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The Rural Health Program
The health program for dispersed rural communities was conceived and structured within the framework of malaria programs. In the first half of the 1970s, malaria was under control in Costa Rica. Almost all low coastal zones were classified as being in the consolidation phase. In other words, even though no malaria cases were detected in the area, ongoing epidemiological monitoring, implemented by staff specifically trained for that purpose, was required. For the first phase of the Rural Health Program, malaria staff was trained to implement other health actions. In point of fact, malaria staff received the first courses for rural health assistants. As explained later, however, only a small group of the malaria personnel who were so trained kept a specific post within the Rural Health Program.
It is important to mention that the methodological structure of the Costa Rican Rural Health Program was designed following the premises of a Malaria Control Program which had had undeniable success in the second half of the 1960s. It was known that the program had been successful because of its excellent organization and its outstanding staff discipline at all levels.
This article presents a detailed analysis of the principal methodological elements of the program, with a view to drawing some important conclusions. There is no doubt that the most important components for the success of the Costa Rican Rural Health Program were, on the one hand, that it was implemented at the right time and in the right place (within a given geographic area), and on the other hand, that it was implemented in a disciplined manner over a long period of time. The conceptual methodological bases established during the first years of the program are still observed today. Nevertheless, starting in the 1980s, the program had to face a severe crisis, which has worsened since then.
Objectives of the Rural Health Program
The Rural Health Program established a series of objectives to be achieved between 1973 and 1980. The objectives aimed mainly at increasing health coverage and health conditions (morbidity, mortality), particularly among mothers and children. The program also established goals regarding the development of the physical and managerial infrastructure of the program itself, which were needed to achieve future changes in the population profile. Both the health care model and the health involvement of various social and economic community sectors prior to 1973 were once more taken into consideration with a view to providing integrated solutions to problems of the community.
Objectives Presented in 1973 Regarding Health Coverage (Ministerio de Salud, 1973b):
• To provide integrated health services to rural population groups living in communities with fewer than 2,000 inhabitants, in two stages:
First Stage. 1973-1977: To cover 80% of the dispersed rural population groups (villages of fewer than 500 inhabitants), to reach 550,000 persons living in 3,300 communities.
Second Stage. 1978-1980: To cover the other 20% of the dispersed rural population groups and the concentrated rural groups living in villages ranging from 500 to 2,000 inhabitants (580,000 additional inhabitants in 988 communities).
• To vaccinate 80% of all children between 9 months and 4 years of age against measles.
• To vaccinate 80% of all children between 2 months and 6 years of age with DPT (diphtheria, pertussis, and tetanus) vaccine.
• To vaccinate 80% of all children between 2 months and 6 years of age against poliomyelitis.
• To vaccinate 80% of all children between 7 months and 14 years of age with DT (diphtheria and tetanus) vaccine.
• To vaccinate 80% of all persons over 14 years of age against tetanus.
• To keep an adequate epidemiological surveillance system of malaria (10% of blood samples).
• To monitor 80% of all pregnant women.
• To monitor 80% of all children under 5 years of age.
• To promote institutional deliveries, striving for a coverage of more than 60%.
• To promote responsible parenthood, striving for a 20% coverage of women 15 to 44 years of age, offering appropriate family planning methods.
• To increase connections of piped water into homes to 80% in concentrated rural population groups and to 50% in dispersed rural population groups.
• To provide 80% of the population with latrines.
Objectives Presented in 1973 Regarding Health Status Changes in Costa Rica
• To increase the 1980 life expectancy at birth to 71 years (i.e., a 6-year increase over 1971, when life expectancy was 65.4 years).
• To decrease deaths among the general population, reducing mortality rates by 20% (for a mortality rate of 5.3/1,000 inhabitants by 1980).
• To decrease the infant mortality rate by 35% (±5%), reaching an infant mortality rate of 36.9 to 43.5/1,000 live births by 1980.
• To decrease mortality rates in children 1 to 4 years of age by 55% (±5%), to attain a child mortality rate of 1.8 to 2.2/1,000 children 1 to 4 years of age by 1980.
