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Impact of the programs on the health of children living in rural areas

Much research and many reports have analyzed the health and nutrition status of the Costa Rican population during the two decades covered by this study (González-Vega, 1985; Ministerio de Salud, 1976; Sáenz, 1985b; Sandiford et al., 1991; Villegas and Ozuna, 1979). Most of them analyze the trends of national health indicators either as a whole or broken down into urban and rural categories. There are two health and nutrition indicators, however, which have been followed through the years by locality (broken down into counties and even smaller geographic units, such as districts). These indicators are infant mortality and height of children entering school. Both indicators reflect the health and nutrition situation during childhood, including the impact on the mother and child of the environment and the health services.

Infant Mortality

Toward the end of the 1960s, infant mortality in Costa Rica was greater than 70/1,000 live births. In 1970, the national average was 68.2/1,000 live births; the Huetar Atlantic Region, however, attained 110/1,000 live births (Behm and Robles, 1988). At the time, Costa Rican infant mortality did not differ considerably from that of other Central American countries (Behm and Robles, 1988; Behm and Barquero, 1990).

All health regions showed a dramatic drop in infant mortality during the 1970s. The drop was proportionally greater in those regions which had higher infant mortality figures initially (see Table 4).

Infant Mortality by Degree of Urban Density

The higher the degree of "rurality," the more unfavorable living conditions are for the population. Therefore, infant mortality is expected to be higher in rural than in urban areas. As shown in Table 5, this difference was noticeable in 1970; however, it began to disappear by the end of the 1970s.

Infant mortality rates were stable from 1980 through 1985 and then dropped further. Thus all population groups studied, and particularly those from rural areas, showed a significant decrease in infant mortality rates. The absolute difference between urban and rural infant mortality rates, therefore, tends to decrease with time. All this implies that in both absolute and relative terms, the infant mortality rates of rural areas decreased more than those of urban areas.

Causes of Death in Children Under One Year of Age

By 1986,82% of all deaths of children under 1 year of age were certified by a physician, and nearly all deaths were duly registered (Behm and Barquero, 1990). In 1970, the main cause of death in this age group was infectious disease: approximately 25% of the children died of intestinal infections and 20% of respiratory infections. Ten years later, infant mortality rates had decreased as a result of the control of diarrheal diseases (36% of the total decrease in infant mortality rates), control of acute respiratory tract infections (22%), and vaccinations to prevent other infectious diseases (9%). Perinatal causes of death also decreased during the same time, but to a lesser degree. At present, perinatal events continue to be the most frequent cause of infant mortality (see Table 6). It should be noted, however, that they decreased significantly in both rural and urban populations between 1985 and 1989.

TABLE 4. Trends in Infant Mortality by Costa Rican Health Region, 1970-1990

^a Office of the Director of Statistics and Surveys; tabulations of deaths, 1990

Source: Behm and Robles, 1988

TABLE 5. Infant Mortality in Costa Rica by Degree of Urban Density, 1970-1989

^a Includes 10 cities with more than 12,000 inhabitants

Source: Behm and Robles, 1988; Behm and Barquero, 1990

Trends in Infant Mortality Rates by Counties

In 1970, 71 out of 75 counties in the country had infant mortality rates greater than 30/1,000 live births, and some of these even had rates greater than 100/1,000. In 1981, however, only 7 out of 81 counties had infant mortality rates of more than 30/1,000, and 51 had rates of less than 20/1,000.

Infant mortality rates continued to improve in 1988. More than one-third of all counties (31 out of 81) had rates below 10/1,000, and only two had rates greater than 30/1,000 (see Table 7).

Nutritional Status of Children: Height Censuses of Children Attending First Grade

The height of seven-year-old children is an indicator that reflects the nutritional and health history of children in a population. In the early 1970s, Bengoa proposed height for age in seven-year-old children as a nutritional indicator to measure how social problems affect early childhood. Stunting at this age reveals, both the impact of nutrition, infections, and the effectiveness of health services. The first height census with national coverage was implemented in Costa Rica in 1979, as part of a national information system on nutrition. At the time, studies were being initiated in other Central American countries on stunting in seven-year-old children and its relation to other social indicators (Valverde et al., 1981). It was concluded that height at age 7 was a highly significant indicator of the social, nutritional, health, and environmental factors that have an adverse impact during the first years of life and, prevent children from developing their full growth potential.

TABLE 6. Infant Mortality Rates by Cause of Death, 1970-1989

Source: Behm and Robles, 1988; Behm and Barquero, 1990

The national height censuses included all children registered in first grade throughout the country. Altogether, five censuses of this kind have been done in Costa Rica, in 1979, 1981, 1983, 1985, and 1989.

The growth standard recommended by the World Health Organization (WHO) has been used to compare height data among countries and within a single country in different time frames. Variations between average growth and the reference standard are expressed in terms of standard deviations (Z scores) and are classified according to the following break points or risk levels:

In this analysis, all children under -2.00 SD are considered stunted.

Table 8 summarizes the height trends of Costa Rican children as perceived in the five height censuses done in the country's 81 counties (M.E.P./OCAD/SIN, 1979, 1981, 1983, 1985, 1989).

Counties with less than 5% are considered to have no public health stunting problems. Those with 21% or more stunted children entering first grade (about age 7) are considered to have high prevalences of stunting. Counties in the three intermediate categories, i.e., 6-10%, 11-15%, and 16-20%, are considered to have low, medium, and high stunting prevalence rates, respectively. In 1979, there were no counties without height deterioration, and 60 of the 81 counties had either a low or high prevalence of stunting.

