THE HEALTH SITUATION IN REVOLUTIONARY NICARAGUA
The gains realized in matters of public health during these four years in Nicaragua have no parallel in the country’s history. There is an abysmal difference between the health situation that the Governing Junta of National Reconstruction found in 1979 and that which exists today.
In the nearly four years that have passed since the popular forces overthrew Anastasio Somoza, in July 1979, achievements in the area of health have been unparalleled in the history of Nicaragua. The health situation of the country at the time the Government of National Reconstruction took over was abysmal. Health care delivery services under Somoza were designed in such a way that they gave good attention to the wealthy and less than minimal attention to the poor. Enacting by law a unified and coordinated health care delivery system just weeks after assuming control, the Sandinista government has initiated a wide spread health program that emphasizes public health and preventive medicine and at the same time strives to provide adequate medical coverage for all of its inhabitants. Despite the more coordinated approach to health services and the achievements reached in the area of public health, many problems still plague the Nicaraguan health system, especially in the areas of health care delivery. The problems facing the Ministry of Health can be described as problems of development, structure, economics, and organization.
UNDER SOMOZA, HEALTH WAS A PRIVILEGEPrior to 1979, little attention was paid to the accumulation of accurate health statistics. The officially declared rates of natality, morbidity, and mortality reflected the enormous under-registration of births, the almost total lack of medical certification of deaths, and the unwillingness of the Somoza government to publish embarrassing vital statistics. Nevertheless, estimates of health indexes made at that time paint a clear picture of the health situation. The infant mortality rate, one of the most sensitive indicators of health conditions in a country, has been estimated to have been 120 per 1000 live births in the city and 300 per 1000 live births in rural areas. (Official rates were 45/1000 in 1971 and 46/1000 in 1973). Seven out of every ten children were malnourished. The mortality rate for children between the ages of one and two (period of weaning and indicative of the nation's ability to provide adequate nutrition) was estimated to be 149/1000. The life expectancy for men was 54 years of age and for women 52 years of age, although for wealthier Nicaraguans it was estimated to have been 70 years of age and for poorer Nicaraguans between 40 and 50 years of age. Thirty five percent of the urban population and ninety five percent of the rural population lacked access to potable water. The principal causes of death, especially among children, were mainly preventable diseases such as dehydration, measles and tetanus. Malaria, tuberculosis, and parasitism were endemic. One third of the population contracted malaria at least once in their lives. In 1979 two out of every five people who sought medical attention were diagnosed as having malaria. The mortality rates were high. Official figures published in 1976, which were probably low, placed the mortality rate due to malaria at 1175 per 100,000 inhabitants.
The health care delivery system prior to 1979 was extremely inadequate to meet the needs of the Nicaraguan people. In 1977, said to have been Somoza's "best" year economically and before the escalation of violence, only 5.1% of the national budget was allocated toward the health sector. Of this amount 37% went to the National Social Security Institute, which was designed to give health care for working people but covered only 8% of the population. The remainder was divided among the Ministry of Public Health (25%) and various disjointed local organizations for the provision of health care. Several religious organizations ran reputable hospitals but predominantly for those who could afford to pay cash. The National Guard had its own system of hospitals and clinics, including specialties. It has been estimated that 90% of the medical services were provided to 10% of the population. More that one half of the physicians and hospital beds were located in Managua, the capital city, The 1976 80 Health Plan projected coverage for only 20% of the pregnant women and less that 20% of those under 5 years of age. The average number of medical consultations in 1974 was 0.02 consultations per person per year.
The health infrastructure inherited by the Sandinista government was extremely weak. In the 1972 earthquake, every acute care bed in Managua was destroyed. Replacement of those beds was far from completion when the violence of the Revolution destroyed even more hospitals and clinics nationwide. The regional hospital in Rivas was completely destroyed, and major damage was suffered by the regional hospitals in Esteli, Matagalpa and Leon. Damage was inflicted upon five other hospitals and nineteen health centers. Four hospitals reported 100% of their equipment damaged. As a final blow, the paralysis of the economy in the last few months of the war diminished the reserve of medicines, laboratory reactives, and other materials needed for the functioning of the health system. Pharmaceutical houses suspended production, and the shortage of foreign exchange prevented the importation of more drugs. Of the 1300 registered physicians, an estimated 300 had left the country by the end of the war. The health care system was left disjointed, disrupted, and devoid of the necessary infrastructure to maintain itself.
