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Comparative public health: Costa Rica, Cuba, and Chile

Abraham Horwitz
Director Emeritus, Pan American Sanitary Bureau, Regional Office for the Americas, World Health Organization

In making a comparative analysis of the health services of Cuba, Costa Rica, and Chile, it seems pertinent to ask, Why the comparison, and why those three countries? There is increasing interest in identifying "countries that cope"-that is, those that, having been exposed to political vicissitudes, severe economic crisis, epidemic outbreaks, and other social banes, have been able to overcome them and create the conditions for continuing improvement of the welfare of the people. In the same historical period, however, other countries-some with even greater resources and fewer riskshave not fared well: their people, particularly their children, have borne the brunt of misguided economic and social policies.

In the developing Americas, Costa Rica, Chile, and Cuba are regarded as countries that have succeeded in their efforts to promote equity and to satisfy basic needs of a large proportion of the people. For this reason they have been singled out in the region, and scholars have shown genuine interest in knowing what worked, under what circumstances, and at what cost, and whether or not they provide lessons for other developing societies of the world.

Overview of health in the Americas

In most countries of the Americas the last 30 to 40 years have seen some improvement in the health and nutritional status of the people. While infant mortality in Latin America declined by about 60% between 1950 and 1980, the number of infant deaths diminished by less than 25%. This relative difference reflects the region's population growth of 124%, or 2.7% per Year. Nevertheless, in 1980 more than 904,000 babies survived who would have died had the 1950 rate prevailed. Despite this progress, the problem is still with us: too many children are dying when they could survive.

The decline of early childhood mortality between 1950 and 1980 was even more significant than the rate for infants. While in North America the reduction was 53%, in Latin America it reached 70%. This means that, as an average, for every 1,000 children between the ages of one and four years, six more die in Latin America than in North America-in excess of 163,000 deaths in 1980.

Other sources of information on Latin America and the Caribbean focus on the period 1980-1985. The goals are those of the Pan American Health Organization approved by its member governments for the movement "Health for All by the Year 2000" [1]. Table 1 shows that 12 countries, which have 7.1% of the total population of Latin America and the Caribbean, have already reached the goal for life expectancy of 70 years; 11 more, with 35.1 % of the population in the region, have a life expectancy between 65 and 69.9 years. The greater the reduction in infant mortality, the sooner they will reach the goal for life expectancy table 2 presents the distribution of infant mortality per 1,000 live births in Latin America and the Caribbean for 1980-1985, the goal being 30 or fewer [1]. Eighteen countries, with 5.7% of the population, have already reached it. Another eight, with 5.8% of the population, are very near it and should attain it before the turn of the century. Thirteen countries, with the largest portion of the population of theregion -over 78% -still have infant mortality between 40 and 80 per 1,000 live births.

TABLE 1. Life expectancy at birth in Latin America and the Caribbean, 1980- 1985

Life expectancy at birth (years) Number of countriesa Population
Number(1,000s) %
70 and older 12 25,868 7.1
65-69.9 11 127,543 35.1
60-64.9 6 174,141 47.9
Under 60 5 35,428 9.7
Unknown 12 790 0.2
Total 46 363,770 100

a. Includes countries and other political units.
Source: Ref. 2

TABLE 2. Infant mortality in Latin America and the Caribbean, 1980-1985

Rate per1,000 children Number of countriesa Population
Number (1,000s) %
< 30 18 29,704 5.7
30-39.9 8 21,207 5.8
40-49.9 5 42,202 11.6
50-69.9 5 108,829 29.9
70-79.9 3 135,138 37.2
80-99.9 3 24,049 6.6
> 100 2 11,379 3.1
Unknown 2 262 0.1
Total 46 363,770  

a. Includes countries and other political units.
Source: Ref. 2

The situation is apparently somewhat better with regard to mortality in early childhood, that is, between the ages of one and four years [1]. As shown in table 3, the goal of 2.4 per 1,000 has been attained by 19 countries, with 21.1% of the population. In another 10, with more than half the regional population, the rate is as high as 4 per 1,000, and in 7 more it exceeds that figure.

