RHP&EO is the electronic journal of the International Union for Health Promotion and Education

Go back to: Case Studies On Health Promotion Initiatives From The Nordic Countries

Case study #7: Health policy development in Costa Rica

Rationale for Initiative

As part of research project dealing with an assessment of the health policy in Costa Rica, some reflections will be shared regarding successful health promotion initiatives in this country which is more developed socially than economically. Three different examples will be given.

During the 70´s the development in the country was very different in the different cantons. Epidemiological data clearly showed inequalities in health. One example is the infant mortality rate which varied from 10 to 80 per 1000 births. Priority areas were identified based on health indicators.

During the 80´s a severe economic recession had widespread impact on the possibility for the government to maintain the services in the country. A special challenge was to reduce the burdens of the recession on the weakest and most vulnerable groups in the country.

During the 90`s the traffic intensity increased very much and the incidence of traffic accidents reached epidemic proportions.

Objectives of Initiative

During the 70´s a change took place in thinking with respect to the solution of the country's public health problems. Research had shown that malnutrition was second only to infectious disease as primary causal factor behind the high infant mortality. The approach taken was an infectious diseases paradigm which present infectious diseases, intestinal parasitosis, unwanted pregnancy, low birth weight, artificial feeding, limited health services supply and hospital based services as proximal causes for problems such as malnutrition, high morbidity, high mortality, high hospitalisation rates and low coverage of health services. The strategies were control or eradication of infectious diseases and intestinal parasitosis, family planning, promotion of breastfeeding, universal primary health care, use of appropriate technologies and legal and administrative reforms to the health sector. A group of experts and politicians developed a primary health care program based on health posts and health centres. The program aimed at increasing the access of health care and improving health conditions in the most disadvantaged parts of the country.

The national development plan 1986-1990 included the following objectives (1986-1990):

• To attain increasing level of equality of access to necessary resources for production and for distribution of wealth.
• Recuperation of the Gross Domestic Product and maintenance of a steady and elevated rate of economic growth.
• Reduction of extreme poverty and attention of basic needs for the entire population.
• To achieve a high level of social mobility, based on merit, for each and every inhabitant of the country.

During the 90´s the need for a health sector reform has been addressed. Improved quality of health services is one central objective. The integration of health services into a national health system under the social security system (Caja Costarricense de Seguro Social) is another main objective. Moreover, the Ministry of Health will have the role as rectorial, i.e. setting norms, supporting health promotion and prevention. A special objective for the Ministry of Health is to coordinate inter-sectoral activities in priority areas from a public health point of view. One such challenge is transport and traffic accidents.

Description of Initiatives

Costa Rica is a small, democratic country without any army, and the country is regarded as one of the world's success stories in primary health care. Costa Rica belongs to a group of developing countries which have succeeded in reaching difficult health targets. During the 40´s important social reforms were carried out, and the oligarchic model, inspired by the European liberalism, was replaced by a social democratic, welfare-oriented system of government. Since then, the public sector has strongly favoured social programs in areas such as education, labour, social security and health.

A Rural Health Program started 1973 in the cantons with the strongest needs. The program included training of community health workers, which visited the homes in the catchment areas to assist in improving the health development, sanitation, and vaccination of children. A similar program was later developed, targeting the more urban areas. The local health workers were successors of the previously involved anti-malaria workers.

During the economic recession of the 80´s special programs were implemented to assist the poor groups (Programa Ruta Social). The commitment to equity is an integrated part of the national policy in Costa Rica. Moreover, the emphasis on education has resulted in a high degree of literacy among both men and women. The health-related knowledge in the population also seems to be comparatively high, partly a result of the investments in health during the 70´s.

As part of the on-going health sector reform, the roles of the Ministry of Health, the Social Security System and other national actors have been outlined, and a comprehensive national health system is under development. The Ministry of Health has a leadership role with regard to public health programs. Last year an inter-sectoral committee was organised with the task of developing a comprehensive program for the prevention of traffic accidents. The first phase concerns an intensive analysis of the natural history of traffic accidents in the country. Already from the start, health education and public information is part of the activities. In march 1997 a year of prevention of accidents will be announced with the objective of increasing awareness, motivation and knowledge about safe traffic and accident prevention.

Evidence of Success

The infant mortality rate (IMR) decreased from 44.1 in1972-74, 32.8 in 1975-77 to 19.5 in 1980-82. Moreover, the proportion of cantons with an IMR less than 20 increased from 5%

in the early 70´s to 64% a decade later. An ecological analysis of determinants to the decline in IMR showed that primary care (41%), secondary care (32%) and socio-economic progress (22%) accounted for the main parts to the decline, while the contribution from fertility reduction was only 5%.

