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Information System

The Rural Health Program developed its own data system using the model established by the Department of Statistics of the Ministry of Health as a reference. It provides information for assessing and monitoring health activities at the local, regional, and central levels. It also generates information for community and family diagnoses, for programming of activities in health centers, villages, and health areas, for implementation of activities, and for control and assessment of results.

The health staff records all health activities that have been implemented using specific forms, such as vaccination forms to record the number and type of shots given, as well as the age group vaccinated; mother and child forms to register weight and height of children under five years of age, prenatal monitoring, and family planning; population forms to record basic demographic information such as births and deaths in the community; medical care forms to keep track of all health services provided to individuals; and daily activity forms to record health services provided for each house. Every month, the health staff transfers the data contained on the daily activity forms to the monthly report forms, which provide an overview of all health activities broken down by date, village, and type of work. The health staff sends the monthly report forms to the corresponding health center and regional office, where they are analyzed for purposes of control.

Costs and Financial Resources

During the 1970s, the income redistribution mechanism implemented by the government led to a remarkable increase of financial resources assigned to health and nutrition (Table 1). As a matter of fact, from 1970 through 1980, per capita expenditure in the health sector increased constantly from US $29.5 to US $155.0. Costa Rica's severe economic crisis during the first half of the 1980s, nevertheless, resulted in a marked curtailment of the country's health budget. In 1983, per capita expenditure had dropped to US $72.5 (Sáenz, 1985).

In 1973, the total cost of the Rural Health Program represented 0.4% of the country's health budget, reaching a 2.5% peak in 1977. Later, this figure started to decline despite rising absolute costs of Table 1. In 1982 it had fallen to 1.97% and was expected to continue dropping; no updated data are available, however, to confirm or reject this estimate.

Per capita cost of the Rural Health Program was estimated at US $2.5 at the beginning of the program. In 1975, this figure had increased to US $5.5, reaching US $9.5 in 1980 (Sáenz, 1985). Data include program outlays to acquire and install water pumps and latrines, particularly after 1976. However, direct per capita cost of the program was US $2.72 in 1973 and US $3.21 in 1982; these figures do not include wages of professional staff at the central level, drugs, laboratory materials, or construction of facilities.

Extension of Coverage

At the end of 1973 and the beginning of 1974, the Rural Health Program already had 70 working health posts covering 230,000 persons. By the end of 1975, another 70 health posts had been installed and the program was covering 437,000 persons living in 2,240 communities (see Table 2).

Beginning in 1973, the coverage of the program and the number of installed health posts increased steadily up through 1989, to cover approximately one million inhabitants with 371 functioning health posts.

TABLE 1. Total Expenditure on Health and Primary Health Care Programs in Costa Rica, 1973-1983

Source: Sáenz 1985a, pp 42-44

From 1982 to 1979, 1 US$=8.60 Costa Rican colones; in 1980, 1 US$=9.2 colones; in 1981, 1 US$=21.2 colones; in 1982, 1 US$=40.0 colones.

The Community Health Program for Urban Areas

The Community Health Program for Urban Areas started in 1976. Two years later, the Ministry of Health analyzed the health situation of the San José metropolitan area and the country's medical care system. At that time, the Ministry became aware that large underprivileged areas had emerged in conjunction with the recent Costa Rican urbanization process. Furthermore, the Ministry recognized that in the deprived areas, most families were very poor, lived in improvised dwellings, had high unemployment rates, and showed marked social pathology. Fathers were missing in many families and mothers were responsible for raising their numerous offspring. Their adult educational level was below the national average. As a result of poverty, overcrowding, and undesirable sanitary conditions, the population, especially children, had a high prevalence of infections and malnutrition. Not only the capital city, San José, but also other urban centers, particularly the ports of Limón and Puntarenas, had similar problems.

The traditional health care system was not able to cope with the situation. Health centers, accustomed only to providing health care on demand, responded inefficiently to the health needs of the communities. Additionally, the social characteristics determined that the majority of the population sought health care only when people were very sick, in other words, when the harm caused by the disease was already advanced. None of the preventive health actions, such as vaccines, prenatal control, reproductive health measures, and others, were reaching their goal. As a result of this, sanitary conditions at the home and community levels did not spontaneously improve, and the health system was not able to introduce any corrective actions in this regard.