Considering only these three indicators-life expectancy, and mortality in infancy and in early childhood - progress toward better health in the Americas is evident in a minority of countries. Similar conclusions result from an analysis of other health, social, and economic indicators [1]. Countries with the largest proportion of the population of the developing Americas are not applying tested knowledge and proved experience required to satisfy their most urgent needs, and they should. To this end, the lessons stemming from an analysis of sustained health advances in Costa Rica, Chile, and Cuba are of great value for other developing nations. This is the best justification for a comparison of the services provided by them and the outcomes during the last 25 or more years.

TABLE 3. Mortality in early childhood (1 -4 years) in Latin America and the Caribbean, around 1980

Rate per 1,000 live births Number of countriesa Population
Number (1,000s) %
< 1.0 6 761 0.2
1.0-1 4 6 27,224 7.5
1.5-2.4 7 48 825 13.4
<2.5 19 76,810 21.1
2.5-3.9 10 205,042 56.4
>4.0 7 67,308 18.5
Unknown 10 14,610 4.0
Total 46 363,770 100

a. Includes countries and other political units.
Source: Ref. 2.

It is noteworthy that today these countries have widely different political systems. For Chile, this was not the case up to 1973, for it had a democracy similar to Costa Rica's. For the purpose of this analysis, what is essential is the political will leading to decisions that are translated into policies and programmes, and that are reflected in historic trends and rates of health and nutritional status, whatever the prevailing ideology. in a conference on health progress in China, Kerala State in India, Sri Lanka, and Costa Rica, Warren [31 emphasized the significance of political will mediated through education, health, and nutrition: "Education thus appears to play a catalytic role and, in relation to the equitable distribution of health, also appears to be highly synergistic, with the whole being far greater than the sum of the parts."

Mortality rates in Costa Rica, Cuba, and Chile

Mortality rates -particularly of mothers and of children under five years old -are frequently used as a measurement of the quality and quantity, as well as the accessibility and effectiveness, of health services. Although these are important, it is other biological, social, and economic conditions that determine the dynamic of health and disease in society. Still, some would argue that infant mortality not only has an intrinsic value but also reveals the state of development of a country, and reflects, in the absence of sustained health care actions, periods of recession in the economic process. Let us examine how mortality rates have evolved in Costa Rica, Cuba, and Chile.

In 70 years, infant mortality in Costa Rica declined to one-tenth of what it was in 1910. Rate reductions between decades, although significant, cannot be attributed exclusively to health services. Still, the 6.9% annual average between 1970 and 1980 is striking.

If the infant-mortality data are separated into those for neonatal and for post-neonatal deaths, up to 1970 there was a mild downgrade in the latter (fig. 1). Neonatal rates basically did not change. From 1970 to 1980 the rates of reduction were 12.9%, 17.2%, and 8.7% for infant, post-neonatal, and neonatal deaths, respectively. The early 1960s and 1980s were periods of economic recession in Costa Rica. It was estimated that in those years infant mortality declined by an average of 1.4%, while in normal years it increased to 3.8%. The same relationship was registered for adult mortality, with 2.0% and 3.6%, respectively.

Between 1970 and 1983 mortality decreased in Costa Rica for the general population, infants, and children one to four years old. Health services did not concentrate exclusively on children, but they were accorded preference. By 1983 general mortality had reached a low of 3.9 per 1,000 inhabitants, similar to rates in industrialized nations.

In Chile between 1940 and 1983 all the rates decreased slowly but steadily. In 43 years infant mortality was reduced to almost one-tenth of the 1940 figure. The decline in early childhood mortality from 1965 to 1980 paralleled that of infant mortality [4].

The figures for Cuba are comparable to those in Costa Rica and Chile, with declines in infant, neonatal, and perinatal mortality for 1971-1980. For ecological reasons that have not been clearly defined, persons living on islands had better health than those living in countries at the same latitude in the continental area. In the case of Cuba, figures registered and/or estimated for infant mortality by the United Nations since the early 1920s were significantly lower than those for Costa Rica or Chile in the 1950s and later decades 15]. Infant mortality in Cuba was 18.5 in 1981 and dropped to 16.8 in 1983; corresponding pre-school mortality was 1.1 in 1981 and 0.8 in 1983 [6].

