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The remarkable improvement in health and nutrition statistics in Costa Rica from those of a developing country to those of industrialized countries in a single decade in the 1970s is without precedent. In 1970 the infant mortality rate in Costa Rica of 68 per 1,000 did not differ markedly from that of other Central American Countries and, in common with these countries, less than 10% of the health budget was allocated to preventive health measures (PAHO, 1994).
At the end of the decade the infant mortality rate had dropped to 19.1 (World Development Report, 1993) and health posts emphasizing prevention of communicable diseases, mother and child health, environmental sanitation, and health education covered 84% of the total population. Moreover, it was done with social harmony by the democratic government of a poor agricultural country that resolved to devote more adequate resources to the social contract. Although the improved economic circumstances of the 1970s helped to make a major increase in support of the health sector possible, it was no greater than in the other Central American countries that failed to utilize this opportunity. Today, despite the structural adjustment crisis of the 1980s, its infant mortality rate of 13.9 per 1,000 is the lowest on the mainland of Latin America and is as low as that of some industrialized countries. It compares with a range of 48.4 to 71.8 for the other countries of Central America.
This book, written almost entirely by Costa Rican officials who were intimately involved in this health revolution explores what was accomplished, how it was done, and why it was done. It describes the background and the astonishingly wide range of social initiatives taken by the governments of the 1970s not only in the health sector but also in primary and secondary education, technical colleges, the national university, distance learning, the development of cooperatives, consumer protection measures, and physical infrastructure improvement. It also analyzes the response of the health system to the economic crisis of the 1980s and discusses its evolution and sustainability. One point not emphasized in the text is that Costa Rica has achieved the health transition with only an incomplete demographic transition. The crude birth rate was 33 in 1970 and 27 in 1991 (World Development Report 1993). The impact that this has on current economic problems is scarcely mentioned.
The first chapter by Dr. Edgar Mohs, Vice-Minister of Health from 1975 to 1978, and Minister of Health from 1986 to 1990 recounts that when José Figueres became president of Costa Rica in 1970, he and his cabinet immediately started work toward their promised goal of eradicating extreme poverty in Costa Rica. While increased productivity was seen as the means of achieving this objective, it was approached by focusing on the health and education sectors. Aware that, after two prior separated terms, this would be his last chance to serve the country as president, Figueres used his power and experience to give impetus to momentous social transformations. Costa Rica became the only country in the Americas to abolish its armed forces and to do so in order to devote more of its resources to social welfare and development.
Professional associations opposed the new plans for the health sector, some arguing that a diversion of funds from curative to preventive medicine would result in an increase in mortality. There was even strong opposition from the officials of the regional office for the Americas of the World Health Organization (PASB) to the transfer of all hospitals to the Social Security Institute as noted by Mohs in Chapter 1. The decisions were taken and implemented despite such opposition. The improvement, actually achieved in such a short period of time, had been previously considered absolutely impossible. Throughout, these major health reforms were achieved by acting within the legal framework and by seeking consensus through conviction rather than by force.
In the 1980s the growing debt burden precipitated an economic crisis which also seriously affected Costa Rica. The price of further support from the International Monetary Fund and the World Bank was "structural adjustment." One aspect of this was pressure to streamline social services and eliminate or privatize many of them. Thus the first part of the 1980s was a struggle to save the National Health System and to protect the health status of the population during the severe economic crisis. Mohs describes how this was achieved and states how by the late 1980s, while he was still Minister of Health, the main objective was to return to progress. Carlos Muñoz returns to this theme in Chapter 6.
The second chapter by Guido Miranda, Assistant Director of the Costa Rican Social Security Institute from 1970 to 1978 and later Executive President, describes the evolution of the social security system. Unlike the pattern in other countries, it expanded from the initial traditional coverage of the employees of large farms and industries to include first all members of their families and then by the end of the 1970s virtually all of the population. The transfer of all hospitals in the country to the Social Security Institute was essentially complete by 1977. In this hemisphere only Cuba, with a centralized economy, and Canada, which adopted a universal health insurance plan, achieved similar population coverage.
