Healthcare in Nicaragua

Nicaraguan nurse preparing to administer a Papanicolaou test

Healthcare in Nicaragua involves the collaboration of private and public institutions. Although Nicaragua's health outcomes have improved over the past few decades with the efficient utilization of resources relative to other Central American nations, it still confronts challenges responding to its population's diverse healthcare needs.[1]

The Nicaraguan government guarantees universal free health care for its citizens.[2] However, limitations of current delivery models and unequal distribution of resources and medical personnel contribute to the persistent lack of quality care in more remote areas of Nicaragua, especially amongst rural communities in the Central and Atlantic region.[1] To respond to the dynamic needs of localities, the government has adopted a decentralized model that emphasizes community-based preventative and primary medical care.[3]

While communicable diseases such as dengue, chikungunya, and Zika continue to persist as national health concerns, there is a rising public health threat of non-communicable diseases such as diabetes, cardiovascular disease, and cancer, which were diseases previously thought to be more relevant and problematic for more developed nations.[4] Additionally, in the women's health sector, high rates of adolescent pregnancy and cervical cancer continue to persist as national concerns.[5][6]

Healthcare system

History

Before the 1979 Sandinista Revolution

Before the 1979 Sandinista Revolution, the Nicaraguan health system consisted of four distinct agencies and independent health ministry offices in each province. There was little coordination amongst these institutions, and this system was fraught with provincial differences in salaries, administrative procedures, and more.[7] During this 1970s period, Nicaragua had one of the worst life expectancies at birth and one of the highest levels of infant mortality in the regional area. Both of these measures have improved markedly up to 2016, average life expectancy now reaching 74.5 years.[8][9]

There also existed an unequal distribution of health resources. Only 25% of the total health budget was controlled by the Ministry of Health, and 90% of the services went to 10% of the population.[10] Even though only a quarter of the population lived in the capital city of Managua, health professionals were disproportionately concentrated there. In 1972, half of all Nicaraguan doctors and more than two-thirds of nurses worked in Managua.[11]

Post-revolution

After the 1979 Revolution, the new government established a new Unified National Health System that instated the Nicaraguan Ministry of Health (MINSA) at the head of health services throughout the nation. This system also integrated the Nicaraguan Social Security Institute (INSS) under MINSA's direction in order to make it financially feasible to provide a single national health service available to all Nicaraguan citizens, regardless of socioeconomic background.[12] With the combination of these institutions, the INSS hospitals and clinics, previously only accessible to insured employees, then opened their doors to the larger population.[7]

In 1984, in order to improve existing institutional infrastructure, 10% of the national budget was allocated to the health sector. From 1979 to 1984, the government also successfully pushed for the construction of 309 new primary healthcare facilities and the training of over 3,000 health professionals.[10] Following the wake of the Revolution, MINSA promoted several prevention-based health efforts, one of the earliest being its Brigadista program. This Brigadista program involved the training of community health advocates, the majority of whom were chosen from the Sandinista Youth Organization, who were selected to be trained and transported to serve in underserved rural regions.[13]

Since the 1990s the Nicaraguan government has been changing towards more market-oriented economic policies that have affected the health sector. This healthcare shift has involved increased private sector activity as well as the decentralization of public services.[3]

Levels

The current Nicaraguan public health system follows a decentralized model. This model consists of three distinct administrative levels, each associated with different health services. Levels include (1) the central level, (2) the SILAIS (Local Systems of Comprehensive Care) level, and (3) the municipal level. The Nicaragua Ministry of Health (MINSA) directs the central level and is committed to ensuring universal access to free health services.[2]

This decentralized model involves annual contracts between MINSA and local hospitals and health centers that are negotiated to set upcoming specific actions, goals, and funding allocation. The contract system is incentive based, and the amount of federal funding decided upon involves the consideration of institutional performance.[14] As part of the public sector, the revenue generated from hospitals, healthcare centers, and SILAIS are consolidated and calculated by the Ministry of Finance before redistribution of certain percentages to the original institutions.[15]

Pacayita health post in Catarina, Masaya, Nicaragua

Model of Family and Community Health (MOSAFC)