FIG. 1. Infant, post-neonatal, and neonatal mortality rates in Costa Rica, 1955-1982 (Source: ref. 7)

Today the three countries show similar rates of infant and early childhood mortality. Caring for the health of the people was perhaps more arduous in Costa Rica and Chile, however, because the problems there were more severe and widespread, the geography made travel more difficult, the climate was more inclement, poverty was more critical, the prevalence of acute disease and malnutrition was greater, and human and material resources were in shorter supply.

Life expectancy

It is generally true that the lower the infant mortality rate, the greater the life expectancy at birth. A comparison was made among Costa Rica, Latin America as a whole, and several industrialized countries in Europe and the United States between 1970 and 1980. Life expectancy in the industrialized nations, as a group, reached 73.7 years by 1975. In 1980 the age in Costa Rica was 72.6 and in Latin America 63.6 years [7]. Life expectancy at birth in Chile was estimated to be 69 years in 1983, and in Cuba 71.8 years in 1980 [8].

Infections and malnutrition

Infections and malnutrition have a well-proved synergistic effect, inducing high morbidity and mortality. Among the former, diarrhoea and respiratory infections occur with high frequency in developing nations. Health policies of the three countries under review have given priority to and developed programmes for the control of communicable diseases.

As a result, Costa Rica experienced a downward trend for infant infection between 1960 and 1982, which accelerated starting in 1972. The control of diarrhoeal diseases and respiratory infections accounted for three-fourths of the total decline of infant mortality between 1955 and 1972, decreasing to 50% after the latter Year [7]. After that, three broad categories of conditions prevailed: immaturity, largely reflected in low birth weight and high risk of morbidity and mortality; diseases preventable by vaccines, mainly measles, tetanus, and polio; and diseases preventable by early diagnosis and appropriate treatment, in particular, septicaemia and meningitis. Mortality for these categories, as well as malnutrition, has declined to less than 1 per 1,000 births. Breastfeeding, sanitation, immunizations, appropriate maternal and child care including timely treatment of intercurrent infections, health education, and, when indicated, food supplementation are among the major measures that account for these remarkable outcomes in Costa Rica.

With respect to respiratory and diarrhoeal diseases, Chile had similar experience. The reductions over 20 years in neonatal, post-neonatal, and infant mortality attributed to these conditions are most unusual among the developing countries of the world. This is particularly true for neonates, because these babies require a rather sophisticated healthcare system for adequate diagnosis and effective treatment.

In Cuba in 1970 influenza and pneumonia and enteritis and diarrhoeal diseases accounted for 27.3% of all deaths of children under one year of age, while in 1980 this was reduced to 13.7% [6]. The government developed a categorical programme to control diarrhoeal diseases, which started in 1963. By 1980 the prevalence of these conditions was 105 per 100,000 live births, while for Latin America as a whole it was 903.8, compared with 21.9 for the United States. The 1980 rate of 210.6 for Chile was reduced to 139.6 by 1981 [9].

Nutritional status is highly correlated with infant mortality. The proportion of children with growth retardation below 75% of the standard diminishes in tandem with the reduction in infant mortality rates as a result of health care and other socio-economic programmes in Chile, Costa Rica, and Cuba (table 4) [10]. During the 1970s in Costa Rica total malnutrition as well as moderate and severe types were progressively controlled by an extended programme of food supplementation that complemented and enhanced the other inputs of the health-care system.

In Chile by 1982 total malnutrition, as measured by weight for age of children under six years old, was 8.8% -a remarkable result. Severe cases in those over two years old had virtually disappeared, while the rate was only 0.1 % for children between the ages of one and two years. It is worth noting the size of the population served by the National Health System: more than a million children. The country has perhaps one of the most sophisticated nutrition surveillance systems in the world. Data on approximately 400,000 children and 200,000 mothers are regularly collected, collated, analysed, and used for decision-making by the Ministry of Health. There is a regular flow of information from every unit of the health system to the central computer service and back to each source, with appropriate comments when justified.