HEALTHIER BABIESOn August 8, 1979, the Government of National Reconstruction enacted by law the National Unified Health System (SNUS) in which the health services of all medical institutions were to be integrated into one national health system under the Ministry of Health. In declaring SNUS, the government promised free medical attention to the entire population, the provision of hospitals and clinics in every region of the nation, and the initiation of massive campaigns to eradicate the endemic diseases and to prevent epidemics. Health was recognized as a right of all individuals and a responsibility of the state and the organized people. The country was divided into nine health regions in order to decentralize and facilitate administration. A system of referral was established from rural to better-equipped urban hospitals. Among the various programs initiated were projects to bring potable water to both urban and rural areas and the training locally of all levels of health personnel. One of the most successful programs has been the "People's Workday for Health" (Jornadas Populares de Salud), in which trained volunteer health brigades participate in wide ranging projects, from vaccination campaigns to the cleaning up of open sewage systems and filling in of stagnant pools.
The Ministry of Health has placed maternal and child health and the health of the worker as its two top priorities. Achievements in these two areas, as well as other fields of health, have been remarkable. In 1980, the death rate in the first year of life was estimated to have been 101.7 per one thousand live births. In 1982, the number was estimated to have been reduced to between 70 80 deaths per 1000 live births. The most outstanding reason for this decline has been the construction and maintenance of local oral rehydration centers to combat the deadly dehydration that results from prolonged diarrhea. Due to the oral rehydration centers, hospital mortality secondary to diarrhea has been decreased by 75%, far surpassing in the first year alone the 50% reduction rate set as a goal.
A second very important reason for the decline in infant mortality has been the success of the vaccination campaigns. The first vaccination campaign took place in September 1979 and was directed against polio. Since then vaccination campaigns have been realized against polio, measles, diphtheria, tetanus, and whooping cough in schools, factories, and residential areas. The results have been impressive. In 1982 there was not one confirmed case of polio, although there were ten cases under investigation. In 1980 there were 3784 reported cases of measles; in 1982 there were 226 cases.
Another major effort has been directed toward the reduction of malnutrition. A nutritional survey indicated that 68% of the children under the age of four suffer from varying levels of malnutrition. The principal cause of this malnutrition was determined to be the insufficient consumption of protein and calories. To combat malnutrition on a nationwide level, the government has been attempting to increase the production levels of basic foodstuffs and to increase the efficiency of food distribution, eliminating hoarding and speculation. The three basic grains (corn, rice and beans) are subsidized by the government to assure that they remain within the financial reach of all households. Levels of endemic goiter as a result of iodine deficiency have been reduced from affecting 33% of the population before 1979 to 20% in 1982. The decrease is due to strict control of iodization by the Ministry of Health in the nation's salt processing plants. In addition to these national programs, local programs of nutritional vigilance and food supplementation have been initiated in areas of high malnutrition for high risk populations (mostly pregnant and lactating women and children under five).
To combat "baby bottle disease" (infant diarrhea due to misuse of powdered milk products), pro formula advertisements are banned and breastfeeding is promoted in a joint effort by the Ministries of Health and Education. The first maternal milk bank was initiated in late 1982 at the maternal child hospital in Managua. To provide better attention to those children under five whose mothers need to work, twenty centers for child development have been constructed, and more are planned. The centers are run by psychologists and social workers with the objective of avoiding the abandonment of children during the workday.
Better care to pregnant and lactating mothers has been achieved through a more comprehensive health program for women that includes, in some urban areas, health care by a nurse on a block by block basis. Rural areas are visited regularly by a nurse. A program to improve the skills of traditional birth attendants is scheduled to begin in mid 1983. Family planning methods are available in the local health center for those women requesting such services.
