PH 623- Country Report: Nicaragua

Nicaragua is a country of vast mountainous rainforests and large plots of land

dedicated to agricultural practices. Currently, 70% of the population of Nicaragua

participates in agriculture, in some form or another, as it contributes to 20% of the Nation’s

GDP and sustains the country’s main export 1. Although this number has been drastically

reduced since the 1960’s, the amount of people in direct contact with land or animals on a

regular basis is significant and contributes heavily to the health disparities between the

wealthy/urban and poor/rural communities. Nicaragua continues to be the second poorest

country of Latin America. Poverty is the main social determinant of the population’s

overall health status with an estimated poverty rate of 45% and 17% living in conditions

of extreme poverty 1. Nicaraguan healthcare currently operates in a socialized medical

system, but the pathway to their current health system was wrought with dictatorships,

uprisings, proxy wars, and foreign interventions, all of which eventually led to the general

stabilization of the system we see today.

The Nicaraguan region became occupied, sometime after 500 CE by Central

Mexican natives. This culture lived in a relatively peaceful existence through hunting, fishing,

agriculture, and trading with Caribbean islands. However, this all changed after the territory

was occupied by Spaniards in 1522 AD with the eventual full colonization in 1524 AD 15. The

clashes between Spaniards and native populations, along with the introduction of novel

diseases, led to the demise of the tribes and cultures that existed in the region. The land

became parceled out by conquistadors and the natives were enslaved to work in agriculture

in Western Nicaragua and in the mines in the Northern region 15. The great majority who

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were not of working ability were sent as slaves to Panama and Peru. Eventually the

Nicaraguan natives, along with 5 other nearby provinces’ indigenous people, banded

together to fight for independence against Spain calling themselves the Federal Republic of

Central America in 1821. This united front overthrew the overseeing Mexican monarchy in

1823, ousting Spain, and gaining their sovereignty. Nicaragua attained its definitive

independence in 1838. Health systems during this period were like many others across the

world, involving independent practitioners trained through mentorships in their field and

getting paid directly per services rendered. Medicine was a mix of Western and indigenous

styles; Spain influenced procedures mixed with native remedies handed down through the

generations. There were no governmental agencies overseeing licensing, practicing, or

subsidies for the population to gain access.

Nicaragua, once again lost its sovereignty during the United States’ occupation of the

country through the Banana Wars. The military invasion occurred between 1912 and 1933 in

order to prevent any other country from building the Nicaraguan Canal 2. Similar to previous

historical occupations, the intervention brought an era of rebellions and uprisings both

against US and within factions inside the country. The United States Marines brought with

them communicable diseases, which were rapidly spread through the vulnerable

populations and created new endemic diseases in the country that we still see today. Death

rates from famine and novel diseases spread rapidly across the country, which in part led to

the eruption of Civil War in 1926 and the subsequent pullout of US troops.

Post-Civil War, the Somoza dynasty emerged as a stern military dictatorship.

However, healthcare access during this period saw significant improvements, albeit fraught

with its own tribulations. Between 1942 and 1959, factions of the Nicaraguan work force

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became “organized as a result of expansion of commercial agriculture, industry, and the

state of bureaucracy” 3. This collective power structured a primitive form of social security in

order to provide health services to the working class. Before the next revolution in 1979, this

system now termed as the “Nicaraguan Social Security Institute (NSSI)” was serving 16% of

the economically active population 3. This economically active population consisted of

mostly government workers (66%), industrial workers (28%), and to a lesser extent

agricultural workers (2.7%) 3. Obvious class disparities existed in this structure as the lower

economic group of citizens and most at risk to communicable diseases and injury received

the least support through the NSSI. During this period the Ministry of Health, consisting of

separate provincial offices with little communication between the divisions, was formed as a

result of NSSI in 1956 16. The overall Ministry of Health’s budget accounted for 16% of

health sector expenditures (i.e. medical care) and 80% to “operating expenses” for the MOH
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. Fraud infected this organization and embezzlement was a common practice. Of the 16%

of health sector expenditures, 79% went to healthcare within the capitol Managua, in which

~20% of the citizens lived at the time 3. The effect of these allocation policies left the vast

majority of Nicaraguans in the rural and agricultural areas to seek medical care in the

sparsely available private sector. The morbidity and mortality rates of disease in many rural

citizens immensely outweighed those of the urban population. Malnutrition during this

Somoza era was a significant issue, in which 57% of children less than 5 years of age

suffered from some degree of malnutrition, with the majority of the crisis occurring in rural

regions 3. Also being location/class specific problem was maternal and childhood mortality. It

was estimated that almost 70% of child birth occurred outside of the NSSI medical system.

This, in combination with poor nutrition and lack of maternal care caused the infant mortality

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to rise to 15% in the mid-1970s. Childhood death accounted for 32.3% of all deaths in

Nicaragua in 1975 3. The failure of the Ministry of Health to address the severe public health

problems and class disparity was rooted in the vertical control system of the dictatorship and

fragmentation of the 23 institutions making up the public health sector.