When the debt crisis hit Costa Rica in 1981-82, its impact was extraordinary high. Cut off from external finance, the public sector was forced to reduce its deficit from 8% to 2% of GDP. What is unusual about Costa Rica is its dramatic reduction in poverty during the recovery. By 1989 poverty was far less widespread than it had been in 1981, even though the per capita income was actually lower in the former year than in the latter. The key to understanding how Costa Rica´s recovery was so progressive, seems to be that it was led by agriculture, the income source of the nation's poor. The country has its poor heavily concentrated in a traded goods sector. Real devaluation and other export-promoting policies then permitted an economically justifiable increase of both wages and demand for the type of labour that could be supplied by the poor. This was further aided by the relatively equal distribution of agricultural land and by the government's decision to raise the minimum wages. These initial conditions and policy decisions helped the poor share in the benefits of the export-led recovery that took place.

During the 80´s a legislation concerning safety belts in cars was passed in the parliament. However, the law was challenged and its implementation was delayed due to appeal to the high court in the country. Initial positive impact was stalled. The new initiative has been successful with regard to participation of different members from different ministries and agencies. However, it is still too early to assess the effects of the present measures.

Evaluation

The infant mortality rate decreased more than what can be expected from economic and social development. Researchers at the INISA and INCIENSA, research institutes at the university and within the MoH respectively, and at the universities of Costa Rica have been analysing different aspects of health development in the country. Over the years several projects include international collaboration as our with is based at the Nordic School of Public Health in Göteborg, Sweden.

Reflections

The development in Costa Rica has its specific geographical, ethnical, social, political and economic context. The development of healthy policies were among the key elements which was part of the constitution that was written in the late 40´s. In many countries health and medical services became a low policy area, but in Costa Rica some of the presidents regarded health as a high policy area. During such periods windows of opportunities are available. The political will is one important precondition for appropriate policies and actions.

A second important characteristic is the knowledge-based policy development. The epidemiological information system has been of a remarkably good quality. This is reflected in the high quality of the home page (http://www.netsalud.sa.cr) on the internet. When the Rural Health Program was planned, analysis of epidemiological and other relevant data seems to have played a central role in targeting the introduction of the program. Situational analysis has been part of the approach in the three examples in this case study. Moreover, the knowledge about determinants and possible measures to the prevention of health problems has also been used. For example, the changing emphasis from malnutrition to infectious diseases control was done due to new scientific knowledge. This change took place despite the fact that a considerable amount of money was involved in the nutrition program.

A third feature of the Costa Ricean success stories is the empowerment of the people with regard to health. Health knowledge is regarded as an essential part of education at all levels. The media covers health issues in details. The activities to prevent the threatening cholera epidemic were very successful. The participation of the people in community development and political life has been comparatively high in the country. However, during the last years lots of effort has been put into developing a strategy for sustainable development in the country with regard to equity and integration, economy, natural resources, democracy and good governance, social relations and values. This combinations of key areas illustrate the broad policy options in Costa Rica.

Dissemination

Costa Rica has been presented as one of the countries with health development at low costs. Politicians and researchers have contributed to different conferences and publications. The experience of the 70´s have been presented in a recent book published in Canada. As part of the on-going research collaboration a book is under preparation presenting the development during the last 25 years.

Lessons learned

In contrast with many other countries Costa Rica shows that it is beneficial and possible to create a coalition between politicians, professionals, researchers and the people. This means that it is possible to develop an evidence-based public health, which guide policy-makers and professionals involved in health programs. Moreover, given an democratic government it is also possible to maintain a commitment to equity even in periods of economic recession and recovery. Furthermore, an individual, social, professional and political (governmental) responsibility or justice is possible to combine for the health development in a country. Visions and missions can successfully be fulfilled given that priorities are made and that knowledge and skills are put into use for the benefit of all.

References

Eriksson,C.-G. (1990). Health policy assessment. Scandinavian Journal of Social Medicine, Suppl.46.

Morley,S.A. (1995). Poverty and inequality in Latin America. Baltimore: Johns Hopkins University Press.

Munoz,C. & Scrimshaw,N.S. (red.) (1995). The nutrition and health transition of democratic Costa Rica. Boston, MA: International Fund for Developing Countries.

Go back to: Case Studies On Health Promotion Initiatives From The Nordic Countries

Copyright © 1999-2001 Reviews of Health Promotion and Education Online,
Last modified: October 07, 2000

Internet Explorer 5.0 or later version gives the optimal visual effect of this website.