INDUSTRIAL HEALTH A PRIORITYThe government has also placed emphasis on the health of the worker. Unlike many developing nations in which worker health and safety loses importance in the rush to industrialize and produce goods, the Revolutionary government is attempting to promote worker health and minimize safety risks. A National Commission of Integral Worker Health has been created, combining representatives from the Ministries of Labor, Health, and Industry. In addition, there are representatives from the National Institute of Agrarian Reform, the Association of Farm workers, and the Sandinistas’ Workers' Confederation (central organization of various unions). In the one year that it has been functioning, the commission has begun a study of the correct use of pesticides and control of importation of toxic pesticides. In addition, the Commission is involved in recommending safety levels of physical agents such as heat and vibration, and noise and chemical agents such as lead and mercury that could be detrimental to the human body.
In addition to the work of the National Commission of Integral Worker Health, the Ministry of Health, Department of Occupational Health, is developing specific programs to minimize health risks and improve safety both in the factory and on the farm. Although limited by inadequate funds, a small staff, and lack of trained personnel in this field, the department has developed a program according to a list of priorities. The priorities delineated by the department include control of lead intoxication, benzene derivatives, toxic pesticides, lung diseases of miners, and health risks of the agricultural worker. The department is attempting both to educate the worker in regard to health and safety risks and to train its own staff as inspectors and occupational health educators. Two studies have been carried out; the extent of lead intoxication in the blood of battery factory workers; and the extent of lung disease in the mining regions along the Atlantic Coast. Because of economic and technical limitations, only biological (human body) monitoring and not the complementary atmospheric testing can be carried out. Altering the physical structures that present health and safety risks, especially in older factories, would require massive investments of funds that are not available. Therefore the Department of Occupational Health concentrates on reducing exposure to risks by recommendations such as time limitations and ventilation until structural changes can be made.
COMBATING MALARIA AND TUBERCULOSISMajor successes have been realized in the area of endemic infectious diseases. In November of 1981 a massive health campaign against malaria was conducted which involved 80,000 trained volunteers. These volunteers distributed therapeutic doses of an antimalaria drug in a uniform 3-day treatment to an estimated 75% of the nation's population. Regular monthly statistics indicated a 98% decline in new cases of malaria shortly after the campaign. The campaign necessarily includes on-going community efforts to decrease mosquito larvae. In July 1982 a massive campaign was undertaken to drop larvacide containing cloth bags into barrels, laundry basins, and other water reservoirs. ongoing community efforts to drain swamps and fill in ditches have also been designed to decrease the mosquito population. Regular aerial spraying in areas of endemic malaria has been successful in reducing the transmission of the disease. But the battle against malaria is long and difficult. Floods in May 1982 caused an increase in the incidence of malaria the following August. In 1982 there were 15,300 cases of malaria.
To combat tuberculosis, which is endemic especially in the mining areas and the Atlantic Coast, efforts have been made to improve the prevention as well as the detection and treatment of the disease. The TB vaccination BCG is currently administered to 70% of all medically attended births, and the remainder are to be vaccinated in the local health centers. Whereas before each physician followed his/her own style of treatment, there is now a nationwide protocol for both detection and treatment of tuberculosis. Any patient with respiratory symptoms of over three weeks' duration is sent immediately for X rays and laboratory examinations of pulmonary secretions. An estimated 3000 new cases have been found in the Atlantic Coast and mining areas alone since the Revolution. Treatment has been prolonged to one year, with two visits per week to the health center. Although there are some 23,000 people under treatment, the dropout rate is still high (40% in 1980). Efforts are being made to decrease the dropout rate by making the TB therapy programs more accessible.
NEED FOR MORE DOCTORS AND NURSESThe improvement of the existing health infrastructure has been one of the most pressing challenges of the Sandinista government. Through training of health professionals and construction of hospitals and clinics nationwide it is hoped that health care services can be brought to areas either grossly underserved or never served in the past. In the three and one half years since the Revolution, 1400 medical professionals have been trained in eight different careers. In 1981 a second medical school was opened in Managua to supplement the school in Leon. The total medical school enrollment was increased from 100 to 500 students. Nursing students have increased five times in number in the past three years. A master’s program in public health and epidemiology was begun in 1982. Allied health career training has been established in various areas, such as dental assistants, X ray technicians, dieticians, and bio-statisticians. Their training has been facilitated by the creation in 1980 of the Polytechnical Institute of Health. Currently there are nearly one thousand health technicians, aides and nurses enrolled.
