local Health knowledge and universal primary health care: A behavioral case from Costa Rica

This paper describes a group of rural people living in 2 communities in the Atlantic lowlands of Costa Rica and the health options available to them namely health posts clinics and hospital services private physicians and the traditional health system (bush medicine). The health posts are part of a comprehensive rural health program initiated by the Ministry of Health to offer basic health services to communities. The major barriers to the functioning of the PHC program are administrative: poor transportation scheduling and lack of personnel. People said their reason for not using the health posts is lack of confidence in their reliability. The peoples perspective about the solution to the problems of the health care system demonstrates some understanding of their own problems. The most frequently suggested change in the system is to have a permanent physician in the communities followed by the suggestion to have a permanent nurse and more medicines at the health post. All their suggestions involve the health post the most underutilized health resource in the community. Other suggestions involve the community level and the overall health delivery system and general improvement of living especially economic conditions. Health seeking strategies demonstrate a utilization patterns are: perceived seriousness of the illness; cost of services and methods of payment; perceived efficacy of the provider and treatment; accessibility and transportation. Consultations with family and friends praying and using bush medicines were reported for almost all illness episodes. The people of the 2 communities are active participants in their health care and in the health care system. The majority assume that there are limited health resources and that they must utilize all the alternatives. Preventive medicine is practiced by most of the people by keeping the body in balance through proper use of diet drinking bush teas avoiding certain behaviors and/or situations and using doctors medicines. The major factors that motivate their health seeking behavior are based on a combination of bush and Western knowledge in a pragmatic framework. There is a negotiation process between bush and scientific medicine in the cognitive processes of the people. A participatory model for PHC in which the micro and macro systems become interdependent is suggested. Health planners should ask whether the program will have access to people an answer to which is possible through knowledge of the culture i.e. the clients perspective. The planner should also pay attention to the factors that motivate people to seek health care and policies should involve community people in the planning process. Local participation in PHC is crucial in integrating the various levels in the health system. PHC must begin at the local level and with community involvement in planning. The specifics of the policies and plans however must be left open to negotiation depending on the culture and structure of the involved communities.