TABLE 4. Tendencies in nutritional status and infant mortality in Chile, Costa Rica, and Cuba, 1965-1983

  Growth retardationa Infant mortality
Year % Year Rateb
Chile 1965 23.7 1965 107.0
1975 4.1 1970 79.3
1980 1.9 1975 55.4
    1978 39.7
1981 27.2
1983 23C
Costa Rica 1966 13.5 1965 76.0
1975 12.3 1970 61.5
1978 8.6 1975 37.9
    1978 24.0
1980 19
1983 16c
Cuba _d 1969 46.7
1975 27.5
1978 22.6
1981 18.5
1983 16.8

a . Percentage of children below 75% of standard.
b. Deaths per 1,000 live births.
c. Provisional.
d. Data not available, but estimated at less than 5%.
Sources: National statistics, Pan American Health Organization, 1982 ref.10.

The lower the infant mortality, the greater the significance of perinatal mortality and low birth weight. These children are exposed to great risks because of their immaturity and lowered resistance to environmental stresses, particularly infections and malnutrition. Costa Rica was able to reduce infant mortality due to immaturity drastically thanks to improved nutrition and an effective health-care system. Between 1975 and 1982 Chile experienced a sustained decline in both infant mortality and low birth weight, the latter reaching the low figure of 6.9%.

In general, it is safe to state that countries are not homogeneous and that they show clear differences between and within urban and rural areas with reference to morbidity, mortality, and other health and social indicators. In addition, they differ as to the quantity and quality of services and benefits provided by the state. For instance, from 1970 to 1980 mortality in Costa Rica fell from 64 to 21 per 1,000 live births; this reduction varied in countries in which coverage of health and nutrition services was higher. A similar relationship was observed between life expectancy and the length of time that rural health programmes were in effect. In countries in which no programme was in operation, an average gain of 2.40 years was noted between 1970 and 1976. Where health services had been provided for three years, however, life expectancy increased by an average of 5.06 Years [11].

Infant mortality in Cuba was clearly different in urban and rural areas of the same region, and within groups of regions classified according to percentage of rural population. Furthermore, rates were higher where the rural populations were larger.

Since Chile's establishment of a National Health Service in 1953, significant differences have been noted in general and specific mortality rates between the provinces and between urban and rural communities within each province [12]. A special 1968 nutrition survey in Curicó, which is representative of Chile's central agricultural zone, recorded the percentages of children under seven years of age who were below percentiles 3 and 10 for weight and height on the Iowa Scale [9]. The rural figures were consistently higher than the urban ones, with the exception of children from birth to one Year old with respect to height. These differences within and between provinces have now been reduced markedly. Still, dwellers in isolated communities continue to live in extreme poverty, as do the culturally isolated persons who do not demand health and social services and who show the highest rates of morbidity and mortality.

Mother's education

Consistent evidence supports the value of the mother's level of education in increasing the life expectancy of her children. Both in Costa Rica and in Latin America as a whole, an enormous difference exists in the mortality of children under two years old between those whose mothers are illiterate and those whose mothers have seven years or more of education. For the years 1975-1979 the rates were 33 and 16 per 1,000 live births respectively [7]. Furthermore, for both levels of schooling, infant mortality diminished markedly from the rates between 1965 and 1969, particularly for the lower level.

The same strong correlation between perinatal and infant mortality and the mother's level of education exists in Cuba. There is also a parallel correlation between education and prenatal consultations and child care. Cuba developed an extensive educational system with high participation of the population, especially during the 1970s for primary and high school.

Family planning

Maternal age, particularly under 18 and over 35 years, parity of more than four children, and birth intervals of less than one year have independent effects on the risk of infant mortality. The frequency of immaturity and low birth weight at the extremes of these variables is high [13].

The availability of family-planning services and effective education can have a significant impact, as reflected in the death rates of mothers and children. Costa Rica, Chile, and Cuba are good examples in this regard.

In Costa Rica in 1961-1975, a small number of children per family, spacing of two to three years, and age of the mother between 18 and 35 years led to reduced infant mortality (fig. 2). It is worth noting that two-thirds of those who practiced contraception in 1981 used state-provided services; this included 90% of agricultural labourers.

