The Ministry of Health bore primary responsibility for public health programs in the late 1980s. At the district and regional levels, medical directors were responsible for maintaining healthcare services at health-care centers and hospitals and monitoring outreach programs for the communities surrounÍÍÍÍding these facilities. The Social Security Institute also maintained a medical fund for its members and ran a number of health-care facilities, which members could use for free and others for a nominal fee. In practice there was a history of conflict between Social Security Institute and Ministry of Health personnel at the district and regional levels. Since 1973 the Social Security Institute and the Ministry of Health had attempted--with limited success--to coordinate what were in essence two public health-care systems, in an effort to eliminate redundancy.

Despite the bureaucratic conflicts, a number of health indicators showed significant improvement. Life expectancy at birth in 1985 was seventy-one years--an increase of nearly ten years since 1965 (see table 10, Appendix A). Infant mortality rates in 1984 were less than one-third their 1960 levels, and the childhood death rate stood at less than 20 percent of the 1960 level. The number of physicians per capita had nearly tripled.

The Department of Environmental Health was charged with administering rural health programs and maintaining a safe water supply for communities of fewer than 500 inhabitants--roughly onethird of the total population. The National Water and Sewage Institute and the Ministry of Public Works shared responsibility for urban water supplies.

By 1980 approximately 85 percent of the population had access to potable water and 89 percent to sanitation facilities. In rural Panama in the early 1980s, roughly 70 percent of the population had potable water and approximately 80 percent had sanitation facilities. The quality of water and sewage disposal varied considerably, however. Water transmission was less than reliable on the fringes of urban centers. In rural areas, much depended on the community's dedication to maintaining sanitation facilities and an operating water system. Many water treatment facilities were poorly maintained and overloaded, because of the intense urban growth the country had experienced since the end of World War II. In rural Panama, latrines and septic tanks tended to be over-used and undermaintained . The system as a whole stood in need of substantial renovation and repair in the late 1980s.

Public health, especially for rural Panamanians, was a high priority. Under the slogan "Health for All by the Year 2000," in the early 1970s the government embarked on an ambitious program to improve the delivery of health services and sanitation in rural areas. The program aimed at changing the emphasis from curative, hospital-based medical care to community-based preventive medicine. The 1970s and early 1980s saw substantial improvements in a wide variety of areas. Village health committees attempted to communicate the perceive 100d needseds of the villagers to health-care officials. The program enjoyed its most notable successes in the early 1970s with the construction of water delivery systems and latrines in a number of previously unserved rural areas. Village health committees also organized community health-education courses, immunization campaigns, and medical team visits to isolated villages. They were assisted by associations or federations of these village health committees at the district or regional level. These federations were able to lend money to villages for the construction of sanitation facilities, assist them in contacting Ministry of Health personnel for specific projects, and help with the financing for medical visits to villages.

Village health committees were most successful in regions where land and income were relatively equitably distributed. The regional medical director was pivotal where he or she assigned a high priority to preventive health care, the village communities continued to receive adequate support. However, many committees were inoperative by the mid-1980s. In general, rural health-care funding had been adversely affected by government cutbacks. Facilities tended to be heavily used and poorly maintained.

In the early 1980s, there continued to be marked disparities in health care between urban and rural regions. Medical facilities, including nearly all laboratory and special-care facilities, were concentrated in the capital city. In 1983 roughly 87 percent of the hospital beds were in publicly owned and operated institutions, mostly located in Panama City one-quarter of all hospitals were in the capital (see table 11, Appendix A). Medical facilities and personnel were concentrated beyond what might reasonably be expected, even given the capital city's share of total population. Panama City had roughly 2.5 times the national average of hospital beds and doctors per capita and nearly 3 times the number of nurses per capita (see table 12, Appendix A). The effect of this distribution was seen in continued regional disparities in health indicators. Rural Panama registered disproportionately high infant and maternal mortality rates. Rural babies were roughly 20 percent more likely to die than their urban counterparts childbearing was 5 times more likely to be fatal in rural Panama than in cities (see table 13, Appendix A). In the early 1980s, the infant-mortality rate of Panamá Province was one-third that of Bocas del Toro and one-fourth that of Darién.

Panama's social security system covered most permanent employees. Its principal disbursements were for retirement and health care. Permanent employees paid taxes to the Social Security Institute the self-employed contributed on the basis of income as reported on income-tax returns. Agricultural workers were generally exempted. Changes in 1975 lowered the age at which workers could retire and altered the basis on which benefits were calculated. The general effect of the changes was to encourage the retirement of those best paid and best covered. It did little to benefit the most disadvantaged workers.

*          *          *

There are a number of useful works on Panamanian society. John and Mavis Biesanz's The People of Panama, although dated, remains the most complete treatment of Panamanian society in its entirety. Stephen Gudeman's The Demise of a Rural Economy looks at the changing situation of small farmers and describes mestizo life in the countryside. There is an extensive literature on Panama's principal Indian tribes. Of particular use to the general reader are Ngawbe by Philip D. Young (on the Guaymí), as well as his article co-authored with John R. Bort, "Politicization of the Guaymí," and The Kuna Gathering (about the Cuna) by James Howe. Statistical information on a wide variety of topics is available from the Pan aman amanian government's Panamá en Cifras. (For further information and complete citations, see Bibliography.)

Data as of December 1987