Prior to the Revolution, the formation of medical specialists in Nicaragua was done on an informal, apprenticeship basis. Most formal post graduate medical education was received outside of the country, costing Nicaragua not only millions of dollars, but frequently resulting in the permanent loss of its physicians, who remained to practice in the area where they had been trained. Since July 1979, fifteen medical specialty training programs have been established ranging from the primary care specialties of pediatrics, obstetrics gynecology, and internal medicine to specialized fields of ophthalmology, anesthesiology, and maxilla facial surgery. By training inside the country, it is estimated that the government is saving 10 million dollars annually. Nevertheless there are opportunities for health professionals to study abroad, and scholarships have been increased as well as agreements reached for health professional training in neighboring countries such as Belize and Cuba.
VOLUNTEERS: A DECISIVE FACTORThe construction of clinics and hospitals has been another major program of the Nicaraguan Government after the National Unified Health System was enacted. It was determined that there were only 188 health centers nationwide. Currently there are 420 health centers, with 37 more scheduled to be constructed in 1983. There are five hospitals under construction that are to be completed in 1983, bringing the total from 26 to 31 hospitals nationwide. Although the government has invested 10 million dollars in the construction of health centers and hospitals and received a great deal of international aid, the key to the successful improvement of the health infrastructure has been the participation of the organized people themselves. In many areas, clinics have beer constructed by the people using volunteer labor.
In order to augment popular participation in health care, health management teams have been formed that bring together representatives of the Ministry of Health with representatives of the mass organizations, professional societies, and health workers. From the national level to the local village or barrio level, "Popular Health Councils" motivate and encourage community organizations to participate actively and responsibly in the new health system. These councils are responsible for the planning, execution and evaluation of all public health campaigns (vaccinations, malaria control, etc.) In addition, they serve as a channel through which the concerns and complaints of the health care recipients can be expressed from the base level to the regional and national levels.
Despite advances made in public health matters and the provision of free medical care to all Nicaraguans, the Government and the Ministry of Health face innumerable problems, especially in the area of delivery of health care services. These problems can be grouped into four basic areas: developmental, structural, economic and organizational. A recent investigative series published in the government newspaper Barricada highlighted these problems and their effects on the ability of the five public hospitals in Managua to provide services. As a consequence, concrete efforts are being made to alleviate the now near crisis in health services for acute illnesses.
THE NEED FOR EDUCATIONMany of the problems facing the Ministry of Health can be considered problems of development. The National Unified Health System (SNUS) is barely three and a half years old and in that short amount of time health coverage has been quickly and widely expanded. In addition, SNUS introduced the idea of regionalization of health care and the concept of primary, secondary and tertiary health care services (a referral system from clinic to local hospital to regional center). As a result, the public does not know how to best utilize the system. Attempts have been made at public education, but habits are hard to change. People still go where they have always gone, to the hospital. Consequently, the emergency rooms in the public hospitals are overcrowded with patients seeking assistance for such minor ailments as headaches or toothaches that could easily be handled at the local health center. A survey recently completed at one Managua hospital indicated that 60% of the cases in the emergency room were not emergencies.
Another consequence of expanded health services is that the system is overloaded. In 1982 there was an average of nearly 2.0 medical consultations per person per year up almost 100% from the time of Somoza, The infrastructure has not been able to keep up with the demand. Predicting health consumer needs, manifested especially in the availability of pharmaceuticals, is difficult because of the lack of historical information that could be used as guidelines. The Ministry of Health acknowledges its lack of experience and expertise in the new health care delivery scheme. Moreover, expansion of health care into areas never served before carries its own problems, from lack of infrastructure to the arousal of suspicion of government motives, especially in rural areas.
