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Healthcare in Nicaragua : overcoming the legacy of neglect

by Karla Jacobs, 2nd September 2009

On January 9th 2009 Health Minister Guillermo González presented the final version of the FSLN government's national health policy. The document contains an extensive analysis of the state of the nation's health and of the severe problems facing the national health system as well as an outline of the Sandinista government's priorities and aims as part of what Minister González described as the proposed "transformation" of the health care system in Nicaragua.

A study carried out during 2007 and 2008 by MINSA with support from the Pan American Health Organization (and cited as part of the presentation of the National Health Policy) gives an idea of the extent to which the health of the Nicaraguan population suffered as a result of the effective privatization of the public health system and the other failed social and economic policies implemented during previous neo liberal governments.

Persistent inherited structural deficiencies

The study found that 58% of Nicaraguans are unable to access adequate healthcare and treatment due to poverty and social exclusion from health services. The Caribbean Coast regions (RAAN and RAAS), Jinotega, Matagalpa and Río San Juan were identified as the areas where the population has least access to medical attention. In general the sectors of society least likely to get adequate treatment when ill are those living in poverty, rural inhabitants, women and young people.

The study also found that 20% of children under five years old suffer from chronic malnutrition and 6.3% from severe chronic malnutrition. The areas where the child population is most affected are the RAAN, RAAS, Jinotega and Madriz. In general the peoples of the Caribbean Coast regions were identified as the sector of Nicaraguan society with the worst quality of life. 

A factor that aggravates the public health system's inability to respond to the population's healthcare needs is the fact that 80% of the working population have no health insurance and 90% of the elderly population have no social security benefits.

As part of the study a survey was carried out to determine the frequency with which Nicaraguans tend to fall ill with common ailments (mainly respiratory and gastric complaints). 38.2% of those surveyed said they had been ill within the last 30 days.

The kinds of diseases the population are likely to suffer depend to a large extent on the area of the country they live in. For example, in Managua 9% of the population has diabetes and 25% have high blood pressure while the proportion of the population to suffer from these two complaints is significantly lower in rural areas.

A report by the former MINSA authorities in 2006 (and cited as part of the National Health Policy) confirmed that the Aleman and Bolaños administrations' health policy had indeed actively reduced access to basic healthcare services. It was demonstrated as part of the report that the number of family planning consultations, antenatal checkups and checkups for children under five years old had gradually fallen between 2000 and 2005. The number of vaccinations provided as part of the public health system also decreased during the same period.

The infrastructure and equipment inherited by the FSLN government as part of the public health system is described in the Health Policy document as "obsolete." As a result of the lack of capacity and resources in local health centers, emergency rooms and out-patient services in regional hospitals tend to be overwhelmed with patients who should be receiving treatment locally.

Finally, a nationwide analysis of medicine and medical services sales shows that 61% of all spending on healthcare in Nicaragua in 2004 was paid by the private sector (individuals, companies and NGOs), 28% by the government and 11% as part of international aid programs.

Transformation against the odds

Faced with such adverse circumstances - a population afflicted with abundant and complex health problems, a healthcare system near collapse and limited financial resources - it is hard to imagine even the most committed and capable team of experts transforming the healthcare system in the short term. Nevertheless, that is what the MINSA authorities say they are trying to do.

As part of MINSA's mission to "provide medical attention to Nicaraguans according to their needs, guaranteeing free and universal access to healthcare services and promoting healthy practises and lifestyles that contribute to improving the quality of life," the specific objectives are:

* to guarantee free and universal access to integral healthcare services
* to develop a national culture of preventing risks and protecting health
* to permanently improve the quality of health services in line with the needs and expectation of the Nicaraguan population
* to strengthen the model of citizen participation in activities that contribute to the wellbeing of the population

Among the specific aims outlined in the National Health Policy are:

* to significantly reduce surgery and external consultation waiting lists.
* to create access to healthcare services for the most vulnerable sectors of society
* to implement the regionalization of the health system in the RAAN and RAAS by empowering the health authorities in those regions

The most obvious and crude way in which to begin to improve the public health system is by increasing the health budget over and above any overall increase in the general national budget. And the FSLN government has implemented significant nominal increases since coming to power in 2007 (see table below). Considered within the context of the spiralling inflation registered over the last few years as a result of the extremely volatile international economy situation, however, it becomes clear that the real value of those nominal increases is significantly reduced.

yearamount (US$ millions)increase YOY (US$ millions)% increase YOYinflation rate

sources: Nicaraguan Central Bank, Ministry of Finance

Like in so many other areas of government institutional work, though, the positive changes achieved by this government in the national health system are the product not of a major increase of resources but of better use of the resources available.