TABLE 7. Infant Mortality Rates by Counties in Costa Rica, 1970-1988

Source: Sistema Nacional de Salud, 1990, p. 28

Table 8 shows that the height status improved progressively in time up to the last height census taken in 1989. As a matter of fact, in 1989 only three counties fell into the high stunting prevalence category and none had a very high prevalence of this condition; 45 had a low stunting prevalence. Without exception, all counties show a trend toward a decrease in the percentage of stunted children. Whereas in 1979 most counties had very high stunting prevalences, as time went by they moved into the no deterioration or low stunting categories. The three counties that still had a high prevalence of stunting in 1989 were highly rural counties with very dispersed populations that were predominantly Indian (Talamanca and Buenos Aires) or indigent Nicaraguan emigrants (Upala).

Conclusions

During the first half of the 1970s, the convergence of a number of factors led to the political decision to develop a health and nutrition program for rural communities. The experiences of both the Mobile Health Unit program, started in the prior decade, and the successful malaria control program were used to design and implement the Rural Health Program.

TABLE 8. Height Trends in Children Attending First Grade in Costa Rica, 1979-1989.

Height Censuses Taken in 81 Counties

^a Talamanca, Buenos Aires, and Upala counties.

^b Talamanca and León Cortés counties.

Source: Evolución de la situación nutricional pare áreas geográficas DESAF-SIN, 1990 (M.E.P./OCAD/SIN, 1979, 1981, 1983, 1985, 1989)

The Rural Health Program was conceived for dispersed rural population groups that live isolated from population centers and that are less protected by health services and other services provided by the Costa Rican government. Three or four years after its inception, the program covered more than 80% of the target population, i.e., one-third of the total Costa Rican population.

The rural health model developed incorporated several elements of the malaria control program. New staff were rapidly trained to carry out the specific tasks required by the health program in the rural areas. Functions were designed to control the principal diseases and health risk factors of the target population. An outstanding feature of the Costa Rican Rural Health Program was the home visits by the health staff. No matter how isolated a home was, it was visited three or four times a year.

Through the home visit strategy, the health staff was able to identify and modify the main environmental problems, as well as to develop an ongoing sanitary health and nutrition education process for the family. By designing specific activities, having an adequate selection of equipment and supplies, and careful programming and supervision, program staff were able to identify dearly resources needed and program costs for each health area. Because of this, the program expanded rapidly and adequate financial resources were provided.

All of the experiences obtained during three years of the Rural Health Program, together with the observation that the program had a positive impact on the health conditions of rural populations, led to the political decision to implement a similar program for deprived urban groups. The new program expanded rapidly to most populous centers as well as to provincial and county capitals. In this manner, a greater impact on the health status of the whole population was achieved.

The nutritional situation of the Costa Rican population was evaluated in the mid-1960s. At that time, a severe protein and calorie deficiency, particularly among children, was detected. Other specific nutrition problems, such as iodine, iron, vitamin A, folic acid, and fluoride deficiencies, were also identified. Most children showed some degree of stunting. The fact that diets were deficient in these key elements and that intestinal infections and parasites were highly prevalent contributed to the deterioration of the already weakened nutritional status of the population.

The first programs to deliver foodstuffs, provide food education, and promote small-scale family food production were started in the 1950s. During the mid-1970s, they were expanded rapidly to rural communities. Additionally, the iodization of common salt and the fortification of sugar with vitamin A were established at that time. The main activities of the rural and urban health programs included the control and prevention of vaccine-preventable diseases (measles, polio, whooping cough, tetanus, diphtheria, and tuberculosis) and the prevention and treatment of intestinal parasitic diseases. These activities, in conjunction with other health measures targeting high-risk population groups, contributed to a dramatic improvement in the health status of Costa Ricans, especially the youngest generations. Complementary feeding programs were extended to the most vulnerable.

Several factors, during the 1970s, unrelated to the health sphere certainly favored the extraordinary impact achieved on health indicators by the end of that decade. According to L. Rosero (1984), at least 40% of the changes observed can be explained by the primary health actions undertaken. It must also be borne in mind, however, that these dramatic changes occurred in a very short period of time after the profound health reforms were instituted.

Health and nutrition programs for rural communities and deprived urban population groups have had the political and financial support of different governments in Costa Rica during the last two decades. Recently, however, programs deteriorated progressively. In 1995 they are emerging from a severe crisis. Insufficient supplies and transportation, a shortage of supervision, and the lack of training for new personnel to replace staff or to open up new areas are some of the major constraints on the nutrition and health programs. As a result the rate of improvement in health statistics has declined, but the gains have not been reversed.

This deterioration is related to the restructuring process of the Costa Rican government, including the health sector, which began in 1990 as a result of the external debt crisis. One premise of the restructuring process is that all human health care programs should be the responsibility of and managed by the Costa Rican Social Security Institute (CCSS). In the framework of primary health care, the model encouraged by the CCSS contemplates integrated care to individuals, families, and communities, the delimitation of geographic areas with 600 to 700 families, and the establishment of basic teams for integrated health care (EBAIS). The EBAIS are made up of a general practitioner or family physician, a nurse's aide, and a primary health care assistant. In other words, the model that already existed in urban and rural communities was reinforced by the permanent presence of a physician. Approximately one thousand EBAIS are needed in Costa Rica. At present, the new model proposed by the CCSS is being successfully implemented in a number of areas. As the economic situation improves and the government's commitments to health are renewed, it is hoped that Costa Rica's health progress will continue.

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