Natality per 1,000 inhabitants was reduced in Cuba from 29.5 in 1971 to 14.1 in 1980. A factor to be considered is the extended family-planning programme offered by the health-care system.

Between 1964 and 1979 in Chile the percentage of women who used contraceptives rose strikingly, and birth rates, infant mortality, and maternal mortality decreased just as dramatically (fig. 3) [14]. The results were particularly notable for women younger than 15 or older than 30 years. In the same period, the number of hospitalizations as well as maternal deaths due to abortion declined drastically.

It was estimated that changes in the birth rates in Costa Rica (1960-1977) and Chile (1972-1978) were responsible for a 21 % reduction in infant mortality, 19.3% in neonatal mortality, and 22.1% in post-neonatal mortality [15].

Food supplementation

Food supplementation for mothers and children is another of the health and nutrition interventions through primary health-care services considered to influence pregnancy outcome, low birth weight, and infant and early childhood mortality. Costa Rica and Chile enacted important legislation followed by significant investments in this field. The rationale of food supplementation can be expressed as follows: it represents a transfer of energy and nutrients, and also of income, for the family; it attracts the mother to the health centre to obtain the food allotted, as well as preventive and curative services for herself and her children. It also reflects social policies for social equity

FIG. 2. Infant mortality by interval since last birth. age of mother, and birth order, in Costa Rica, 1961-1975 (Source: ref. 7)

The impact of malnutrition on childhood mortality is clear: it impairs immunocompetence; it increases the frequency of infectious diseases, which last longer and are more severe; and, as a result, it leads to greater mortality [16]. Food supplementation appears to be associated with lower infant mortality [17].

Costa Rica recorded significantly reduced infant mortality and a sharp rise in per capita energy availability from the 1950s to 1981 (fig. 4). The accelerated reduction of the former since 1972 coincided with a significant increase in the latter [17]. Food is distributed through lunches in all schools. Other services include Centres for Education and Nutrition (CEN) for pregnant and lactating mothers and children two to six years old at risk of malnutrition, and Children's Centres for Integral Care (CINAI), especially for working parents, which provide health care, stimulation, education, and appropriate social interventions. All these programmes are financed under legislation for Social Development and Family Allowances. A recently passed law covers the costs of 120 ClNAls throughout the country. There is a plan to enlarge the CENs and turn them into Centres for Integral Care.

FIG. 3. Infant and maternal deaths in Chile, 1964-1979 ( Source: ref. 14)

FIG. 4. Infant mortality rate and per capita dietary energy availability in Costa Rica, 1950-1981 ( Source: ref. 17)

In Cuba the system is based on direct food subsidies through family food rations. Children under eight years of age and pregnant mothers qualify for a litre of milk per day. Food is provided through special distribution stores by rations. Although reductions in the availability of energy coincide with slight increases in infant mortality, when the latter began to decrease a: an accelerated pace from the early 1970s on, energy per capita reached high levels, nearly 2,800 calories. Severe malnutrition has been virtually eliminated.

Milk supplementation through the health services for mothers and children has been traditional in Chile- a true social right. It has developed progressively during the present century and expanded as coverage of the National Health Service proceeded. It is one of the nutrition interventions that are integrated into primary health care.

A favourable cost-benefit ratio of the programme was confirmed, but only for those in the lowest two quintiles of the income scale, that is, the poorest groups of beneficiaries [18]. This is its major justification, not only as a supplement of energy and nutrients but as a transfer of income to those in greatest need.

Water supplies and basic sanitation

Water supply, particularly house connections, and sewage-disposal and basic sanitation systems, particularly if combined with hygienic practices, help reduce childhood morbidity and mortality from communicable diseases [19, 20].

In 1980 Costa Rica reported that 68% of its rural population had adequate water-supply coverage and 95% of its urban population had house connections, while only 5% depended on public tap water. With regard to sanitation, the breakdown was 82% for rural coverage with an adequate system, 43% for urban coverage with sewerage, and 50% with some other system [21].