The Sandinista revolution fell the Somoza dictatorship in 1979 and left the country

largely in ruins. The revolution caused approximately 600,000 people to be homeless and

150,000 to be in exile out of a total of 2.8 million population 4. Outside support, particularly

from USA supported the regime change and infused money into the new government. New

armed conflict almost immediately arose in 1981 due to the CIA backed Contra Wars, and

outside financial aid was subsequently ceased. Although this was a tumultuous period, the

new Nicaraguan government established a Unified Health System that instated the

Nicaraguan Ministry of Health (MINSA) to spearhead health services throughout the nation.

This system integrated the old NSSI to be under the direction of MINSA in order to make a

financially feasible single national health service available to all Nicaraguan citizens

regardless of background, class, or location 5. This allowed for the NSSI hospitals to open

their doors to the entirety of the population, not just the working citizens. In 1984 10% of the

national budget became allocated to supporting the health sector, which led to the

construction of 309 new healthcare facilities and training of over 3,000 new health

professionals 5. MINSA also began the country’s first public health programs geared at

prevention based health efforts such as hygiene practices and communicable disease

prevention strategies. MINSA supported the development of the “Brigadista” program

geared at training community health advocates to be educated in healthcare and have them

serve in underserved rural regions 6. Despite Contra attacks, lack of supplies, and war-

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related attacks on health facilities, malarial control efforts became quite successful during

this period in which 8 provinces attained zero cases within the country 7. However, war

related population movements promoted the spread of other diseases such as dengue and

leishmaniasis. The most important medical event during this period was the 1985-1986

measles epidemic, thought to be directly attributed to migration from conflict zones and high

levels of contact in refugee camps. Over 2000 people, mostly children, were affected.

MINSA, with the help of outside influences and their money, expanded their vaccination

strategies to refugee camps and rural regions affected by conflict 16.

After the cessation of the Contra Wars in the early-90s, the Nicaraguan government

has been shifting towards a more market-oriented economic policy that has significantly

affected their healthcare sector. This healthcare shift has increased the private sector

healthcare activity as well as decentralized many important public services. However, the

current healthcare system in Nicaragua is still ultimately vertically governed by the

Nicaraguan federal government and involves the collaboration of these private and public

institutions. This healthcare platform provides universal free health care for all citizens

regardless of class, status, or employment as had been previously attempted before 8.

Nonetheless, this model still poses issues with unequal distribution of resources and

personnel that contribute to the persistent lack of quality care or access to care in remote

areas of the country. Services offered by the public hospitals and clinics are very limited in

their scope. Treatment offered in these public facilities is restricted to outpatient care,

minimal diagnostics, and occasional minor procedures. The decentralized healthcare model

consists of three distinct administrative levels, each providing different services. These levels

include a central level, a local system of comprehensive care level, and a generalized

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municipal level 8. The MINSA controls only the central level in an attempt to trickle down the

funding to the lower levels. The model involves the use of annual contracts between MINSA,

local hospitals, and rural healthcare centers. These contracts are formed through

negotiations via the medical centers based on predicted levels of annual goals and specific

actions by the healthcare centers. The contract system is wrought with problems as

predictions are generally over measured and under funded with minimal oversight into the

spending of the allocations 10. Regardless, the contract system is meant to be incentive

based with the amount of federal funding dependent upon the institutional performance 10.

As part of the public health socialized system, the revenue generated from the hospitals and

health centers are consolidated and calculated by the Ministry of Finance before

redistribution back into the original intuitions can occur. This leaves a significant lag of

months to years before a medical center will receive the funding they deserve, and can lead

to a substantial lack of care to facilities regionally overwhelmed by disease or unpredicted

events 13. The government of Nicaragua has been attempting to strengthen its efforts in the

healthcare sector in the 21st century and received a $60 million investment by the World

Bank in 2020 to do so 9. These funds are allocated to increasing the number of emergency

services, ambulance vehicles, and hospitals in the country. Additionally, the Inter-American

Development Bank and South Korea invested $50 million to expand Nicaragua’s broadband

infrastructure to connect the country’s 276 health care centers nationwide. Regardless of its

internal follies, the Nicaragua system is still fulfilling its human right to healthcare based on

level of income as it sits at 96.1% access to care according to the Human Rights Measure

initiative 11.

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 The most recent global burden of disease study in Nicaragua was performed in

2019. Although this information is relatively dated, the medical issues that continually persist

in the country tend to have a stable trend on their projections. In terms of years of life lost,

the largest causes in descending order are lower respiratory infections, ischemic heart

disease, diarrheal diseases, and pre-term birth complications generally associated with

malnutrition or drug/alcohol exposure 12. Although diarrheal disease deaths have decreased

almost 25% between 1990 and today, they still account for the 7th leading cause of death in

Nicaragua and are completely preventable and usually treatable 14. The risk factors

associated with the highest disease burden in Nicaragua are connected to dietary risks,

elevated blood pressure, and alcohol abuse 13. In the Western hemisphere, Nicaragua ranks

as the worst country for major nephritic diseases and the worst country for alcohol abuse per

capita 13. As the development and westernization of Nicaragua progresses, these lifestyle

associated disease burdens expand along with it.