A key factor in Costa Rica's success was its development of primary health care and preventive medicine services that reached both rural and urban communities. In Chapter 3 William Vargas, Director of the Preventive Medicine Department of the Social Security Institute and of the Public Health Department of the School of Medicine of the University of Costa Rica, explains how primary health care was made an integral part of the social security coverage. It was claimed that offering health services would lead to increased usage and costs. For the medical care of children the opposite occurred. Pediatric beds are now barely two-thirds those required in 1934 although the child population has doubled.
The three initial chapters discuss the basis for the Costa Rican health transition. Chapter 4 on the Evolution of the Epidemiological Profile by Lenin Sáenz, Chairman of the Sectorial Planning Unit of the Ministry of Health, describes the impact of the programs described in the previous chapters on patterns of disease and death. The evidence for the rapid decrease in disease associated with infection and malnutrition is presented in detail. However, "health transition" in the title of this book has a double meaning. It can be seen first and foremost as a change from the high morbidity and mortality due to the synergism of malnutrition and infection, particularly during the early years of life, characteristic of most developing countries, to the low rates of industrialized countries. It is also a transition to the emergence of chronic diseases associated with the dietary patterns of the more affluent countries.
One reason for this is that as mortality associated with nutritional deficiency and infectious diseases decreases, that due to chronic diseases becomes a relatively more important part of the total mortality. Another is an actual increase in these diseases, particularly hypertension, ischemic heart disease, and diabetes as a result of higher caloric intakes leading to overweight and obesity and to more fat in the diet. A third reason has been suggested by the studies of DJP Barker and colleagues (Barker, 1992) who found that individuals in England and Wales whose birth weight and weight for age at one year of age had been low are more susceptible to diseases of dietary excess in later life.
In Chapter 5, María Eugenia Trejos, Professor of Economics at the University of Costa Rica, reviews the socioeconomic factors associated with the health policy advances of the 1970s. Recognition of social demands followed by efforts to respond to them was the prevailing style of government in the 1930s and 1940s. The governments of the 1950s and 1960s continued this social tradition but believed that it would be best served by measures that would stimulate agricultural and industrial production. The social actions of the period included the promotion of agricultural and industrial technology, training of workers and technicians, and development of infrastructure including water supply, urban sewage disposal systems, postal and port administration, an autonomous railroad, building of highways, bridges, rural roads, telephones, and the nationalization of banks.
This approach did result in increased internal market production. However, the other authors repeatedly emphasize a social rather than an economic motivation for the policy. There is a consensus that the entrepreneurial governments of the 1970s were strong and decisive and willing to intervene in different social spheres when the private sector could not or would not.
As Carlos Muñoz, the Director of the Department of Primary Health Care of the Ministry of Health, and José Manuel Valverde point out in the final chapter, there were three stages in the development of the health delivery system in Costa Rica. The policies and programs within each account for the improvements in the health of Costa Ricans over this period. The first period laid the groundwork for the rapid changes resulting from the development of new policies and programs and the dedication of vastly increased resources in the decade of the 1970s.
The second period was one of rapid expansion of the primary health care system and hospital access with falling infant and child mortality rate and striking improvement of other social indicators. It was a period of increasing expenditure by the health delivery system.
In the third period new goals for reducing infant and preschool mortality, malnutrition, and infectious disease were formulated. Additional ones for the prevention of chronic degenerative diseases of later life were identified and applied. As a result the Costa Rican health system must now also be concerned with the promotion of diets and other aspects of a healthy life style for the prevention of these diseases that are the major health concerns in the industrialized countries. The increased life expectancy and decreased mortality and birth rate are changing the demographic profile of the country.
Muñoz believes that the capacity to change one paradigm for another in order to adapt to a rapidly changing national health picture was the key to the continuing overall effectiveness and current health achievements of Costa Rica. This permitted an effective response even to the structural adjustments required in the third period. The health system in Costa Rica is now evolving toward a mixed model. In 1994, 15% to 19% of social security services were subcontracted to private providers.
A chapter reviewing international and other external influences on the health and nutrition policies of Costa Rica during the period of transition was planned but never obtained. References to these influences are scattered throughout the chapters. It is noteworthy that the seminal health event of the period, the WHO Alma Ata Conference on Primary Health Care in 1977, came after Costa Rica had already embarked on the path of its recommendations. The goals enunciated in 1973 were also more comprehensive than those enunciated in the UNICEF sponsored Summit for Children in 1990.