TABLE 2. Indicators of the Costa Rican Rural Health Program

Source: Ministerio de Salud (1975), and records from the Primary Health Care Department

Faced with this dramatic health situation in San José and other urban centers, and recalling the positive experience with the rural health posts as opposed to the static role of the health centers, the Ministry of Health decided, at the end of 1974, to seek a new health care strategy for deprived urban communities.

A priority action of the 1974-1978 National Plan for Economic and Social Development was the improvement of the health status of Costa Ricans. It was considered fundamental "to close the social gap" and to improve their standard of living. The Social Development and Family Allotment Law, enacted at the end of 1974, provided the economic resources to implement health and nutrition programs in deprived urban and rural communities. Funding for this law comes from contributions paid by employers, amounting to 5% of the salaries and wages of all employees. Whereas in 1975 this fund provided 20.0 million colones (US $2.3 million) to health and nutrition programs, in 1980 it reached 154.0 million colones (US $18.0 million).

In 1974, the Ministry of Health started a health diagnosis survey using information collected from family record cards in a suburban population group of San José with 8,000 dwellings. The Ministry prepared the Community Health Program for Urban Areas during 1975. With a view to implementing it, the Ministry trained staff, established work methods, and developed standards for the program. Additionally, the Ministry of Health expanded the same diagnostic survey to other zones of the San José Greater Metropolitan Area. It also delimited health areas including 750 to 800 homes each. In 1976, 18 urban community health areas started to function, containing approximately 15,000 homes and 84,000 inhabitants.

The health program for urban communities was based on 12 principles, which deserve emphasis:

Service mystique. Program staff must be convinced of the need and importance of the program in order to dedicate themselves fully to its implementation.

Extramural work. All health actions aiming at knowing and improving the health situation of families and communities and at solving detected health problems require staff work at the home and community levels, i.e., outside the health centers.

Active involvement of the community. If a community is properly motivated, it will participate fully in the search for solutions to undetected problems. Program staff should focus the community's attention on health, social, economic, and cultural issues, always trying to profit maximally from available community resources.

Coordination. Actions should be coordinated with other health care and social welfare agencies working in the community. In this way duplication of services can be avoided and integrated solutions will be achieved at a lower cost.

Diagnostic survey and definition of health areas. A diagnosis of families and communities is necessary to ensure effective solutions to local problems. All areas chosen for the program should be surveyed before any program activity is implemented. A community health survey card should be used for this purpose. The card allows the collection of information needed to make the health diagnosis and to plan future activities at the local level.

Holistic approach. The solution to community health problems requires a holistic approach, which should take health promotion, prevention, and recuperation into account, as well as rehabilitation of physical, mental, and social damage to individuals and to the community as a whole.

Consultants in specific areas. The work done by the staff of the health centers as well as by primary health personnel must be complemented with the expertise of advisors for specific areas, such as experts on community organization and development.

Redistribution of functions. The solution to health problems in urban deprived communities requires the redistribution of health functions and activities of all the staff working at the basic intermediate level. In this context, auxiliary personnel should take care of problems of low complexity, thereby increasing the program's usefulness and coverage.

Continuous in-service education. A continuous in-service educational program for all the staff should train the human resources needed to implement the Community Health Program for Urban Areas efficiently.

Supervision. The program needs permanent supervision to see to compliance with the established standards and the achievement of its initial objectives and goals.

Evaluation. The program objectives and goals should be evaluated periodically in terms of costs, coverage, impact, quality, and performance, with a view to making the necessary adjustments.

The activities of the Community Program for Urban Areas are similar to those of the Rural Health Program, but they give priority to health and nutrition of children and women, as well as to basic sanitary and health education. During its first year, the program had as basic staff nurse's aides who had 11 months of training. At present, nurse's aides are stationed at the health centers, from which they go daily to their health areas to visit 12 to 14 homes each, for a monthly average of 200 to 225 homes per nurse's aide.

Nurse's aides organized Committees of Neighbors by obtaining the participation of other government agencies that also worked with deprived population groups. Volunteer workers, called block leaders, were identified through the Committees of Neighbors and were trained in health promotion, detection of persons with chronic illnesses, detection of pregnant women and children who were not being monitored by the health center, and environmental sanitary measures. In 1977, health volunteers received a three-month formal course, thus becoming community health assistants and acquiring the status of auxiliary institutional personnel of the Ministry of Health. Since then, they have become the program's basic staff.

In 1977, the number of homes per health area had to be decreased to 450-500 to give basic staff additional time for activities with schools and organized groups. The same year, the program was progressively expanded to other urban centers. By 1979, the program had already established 240 health areas and was covering 600,000 persons; this coverage was maintained during the 1980s.

