areas - thus merging the extramural and intramural work of auxiliary health staff. Additionally, more than 500 urban and rural nutrition centers were built. All these facilities serve to implement a health and nutrition program covering dispersed population groups in the rural areas, as well as deprived urban groups. They also manage a community-based environmental program, run by auxiliary personnel, which uses socially acceptable, low-cost technologies.

This chapter analyzes the main methodological characteristics, strategies, and results of the following health and nutrition programs, all of which were begun or were strengthened in the first half of the 1970s:

• The Rural Health Program (for rural communities);

• The Community Health Program for underprivileged urban population groups;

• Two Rural Health Programs implemented in specific geographic areas: the Hospital Without Walls program of San Ramón and the Rural Health Program of San Antonio de Nicoya;

• The nutrition program targeting children under six years of age, school children, and pregnant and breast-feeding mothers.

These programs, each one with methodological and financial differences, are the foundations of primary health care in Costa Rica. The staff of the Costa Rican Ministry of Health has coordinated and implemented all of them, with the exception of the one in San Antonio de Nicoya. The structuring of the Rural Health Program was started in 1972, and that of the Community Health Program in 1974. The nutrition program had its inception in the 1950s and was strengthened in 1975, when it started to receive substantial national and international financial resources.

All the programs are in agreement with the 1974-1980 Costa Rican National Health Plan, which defined the following key concepts in health (Ministerio de Salud, 1973a):

• The right of the population to health care and the obligation of the government to organize and provide health services.

• Holistic health care, taking into account health promotion and prevention, as well as the cure of disease and rehabilitation.

• Regionalization and decentralization of health services.

• Expansion of health services to all the population.

• Outpatient care as a priority.

• Promotion of educational and training activities in the area of health.

• Compatibility of health expenditures with the country's economic capabilities.

Parallel to the Community Outreach Program, encompassing health and nutrition in rural and underprivileged urban populations, a more complex process started to develop within the health services. As of 1974, and during the following three years, all hospitals managed by the Ministry of Health and the Costa Rican Banana Company were transferred to the Costa Rican Social Security Institute (CCSS). In this manner, 25 hospitals, ranging from highly sophisticated to small rural hospitals, were transferred to the CCSS. During the 1970s, social security coverage increased to 80%. Thus, low-income population groups stopped receiving charity health care and obtained the right to health care on the basis of social security.

Background information on community outreach programs

Organization of the Health Services Prior to 1970

In 1970, 18 borrowing institutions were in charge of health care in Costa Rica (Ministry of Health, Costa Rican Social Security Institute, Manager's Office for Medical and Social Assistance, Boards for Social Protection, Insurance Institute, and others). Unfortunately, all of them had different regulations, management, and financial sources. Furthermore, they barely coordinated their activities and, over and above the already complex health structure at the time, there was improper utilization and unequal distribution of resources. All of this produced a chaotic situation in public health: incomplete health coverage of the population, all kinds of differences in health services as to quantity and quality, preventive health programs considered of little importance, while stressing curative assistance and a marked autonomy of all health institutions based on the laws that established them. In 1969, less than 10% of the total health budget was allocated to preventive health measures.

Additionally, regionalization of the health services was unknown in Costa Rica. All health resources, which were mainly directed toward curative actions, were allocated to San José, the capital. The national territory was divided into 19 Sanitary Districts in 1969 with a view to improving the management of the health services. Five health zones were established in 1971 but were changed to seven health regions in 1983. Prior to 1970, communities had limited participation in the health process. Early in the 1970s, however, the government launched an initiative seeking to mobilize community resources. Its goal was to support malaria programs and mobile medical care units in the rural areas.

Prior to 1970, environmental sanitary activities targeted densely populated nuclei. At the time less than 50% of the rural population had potable water (mainly from public fountains) and less than 40% had any sanitary means for disposing of excrete. In fact, intersectoral involvement in health was limited to health promotion activities sponsored by the Ministry of Public Education (sanitary education, school gardens).

In 1970, Costa Rica had the following human resources working in the health sector per 10,000 inhabitants (Ministerio de Salud, 1978a): 5.2 physicians, 1.4 dentists, 4.2 nurses, and 13.6 nurse's aides; these numbers were insufficient to meet the health needs of the population. In the same year, the country had only 2.9 hospital beds per 1,000 inhabitants. Health per capita expenditure was US $29.5 in 1970, 5.1% of the gross domestic product (Sáenz, 1985b). Consultations and hospitalizations used up most of the health budget.

Mobile Medical Units

The Costa Rican Program of Mobile Medical Units was created in the early 1960s. It was funded mainly from foreign sources through the Alliance for Progress Program. At the end of the decade, Costa Rica had nine mobile units on land and one at sea. The health teams were made up of a general practitioner, a nurse's aide, a sanitary inspector, and a driver, and had a four-wheel drive jeep at their disposal. The basic health team was stationed in a health center located at the capital of a county. Each mobile unit covered 12 to 18 communities, all of them between 5 and 20 km away from the health center, generally visiting for one day, on a monthly schedule. In the most distant and in the most densely populated communities, the mobile unit stayed two or three days.