• To decrease proportional mortality of children under 5 years of age by 35%, to attain figures ranging from 34.5% to 28.6% by 1980.
• To decrease maternal mortality rate by 25% (±5%), achieving a maternal mortality rate of 0.66 to 0.76/1,000 live births by 1980.
• To keep malaria incidence levels below 0.1/1,000 inhabitants.
• To decrease the incidence of diphtheria by 80% to obtain incidence rates below 0.66/100,000 inhabitants by 1980.
• To decrease the incidence of poliomyelitis by 100%, thus eradicating polio by 1980.
• To decrease the incidence of pertussis by 80%, to obtain incidence rates below 14.2/100,000 inhabitants by 1980.
• To decrease the incidence of measles by 80%, to obtain incidence rates below 53.1/100,000 inhabitants by 1980.
• To decrease mortality rates for acute diarrheal diseases by 50%, to attain rates below 35.1/100,000 inhabitants by 1980.
• To eradicate tetanus neonatorum by 1980.
• To decrease measles mortality rate to less than 53.1/100,000 inhabitants by 1980.
• To eradicate tuberculous meningitis in children and young adults under 15 years of age by 1980.
Activities Rural Health Program
All activities of the Rural Health Program were based on the analysis of health problems and their conditioning factors affecting the rural population. Program activities were implemented by auxiliary health personnel who were either rural health assistants (with a four-month training course) or nurse's aides (with an 11-month training course). From the beginning, program staff recognized the need to establish a minimum activity "package." The package then became the basis for establishing the logistics of four fundamental program aspects: staff training, supervision, adaptation of equipment and supplies, and design of an information system. Bearing these aspects in mind, training modules, as well as equipment and supply modules, were established for each health post.
The following activities were implemented (Ministerio de Salud, 1973b):
Prevention and control of communicable diseases: malaria, intestinal parasites, tuberculosis, and immunopreventable diseases (measles, tetanus, pertussis, diphtheria, tuberculosis, and poliomyelitis) through the application of measles and polio vaccines, as well as DPT and BCG (bacillus Calmette-Guérin) vaccines.
Mother and child health activities: stressing detection and monitoring of pregnant women, promotion of institutional deliveries, family planning (provision of barrier methods), and periodic monitoring of children under six years of age.
Treatment of common diseases (diarrhea, respiratory infections, and skin infections) and first aid for accidents: The staff was trained in these subjects and was provided with the necessary equipment to identify common health problems in children and adults. The staff was also trained to refer patients needing medical consultation to the nearest health post or Center and to refer special cases to the corresponding hospital.
Rural health personnel were also involved in the discovery of traditional midwives, who were then referred to health centers for periodic training.
Environmental sanitation: mainly oriented towards the promotion and use of latrines, sanitary garbage disposal, sanitation of dwellings and their surroundings, and provision of information on the correct use of available water. In some areas, rural health staff also promoted the use of water pumps for schools and community groups, which they also supplied to the people.
Health education and promotion of community organization: educational activities on health topics, organization of community groups, implementation of an information system, and development of physical infrastructure for the program. A health post, a health committee, or an association for the development of the community had to be established in each health area.
Health Areas
The health area is a functional working unit with an average area of 150 km². It contains 12 to 16 villages or small population centers, 600 to 650 dwellings, and approximately 3,000 persons. Each health area has a health post located in a specifically chosen village, frequently the district capital. The selection of the village takes into account the road network to neighboring communities within the same health area with a view to facilitating users' access to the health post, on the one side, and to facilitating health staff's access to the village dwellings, on the other. The operating range of the health post, considering the distance to the most remote houses, usually does not exceed 10 km.
Health Posts
In several cases, health posts were actually community houses provided by the population, equipped to take care of the basic health needs of the area. In the first phase of the Rural Health Program, prefabricated modular health posts were installed in a period of two weeks. They were wooden structures (55 m² in area) with cement floors and zinc sheeting roofs. In some villages, larger facilities made of cement blocks were built for use simultaneously as Education and Nutrition Centers (CENs). The CENs, discussed later, are part of the nutrition program Network of the Ministry of Health.