A graduate nurse working at the health center undertook the technical and administrative supervision of the program. Usually, she was in charge of four to six community health assistants, thus establishing community health sectors for population groups of approximately 10,000. Medical directors of the health centers, with few exceptions, were not directly involved in the program's development. Nurses promoted and supervised the program from its inception and were also responsible for in-service staff training.

As in the Rural Health Program, home visits are also a priority activity of the Community Health Program for Urban Areas. In both programs, home visits are made systematically and in rotation, and have similar objectives. The reader should be aware, nevertheless, that urban and rural areas face different problems, particularly regarding social pathology (drug addiction, aggression against children and women, juvenile prostitution, and others).

Even though the Community Health Program for Urban Areas planned the construction of premises for health posts, this was not put into practice. The already existing urban health centers and the clinics built by the Costa Rican Social Security made the construction of the health posts unnecessary. Staff working the Community Health Program, including graduate nurses supervising it, have no vehicles available. They generally walk or use public transportation. In contrast to the male rural health assistants, community health assistants are predominantly female.

The following example illustrates how the Community Health Program for Urban Areas actually works:

Rita is a 23-year old community health assistant who has been working two years in the program. When she finished high school three years ago, she immediately applied for the course on community health, and received full-time training for four months. Rita comes from a working family and lives in the Los Hatillos Housing Development south of San José. At present she works in the Hatillo health center, 1 km from her home, and her work area is Aguantafilo, a deprived neighborhood located 500 m from the center. At the health center, Rita has a small desk and an outline of her work area on the wall. The layout is a detailed representation of all houses and buildings (numbered sequentially and by block), as well as higher risk sections or problem areas (indicated by different-colored pins) which require special attention, e.g., areas with chronic patients, pregnant women, malnourished children, or homes in poor condition. Rita has a file with family record cards of the 535 homes in her work area.

Every day before leaving the health center for community work, she reviews the corresponding record cards and prepares a small case with the following items: report forms, thermometers, a sphygmomanometer, referral sheets, educational material, and a small thermos bottle containing DPT, polio, and measles vaccines, as well as tetanus toxoid. She comes back to the health center at approximately 13:00, where she does work such as recording the results of her visits on the family cards, reviewing family record cards of all homes visited to verify the families' vaccination status and other social or health problems, and preparing a daily report, which includes a standard form listing all vaccinations given. Furthermore, she usually discusses with the supervising nurse, the social worker, or the basic sanitary inspector the problems identified that may require further interventions.

Rita's daily activities also include analyzing the conditions of families and homes, reviewing health cards of children and mothers, inquiring about non-monitored pregnancies or about the use of family planning methods, checking medical appointments and drugs used by chronic patients, and informing people on how to prevent home accidents. Finally, Rita is in charge of keeping in touch with community leaders and of meeting once or twice a week with the main committees of the community.

The San Ramón Hospital Without Walls Program

In 1972, the director of a 110-bed rural hospital located in the county of San Ramón decided to establish a community outreach program, which he called Hospital Without Walls (Ortiz Guier, 1974). With this term, Dr. Juan Guillermo Ortiz Guier wanted to describe an open-door hospital committed to projecting its staff, mainly physicians and nurses, to the 40,000 people living in the rural communities of the county. In the three to four years after 1972, the Hospital Without Walls Program expanded to three more counties - all of them coffee-producing counties with the lowest per capita income in Costa Rica - within the area of influence of the San Ramón Hospital. The program reached a peak coverage of approximately 80,000 people living in dispersed rural population groups, without taking into account the residents of the four county capitals. By the end of 1976, there were 44 functioning health posts.

The basic idea of the program is the establishment of health posts, each run by a nurse's aide, conveniently located in small rural communities covering 1,000 to 1,500 persons (200 to 300 homes). The nurse's aides were trained to carry out mother and child health activities, to handle emergencies and common uncomplicated diseases in adults, and to follow up chronic patients. Furthermore, they were trained to implement basic sanitary measures, as well as community organization and development activities. The health posts of the program were properly equipped to permit nurse's aides to do their work and to give medical or nursing consultations to the population once a week.

One of the strengths of the Hospital Without Walls Program was that it organized communities into development associations or health committees. These associations participated actively in constructing, equipping, and later maintaining the health posts. They were also involved in a series of activities for the well-being of the community, such as the construction and improvement of roads, bridges, and electrical networks, and agricultural and animal husbandry activities. The program fostered the organization of cooperatives in different areas of the four counties. It also contributed to integrating the representatives of the associations and committees into a federation of associations, which is represented and empowered to make decisions in the Health Council, the governing body of the Hospital Without Walls Program.