The main functions of the mobile units were medical consultation for the sick, environmental sanitary actions (construction of latrines, sanitation of houses, and improvement of water sources), educational actions, creation of health committees, and promotion of food production in family and community gardens. Even though the Program of Mobile Medical Units had strong political backing and solid foreign resources, it had several limiting factors. On the one hand, some communities were practically inaccessible by car during the rainy season. On the other hand, higher-risk populations, i.e., the most distant communities, did not have access to the program: poor road conditions badly affected the unit's vehicles, compelling the team to interrupt their visiting schedule each time the vehicle broke down or when it had to be replaced (every two or three years). Another important restriction to the mobile unit program was its limited coverage: only 130 of the 3,000 communities with fewer than 2,000 inhabitants. Furthermore, the program had a predominantly curative approach: the health team had to cover a patient demand of 60, 80, or even more patients per day, which limited their time for other health actions.

Some communities with severe restrictions on basic health services benefited from the Program of Mobile Medical Units. However, in the county, where the program was implemented for several years (Puriscal, San Carlos, Perez Zeledón, Nicoya, Santa Cruz, and Buenos Aires) no significant changes in infant mortality could be interpreted as a positive impact of the program (Vargas, 1976).

Mobile units continued working throughout the 1980s and are still active today. Their main function continues to be curative, since they visit health posts to support health activities developed by the local staff. Thus, units increased the supply of health care and curative services to the population.

Searching for a New Health Care Model

In the second half of the 1960s and the beginning of the 1970s, several Latin American countries discussed ways to expand their health services to dispersed rural populations, particularly to communities with fewer than 500 inhabitants, as well as to families living on river banks and along roads. The concept of "simplified medicine" emerged from these deliberations. The concept is implemented by auxiliary personnel, who, after a training course that lasts only a couple of months, are capable of looking after and solving most of the common health problems of the population. At that time, Venezuela established a "simplified medicine" program for rural populations. In Chimaltenango, Guatemala, Dr. Carroll Berhorst trained Indian leaders to participate as "health helpers" in their communities. During the same time frame, Latin American scholars studied and disseminated information on primary health care models used in other parts of the world

Political Support

In May 1970, a new social democratic government came into power. President José Figueres, who had a profound knowledge of the problems affecting rural areas, committed his political program to changing the fate of the rural population.

In October 1972, the Special Meeting of Ministers of Health of the Americas made a recommendation

to expand minimum coverage of integrated health services to all persons living in villages with less than 2,000 inhabitants, allowing auxiliary health personnel - duly trained for this purpose - to take over health services. It is understood that this basic health care, with different quality levels, should be complemented with a coordination and referral system permitting access of all of the population to more specialized health care (Ministerio de Salud, 1973b).

The basic reference paper of the Ministers' Meeting recommends the establishment of "minimum integrated health services" that should cover the following elements: tending the sick in emergencies; health care for mothers and children under five years of age, including family and community education on sanitary topics, as well as on food and nutrition; immunizations; basic sanitation; recording of statistical data; and patient referral to more complex health units. The paper also states that these health services should be in the hands of elementary health units, run by trained auxiliary personnel and supervised by higher levels. Furthermore, they should each have the capability to take care of 5,000 inhabitants.

When Costa Rica implemented the community outreach strategy of mobile units in the early 1960s, it destroyed the traditional health care scheme and created new needs among the population groups that had traditionally been forgotten by governments. The country, nevertheless, did not obtain the impact it was looking for. In the first half of the 1970s, various technical groups in Latin America and other parts of the world analyzed alternative strategies and activities to develop a health program targeting rural communities. Their efforts led to the 1978 Alma Ata Declaration.

From this it can be inferred that the development of community outreach programs for rural and urban areas in Costa Rica was facilitated by different circumstances. On the one hand, President Figueres supported the new health initiatives targeting rural population groups. On the other hand, the Ministers of Health of the Americas adopted the expansion of "minimum integrated health services" for rural populations on the basis of trained auxiliary personnel as a regional health policy.

Working Group

In view of all health and political elements discussed above, the Ministry of Health in Costa Rica became the ideal entity to develop a new health program for rural population groups. As a matter of fact, this power was formally vested in it through the tripartite convention signed by the government of Costa Rica, PAHO/WHO, and UNICEF in March of 1972.

With a view to developing the new health program, the Pan American Health Organization (PAHO) appointed a public health specialist and a sanitary engineer who had been working several years in Costa Rica in the Malaria Control Program. Both of them knew the country and particularly rural communities located at low altitudes, all of them typically malaria endemic zones, which were considered priority areas for the rural health program. The Costa Rican counterparts to the PAHO staff were a Manager for Field Operations, chosen from the Malaria Control Program, and a graduate nurse trained in public health. Lack of financial resources, however, led to the decision to limit activities in 1972 to staff training only. That year, two three-month courses on rural health were given to 34 evaluators and 17 volunteers working for the Malaria Control Program.