With the intention of maintaining decentralization while expanding citizens' access to quality healthcare, the Nicaraguan government implemented a structural framework model entitled the Conceptual Model of Family and Community Health (MOSAFC) in 2007.[16] As determined by Nicaragua's General Law of Health (No. 423) the overall aim of MOSAFC is to establish integrated networks of public and private service providers that work together to harbor the responsibility of addressing the health needs of specific populations.[17] The overarching goals of this framework were to offer more efficient delivery of health services, improve patient satisfaction with services, and advance the financial protection of citizen's health.[18]

Healthcare workers

There is an unequal distribution of healthcare workers throughout Nicaragua's different provinces. Most healthcare workers are located on the Pacific coast region, while there is a huge need for primary health professionals in the cities of Jinotega and Matagalpa, as well as along the Caribbean coast.[2] In the year 2000, while Managua contained 20% of the population, the city continued to harbor around half of the country's entire health care professionals.[19]

This trend can be explained by overall low financial incentives for health care personnel, especially for work in remote areas. The average monthly salary for a general practitioner in Nicaragua under MINSA is $544 USD while that of Honduras is $1,332 USD and that of Panama is $1,025 USD.[20] Additionally, although 52% of Nicaraguan doctors are specialized in training, this specialization level fails to meet widespread community needs for primary care.[19] In order to improve the healthcare access of those living in more isolated areas, the public medical schools in Nicaragua require their graduates to perform two years of social service in high-need settings, after which they can opt to work in private institutions. This requirement aligns with MINSA's objective to encourage these graduates to work for the public health sector.[7]

Amongst Nicaraguan doctors, there persists a lack of gender diversity. Nicaraguan women are underrepresented in the field of medicine, and within the healthcare field have an unemployment rate that is 3.5 times higher than that of men.[19]

Health conditions

Chronic diseases

There has been an observed increasing prevalence of chronic diseases such as type 2 diabetes, obesity, and hypertension. This increase in prevalence of chronic diseases has been attributed to lifestyle changes and increased urbanization.[21] Improved access to processed foods has led to higher consumption of highly processed snacks and sugar-containing drinks in rural areas of Nicaragua, and raw sugar cane is often freely available. Complementary feeding practices involving breastfeeding paired up with supplementation of artificial snacks were frequently observed amongst 6-to 8-month-olds. These early introduction to highly processed foods leads to increased risk of infections and impaired developmental growth.[22] In 2008, WHO reported that 55.5% of the population was overweight and 22.2% classified as obese,[23] and trends reveal that obesity rates are steadily rising.[24]

Hypertension and pre-hypertension are significant national medical concerns. Studies conducted in rural communities of Nicaragua that have revealed that 41.1% of their residents have hypertension. Beyond these patients who have met this traditional hypertensive minimum cut-off, there is also a large population of pre-hypertensive patients. Health promotional efforts that focus on preventative measures have been proposed to address this pre-hypertensive sub-population.[25]

Communicable diseases

Tuberculosis

In Nicaragua, 48% of tuberculosis (TB) patients have encountered issues with employment and 27% had reported social problems because of stigma associated with the disease.[26] In order to reduce false community beliefs and fears about tuberculosis that could be feeding into this social stigma, various solutions have been proposed and attempted in communities throughout the country.

In order to increase local awareness of this disease and improve TB control, volunteer-run TB clubs have been created in municipalities across Nicaragua to facilitate the creation of supportive community networks and lead educational workshops for citizens. These TB clubs have been reported to be a cost-effective strategy for controlling the spread of TB in Nicaragua; however, some have argued that they lack lack of sustainability in funding.[27] Outside of the educational realm, a team of researchers found that they could reduce internalized social stigma of TB patients in rural Nicaragua by pursuing patient-centered care that allowed for medical professionals to see patients at their homes and gain a better understanding of the support given to them by their social networks.[28]

HIV/AIDS

Though the prevalence of HIV/AIDS amongst Nicaraguan adults was estimated to be 0.3% by UNAIDS in 2015,[29] in the past UNAIDS' numbers have been claimed to be grossly underreported due to data collection issues.[30] Nicaragua's high prevalence of sexually transmitted infections (STIs), high risk sexual behaviors associated with the culture of machismo, low prevalence of condom usage, and the early age of first sexual intercourse of its citizens all contribute to concerns about rising HIV/AIDS rates.[30]

