International politics and primary health care in Costa Rica.

Costa Rica's internationally-renowned rural health program exemplifies the principles put forth by the 1978 Alma Ata Declaration on Primary Health Care with one exception: the government has not succeeded in achieving active community participation in health. This paper uses a historical and political-economic perspective to explain why the Costa Rican government failed in its efforts to enhance community participation after Alma Ata. International agencies have been closely involved in the design and implementation of rural health services in Costa Rica since the early 1900s, yet community participation did not figure in these programs until the mid-1970s. The demise of community participation in the early 1980s is attributed to a combination of factors including partisan conflicts, social class conflicts, interest group politics and, particularly, to the shifting priorities of international health and development agencies.