PRIMARY HEALTH CARE AND PLANNING IN CUBA AND COSTA RICA A Thesis Presented to the Faculty of the Graduate School of Cornell University in Partial Fulfillment of the Requirements for the Degree of Doctor of Philosophy by Priscilla Rivas May 1988 FI hi £ Thesis hJA loci m i 1^ 612 © Priscilla Rivas 1988 ALL RIGHTS RESERVED PRIMARY HEALTH CARE AND PLANNING IN CUBA AND COSTA RICA Priscilla Rivas, Ph.D. Cornell University 1988 This dissertation compares the efforts of Cuba and Costa Rica to provide primary health care (PHC) through the integration of health and development planning, regionaliza­ tion of health services, and community participation. The study reports the delivery of PHC and the health planning processes through which PHC has been organized. The central questions examined are: (1) whether Cuba and Costa Rica have delivered PHC to the extent they claim? (2) what role, if any, the integration of economic and health planning, regionalization of health services, and community participation have played in the delivery of PHC? and (3) whether the delivery of PHC is dependent on health planning and, if so, what type? The purpose has been to establish the relationship between health planning and the delivery of PHC in the two Latin American countries with best health indices. Both have successfully implemented PHC, but their socioeconomic structures are different: Cuba is a socialist centrally planned economy and Costa Rica is a capitalist, market economy. The fulfillment of descriptive criteria for PHC in Cuba and Costa Rica was used to examine the central questions from a historical and institutional perspec­ tive. The data were gathered through interviews with planning officials and with the PHC unit staffs of each country. Six months were spent in Cuba, and twelve months in Costa Rica, between 1983 and 1985. More similarities than differences in the delivery of PHC and the health planning process in both settings were found. Despite the lack of formal integration of economic and health planning, the problems in establish­ ing regionalization as a process, and limited community participation, Cuba and Costa Rica have been able to successfully deliver PHC and improve health status. Many health and non-health related activities were responsi­ ble for the achievements in health status and PHC in both countries. The main conclusion is that health improve­ ment and the effective implementation of PHC can be achieved in different settings using multiple approaches if those with political power are willing to invest resources in the health sector and in the economic and social sectors relevant to health status improvement. BIOGRAPHICAL SKETCH Priscilla Rivas was born in Manhattan, New York on February 5, 1953 and attended private elementary schools in San Juan, Puerto Rico. Later she attended the University of Puerto Rico High School. Rivas received a Bachelor of Science degree in Nutrition and Dietetics from the Univer­ sity of Puerto Rico in 1975. Subsequently she completed a one-year Clinical Dietetics Internship in the San Juan Veterans Administration Hospital. As a Registered Clinical Dietitian affiliated to the American Dietetic Association she worked for two years in Veterans Administration Hospitals in Illinois. At the time, she also worked as a volunteer with Mexican migrant workers. The latter experience brought about the sudden awareness that the poor lacked adequate health services in the wealthiest nation of the world. This started a period of intense questioning about the reasons behind the unequal access inherent in the traditional delivery of health services in the United States and Latin America. A rigorous course of study that could lead to the answers pursued and possible solutions led the author to enter the International Nutrition Department at Cornell University. However, one year later a greater interest had developed in health and development planning issues in the Third World. As a result, the author entered the City & Regional Department (C&RP) at Cornell University to complete a doctorate in that field. iii The authors' interest in comparative studies in health and development led to the dissertation research topic, namely health planning and primary health care in Cuba and Costa Rica. In 1981, Rivas traveled to Cuba to do preliminary research for a period of two weeks. Prelimina­ ry research was also undertaken in Costa Rica in mid-1983 funded by a Scott Paper Company research grant. After extensive talks with Cuban officials in the Cuban Interests Section in Washington, D.C. the Cuban government granted her permission to do research in Cuba for a period of six months in 1983. The author was funded by a Cornell University Latin American Studies Grant. In 1984, she won a Fulbright Research