Each health post was provided with basic furniture and modular medical equipment. Generally, the community made the furniture or paid for it, while UNICEF donated the medical equipment. The Rural Health Program also prepared a list of 20 basic drugs to be used by nurse's aides and rural health assistants. To store vaccines, all health posts were equipped with an electric refrigerator in villages with electricity or a kerosene refrigerator in villages without electricity.
Health Staff
A nurse's aide and a rural health assistant (now called a primary health care assistant) are in charge of the health areas. Nurse's aides spend most of their time visiting houses in the village and the communities within 1 to 2 km from the health post. To deliver medical care to individual persons, the nurse's aide works half a day three times a week and a physician visits the post once or twice a month.
The primary health care assistants are in charge of all other villages not visited by the nurse's aide. They work five days a week visiting all houses in rotation. On Saturdays, the primary health care assistant stays at the health post and, together with the nurse's aide, provides medical care to individuals and prepares reports.
Nurse's aides have a basic 11-month training course that qualify them to work in hospitals or health centers under the supervision of a graduate nurse. To work in a health post, the nurse's aide requires four more weeks of training that stresses environmental sanitation, drug use, and local programming. At the beginning of the Rural Health Program, all persons applying for the training course for nurse's aides were required to have nine years of schooling; this requirement was later modified to a high-school diploma (11 years of schooling in Costa Rica).
The first rural health assistants were malaria workers, most of whom had ample field experience in the Malaria Control Program. The staff of the Rural Health Program assumed that it was feasible to hold four-month training courses for malaria workers, at the end of which they would be able to implement the program's activities satisfactorily. Unfortunately, this assumption did not prove to be correct. The limited basic education of the malaria workers, most of whom had not finished primary school, was identified as a limiting factor; in four months they were not able to learn all the information and skills required by the Rural Health Program. Therefore, after the first courses, only malaria workers with nine years of schooling were accepted as candidates for the training. Three years later, only high school graduates were considered.
Staff at this level came from rural areas, although not necessarily from the county or village in which they were working. Some did not want to go back to their places of origin because they feared that their own people would not accept their advice, quoting the saying that no one is a prophet in his own country. Although some women were trained as rural health assistants, they resigned because they felt that they could not fulfill the post's functions. As a matter of fact, rural health assistants have to take isolated roads or mountain paths and travel on foot, horseback, motorcycle, or boat. They also have to perform strenuous physical work carrying medical equipment and a thermos flask for vaccines.
All rural communities accepted the home visits made by male rural health assistants, as well as nurse's aides (generally women), and rapidly trusted them. The rural staff is characterized by its work mystique, its involvement in community organizations and groups, and its desire to help people, all of which are factors that allowed rural health assistants and nurse's aides to identify completely with rural communities in Costa Rica. Throughout the years, rural health staff have been respected the people and are known to respect the religious, political, and cultural beliefs of the communities. Thus, few conflicts between health staff and the population have required the intervention of health supervisors or transfers.
Education and Training
As indicated, the first rural health assistants were chosen among malaria workers. During the initial phases, as the Rural Health Program did not have any staff selection criteria (i.e., neither admission requirements nor passing of specific aptitude tests), the groups we requite heterogeneous and difficult to train. The program also lacked adequate teaching facilities and experienced teachers to develop the skills of the future rural health assistants. The first courses lasted only three months. In 1974, they were expanded to four months and included selection criteria, of which two of the most important were the applicant's age (between 18 and 3 5 years) and nine years of schooling (later increased to 11 years).
In 1977, personality traits were incorporated into the selection criteria. In 1984, courses were increased to five months and a single training course for rural and urban health assistants was implemented The same year, the Nursing School of the University of Costa Rica recognized the courses as part of their own Teaching Extension Programs (Garro et al., 1989) and gave them university credits.
Thirty courses (with an average of 30 students per course) were given from 1971 to 1991 for a total of 915 graduates. At present, 550 of those who attended the courses are still working for the health program.
Since the beginning of the program, graduate nurses and program officers, working at the central level of the Ministry of Health, coordinated and gave the courses. Physicians, nutritionists, and social workers were also invited to participate in the courses, but to a lesser extent. The teaching staff generally had field experience in the program, particularly as supervisors.
