Issue XLIII: Back the Future: Good Health at Low Cost

20 Oct

This is my article still waiting for review at the Student BMJ.  Enjoy the draft!


Back the Future:  Good Health at Low Cost

Ideas can come in and out of fashion.  Primary health care and achieving health equity is two of them that are coming back into the spotlight.  In 1978, the World Health Organization convened a meeting in the Soviet Union that lead to one of the biggest documents in the history of international health policy.  The conference unanimously issued the radical Alma Ata Declaration.  This document declared that health was a human right and that primary health care should be the cornerstone of all national health systems.  Health systems should not only address formal health care, but the underlying problems of poverty, education, housing, employment, and environment behind ill health.  Equitable access to resources and power drives a truly primary health care approach to health systems.

In 1985, the Rockefeller Foundation convened a meeting in Italy to discuss the successes of four developing states.  The conference was titled “Good Health at Low Cost” and featured China, Costa Rica, Sri Lanka, and the Indian state of Kerala.  All four had achieved good health despite low income levels and relatively modest levels of health care expenditures per capita.  Here is how two of them did it.


Kerala is a coastal state in south India which has developed dramatically differently from the rest of India.  Kerala is famous for having the highest level of human and social development in India.  Life expectancy is high, infant mortality and birth rates low, and illiteracy rare.  Furthermore, the gaps between rural and urban areas in health and education are slight while gender equality is stronger than the rest of India (Ramachandran 1996).   Kerala has a rural literacy rate of 98% with a nearly 100% school enrolment in both rural and urban areas (Sen 1996), something unheard of in the rest of India.  How did this come about?         Before Independence, two of its regions (Travancore and Cochin) were ruled by enlightened maharajahs who promoted development and education (Ramachandran 1996).  After the Republic of India redrew states based on language, the Malayalam-speaking state promptly voted the Communist Party into office in 1957.  Communist politics pushed against the caste politics that dominates India, emphasized universal social welfare provision for all, not just the dominant caste’s supporters.  Mobilization of lower caste communities promoted the focus on primary education instead of the traditional elite focus on universities seen in the rest of India (Sen 1996).  Traditions of matrilineal inheritance and missionary schools encouraged female literacy.

Political mobilization and community participation improves the quality of governance in Kerala.  In a developing country, good governance leads to real health outcomes.  Having the best public distribution of food means that government food programs actually feed people instead of being stolen by corrupt officials.  Kerala’s achievements are even more remarkable given that it has the highest unemployment in India and a lower than average per capita GDP.


Costa Rica
Costa Rica is a small Central American nation that has achieved successes not seen by many of its neighbours.  What sets it apart?
Costa Rica has a long and stable tradition of social democracy unfamiliar to a hemisphere which oscillates between neoliberalism and socialism, dictatorship and democracy.  In fact, Costa Rica abolished its military in 1948 and president-economist Óscar Arias won the 1987 Nobel Peace Prize for his peace negotiations to end the civil wars plaguing Central America.  Eliminating defence spending helped free up the budget for health and education.
Costa Rica emphasized intersectoral actions in its approach to health, recognising that health does not come from health care alone.  The government expanded primary and middle schooling in the 1940s and 1950s while strengthening its universities.  This led to a dramatic increase in women’s education (Irwin & Scali 2005).

In 1971, the government started a universal social security fund, CSSF, which guarantees hospital and medical care to all Costa Ricans.  The social security scheme is funded by mandatory worker contributions and government funding.  All workers received benefits from this fund regardless of their income.  This stands in contrast to the typical “segmented” health care systems of Latin America which typically consist of private health care for the rich, social health insurance for civil servants and/or formal sector workers, and government health systems for everyone else (which may not be available or functioning in all parts of the country).
The government then started the Rural Health Program (RHP) and the urban Community Health Program which expanded access to clean water and medical care to previously underserved areas (Morgan 1990).  Community health workers, preventive care, and environmental health (clean water, sewage, housing) were all emphasized.  By 1980, 60% of the population had access to primary health care versus less than 20% in 1971.  Between 1970 and 1983, general mortality fell 40% while infant mortality fell 70% (Irwin & Scali 2005).  It probably does not hurt that the nation has been ranked the happiest nation on Earth.

These four states had five social and historical factors in common (Irwin & Scali 2005).


  1. Historical commitment to health as a social goal
  2. Social welfare orientation to development
  3. Community participation in decision-making processes relative to health
  4. Universal coverage of health services for all social groups (equity)

Intersectoral linkages for health

These countries show that visionary thinking and institution-building can lead to attainable health equity in the poorest of countries.  This year is the 25th anniversary of Good Health at Low Cost, and five new participants have been invited: Bangladesh, Ethiopia, Kyrgyzstan, Thailand, and the Indian state of Tamil Nadu.

On the thirtieth anniversary of the Alma Ata Declaration, the international community has come to appreciate the vision of the declaration.  The proliferation of global health initiative cannot replace local people, local institutions, local traditions, and local visionaries that helped these countries achieve so much with so little.  Perhaps we in the developed world can learn from the developing world when the new book comes out next year.





  • Irwin A & Scali E (2005), ‘Action on Social Determinants of Health: Learning from Previous Experiences’, Background document for the Commission on Social Determinants of Health, Geneva: World Health Organization.
  • Morgan L M (1990), ‘International politics and primary health care in Costa Rica’, Social Science & Medicine 30 (2): 211-219.
  • Ramachandran V T (1996), ‘On Kerala’s Development Achievements’, in Dreze J & Sen A (ed) Indian Development: Selected Regional Perspectives, New Delhi: Oxford University Press.
  • Sen A (1996), ‘Radical Needs and Moderate Reforms’, in Dreze J & Sen A (ed) Indian Development: Selected Regional Perspectives, New Delhi: Oxford University Press.


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