In Latin America, stigma and discrimination against HIV/AIDS serve as barriers to effective responses and are linked to social inequalities associated with gender, living status, and sexuality.[31] One study found that while 90% of Nicaraguan adolescents would accept and care for a family member with HIV/AIDS, only 69% would tell anyone else if they got diagnosed as HIV-infected and only 46% would share food with someone who was infected.[30] Nine years following the detection of the first HIV case in Nicaragua, the Nicaraguan government instituted Law 238 to protect the rights of those infected with HIV/AIDS in regards to confidentiality, access to healthcare, and nondiscrimination,[32] setting the precedent for future intervention strategies focused on decreasing AIDs stigma amongst various professionals, including health care workers.

Mosquito-transmitted diseases

The chikungunya, dengue, and Zika viruses co-circulate in Nicaragua, and those infected with one or multiple of these viruses can present with similar clinical symptoms, making clinical treatment and diagnosis more difficult.[33] Co-infections are common in endemic areas in Nicaragua.[33]

Malaria has also been a historically major health issue in Nicaragua, and during the 1930s up to 60% of the population had malaria.[34] Usage of bed-nets protecting against mosquitos have been reported to be 25.3% amongst all Nicaraguan households. Within these households, it was found that children were more often protected than adults with 46% of bed-net coverage of infants under 1 year.[35]

Women and children's health

Women waiting outside a gynecological exam room in Masaya, Nicaragua

Reproductive health

Nicaragua's adolescent fertility rate is one of the highest in Latin America. Around half of women in Nicaragua give birth before the age of 20. Approximately one quarter of all the births in the country involve adolescent mothers.[6]

Lack of use of contraceptives contributes to this high pregnancy rate. Out of all sexually active female adolescents, only 7% utilize condoms and only 47% use any modern method of contraception.[36] A highly tradition-based culture, a conservative government, and the Catholic Church's domination have been observed to negatively impact contraceptive use.[37] Educational promotion of contraception is generally only conducted by nongovernmental agencies or women's groups, and it is popular belief among many that various forms of contraceptive methods are detrimental to one's health.[38]

Cervical cancer

Nicaragua has one of the highest cervical cancer incidence rates in the world and the second highest morbidity rate in Latin America, second only to Haiti.[5] Although screenings are provided through their national public health system, only 35% of women have had a Papanicolaou (PAP) smear test by the age of 35 years.[39] A study showed that even when screenings services are adequate, patient follow-up and treatment after abnormal results is of poor quality.[40] A low-cost early detection alternative to PAP smears used in Nicaragua involves visual inspection of cancerous cervical legions with acetic acid.[41]

Infant health

A study conducted in 2000 revealed that poverty of Nicaraguan families heightened the risk of infant mortality. Its findings also showed that social inequity, or the contrast in wealth between a household and its surrounding neighborhood, further increased this risk.[42] In addition to income levels, it has been shown that violence against mothers increases the risk of infant and child mortality.[43] Intimate partner abuse also contributes to low birth weight of infants.[44] Overall decreasing national infant mortality trends correspond with higher educational levels of mothers and lower fertility rates.[45]

Violence against women

Out of Nicaraguan women married or previously married women of childbearing age, 52% have identified having had experienced physical violence by an intimate partner at least once.[46] Additionally, 21% of these women report having experienced a full combination of physical, emotional, and sexual violence at one or more points in their lives.[47]

Domestic violence has immediate and lasting effects on its victims. An overwhelming majority of emotional distress cases amongst every-married Nicaraguan women is attributable to current or former experiences of domestic abuse.[46] Domestic abuse is also correlated with higher incidence of unintended pregnancies in Nicaragua.[48]