LACK OF DOCTORS, EQUIPMENT, TECHNICIANS AND MEDICINEThe structural problems facing the Ministry of Health and SNUS are most keenly felt in the area of medical supplies and equipment and in the area of health professionals. The situation in the five Managuan public hospitals is grave. The X ray apparatus at three of the five major Managuan hospitals has not been functioning for up to two years for lack of spare parts. It has been necessary for the Ministry of Health to pay up to 70,000 cordobas (about 2500 dollars) monthly to private laboratories for X rays. Lack of anesthesia, surgical gloves, and suture material is delaying or completely canceling some surgeries. There is no insulin in any of the public hospitals. Liquid disinfectant soap is scarce. Velez Paiz Hospital, which averages forty five births and twenty surgeries per day, has no heparin and no Rho gam (vital injection for mothers with Rh negative blood who give birth to babies who are Rh positive). Although women only stay twelve hours after giving birth, there are two mothers to a bed and up to three infants per incubator. Hospital Lenin Fonseca spends an average of 20 25,000 cordobas (800 to 950 dollars) per month to have tests run in private laboratories because its own laboratory lacks the necessary chemical reagents. The shortage of needed drugs and supplies slows down patient recuperation and increases the length of hospital stay. In addition, a good percentage of the patients return to the hospital either seeking more treatment or because they have suffered a relapse. Therefore, a particular cure might cost the state twice as much as necessary. Improved morbidity and mortality rates are threatened.
The problem of sophisticated medical equipment is critical. The machinery in the Managuan public hospitals is old, as well as insufficient. Most of the equipment is more than twenty years old, and many times the needed replacement part is no longer available. Moreover, the needed tools and experienced technicians to repair the machine are lacking. Many hospitals need to have whole electrical systems changed to adapt to the sophisticated machinery. Technicians are not always certain how to run the machines, and there have been cases of sabotage of equipment. It has been necessary to cannibalize two or three machines to get one into a functioning state.
Concurrent with the problem of scarcity of pharmaceuticals and medical equipment is the acute shortage of trained health professionals. During the time of Somoza, there were not enough physicians per patient population; now the situation is worse. Despite international assistance (roughly 600 Cuban and 250 other foreign physicians are currently working in Nicaragua), the demand created by wider distribution of health care and increased number of people seeking health care exceeds the number of physicians available. Many physicians only work mornings and prefer to run a private practice in the afternoon and evening in order to enhance their income. Although the government does not discourage this practice (the Ministry of Health cannot afford to provide the physicians with good salaries and the practice does allow private medical care for those who can afford it), there are not enough physicians willing to work full time in the public health facilities. In addition, many Nicaraguan physicians have been required to take administrative positions in the health system rather than become involved in actual clinical care. The shortage of health professionals is felt in all the public hospitals at all levels of health care, from sub specialists to nurses' aides. The poor salaries offered by the Ministry of Health are no competition to those offered by the private sector. Nurses aides, who receive a salary of 1800 cordobas (about 65 dollars) a month, can earn more by selling food on the streets. In addition, there have been complaints of poor treatment of the patients by the health workers. High absenteeism and poor discipline have given way to low worker productivity. Attempts have been made to alleviate the crisis of health personnel by increasing the number of health science students and strengthening the medical associations that could serve not only as a means of motivating the health worker, but also function as a channel for health worker complaints.
SHORTAGE OF MEDICINE, ABUNDANCE OF BUREAUCRACYAs in all the government ministries, the tight economic situation in which Nicaragua is living is felt acutely by the Ministry of Health. The 1983 budget for the Ministry of Health is 1.5 billion cordobas (about 150 million dollars), the highest budget allocated to health in the history of Nicaragua. However, escalating health costs and the ever increasing demands on the health system quickly devours available funds. Nowhere is this felt more acutely than in the area of pharmaceuticals. The vast majority of the drugs consumed in Nicaragua need to be imported. Of the 60 million dollars requested by the Ministry of Health for the importation of drugs, only 40 million dollars were allocated. Medicines and medical supplies are in such shortage now that a recent study indicated that 55 million dollars would be needed just to alleviate the shortage, without even considering the cost of maintaining adequate availability of pharmaceuticals. Credit for the purchase of medicines is not readily available. Poor handling of debts in the early months of the Revolution closed off channels for more drugs when many international pharmaceutical houses discontinued credit. Other international drug companies are claiming political instability to freeze business. The government has been attempting to assist local pharmaceutical houses to increase production. However, of the 60 million cordobas contracted to make drugs locally, only 20 million cordobas could be paid. Although rich in primary material, Nicaragua lacks the technology to produce a large and varied quantity of needed pharmaceuticals.