The program included a weekly medical visit to each health post by physicians of the local hospital, general practitioners, pediatricians, gynecologist-obstetricians, and internists. Most of the consultations, even for patients with complex conditions, were given at the health posts. Physicians and graduate nurses working at the health centers of the program area also participated in the medical visits to the health posts of the program. In this manner, the program structured and developed an excellent health service network which covered 100% of the population, while implementing a series of decentralization actions at the community level.

The Hospital Without Walls Program visited families living in the sphere of influence of all program health posts even though home visits were not planned in a cyclic manner. The families that were visited were those considered at high-risk because of deficient housing conditions or the presence of malnourished or low-birth-weight children, elderly family members, or patients with chronic illnesses (diabetes, hypertension, psychiatric conditions, cerebral lesions). Occasionally, nurse's aides replaced graduate nurses or even physicians on the home visits.

The program also included the training of health volunteers, who became very involved in the health process by participating in the health post activities, visiting homes, and implementing environmental sanitary measures. Graduate nurses assigned to the Director's Office for the program in San Ramón or to the health centers in the other three counties were responsible for supervising field staff.

The Hospital Without Walls Program developed importantly after its initial years until the mid-1980s, due above all, to the unquestioned leadership of its founding director for fifteen years. During this period the program achieved an important national impact. It was presented and analyzed by various groups at medical congresses and specific meetings. However, only one additional hospital, La Anexion, in Nicoya implemented a similar project. Since the first director, the program has had four more directors, none of whom were directly linked to the hospital. It also has the drawback that hospital physicians have had a limited participation in the program, and that the hospital's administration was transferred from the Ministry of Health to the Costa Rican Social Security Institute. At present, the program continues to work on community organization and the promotion of community participation. Graduate nurses and general practitioners of the health centers continue to visit the health posts. However, the strength and dynamism of the program, which were derived from its founding leader and which characterized the program for nearly 15 years, are no longer present.

The Rural Health Program of San Antonio de Nicoya

San Antonio is a district of the Nicoya County in the northern region of the country. In 1974, when a rural hospital in the capital of Nicoya County was inaugurated, two pediatricians - a recently graduated specialist and a professor of the Costa Rican School of Medicine - decided to establish a community health program in San Antonio (Becerra-Gómez et al., 1976-1977). At the time, the district had approximately 7,500 inhabitants distributed among 1,200 families living in small villages and in dispersed rural population groups. The San Antonio program emulated the San Ramón health community model and established small health posts run by trained nurse's aides in five different communities. The program stressed the importance of periodic home visits for the purpose of improving sanitary conditions of the homes and implementing some health actions for the people. Health education and mother and child activities were also considered important. Once a week, each health post was visited by a general practitioner from the hospital or by a pediatric resident who was doing two months rotation of field work as a postgraduate student at the National Children's Hospital. As in San Ramón the staff of the San Antonio program fostered the integration of health committees, community development associations, and cooperatives. The program also trained volunteers to do health work and promoted community participation with such an impetus that productive projects started to develop and the health status of the community began to improve. During its first 10 years, the San Antonio program showed a tremendous growth. Even today, it continues growing, but with less force.

This rural health initiative had an extraordinary impact on the country. On the one hand, it was the first community health program run by the Costa Rican Social Security Institute. On the other hand, it had a strong teaching component which was used by the School of Medicine of the University of Costa Rica for medical undergraduates and pediatric students doing postgraduate work. According to Dr. Guido Miranda, Medical Administration of Social Security:

We knew that difficulties would confront us in attempting to initiate changes in traditional practices responsible for environmental sanitation, that all countries, and ours is no exception, face extremely closed circles traditionally opposed to change. It was even more fascinating to the health team, in association with other necessary disciplines, to propose and receive support from the community to stimulate the flourishing of small artisans and of agricultural programs with better nutritional yields. (Becerra-Gómez et al., 1976-1977)

There is no doubt, as confirmed by different evaluations, that the San Antonio community health program led to momentous changes in the health status of the population and to improvements in the well-being of the communities. Its most significant achievement, however, was to change the attitude of some professionals in medicine who experienced this. Since then, they have played a leading role in reorienting our health system towards a family and community medicine.