In Chile, as in Costa Rica, increases in these essential but expensive services have been remarkable and reflect a definite commitment to social equity on the part of the people and the government. The most important determinant of the rapid decline in infant mortality for 1975-1982 in quantitative terms was the increase of potable water and sewerage in urban areas [8].

Socio-economic indicators and infant mortality

In Costa Rica from 1930 to 1980 successive administrations enacted legislation and developed programmes to stimulate economic growth and particularly social well-being [22]. Expenditures on per capita public education increased more than tenfold in 50 years and doubled in the last decade. For public health, the growth has been sixfold in the same half century. By 1980 public health expenditures reached 7.4% of the GDP. These trends show progress that may have had an impact on morbidity and mortality.

Despite important variations in basic economic indicators over the four five-year periods from 1962-1966 to 1977-1981, Chile experienced a sustained reduction in infant mortality. Changes in the economy were most significant between 1967-1971 and 1972-1976. Health indicators relating to the use of human and institutional resources showed a sustained increase over the 20-year span, as did the provision of milk to pregnant and lactating mothers and their infants [16].

We do not have similar information for Cuba. For 1971-1980, however, the global social product IGSP) and the health budget increased approximately twofold, funds for education quadrupled, and infant mortality was reduced by half.

On the basis of data for 1978 [4], the indicators and resources of the National Health Services appear to be on a par in the two countries, whose populations are almost the same size. Similarity is also seen in their approach. The health system, with its four levels of care, covers the entire population in Cuba, whose geography makes accessibility to the services easier, and around 90% of the population in Chile. There is strong input from professional staff.

Between 1970 and 1980 Costa Rica recorded a 69% reduction in infant mortality. This was almost three times as great as the predicted reduction of 20%25% [7]. That prediction was based on seven indicators of economic development and three social indicators heavily weighted by education. Also taken into account was a theoretical index of development proposed by the United Nations from a wide range of social, economic, and demographic indicators. It can be strongly inferred from the actual figures that health policies and programmes, including nutrition, may have been primarily responsible for the great decline in infant mortality during the 1970s.

Life expectancy as it relates to income per person in developing countries by 1978 is shown in figure 5 [23]. Cuba, with a lower gross national product (GNP), had a somewhat higher life expectancy than Costa Rica, Chile, Brazil, and Argentina. Bolivia, with an average income slightly higher than US$500, showed a life expectancy far below that of Sri Lanka and China, with US$270 and US$290 GNP respectively.

Given these figures, there is no need to wait for higher per capita income to improve the health conditions of a population. Health can develop in the midst of economic backwardness, although progress is greater when it proceeds at the same pace as economic growth and social equity. The experiences of Costa Rica, Cuba, and Chile show that the natural intelligence and creativity of the people have enormous potential. If given the opportunity, citizens will respond and promote their own health and well-being and that of their families and their communities in a most cost-effective way.

There is a dearth of studies that measure the synergisms-or antagonisms-of economic, health, and social factors and their influence on infant and early childhood mortality. The independent variables with the greatest impact on the decline of infant mortality in Costa Rica during the 1970s were identified by correlation analysis [7]. Primary health care, including nutrition programmes, made the greatest contribution (41 %); intermediate health care in outpatient departments also played an important role (32%); reduction in fertility rates had an impact of only 5%. The remaining 22% was attributable to economic and social progress during the decade. Once again, the health sector contributes significantly through a series of interventions to reduce infant morbidity and mortality.

FIG. 5. Life expectancy in relation to income in developing countries, 1978. (Life expectancy at birth is the average number of years a newborn could be expected to live if current conditions were to continue throughout his or her lifetime.) (Source: ref. 23)

Some common features of the health system in Costa Rica, Cuba, and Chile that may explain the outcomes

Beyond the information that has been analysed, comparison of the three countries is warranted because they stand out among the developing societies in terms of the health and nutritional status of their people. The results obtained can be regarded as truly successful national experiments that may be of relevance to other nations in similar circumstances. We have identified the following common features that may help to explain the outcomes.

It has been a long-range process lasting more than 25 years; there are no panaceas. Continuity in decisions, investments, and actions is a necessity in order to transfer national income to the people through social services.