All students who pass the course receive a certificate and are recognized as rural health assistants. The course certificate provides them with the possibility of working for the Ministry of Health. When they finish the course, they are committed to work in the Rural Health Program for three years. The training of the nurse's aides includes an 11-month Basic Course for Nurse's Aides taught by the Ministry of Health. They also receive a four-week public health course which includes in-service training at a rural health post. Annually, rural health assistants and nurse's aides - under the coordination of the health region - receive refresher courses and meet in small groups for learning purposes.
Through the years, the staff of the Rural Health Program has modified and adapted the training curriculum of health assistants to the changing health conditions of the population. Costa Rica is a small and relatively homogeneous country as regards its health problems and cultural traits. Two markedly different population groups, however, live in well-defined geographic areas: the African-Caribbean community on the Atlantic coast, and the Indian community in dispersed mountain villages with rudimentary means of communication.
The Indian community of Costa Rica consists of approximately 20,000 persons who speak four different Indian languages. About half of them have some knowledge of Spanish. It has been quite difficult to provide them with any government health care. Some health posts have been established, but Indian houses are geographically so dispersed that very little has been accomplished.
Health staff for the Indian community is chosen on the basis of its Indian origin. They almost always have less schooling than the staff working in other parts of the country, because the Indians usually have low education levels: once more, their geographic dispersion is an obstacle to the work of the school system.
The Rural Health Program is constantly developing specific handbooks and brochures for learning purposes and/or to be used as visual teaching aids. The standards and procedures of all teaching materials are subject to periodic updates. In 1989, a team of nurses on the teaching staff of the program edited the book Técnicas Básicas para la Atención Domiciliaria (Basic Techniques for Health Care at Home), which summarizes the subjects to be learned by primary health care assistants (Garro et al., 1989).
Local Programming
The starting point of all health activities in each health area is a diagnosis that is made by the staff of the health post on the basis of a family survey and specific sets of data collected for each community. The health staff then records the family survey data on a printed family record card that summarizes basic information on family members and characteristics of their home.
During the survey, the health staff numbers houses sequentially by village. Later, they record the house number on the family record card, which is then filed at the health post. The same process is carried out in the 12 to 16 communities of each health area. Family record cards are used by the rural health assistant or the nurse's aide whenever a person comes to the health post seeking medical care. Since all family groups know their own house number, it is relatively easy to find their card.
The health post staff also keeps a village record card, which covers the following information for each community: presence (or absence) of schools and community centers, all kinds of construction, organizations, businesses, public transportation, etc. With this information, the health staff prepares a map showing all access roads, numbered houses, and specific geographic landmarks, such as rivers and creeks. The health staff then hangs the map on a suitable wall at the health post and uses it as a constant reference to determine the health post's sphere of action, to locate families, to determine distances between communities and houses, and to locate families at risk or persons with chronic diseases who require medical follow-up (identification with different-colored pins).
The health staff analyzes all information collected and makes a diagnosis which is used to prepare the health post's annual program. For example, by combining village and family record cards, the health staff may determine that in a given village, 20 families are lacking latrines or that a specific group of children under six years of age has not completed its vaccination program. To give another example, if the health staff knows that the health area covered by it has 3,000 inhabitants and a birth rate of 33/1,000, it may calculate that approximately 100 births are expected per year; in practical terms this means that the health post will have to order polio, DPT, and measles vaccines for 100 children.
Community health diagnoses are updated annually with information collected during the last home visit. This information is also used to program the activities of the health post for the coming year.
As already described, one of the most outstanding characteristics of the Rural Health Program in Costa Rica is the house-to-house visits made by its health staff. Programming of the visits is therefore crucial. Both rural health assistants and nurse's aides plan between 8 and 12 home visits per working day, depending on the geographic dispersion or concentration of the houses. The numbering of the dwellings permits the staff to program a specific number of home visits per day, to keep track of all houses visited (using six-month forms), and to set up a work calendar that ensures an efficient system for home visits.
In conjunction with health area personnel, the field supervisors set up the local programming according to the coverage guidelines, goals, concentration standards, types of service, and other elements established in the Guidelines for Programming. The plan of activities enables the identification of the different activities to be implemented by each village.