Main Changes Achieved by the Rural Health and Community Health Programs

In the 1970s, the Rural Health and Community Health Programs did not change substantially. As already stated, in 1977 a health technician with a three-month training course replaced the nurse's aide taking care of urban communities, and the nurse's aide assigned to other functions in the health centers. In 1979, a political change in the country's administrative system gave the health committees an extraordinary impetus through the Ministry of Health. The government created the Community Participation Unit at the central level of the Ministry of Health and gathered financial and human resources to promote the creation and follow-up of health committees throughout the country. During the following three years, the programs promoted the establishment of health committees in all rural and community health areas and trained a considerable number of health volunteers to assist institutional staff in carrying out health activities. The programs started to undermine the population's support of DINADECO and to weaken the health involvement of the Community Development Associations. In several communities, DINADECO and the Community Development Associations started to compete against each other, creating conflicts. As of 1982, DINADECO once more became the most important government agency promoting community organization and development. At the community level, health committees usually were members of the Community Development Associations; the health staff worked with them closely.

During this decade, the staff training course was increased by 1 month and later by another month, thus reaching its present duration of five months. Educational requirements for both programs were increased from 9 to 11 years, i.e., a high school diploma in Costa Rica. The trend still persists of having more women working as urban health assistants and more men working in rural areas.

In 1979, information and data processing systems of both programs were unified. This measure permitted the standardization of data forms, information analysis, and comparative analyses.

During the 1980s, both programs underwent important changes, some of which contributed to their improvement, whereas others had questionable advantages or were simply negative.

Prior to 1984, each program implemented its own staff training course. The unification of both courses in 1984 brought advantages to teaching by increasing the availability of teaching staff and the amount of teaching materials, handbooks, and field work areas.

In 1985, a study on urban impoverishment contributed to the definition of urban operational areas. In 1986, a scoring system based on 10 social and health indicators permitted the identification of 30 priority counties from a total of 81 in the country. In the five years thereafter, UNICEF's Child Survival Project and other national and international agencies strengthened the health programs by targeting people and the environment in the 30 priority counties. The underlying strategy was "to close the existing gap" in health indicators. The Family Care Project Using the Risk Approach was implemented in 1986 by selecting 40 community health areas and 20 rural health areas. Its goal was to decrease the number of homes visited by a health assistant by classifying homes according to family risk categories: higher-risk families were visited more frequently, whereas lower-risk families were either visited once a year or excluded from the program.

Even though the project was put into operation in many urban and rural health areas, it has neither been properly followed up nor assessed. Apparently, health staff did not use the family risk classification system adequately and misinterpreted the home visit criteria.

In 1987, a ministerial decree officially integrated Rural and Community Health Programs. The 1987 decree established joint headquarters at the central level of the Ministry of Health, as well as the name primary health care program. Auxiliary personnel, working at the operational level, became primary health care assistants. The new nomenclature created some confusion in regard to the classical concept of primary health care, because it had the connotation that primary health care was equivalent to the health program implemented by auxiliary personnel. For this reason, another ministerial decree in 1989 changed the name of the program to its present one: Integrated Health Program. It includes rural and community health, nutritional and dental components, and malaria control.

Nurses took on the supervision of technical and administrative aspects of the Rural Health Program in 1989. This meant the elimination of the Field Work Supervisor, who was formerly in charge of supervising administrative activities, transporting supplies, assisting in the annual programming, and giving impetus to the program in various ways. Because there was a lack of graduate nurses, most of the supervisors appointed in 1989 depended specifically on each health center. Unfortunately, means of transportation decreased progressively: the supervision system, which had been an important element of the Rural Health Program, deteriorated to such an extent that it disappeared totally in some areas of the country.

A six-month training course was established in 1989 for primary health care assistants, which conferred the Nurse's Aide Certificate on participants. The fact that the certificate allowed them to work in health centers, hospitals, and clinics of the Social Security Institute, however, had negative consequences: a large number of staff trained in this course did not stay with the program but preferred to work for other health agencies.

The health regionalization process also had an impact on the program. As of 1988, health regions had a greater bearing on budget and program management; furthermore, the central level started to play progressively the role of a standardizing and consulting entity to the health regions. This process, unfortunately, also implied the exclusion of the regional rural health supervisor (replaced by a supervising nurse who, in most cases, was not able to fulfill this task), who had been an excellent link between Field Work Supervisors and the central level. At present, the technical team working at the central level is practically excluded from all direct actions related to the program. Team functions are concentrated on standardization aspects and ongoing educational activities.

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