Sustained political commitment to social equity is essential. Successive administrations in two of the countries, even with different ideologies, did not significantly alter policies and programmes so that trends in health could continue. In addition, fundamental legislation was enacted providing the conceptual and political framework for all the policies and reflecting public opinion.

Community organization for active and informed participation by the people is also basic. In Costa Rica, Cuba, and Chile there is some degree of social consciousness stemming from the interpretation of life and the value ascribed to the health and nutritional status of mothers and children. It is expressed in a natural inclination on the part of people to serve their peers in need. For effective community development, the views of the people, as well as their human, material, and financial resources, are indispensable to planning and implementing successful programmes. Health education can contribute significantly to specific changes in behaviour.

All three countries made use of sound vital statistics and health information - covering no less than 20 years-reguIarly collected, collated, analysed, and used in decision-making. A nutrition-surveillance system is in operation.

No single action can explain the outcomes, but a cluster of actions within the health sector, coupled with interventions from other social sectors, have had an impact on the frequency of morbidity and on mortality. These include education, water supply and sewage disposal, food and nutrition, and family planning.

None of the three countries has had an integrated planning process with the different socio-economic sectors strongly associated with health and nutrition outcomes. Nor have specific programmes usually been implemented in the same geographical areas, which accounts for the differentials in the indicators between and within them. Activities from different sectors have proceeded simultaneously, but not necessarily in accordance with an integrated plan designed to benefit from their synergisms. In the last decade, resources were concentrated on the clusters of poverty, usually in the rural areas, where persons at greatest risk of death and disease live. The accelerated reductions in morbidity and mortality and other indicators may reveal a strong association among the different sectoral inputs. We must admit that there has not been enough research to let us understand the ways in which each activity influences the others and the overall outcomes.

The health system has been developed from ''top to bottom" with different levels of complexity for the performance of preventive and curative actions. It is the system as a whole that ensures coverage with effective referrals of patients. It is universal in Cuba, and serves approximately 90% of the population in Chile and Costa Rica. Primary health care is the major emphasis of the system. Very important in this picture has been the reaching out of the health units, particularly in rural communities, to the homes to identify the sick and malnourished, refer them when necessary, educate families, and collect data. A static health unit, waiting for patients to come, will not be as effective in reducing morbidity and mortality as a dynamic one that reaches the people. This approach has been essential in the three countries to ensure not only geographical but functional, cultural, and financial access to the services. Some categorical programmes for specific conditions, for instance the control of diarrhoeal diseases, have been developed successfully on the basis of the health-care infrastructure.

Primary and secondary education, especially of women, as well as nutrition, water supply, excrete disposal, and personal hygiene have contributed significantly to the effectiveness and efficiency of the health-care system as reflected in all the indicators of use and in the outcomes.

The costs of this major enterprise for human betterment and development must be considered in relation to other investments by the governments and to benefits accrued. For instance, the increase in life expectancy and therefore the gain in productive years was highly significant in the three countries. To this should be added the values that a society ascribes to the well-being of the people in order to ensure a productive life. To judge by their investment in social services over the last 20 years, it can be safely stated that Costa Rica, Cuba, and Chile regard the protection and the promotion of health as a cardinal social value. Still, there is always room to reduce costs and even to increase the productivity and production of the different health and nutrition programmes through research and better organization and management of services.

Are these three national experiments in Costa Rica, Cuba, and Chile relevant to other developing countries in the Americas and other regions of the world? I am inclined to believe that for similar health problems the programmes examined will be successful over time under similar political, social, cultural, and environmental circumstances.

The scientific, technical, and operational bases are evident. Much will depend, however, on sustained political will and commitment to social equity, on the response of the people to the opportunity to contribute to health and human betterment, on the nature and extent of the problems and the quality and quantity of resources available for dealing with them, and on the magnitude of investments from governments and the communities. Taking into account the real progress made by the developing Americas during the last 25 years, I am convinced that the outcomes in Costa Rica, Cuba, and Chile - true models - can be adapted to the conditions in each country to reach progressively similar results.


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