At a workshop in Costa Rica in 1991 to discuss the manuscripts for this book, Dr. Luis Asis, Director of Planning of the Costa Rica Social Security Institute, reviewed the way in which the formulation of clear government policies helped to attract and channel international assistance. He also mentioned external skepticism as to the feasibility of the Figueres government proposals. Negotiation with donors to insure programs consistent with national needs and priorities was critical as was the governments rejection of unwanted assistance.
The Interamerican Development Bank, the World Bank, and other lending agencies played a role in accord with global trends of the times. The United Nations Development Program (UNDP) provided technical support. UNICEF supplied large quantities of dried skim milk (DSM) for school feeding as well as agricultural implements and educational materials. It also furnished the medical equipment for a network of information centers. CARE provided DSM milk as well as vegetables and equipment for the nutrition centers. Donated food furnished by the World Food Program included DSM and a corn-soy blend. FAO provided agricultural extension consultant help and training. The program of mobile medical units, created in the early 1960s was financed mainly through the U.S. sponsored Alliance for Progress.
The Pan American Health Organization (PAHO) provided technical cooperation in health planning, a special information system for monitoring the progress of health and made significant investments in education and training of professionals and nonprofessionals in the health sciences and disciplines. It also cooperated in the control of acute communicable disease particularly the vectors responsible for malaria, yellow fever, and dengue and in environmental health programs with emphasis on water supplies and basic sanitation. Dr. Abraham Horwitz, the Director of PAHO, recalls that during the decade of the 1970s external resources were readily available for health programs, particularly from the Interamerican Development Bank. "Good ideas and sound projects could usually be financed and Costa Rica had plenty of them."
The 1991 workshop pointed out that the Institute of Nutrition of Central America and Panama (INCAP) was responsible for much of the definition of the national nutrition problems, nutrition policy formation, technical assistance in the iodation of salt and enrichment of sugar with vitamin A, information on dietary habits and food composition, the elimination of protein-calorie malnutrition, and the training of nutrition and health personnel at all levels. A separate list of some 26 INCAP publications relating to Costa Rica during the period appears in Appendix 2.
Costa Rica is not the only developing country to achieve health statistics rivaling those of the industrialized countries despite a low per capita income. In Latin America two other countries, Chile and Cuba, also achieved this without major economic improvement. Both deserve great credit for this, but in the case of Chile (Hakim and Solimano, 1978) it was achieved gradually over many decades. In Cuba the process occurred rapidly after the fall of Batista at the end of 1958 as the consequence of government policies but with a different ideological approach (Amador and Peña, 1991). Because the health improvements in Costa Rica were not entirely dependent on economic development, and were achieved rapidly within a democratic framework, they serve as an inspiring challenge and example to other developing countries.
It is not difficult to give reasons why most other Latin American governments experienced little improvement in the health of their people during this same period. They are the antithesis of the characteristics of Costa Rica - lack of political stability and government motivation, resources devoted to the military or diverted by corruption instead of being applied to education and health, poor educational system, badly administered and financed institutions, and when rural health posts exists, they usually lack essential supplies, medical support, and supervision.
Finally, it has been quite impossible to present all of the different perspectives on the Costa Rica experience in this volume. For this reason supplementary reading lists in both English and Spanish are appended (Appendix 2). Some of these articles give quite different insights or assign different weights to the factors responsible. It is hoped that some will be stimulated by the unusual nature of this case study to pursue the further insights represented by these additional writings.
Nevin S. Scrimshaw
References
Amador M, Peña M. 1991. "Nutrition and health issues in Cuba: Strategies for a developing country." Food Nutr Bull 13(4):311-317.
Barker DJP, ed. 1992. Fetal and infant origins of adult disease. British Medical Journal, London.
Hakim P, Solimano G.1978. Development, reform, and malnutrition in Chile. M.I.T. Press, Cambridge, MA.
PAHO. 1994. Health conditions in the Americas. Volume I. Pan American Health Organization, Washington, DC.
World
development report 1993 - Investing in health, world development
indicators. 1993. Oxford University Press, Oxford.