Supervision
The supervision of all activities undertaken by the health staff is an important element of the Rural Health Program. Supervision ensures work quality, continuity of actions, and the possibility of introducing any necessary adjustments.
Two modalities of supervision were established: operational/managerial and technical supervision. A field supervisor takes care of the former, while graduate nurses or physicians take care of the latter.
The operational/managerial modality is in the hands of an auxiliary health staff member who, in recognition of his or her capacity and interest in the work, has been promoted to Sectoral Director, later called Field Supervisor. Each Field Supervisor is in charge of five to seven health areas and visits each of them every four or five weeks according to an itinerary. They have appropriate transportation at their disposal, generally a four-wheel-drive jeep, and all necessary logistic support to facilitate their field work.
The Field Supervisors are the principal links between auxiliary health staff and health centers and are in charge of a whole range of activities. They see to it that all health posts are supplied in a timely manner with drugs, forms, and basic equipment. They participate in data analyses and in the preparation of the local programming. They also indirectly supervise communities and family groups visited by the local health staff and are included in their itinerary. They are responsible for granting leaves of absence (for illness or other causes) and applying minor sanctions to their subordinates, looking after transportation equipment, transporting supplies, and analyzing reports. Once a month, the Field Supervisor drives the graduate nurse in charge of the technical supervision and the physician in charge of selected medical consultations to the rural health centers. Finally, the Field Supervisors coordinate health actions with other institutions working in the geographic area under their command.
The technical supervision is assigned to nurses or physicians, who visit health posts periodically. This supervision is oriented toward ensuring quality in the health services provided to the population. Physicians and nurses of the central level are assisted in this task by staff working in health regions or health centers.
To do their work, operational/managerial and technical supervisors are specifically trained in courses or meetings held for each health region, which use a simple supervision guideline developed by the Rural Health Program. They maintain a close relation with all staff members working in health centers, which rank above health posts. Their goal is to keep the medical and nursing team informed of its compliance with their health work and of the problems arising from it, with a view to implementing immediate solutions. Personnel of health centers in conjunction with Field Supervisors usually execute the technical supervision, using the means of transportation of the Field Supervisors.
Transportation
The staff of the Costa Rican Rural Health Program is characterized by its constant mobility. One of its principles is that no matter how distant or isolated a house may be, it must be visited periodically. The program has provided each health area with transportation suitable to its geographic conditions and means of access, such as horses, motorcycles, bicycles, or motorboats. Supervisors also have jeeps. A preventive maintenance and support system ensures good functioning of the vehicles and gives orientation periodically to field staff on how to take care and profit most from the available means of transportation.
Supplies
Basic equipment and materials are assigned to each work area. For this purpose, different supply modules are prepared containing clinical equipment, drugs, office supplies, clothing, and staff equipment. A quarterly module specifies clinical equipment, drugs, and office supplies. Finally, a specific annual module contains a shipment of clinical equipment, drugs, and forms.
The Rural Health Program uses these modules to program the opening of health posts and equip them fully according to annual schedules, to ensure future health post supplies by registering the number of health areas that are to operate in the coming years, and to adapt and update the allotment of future equipment and supplies according to the situation of each area and the activities to be implemented there. The field health staff is responsible for verifying all allotted equipment and materials upon reception, for giving proper maintenance, and for making good use of them.
Community Participation Organization
Since its very beginning, community participation has been an essential element of the Rural Health Program. The health staff discusses the results of village and family surveys with community representatives, who then commit themselves and the community to participate in the implementation of the program.
At the beginning of 1970, the Costa Rican government fully endorsed popular organizations for the integrated development of urban and rural communities (Villegas, 1978). Governmental support was channeled through the National Director's Office for Communal Development (DINADECO), an agency of the Ministry of the Interior. DINADECO engages promoters to organize communities, to make them aware of their social and developmental problems, and to prompt them into action. The rural health staff coordinates these actions with DINADECO's promoters, with the goal of creating Community Development Committees which, through an organizational maturation process, become Associations for Integrated Development (ADIs). ADIs are made up of at least 100 citizens of both sexes, from one or more communities, linked by common problems, geographic closeness, or political and administrative territorial unity.
