Nicaragua's free universal health care system

Becca Renk *, Nica Notes, July 13th 2023
https://afgj.org/nicanotes-the-best-health-care-money-cant-buy-nicaraguas-free-universal-system

The Best Health Care Money Can’t Buy: Nicaragua’s Free Universal System

In the crowded waiting room, my eyes focus on the feet walking past: unpainted toes in sandals, work boots, pedicures and high heels. I am in the melting pot that is Managua’s Fernando Vélez Paiz Hospital. Although it is a free public hospital, it is not just the poor who come here; it’s one of the largest and best-equipped hospitals in Nicaragua with a reputation for excellent service – even the wealthy seek care here.

The Neo-Liberal Era: Pushed into Private Care

State-of-the-art public hospitals – or indeed even ones that aren’t actively violating basic hygiene protocols – are a relatively new phenomenon. During 16 years of neoliberal rule from 1990 to 2006, health care was effectively privatized. The public budget for medicines and materials was minimal and political will of the governing party in Nicaragua to provide quality care for free was nil. This led to extreme deterioration of the public care system with the result that patients were pushed to pay for care in the private sector.

Nicaragua’s elite took advantage of the situation to make a hefty profit by building modern private clinics and hospitals. In this two-tier system, private hospitals were the gold standard and public hospitals became the last resort – and even there everything had a cost. Doctors often turned patients away for lack of gloves to examine them. When patients managed to be seen by a doctor, there weren’t even basic medicines, so they were given prescriptions they couldn’t afford to fill at a private pharmacy.

Patients unfortunate enough to need surgery had to bring their own alcohol, gauze, sutures and family members who could donate the blood they would need. Laboratory tests, specialized treatments, and surgeries were so expensive that poor families effectively could not access the service. Every family desperate to save a loved one’s life would scramble to pay for private care to ensure they got the best attention available. For Nicaragua’s poor majority, public hospitals became the place where you went to die…unless your family could afford to save you.

Fortunately, that is no longer the case. In today’s Nicaragua, the best care can’t be bought because it’s available free of charge in the public health service. Unfortunately, Nicaraguans got so used to the unjust two-tiered system, that many families still believe they need to make economic sacrifices to seek out private care.

“We Don’t Have the Money”

The woman sitting next to me in the Vélez Paiz Hospital, Susana, is one of those people. She has dressed in her best clothes for the outing: t-shirt and jeans skirt scrubbed clean on rocks and flip flops – she doesn’t own a pair of sandals or shoes. Susana’s husband Hilario holds a small backpack with their overnight supplies: a change of clothes, soap and a comb. His button-up shirt shows faint lines where it was carefully folded – their house is one of just 0.7% of homes in the country still lacking access to electricity and they don’t have an iron…yet. The government has recently slated their community to get connected to the grid.

This is the story of how Susana got to the Vélez Pais Hospital. Our organization recently took a visiting medical delegation up to her village, the El Porvenir coffee co-op. We do regular clinics there because the co-op is located at a two hour walk from the nearest public health post, meaning its access to basic health care is difficult. At 8:30 pm Susana was the last of 89 patients to be seen by the doctors.

At that point, we’d been working for six hours straight, half of that time using head lamps to see in the dark. Susana been waiting since early afternoon and was crying in fear as she showed the doctors the ultrasound test her daughter had paid for her to get in a private clinic four months earlier: the results showed a large ovarian tumor. The doctors called me in to explain to Susana that she needed to seek specialized care immediately.

“I can’t,” she told me. “We don’t have the money. At the private clinic they said the tests I needed cost C$2,000 córdobas [US$55]. I haven’t gone back because we can’t raise that much money.”

“Doña Susana,” I said, laying my hand on her arm. “You won’t pay anything. You just need to get to the public hospital.”

Then I took a deep breath and remembered where I was, remembered that even with the private air-conditioned bus we had chartered, it had taken our group most of the day to get to the co-op, and we had walked the last 5 km up the mountain. I remembered how bewildering even the best health care system can be to those unused to navigating it, I remembered how important it is for those facing serious health issues to have someone to advocate for them.

“Susana, come to Managua,” I told her, “and let’s go to the hospital together.”

More than a decade ago, one of my best friends died of cervical cancer, which at the time was one of the biggest killers of Nicaraguan women of child-bearing age. Martha was beautiful, unapologetically bold, and had a singing voice that would bring tears to your eyes. She fought fiercely to live – she wanted to see her daughter grow up. Although I’ve had the joy and privilege of being godmother to her daughter, I’ve never gotten over the waste of Martha’s death. Cervical cancer is so preventable that no woman should ever die of it. Unfortunately, Martha didn’t get the care she needed; by the time it was discovered, the cancer had already metastasized and it was too late for her.

So today I’m at the hospital accompanying another woman facing the specter of cancer, hoping that it’s not too late for Susana. Fortunately, her chances are much better than Martha’s were.

Revolutionized Health Care

What has changed? Since the Sandinista government was voted back into power in 2007, Nicaragua has made a long term financial investment in public health: over the past 10 years, social spending has gone from being 10% of overall spending to making up 57% of the country’s budget.