See also

References

  1. 1 2 Angel-Urdinola D., Cortez R., Tanabe K. (2008). Equity, Access to Health Care Services and Expenditures on Health in Nicaragua. Health, Nutrition and Population of the World Bank.
  2. 1 2 3 Sequeira M., Espinoza H., Amador J. J., Domingo G., Quintanilla M., and de los Santos T. (2011). The Nicaraguan Health System. PATH.
  3. 1 2 Birn, A. E.; Zimmerman, S.; Garfield, R. (2000-01-01). "To decentralize or not to decentralize, is that the question? Nicaraguan health policy under structural adjustment in the 1990s". International Journal of Health Services: Planning, Administration, Evaluation. 30 (1): 111–128. doi:10.2190/c6tb-b16y-60hv-m3qw. ISSN 0020-7314. PMID 10707302.
  4. ↑ Webber, Laura; Kilpi, Fanny; Marsh, Tim; Rtveladze, Ketevan; Brown, Martin; McPherson, Klim (2012-08-13). "High Rates of Obesity and Non-Communicable Diseases Predicted across Latin America". PLOS ONE. 7 (8): e39589. doi:10.1371/journal.pone.0039589. ISSN 1932-6203. PMC 3418261. PMID 22912663.
  5. 1 2 Drain, Paul K.; Holmes, King K.; Hughes, James P.; Koutsky, Laura A. (2002-07-10). "Determinants of cervical cancer rates in developing countries". International Journal of Cancer. 100 (2): 199–205. doi:10.1002/ijc.10453. ISSN 1097-0215.
  6. 1 2 Blandon L., et. al. Early childbearing in Nicaragua a continuing challenge, In Brief, New York: Guttmacher Institute, 2006, No. 3.
  7. 1 2 3 Garfield, R. M.; Taboada, E. (1984-10-01). "Health services reforms in revolutionary Nicaragua". American Journal of Public Health. 74 (10): 1138–1144. doi:10.2105/AJPH.74.10.1138. ISSN 0090-0036. PMC 1651882.
  8. ↑ Golladay, F. (1980). Health sector policy paper. World Bank.
  9. ↑ http://data.worldbank.org/country/nicaragua
  10. 1 2 Braveman, P. et. al. (1985). Primary health care takes root in Nicaragua. World Health Forum. 6, 369–372.
  11. ↑ Holland B., Davis J., Syncrisis, G. (1972). The Dynamics of Health, #9: Nicaragua. U.S. Department of Health Education and Welfare. DHEW Pub. No. 74-50007.
  12. ↑ Donahue, John (2009-02-02). "The Politics of Health Care in Nicaragua before and after the Revolution of 1979". Human Organization. 42 (3): 264–272. doi:10.17730/humo.42.3.x737h47hqw3r2785.
  13. ↑ Amador, C. (1980). Informe de la Situacion de Salud de Nicaragua. MINSA.
  14. ↑ Chalkley, Martin; Malcomson, James (2002-01-01). "Cost sharing in health service provision: an empirical assessment of cost savings". Journal of Public Economics. 84 (2): 219–249. doi:10.1016/s0047-2727(01)00126-8. ISSN 0047-2727.
  15. ↑ Jack, W. (2003). "Contracting for health services: an evaluation of recent reforms in Nicaragua". Health Policy and Planning. 18 (2): 195–204. doi:10.1093/heapol/czg024.
  16. ↑ Muiser, Jorine; Sáenz, María del Rocío; Bermúdez, Juan Luis (2011). "The health system of Nicaragua". Salud Pública de México. 53: 233–242.
  17. ↑ Drake, J.; et al. (2011). "Stakeholder perceptions of a total market approach to family planning in Nicaragua". Rev Panam Salud Publica. 29 (5): 329–336.
  18. ↑ MINSA. (2007). Marco Conceptual del Modelo de Salud Familiar y Comunitario (MOSAFC). MINSA.
  19. 1 2 3 Nigenda, G. and Machado, M. (2000). From State to market: the Nicaraguan labour market for health personnel, 15(3): 312–318.
  20. ↑ Juan Roque. (2006). "Los salarios en Nicaragua". El Observador económico.
  21. ↑ Aschner, Pablo (September 2002). "Diabetes trends in Latin America". Diabetes/Metabolism Research and Reviews. 18 (S3): S27–S31. doi:10.1002/dmrr.280.