Progress through 2007 and 2008

Details that suggest the government succeeded in significantly increasing access to the public health system in 2007 and 2008 were provided by President Daniel Ortega in his 2008 end of year report presented to the National Assembly on January 10th 2009.

According to the President's report 49% more medical consultations took place within the public health system in 2008 compared to 2006. Simultaneously the amount of prescription medicines provided by public hospitals and health centers free of charge increased by 87.3%, the number of surgeries carried out increased by 46.5% and the number of specialized medical tests increased by 52%.

During the same period, as part of the ALBA-funded Misión Milagro programme three specialized ophthamological hospitals were built in (one in Managua, one in the RAAN and another in the RAAS). Also during 2007 and 2008 fourteen health centers that had been destroyed by Hurricane Felix in September 2007 were completely rebuilt and equipped in the RAAN. Major infrastructure work and repairs were carried out on 24 hospitals and health centers across the country and a brand new regional hospital was built and equipped in Boaco.

Partially completed construction work with completion dates for 2009 and 2010 include the construction of four new regional hospitals, fourteen new health centers, two new "casas maternas" (refuge centers for women from remote areas in the last stages of pregnancy) and major infrastructural improvements in 16 hospitals and health centers.

Much of the major construction work within the public health system has been possible thanks to resources made available as a result of the FSLN government's insistence on its sovereign right to control the designation of foreign government aid.

It is interesting to note that of the 82 construction and infrastructural improvement projects listed above 35 are taking place in towns and villages on the Caribbean Coast, in other words 43% of major projects. This demonstrates the government's commitment to it's aims of increasing access to healthcare for the populations of areas where least access previously existed and of empowering the Caribbean regional health authorities as part of an effort to regionalize healthcare and contribute to the process of autonomy on the Caribbean Coast.

An example of how MINSA is literally taking medical attention to the most vulnerable and excluded sectors of society in Managua is the project Barrio Limpio, Barrio Saludable ("A Clean Neighbourhood is a Healthy Neighbourhood") which is being carried out in collaboration with the local authorities.

This project consists of a mobile clinic and information center which travels from marginalized barrio to marginalized barrio providing healthcare services (consultations for children, adults and the elderly, medicines, basic tests, medical and lifestyle information and advice and even haircuts) free of charge. Simultaneous to the visit from the mobile home the local CPC is encouraged to carry out activities that contribute to better health in the neighbourhood like collecting rubbish, cleaning the streets and drains and planting trees.

Another example of how MINSA's new approach is taking health services to the community and involving ordinary citizens are the wider, more participative yearly vaccination campaigns introduced in 2007. During the last week of April 2009 over 12,000 vaccination points in barrios and rural communities (normally casa comunales, school buildings or community member's homes) functioned as vaccination and prevention centers where children, pregnant women and elderly people recieved vaccinations, vitamin tablets, parasite medicine and medical advice as appropriate. 

An example of how the community health brigades organized by MINSA are contributing to the health of their local communities is the response to the outbreak of dengue during the 2008 rainy season. Health workers, teachers and community health brigades were able to visit 40% of Nicaraguan homes, disinfecting water containers (in order to avoid the reproduction of mosquitos) and giving basic advice about how to avoid dengue infection. As a result of the massive nationwide campaign the number of cases of dengue registered in 2008 was 30% lower than the previous year.  

Of course, while the government is serious about transforming the health system and dramatically improving the population's quality of life, they have a lot of ground to make up. The extreme budget limitations, produced by the combination of a small and weak economy and the current international economic situation, mean the government cannot advance its transformation process nearly as fast as the precarious health of the population requires. One is at once struck by the amount achieved so far and frustrated that such hard times should accompany this change that has been so long coming.