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The progress achieved in improving the health status of Costa Ricans has generated trends and patterns that make it possible to predict and analyze future developments. It is thus possible to identify probable scenarios and to design strategies for improving them. It is also possible to evaluate opportunities for changes thee will produce better health policies on modifications of situations that effect the socioeconomic development of the country. In addition, problems can be identified that are hidden in a current analysis but that may arise in the future in order to determine where to concentrate future resources to obtain the greatest impact in combatting specific health problems. Confronted with the acceleration of the epidemiological transition that began in the 1970s, this type of analysis needs to pay special attention to the evolution of emerging pathologies and to the most vulnerable subgroups.
The following sections summarize some important aspects of the health situation that is likely to develop in Costa Rica during the last decade of this century, assuming thee no significant events modify the trends observed up to 1989. Since the epidemiological transition does not develop at the same rate in all the regions of the country, the analysis will be based on the comparison of three populations: the national average, the vulnerable counties, and the less vulnerable counties. The latter are further subdivided based on geographic, cultural, and economic characteristics.
Trends at the National and County Level
Among all age groups, mortality rates are expected to decline throughout the decade. With the exception of overall mortality and perinatal and neonatal mortality, mortality rates in the vulnerable counties are likely to exceed the national and less vulnerable county average.
At the national level, deaths attributed to communicable diseases are likely to continue to decrease, and deaths due to accidents and chronic degenerative diseases are likely to increase.
With the exception of acute respiratory infections (ARI), mortality caused by communicable diseases will decline more in the vulnerable counties than in the less vulnerable groups and the country as a whole. Deaths attributed to chronic degenerative diseases and accidental and violent deaths are likely to increase in all three populations. Although at the moment the rates are lower in the most vulnerable counties, current trends suggest thee this pattern might reverse in the near future.
Mortality in Some Age Groups
The finding that mortality rates in some of the counties, that did not receive priority attention in the 1970s, are now higher than the national average is the reverse of the situation in the 1970s and of what is seen for the vulnerable age groups. This may be due to aging of the population as a result of lower mortality among youth and to an increase in chronic degenerative diseases that have replaced nutritional, infectious, and parasitic disorders as causes of death in adults. Nevertheless, these patterns vary in different areas. Even though in two areas the actual rates are below the national average, the current ascending trend will lead to rates that are above the national average by mid-decade.
On the other hand, it is expected that infant and postneonatal, neonatal, and perinatal mortality will continue to decline. Whereas infant and postneonatal mortality rates are highest in the vulnerable counties, neonatal and perinatal mortality rates are highest in the less vulnerable counties. In ocher words, they are shifting from a developing country pattern of high infant mortality dominated by infections to a low infant mortality dominated by neonatal and congenital disorders characteristic of industrialized countries.
Mortality among children one to four years of age is highest in the vulnerable counties and is likely to continue to decline at a moderate rate in all of them.
Mortality Caused by Infectious and Parasitic Diseases
Mortality associated with diarrheal diseases is highest the vulnerable counties and is likely to continue to decline at the national level. In 1989, mortality associated with ARI was slightly higher in the less vulnerable counties, where it is likely to decline more rapidly than in the vulnerable counties. Mortality rates associated with ocher infectious and parasitic diseases will vary in different areas, and the rate of decline is likely to be similar in vulnerable and less vulnerable counties.
Gastric Cancer
Mortality associated with gastric, cervical, and breast cancer is likely to show moderate increases at the national level. The increase in prostate cancer is likely to be higher. The rates of cervical and prostate cancer are higher in the vulnerable than in the less vulnerable counties. Gastric and breast cancer rates are lower in the vulnerable than in the less vulnerable counties, but current trends suggest that the vulnerable counties will soon have rates above the current national average.
Mortality Associated with Other Emerging Diseases
Although the proportion of total mortality due to ischemic heart disease and cerebrovascular disease is expected to increase, absolute rates are likely to show a modest decline at the national level. In the less vulnerable counties the rates are high but will decrease while in the more vulnerable ones they will increase.