  22. ↑ Contreras, Mariela; Zelaya Blandón, Elmer; Persson, Lars-Åke; Ekström, Eva-Charlotte (2016-01-01). "Consumption of highly processed snacks, sugar-sweetened beverages and child feeding practices in a rural area of Nicaragua". Maternal & Child Nutrition. 12 (1): 164–176. doi:10.1111/mcn.12144. ISSN 1740-8709. PMID 25134722.
  23. ↑ World Health Organization. (2011). Noncommunicable diseases country profiles 2011: Nicaragua. WHO, 139.
  24. ↑ Laux, Timothy S.; Bert, Philip J.; González, Marvin; Unruh, Mark; Aragon, Aurora; Lacourt, Cecilia Torres (2016-12-12). "Prevalence of obesity, tobacco use, and alcohol consumption by socioeconomic status among six communities in Nicaragua". Revista panamericana de salud publica = Pan American journal of public health. 32 (3): 217–225. ISSN 1020-4989. PMC 4387569. PMID 23183562.
  25. ↑ Alicea-Planas, Jessica; Greiner, Lydia; Greiner, Philip A. (February 2016). "Hypertension and related lifestyle factors among persons living in rural Nicaragua". Applied Nursing Research. 29: 43–46. doi:10.1016/j.apnr.2015.05.010.
  26. ↑ Macq, Jean; Solis, Alejandro; Martinez, Guillermo; Martiny, Patrick; Dujardin, Bruno. "An exploration of the social stigma of tuberculosis in five "municipios" of Nicaragua to reflect on local interventions". Health Policy. 74 (2): 205–217. doi:10.1016/j.healthpol.2005.01.003.
  27. ↑ Plamondon, Katrina M.; Hanson, Lori; Labonté, Ronald; Abonyi, Sylvia (2008-01-01). "The Global Fund and Tuberculosis in Nicaragua: Building Sustainable Capacity?". Canadian Journal of Public Health / Revue Canadienne de Sante'e Publique. 99 (4): 355–358. JSTOR 41995119.
  28. ↑ Macq, Jean; Solis, Alejandro; Martinez, Guillermo; Martiny, Patrick (2008-05-08). "Tackling tuberculosis patients' internalized social stigma through patient centred care: An intervention study in rural Nicaragua". BMC Public Health. 8 (1). doi:10.1186/1471-2458-8-154. ISSN 1471-2458. PMC 2396624. PMID 18466604.
  29. ↑ UNAIDS (2015). Nicaragua Report. Available from: http://www.unaids.org/sites/default/files/country/documents/Nicaragua%20NCPI%202013.pdf
  30. 1 2 3 Manji, A.; Peña, R.; Dubrow, R. (2007-09-01). "Sex, condoms, gender roles, and HIV transmission knowledge among adolescents in León, Nicaragua: Implications for HIV prevention". AIDS Care. 19 (8): 989–995. doi:10.1080/09540120701244935. ISSN 0954-0121. PMID 17851995.
  31. ↑ Ugarte, W. (2013). "Measuring HIV- and AIDS-related stigma and discrimination in Nicaragua: Results from a Community-Based Study". AIDS Education and Prevention. 25 (2): 164–178. doi:10.1521/aeap.2013.25.2.164.
  32. ↑ National Assembly of Nicaragua. (1999). Ley 238: Promoción, Protección y Defensa de los Derechos Humanos ante el SIDA [Law 238: For the promotion, protection, and defense of human rights of people living with HIV/ AIDS].
  33. 1 2 Waggoner, Jesse J.; Gresh, Lionel; Vargas, Maria Jose; Ballesteros, Gabriela; Tellez, Yolanda; Soda, K. James; Sahoo, Malaya K.; Nuñez, Andrea; Balmaseda, Angel (2016-12-15). "Viremia and Clinical Presentation in Nicaraguan Patients Infected With Zika Virus, Chikungunya Virus, and Dengue Virus". Clinical Infectious Diseases. 63 (12): 1584–1590. doi:10.1093/cid/ciw589. ISSN 1058-4838. PMC 5146717. PMID 27578819.
  34. ↑ Garfield, R. (1999-07-31). "Malaria control in Nicaragua: social and political influences on disease transmission and control activities". Lancet. 354 (9176): 414–418. doi:10.1016/S0140-6736(99)02226-6. ISSN 0140-6736. PMID 10437886.
  35. ↑ Kroeger, A.; et al. (1997). "Operational aspects of bednet impregnation for community-based malaria control in NIcaragua, Ecuador, Peru, and Colombia". Tropical Medicine and International Health. 2 (6): 589–602. doi:10.1046/j.1365-3156.1997.d01-319.x.