Grant to undertake doctoral dissertation research in Costa Rica for twelve months. In 1987 the author worked in Nicaragua as a short-term nutrition planning consultant for the Pan American Health Organization. Currently she holds a post-doctoral research position in the Center for International and Comparative Studies at the University of Iowa. iv To the people of Cuba and Costa Rica May their achievements promote health and peace in the troubled Central American region v ACKNOWLEDGMENTS During the extended period of time the author has worked on this research she is indebted to many individuals and institutions who facilitated what seemed, at times, an endless task. My greatest debt, however, is to Professors John Forester and William W. Goldsmith for their friendship, guidance, enduring capacity and patience during the many days spent reading, discussing and offering valuable suggestions for improvement of this work. Their towering intellect and skillful and encouraging assistance was decisive in the determination of my research strategy and the successful completion of this study. Professors Michael Latham and Tom Davis, also committee members, provided invaluable insights and assistance concerning many research issues. Their experience with the nutritional and economic problems of the Third World allowed me to overcome many conceptual hurdles. Many individuals in Cuba and Costa Rica facilitated my research tasks. On the Cuban side, I am mostly grateful to Rene Mugica from the Cuban Interests Section in Washington, D.C.; Dr. Jose A. Pages from the Cuban Ministry of Health; Dr. Mario Escalona from the Health Research Institute; and Dr. Jorge Mugica from the Occupational Health Institute. On the Costa Rican side, I greatly appreciate the help vi provided by Diane Stanley from the U.S. Information Agency in the U.S. Embassy; Dr. Juan Jaramillo Antillon, Minister of Health, and Juan M. Villasuso, Minister of Planning. The financial support of this study was provided by the Cornell University Latin American Studies Program, the Scott Paper Company, and the Fulbright Research Program. I am inmensely grateful to these funding institutions. Finally, I thank my parents and sister all deserving my deepest gratitude and affection during the stressful moments associated with tasks of this kind, and for providing unconditional love and understanding. Most importantly, I must thank my son Jean-Karlo who had to bear with his mother's research and dissertation writing period during the crucial first three years of his life. It was a long and exciting journey, I'm glad I took it. vii TABLE OF CONTENTS Page LIST OF TABLES ...................................... xii LIST OF FIGURES ..................................... xiv LIST OF ABBREVIATIONS ............................... XV Chapter I THE IDEA OF PRIMARY HEALTH CARE ............ 1 Two Kinds of Health Planning for PHC ..... 4 The Plan and Themes of this Study ........ 9 Method of Inquiry ........................ 11 Shortcomings ............................. 15 II HISTORICAL DEVELOPMENT OF THE SOCIOECONOMIC AND HEALTH STRUCTURE IN CUBA AND COSTA RICA ... 16 CUBA ..................................... 17 Historical Evolution ................... 18 Early Efforts in Economic and Health Planning ............................... 27 Political-Administrative Structure ..... 36 Peoples Power .......................... 37 Economic Management and Planning System . 42 Improvement in the Health Sector ....... 45 viii COSTA RICA 53 Historical Evolution ................... 55 Early Efforts in Economic and Health Planning ........................ 70 Improvement in the Health Sector ....... 85 Conclusions ............................ 87 III THE PROBLEM OF EVALUATING PRIMARY HEALTH CARE 93 World Health Organization Guidelines for the Support of PHC ........................... 94 Economic Planning, Health Planning, and PHC .................................. 96 Regionalization of Health Services ....... 107 Community Participation and PHC .......... 110 The World Health Organization Approach .... 113 Descriptive Criteria for PHC ............. 115 IV DELIVERY OF PRIMARY HEALTH CARE IN CUBA .... 119 Cuba's Model ............................. 120 Community Medicine ..................... 120 The Institutional Structure ............ 128 Regionalization of Health Services ..... 135 Popular Participation .................. 141 Innovations ............................ 14 6 Achievements and Constraints ............. 147 First-Contact Care ..................... 147 Coordination of Care ................... 149 Comprehensiveness ...................... 151 ix Longitudinality ........................ 153 Conclusions .............................. 154 V DELIVERY OF PRIMARY HEALTH CARE IN COSTA RICA 155 Costa