This investment has led to the most extensive and well-equipped public health system in Central America. In 15 years, Nicaragua has built:

• 24 new hospitals, with high technology equipment and medical specialists
• 15 more new hospitals are under construction or planned
• 181 maternity waiting homes where rural women can stay two weeks before their due dates, are attended by doctors, and give birth in the hospital
• 190 natural medicine clinics, guaranteeing care with sensitivity to cultural identity
• 73 pain management clinics
• 101 centers for people with special needs
• Three prosthetics and orthotics workshops
• 52 mental health clinics
• Two addiction treatment centers
• The first medical oxygen plant in the region
• The second molecular biology laboratory in all of Latin America
• National Centers for cardiology, diabetes, chemotherapy and palliative care and audiology and speech therapy

Investment leads to results. Over the past 15 years, Nicaragua has seen:

• Cervical cancer mortality reduced by 25%
• Home births reduced by 88%
• Maternal mortality reduced by 70%
• Infant mortality reduced by 56%
• Chronic malnutrition reduced by 46% in children under five
• Chronic malnutrition reduced by 66% in children six to 12 years old
• Average life expectancy increased by three years for men and women alike

Access to specialized care has drastically changed – services such as chemotherapy and radiotherapy that were once only offered in the capital are now offered at regional hospitals. Prior to 2007, many surgeries were only performed by international brigades; now heart surgeries and kidney transplants are routinely performed by local doctors. Nicaraguan doctors became the first team in Central America to perform in-utero surgeries, and now regularly perform these surgeries at two different public hospitals.

Family and community health care model

Nicaragua has a family and community-based model of health care with emphasis on prevention. This model relies on a network of 60,647 lay health care workers and volunteers who attend to patients in their homes and go door-to-door doing health education, mosquito eradication, vaccinations and census taking. These programs are extremely effective. For example, in just three weeks, this year’s annual vaccination campaign applied 2.3 million doses of vaccines to prevent childhood diseases, flu and pneumonia as well as 1.3 million doses of anti-parasite medication and more than 720,000 doses of vitamin A to children aged one to six. Additionally, 94.6% of Nicaraguans aged two and up have been fully vaccinated against COVID-19 and 45.3% have received two booster shots. Thanks in large part to its community-based health care model, Nicaragua faired relatively well in the pandemic; the World Health Organization has reported that Nicaragua had one of the lowest rates of excess deaths during the pandemic.

Health fairs are another way that Nicaragua brings healthcare to communities, carrying out 950 such fairs per week. Additionally, 68 mobile clinics, which are made out of converted trucks confiscated in drug busts, provide1.9 million consultations per year. A new program is doing outreach in schools nationwide, testing students’ hearing and vision, evaluating students’ speech, providing dental care and personal hygiene workshops, and vaccinating against COVD-19 for all 1.8 million students throughout the country.

The Best Health Care Money Can’t Buy

Considering the distance she has travelled, Susana has been given a same day appointment with the gynecologist and orders for an ultrasound and a mammogram. There are 40 women ahead of us in line, mostly pregnant women, others being seen for cryotherapy and colposcopies to treat precancerous lesions.

While Susana is in the exam room with the gynecological oncologist, Hilario tells me how worried he’s been about Susana. “I told her, let’s sell the pig; let’s sell the horse to pay for those tests. We can replace the animals, but we can’t replace you.” Hilario shakes his head, “She wouldn’t let me sell them.”

I know why Susana refused: the pig is being fattened for Christmas, but not for their family. That pig represents a large portion of their cash income and will buy food and school supplies. The horse is invaluable as their transportation, and is used to haul water and provisions; their lives would be so much harder without their animals. We’re surprised when Susana comes out of the exam room smiling.

“I don’t have a tumor at all!” She exclaims. “They did an ultrasound and an exam and I don’t have any tumor. They told me to come back here next year for my checkup.”

Later, I ask a doctor why the first results showed a tumor – was the private clinic simply incompetent or trying to squeeze money out of a poor family desperate to save a loved one? They tell me that while fraud is not uncommon in the private care sector, in Susana’s case, no one can say for sure if the erroneous results were due to negligence or maliciousness. Regardless, she and her family have spent four months worrying themselves sick for nothing.

On the way to the bus station Susana and Hilario are buzzing, effusive with their thanks and joking about the long trip back home; their relief is palpable.

In Nicaragua so many people suffered so much during the neoliberal years that society became scarred. Sometimes it still seems too good to be true – clean, modern hospitals with trained medical professionals for free? Really? Thanks to the Sandinista government’s political will to prioritize the poor and its Herculean efforts to modernize and expand its system, the best health care in the country is now free. Now families like Susana’s are beginning to believe it.

SOURCES:

Gobierno de Reconciliación y Unidad Nacional: Plan Nacional de la Lucha Contra La Pobreza Para el Desarrollo Humano 2022-2026 https://www.tortillaconsal.com/plan_nacional_de_lucha_contra_la_pobreza_2022-2026_al_19-7-2021.pdf

Interview with Ivan Acosta, Nicaraguan Minister for Housing and Public Credit https://popularresistance.org/nicaragua-launches-new-plan-to-fight-poverty-and-promote-human-development/

Ministry of Citizen Power for Health Nicaragua: Advances in Health From 2007 to 2020 http://www.tortillaconsal.com/tortilla/node/11331

Mapa Nacional de Salud en Nicaragua: https://mapasalud.minsa.gob.ni/

Nicaragua News 3 May 2023, 5 May 2023, 12 May 2023

* (Becca Renk has lived in Ciudad Sandino, Nicaragua, for 22 years, working with the Jubilee House Community and its project, the Center for Development in Central America. The JHC-CDCA has been in Nicaragua since 1994 working in sustainable community development and runs a full-time health clinic in Nueva Vida. The JHC-CDCA also works to educate visitors to Nicaragua, including through their hospitality and solidarity cultural center at Casa Benjamin Linder.)