  36. ↑ Zelaya, E.; Peña, R.; García, J.; Berglund, S.; Persson, L. A.; Liljestrand, J. (1996-12-01). "Contraceptive patterns among women and men in León, Nicaragua". Contraception. 54 (6): 359–365. doi:10.1016/s0010-7824(96)00203-x. ISSN 0010-7824. PMID 8968664.
  37. ↑ The World Bank. Effective family planning programs. Washington D.C.: World Bank, 1993.
  38. ↑ Berglund, S.; Liljestrand, J.; Marin, F. M.; Salgado, N.; Zelaya, E. (1997-01-01). "The background of adolescent pregnancies in Nicaragua: a qualitative approach". Social Science and Medicine. 44 (1). doi:10.1016/s0277-9536(96)00084-6.
  39. ↑ Claeys, P.; Gonzalez, C.; Gonzalez, M.; Page, H.; Bello, R. E.; Temmerman, M. (2002-11-01). "Determinants of cervical cancer screening in a poor area: results of a population-based survey in Rivas, Nicaragua". Tropical Medicine & International Health. 7 (11): 935–941. doi:10.1046/j.1365-3156.2002.00953.x. ISSN 1365-3156.
  40. ↑ Vastbinder, M.; Castillo, C.; Bekkers, R. (2010). "Barriers to follow-up of abnormal Papanicolaou smears among women in Leon, Nicaragua". Tropical Doctor. 40 (1): 22–26. doi:10.1258/td.2009.090076.
  41. ↑ Claeys, P.; De Vuyst, H.; Gonzalez, C.; Garcia, A.; Bello, R. E.; Temmerman, M. (2003-08-01). "Performance of the acetic acid test when used in field conditions as a screening test for cervical cancer". Tropical Medicine & International Health. 8 (8): 704–709. doi:10.1046/j.1365-3156.2003.01082.x. ISSN 1365-3156.
  42. ↑ Peña, R.; Wall, S.; Persson, L. A. (2016-12-12). "The effect of poverty, social inequity, and maternal education on infant mortality in Nicaragua, 1988–1993". American Journal of Public Health. 90 (1): 64–69. doi:10.2105/ajph.90.1.64. ISSN 0090-0036. PMC 1446115. PMID 10630139.
  43. ↑ Asling-Monemi, K.; Peña, R.; Ellsberg, M. C.; Persson, L. A. (2003). "Violence against women increases the risk of infant and child mortality: a case–referent study in Nicaragua". Bulletin of the World Health Organization. 81 (1): 10–16. PMC 2572309. PMID 12640470.
  44. ↑ Valladares, Eliette; Ellsberg, Mary; Peña, Rodolfo; Högberg, Ulf; Persson, Lars Ake (2002-10-01). "Physical partner abuse during pregnancy: a risk factor for low birth weight in Nicaragua". Obstetrics and Gynecology. 100 (4): 700–705. doi:10.1097/00006250-200210000-00015. ISSN 0029-7844. PMID 12383537.
  45. ↑ Peña, R.; Liljiestrand, J.; Zelaya, E. (1999). "Fertility and infant mortality trends in Nicaragua 1964–1993. The role of women's education". Journal of Epidemiological Community Health. 53: 132–137. doi:10.1136/jech.53.3.132. PMC 1756845.
  46. 1 2 Ellsberg, Mary; Caldera, Trinidad; Herrera, Andrés; Winkvist, Anna; Kullgren, Gunnar. "Domestic violence and emotional distress among Nicaraguan women: Results from a population-based study". American Psychologist. 54 (1): 30–36. doi:10.1037/0003-066x.54.1.30.
  47. ↑ Ellsberg, M.; Peña, R.; Herrera, A.; Liljestrand, J.; Winkvist, A. (2000-12-01). "Candies in hell: women's experiences of violence in Nicaragua". Social Science & Medicine. 51 (11): 1595–1610. doi:10.1016/s0277-9536(00)00056-3. ISSN 0277-9536. PMID 11072881.
  48. ↑ Salazar, Mariano; San Sebastian, Miguel (2014-01-01). "Violence against women and unintended pregnancies in Nicaragua: a population-based multilevel study". BMC Women's Health. 14: 26. doi:10.1186/1472-6874-14-26. ISSN 1472-6874. PMC 3925120. PMID 24521005.
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