Hypertension and diabetes mellitus-associated mortality is likely to increase substantially in both the less vulnerable and the vulnerable counties, with higher rates in the latter. Mortality caused by accidents, injuries, and poisoning shows an increasing trend in the three populations that are being analyzed.
Epidemiological Profiles in 1989 and 2000
Based on 1989 mortality trends, it is expected that ischemic heart disease, accidents and violence, cerebrovascular diseases, and gastric cancer will be the leading causes of mortality for the remainder of the century. It is also expected that deaths attributed to cardiovascular and cerebrovascular diseases will decrease slightly and those related to accidents and violence will show a moderate increase. Current trends also suggest that infectious and parasitic diseases will continue to decrease and eventually will be displaced from fifth place by diabetes in the ranking of causes of mortality.
In the less vulnerable counties, four leading causes of mortality in 1989 were the same as chose at the national level. The fifth place in these counties was occupied by diabetes. If current trends are sustained, this pattern will remain unmodified for the rest of the century. Whereas the rates of cerebrovascular and ischemic heart disease will show a moderate decrease, the rates associated with the other chronic diseases will increase.
In the
vulnerable counties, the five leading causes of death in 1989
were accidents and violence, ischemic heart disease,
cerebrovascular diseases, infectious and parasitic diseases, and
gastric cancer. If current trends are sustained, by the year 2000
the first two causes of death will trade places, cerebrovascular
diseases will move from third to fourth place, gastric cancer
from fifth to third place, and breast cancer from twelfth to
fifth place. The burden of infectious and parasitic diseases on
mortality will decline.
The study of the evolution of the Health situation in Costa Rica shows that when the Health sector takes appropriate actions that are supported by an institutional response of government, Health indicators can improve beyond expectations, based on national economic growth, and in shore periods of time, as occurred in the 1970s. This analysis also allows for an appreciation of the heterogeneity in improvement of different Health indicators and causes of mortality among different age groups as a result of the actions taken by the country. It also shows how the economic crisis that began in 1980 affected the Health situation. The mechanisms underlying the impact of the crisis were related not only to changes in those factors that directly affect health outcomes, but also to a reduction in available government resources for Health investment.
Given these faces, even though there is no doubt that economic development affects health outcomes at the national level, these analyses show thee even limited economic resources can be invested wisely in Health improvement when the political will exists. If this investment is done in a rational and equitable fashion, the outcome will be health improvements that go beyond predictions based simply on economic growth (Sáenz, 1989).
These
analyses show that Health improvements can occur as a result of
political decisions regarding budgetary allocations even when
these are scarce. This finding discredits the premise thee
economic development is an essential factor without which it is
impossible to improve the Health of a nation and indicates that
poor nations have the ability to achieve health for all if they
have the political will and devote enough well planned efforts to
achieve this goal.
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Rosero L. 1985. "Determinantes del descenso de la mortalidad infantil en Costa Rica. " In: Demografía y epidemiología en Costa Rica. Asociación Demográfica Costarricense, March 1985, p. 18.
Sáenz, L. 1983. Hacia un sistema nacional de salud en Costa Rica. San José, Costa Rica, Ministerio de Salud, February 1983, pp. 15-17.
Sáenz, L. 1985a. Salud sin riqueza. El cave de Costa Rica. Ministerio de Salud de Costa Rica, p. 45.
Sáenz, L. 1985b. "Health changes during a decade. The Costa Rican Case. " In: "Good health at low cost." Proceedings of a conference held at the Bellagio Conference Center, Bellagio, Italy, April 29-May 3, 1985, p. 142.
Sáenz, L. 1988. "Administración de servicios de salud." Editorial UNED. San José, Costa Rica, p. 91.
Sáenz, L. 1989. Logros de una política e impacto de una crisis en la salud de un País. Ministerio de Salud, Costa Rica, 1989. pp. 20-21.
Sáenz, L. 1990. "Mortalidad y programas de salud (La experiencia de un país de la Subregión)." In: La mortalidad infantil en Honduras. La Facultad de Ciencias Económicas, Tegucigalpa, Honduras, 1990, p. 70.
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