Many blame the scarcity of drugs on the lack of foreign exchange. Others blame it on the lack of organization and an overabundance of bureaucracy. There is no doubt that the Ministry of Health and its National Unified Health System is plagued by both poor organization and over bureaucratization. The Center for Medical Supplies (CAM) complains that in order to request dollars for the purchase of medicines it is necessary to go through the offices of eight different ministries, a process that can take an average of six months. Often, by the time the request is approved, inflation has caused the price to go up, and a whole new request has to be made. Also CAM does not control the importation of pharmaceuticals. It cannot smooth the passage of drugs through customs, and frequently desperately needed medications sit in the customs office awaiting clearance. Bureaucratization also takes its toll on health workers. Recently a request for four maintenance workers at one Managuan hospital went from the hospital administration to the regional level and from there to the national offices of the Ministry of Health, where it was then transferred to the Ministry of Finance, which had the last word.
The Ministry of Health has one hundred separate functions, and it is difficult to maintain control over all the departments and sub departments. It acknowledges the theft of existing pharmaceuticals by some of its own workers. The Ministry is aware of "professional patients" who go from clinic to clinic and hospital to hospital requesting and receiving medicines that are later sold on the black market. Poor communication and coordination between the Central Medical Supply, the regions, the hospitals, the pharmacies, and the physicians create shortages and frustration. Managua creates a particular organizational problem because, in addition to being its own region, it is also the referral center for the whole country. Therefore it is often difficult to predict needs and coordinate activities.
As a result of the exposé of the situation in the Managuan hospitals and numerous other complaints from the organized people, steps have been taken by the Ministry of Health to solve some of the more acute problems. A new office has been created: the Vice Minister of Pharmaceutical and Equipment Supply ("Abastecimientos Medicos y Equipos"), designed to improve the distribution of drugs and supplies, smooth passage through customs and increase local production of drugs. A five-year maintenance plan for machinery has been enacted with the intention of creating an inventory of available machinery replacement parts. Movements are being made to mechanize information pertaining to SNUS in order to improve decision-making. Finally, in late March 1983, an intense hospital restructuring was carried out for the purpose of consolidating and maximizing the use of available health resources. One Managuan hospital was designated exclusively for women's health concerns. Managua was divided into two sub regions with each sub region designed to have a pediatric hospital, a hospital for adult medicine and surgery, and a major outpatient clinic with clinical specialists. It is hoped that in this manner the crisis in the Managuan hospitals which affects the whole country as well can be alleviated.
Despite the dismal health conditions inherited by Somoza, an oppressive economic boycott, continuous border aggressions, and natural disasters such as floods and drought, the Nicaraguan Government has made great strides in improving the health of the Nicaraguan people in less than four years. Most of the improvements have been achieved through massive mobilizations of the organized people to vaccinate against the major childhood diseases, to eradicate endemic diseases such as malaria, and to create a healthier environment by eliminating open sewage systems and other environmental risks. Health care coverage is now reaching areas that were never served before medically. Hundreds of health centers have been constructed, and health profession training has been substantially augmented. Infant and maternal mortality rates, once very high, are now on the decline. Problems still face the Ministry of Health as it attempts to carry through its National Unified Health System. These problems are most sharply manifested in the provision of health care for acute illnesses. However, the overall health situation is so vastly improved that in 1982, in recognition of its advances in health, Nicaragua was elected president of the Executive Council of the Pan American Health Organization.
Health Care in the New Nicaragua, Jose Escudero, 1981
El Sistema Nacional Unico de Salud, Ministry of Health, 1982
New England Journal of Medicine, 307; 388-392, Aug. 5, 1982