In the 1970s, the ADIs obtained legal status and gained partial access to the 1.25% of the income tax allotted to communal programs. At the same time, they had easier access to loans from the National Banking System, so that they received donations in a more expeditious manner and the management of their own activities was facilitated. One or two Development Committees, which progressively evolved into Development Associations, were established in each health area. By the end of the 1970s, Costa Rica had approximately one thousand Development Committees or Associations.
Communities organized in this fashion became involved in the Rural Health Program in analyzing the results of the initial diagnosis, donating sites for health facilities, constructing health posts, and providing furniture for the health post, fuel for refrigerators, forage for horses, and other supplies necessary for the development of the program.
Communities and field health personnel at periodic meetings analyzed the progress of the program and the community participation in communal activities, such as the construction of small aqueducts, latrines, wells, and other infrastructure.
To keep the community better informed of its development situation and more involved in the health program, the Rural Health Program designed one-week training courses for community leaders in each health area.
Home Visits
Systematic and planned home visits seem to be the only alternative to make home environments sanitary and to develop disease prevention and health promotion activities among dispersed rural populations and underprivileged urban groups. Since individual housing facilities are considered the first level of service in the primary health care strategy, sanitary actions are undertaken here first. Home visits are important for the following reasons:
• The observation of home and family conditions makes it possible to determine changes to be achieved to improve the home, to prevent or detect diseases early, and to induce healthier attitudes and behavior among the population.
• The educational level and the cultural conditions of these population groups do not permit the people to recognize the importance of the preventive and curative health actions implemented by staff of the health center (vaccinations, pregnancy monitoring, growth and development monitoring in children, etc.). This explains why a many families go to health centers only during advanced stages of a disease.
• Frequently, it takes one or more hours, using poor transportation, to get to the health center. It is more logical, therefore, to have a single healthy person (i.e., the rural health worker) visit the homes of neighboring villages instead of having sick persons, pregnant women, and children go all the way to the health center.
• Home visits permit the detection and proper follow-up of patients with chronic diseases.
• The information obtained from home visits and family surveys may be helpful in designing other development programs and in orienting and supporting operational research studies.
• Home visits may promote health self-care among the people. Further more, home visits may foster the transfer of appropriate technology which allows an active family involvement in health preservation and caring for the ill who require prolonged health care.
The home visit is the key activity of the nurse's aides and rural health assistants working in the Rural Health Program. Even though program staff is aware that volunteers may also be proficient in this task, in Costa Rica only health personnel perform it.
Each health area includes a group of villages or neighborhoods with target groups for which it is responsible. Houses are numbered sequentially either by quadrants or by streets. The number so assigned is painted with a black marker in a visible place at the entrance of the house; an arrow indicates the direction taken by the numbering.
A small card recording the visit is placed inside the house door. It contains the date and name of the health staff member making the visit. The house number is also used for the family record card, which is filed in the health post. Home visits generally last 30 to 45 minutes and are made every two or three months, depending on the time available to the rural health staff.
Actions to Be Undertaken During the Home Visit
Health workers undertake a series of actions during home visits for the purpose of studying the people and their surroundings. They follow a scheme of observation that covers the most important problems of the population group surveyed. Home visits permit the identification of health risks and the design of specific priority activities for each family group. Each home and each family group has special characteristics. In this context, however, the task of the health worker is to identify and stress any special home or family situation that is likely to be improved.
Depending on the resources available and the development stage of the program, home visits may include more complex activities, such as taking the blood pressure of pregnant women and adults, the determination of urine glucose in diabetics, and visual acuity tests.
In a survey done in a specific geographic area in 1988 (Ministerio de Salud, 1976), 77% of the landless and 72% of the landholding peasants considered the home visit of the Rural Health Program very important. Only 2% and 3%, respectively, did not consider it of any importance. Regarding the quality of the home visit, 72% of the landless and 74% of the landholding peasants considered it good. Twenty-five percent and 21%, respectively, considered it fair and 3% and 5%, respectively, considered it poor.