During the first half of 1973, the Ministry of Health appointed a public health specialist as manager of the program, a post which he held for only a few months, as well as another nurse trained in public health. During 1973, the central team was made up by the two advisors appointed by PAHO/WHO, the Field Operations Manager, two nurses, one secretary, and a driver. In May 1974, a physician was incorporated into the staff as program manager. Shortly thereafter, two more public health nurses joined the team. The work team had the following functions: to prepare the program, to train field staff, to design an information system for the program, to supervise the program, and to implement the new health care model, developed by the central team, for rural population groups.

Because concrete outreach programs targeting rural communities were practically unknown at the time, none of the team members felt motivated to visit similar programs in other countries. As a result of this situation, the Costa Rican Rural Health Program was launched, developed, and consolidated using strictly Costa Rican rural resources.

The central team had the task not only of designing the program, but also of directing and implementing it. Several program elements that at the beginning were considered logical, at least from a theoretical standpoint, were later found to clash with reality when put into practice. Fortunately, the team was able to react to this situation and to correct all the mistakes observed in the field.

Characteristics of the Costa Rican Population

According to the 1973 National Population Census, Costa Rica had a total of 1,872,000 inhabitants living in 4,245 communities. The country's population can be subdivided into the following categories: urban, concentrated rural, and dispersed rural. The urban population, distributed in 77 population groups with more than 2,000 inhabitants, represented 47% of the country's population. The concentrated rural population, a total of 418,000 persons living in 494 population groups with 500 to 2,000 inhabitants, represented 22%. The dispersed rural population, a total of 574,000 persons living in 3,684 population groups of fewer than 500 inhabitants, represented 31 % of the country's total population. The latter group became the target population of the first phase of the Costa Rican Rural Health Program (Ministerio de Salud, 1973b).

An in-depth analysis of the Costa Rican rural environment permitted the identification of the following factors that limit the access of the population to health services (Ministerio de Salud, 1978a).

Geographic Inaccessibility

Geographic inaccessibility was directly related to the tremendous population dispersion found in the country, especially in the low coastal and border areas. In the rural areas, access roads were lacking and/or inappropriate; usually, they were blocked during the rainy season, which may last up to eight months a year. As a result of this, much time and effort were required to reach regions where the only means of transportation were horses, carts, and rowboats. The most peripheral health centers were located in the capitals of counties with more than 2,000 inhabitants; the majority of them were accessible by paved or unpaved roads.

Economic Inaccessibility

This factor was determined by the production characteristics of the community. There was a high proportion of landless peasants and small farmers using traditional agricultural practices, i.e., very little technology, for subsistence crops. In several cases, they were wage earners who migrated during the sugarcane and coffee harvest seasons. While poverty levels were estimated at 39% for the whole country, in rural zones they reached 46%. In other words, nearly one of every two persons living in rural areas was classified as poor (Trejos, 1990).

Sociocultural Inaccessibility

This factor is expressed in terms of the community's traditions, inadequate information on the health and disease process, high illiteracy rates or low schooling, and ignorance regarding the benefits derived from health services. In the countryside, the deeply rooted traditional concepts regarding health and the origins of disease, on the one hand, and the lack of rural health services, on the other, fostered native healers and self-medication with traditional medicines. At the same time, alcoholism, machismo, and irresponsible parenthood resulted in a large number of single mothers with small children.

Functional Inaccessibility

This factor was related to sporadic health services, inadequate work schedules, low coverage, and a predominance of curative over preventive health actions. Health care provision in Costa Rica was concentrated in establishments (health centers and hospitals) located either along the main roads or in the most densely populated cities with the most developed economies. Dispersed rural areas received very limited attention from the mobile health units, which provided occasional services and merely treated morbidity aspects. A positive point was that other volunteer groups (ONGs) and the staff of the Malaria Eradication Program were already aware of the health isolation in the rural areas. To summarize, all health problems occurring outside the schedule of the mobile units had to be treated in urban communities, which implied further expenses for the population. Also, patient follow-up was sporadic or nonexistent, and vaccinations were implemented though vaccination campaigns, nearly always as emergency actions.

Technological Inaccessibility

The technological inaccessibility of rural areas was due to inadequate utilization of techniques to meet the prevailing health problems, inappropriate staff training, inadequate management and development, and deficient community organization.

Since its inception, the Costa Rican health program for rural communities has had the goal of eliminating these problems of rural accessibility. For this purpose, it pursued different strategies, such as the creation of small health units that built a health service network for the purpose of reaching the smallest communities, stressing home visits. Thus, each household, regardless of how far away or isolated it was, was periodically visited by the rural health assistant or by a nurse's aide.

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