Although diarrheal diseases have seen significant improvements over the last 30

years in Nicaragua, they remain extremely important in the numbers of years of life lost

(YLL). In 2017, diarrheal diseases accounted for the leading cause of YLL in the country, the

most it has been since the 1990’s 14. Diarrhea is a disease of many causes and underlying

issues. Viral and bacterial infections can stem from contact with a contaminated source, be it

water, food, animals, or other infected humans. Hunger and malnutrition can also lead to

diarrhea through ingestion of potentially toxic or spoiled foodstuffs and poisonous plants.

Diarrhea disproportionally affects children of ages 2-5 years old and has a capability to

dehydrate, debilitate, and cause death. Diarrhea is also a disease of inequity as it affects

poor and marginalized communities the hardest, especially those without safe access to

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water, hygiene, and healthcare. Estimates show that up to 80% of deaths from diarrhea

could be feasibly prevented through improvements to safe water, sanitation, better nutrition,

and access to healthcare 14. Due to funding issues, the Nicaraguan Health and Vital

statistics center has substantial limitations when obtaining hospital and death records in

order to make any financial progress within the country for preventive measure policy

implementation. Certain populations of those affected by diarrheal diseases also die outside

of medical or hospital care and may not even be included in the already inadequate vital

statistic records. Because of this issue, Nicaraguan preventive medicine policymaking is

largely dependent on results of independent epidemiological research in the country by

outside sources 14. The Nicaraguan government and healthcare system does not take

adequate steps to correct diarrheal burdens in the hardest-hit rural communities, but

conversely focuses their efforts on urban populations and diseases of affluence instead. The

disparity of measures made by the government between the rural and urban disease burden

is easily distinguishable.

A positive association between the number of daily hours without water in a home

and increased incidence of diarrhea is directly correlated 14. The majority of Nicaraguan rural

communities and impoverished neighborhoods retrieve water from a well source or open

exposed water sources (e.g. rivers, lakes, & ponds). Although we seem to think of well

sources in the US as relatively safe, the classification of well water in Nicaragua can be a

hole or trenched source of water and generally not deep enough to provide a secure

untainted fresh source 17. Interruption in piped water from local or municipal sources has

also been shown to have a direct correlation to increased rates of diarrhea. This incidence

increase can be described though water stagnation, intrusion of sediment into empty pipes,

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backflow, first flush events, and storage of water at a household level for use throughout the

day 17. The Nicaraguan Ministry of Health and other federal agencies do not incorporate

funding into municipal or rural health campaigns to improve access to water, consistency of

water supply, nor promotion of safe water sanitation practices 13. Instead this issue is left to

individual municipalities and in the case of many rural communities, can be nonexistent.

This substantial underlying issue is directly related to the upstream affect of the diarrheal

disease burden disproportionally affecting the rural population. This does not generally

affect urban populations as they have relatively clean, safe, and consistent water sources

provided by their cities. There are no plans by the government to improve water sources

throughout the country and Nicaragua as a whole is reliant entirely on outside organizations

to help fix the problem 9.

The incidence of diarrhea has demonstrated a seasonal pattern in Nicaragua. The

most recent study has displayed a large peak in cases between May and July with ~200

additional cases of diarrhea per 1,000 person-years from 2015-2017 as compared to

baseline seasonal effects 14. Nicaragua has a bi-modal distribution of precipitation. The

highest amount of rainfall and associated flooding in most regions of Nicaragua occur during

the month of May, with second highest being in October. The etiologic agents most

associated for this increase include Norovirus and Sapovirus, accounting for 45% of all new

diarrheal cases 14. Norovirus and Sapovirus are diseases most associated with fecal-oral

contact. Elevations of the water table and subsequent spillover of waste sites of human and

animal excrement can be attributed to these elevations in diarrheal cases. Although medical

centers are sparse in rural regions and can be otherwise difficult to access normally, they

become drastically more overwhelmed during the wet months. Because contracts and

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funding are based on annual predictions by individual medical centers, the seasonality of

diseases creates a significant lack of care. Individuals are known to not to seek care, if even

available, due to the erroneously long wait times. Because of this issue, many children die

from this treatable disease. The Nicaraguan government does not seem to recognize this

problem, and if they do, they choose to overlook it. They instead adhere to the annual

budget model for funding of medical sites. The MINSA does not seasonally allocate care

workers to hard hit medical centers, as staffing is also based on annual models and

predictions as well 9. This lack of oversight for the seasonality of diseases perpetuates the

disease burden of the country and the overall years of life lost.

Although inadequacies and disparities are largely present in the Nicaraguan

government’s approach to diarrhea, the country has made significant improvements in the

last 30 years in reducing the overall burden of the disease. Since 1990 diarrheal disease

disability-adjusted life years were reduced by 84%, falling from the number one cause of

DALYs to number seven in the country 12. This reduction can be largely attributed to three

main factors; education, international infrastructure improvements, and reduction in

malnutrition 17.

The 1990’s was a turning point for Nicaragua after the end of the Contra Wars for

lifestyle and healthcare improvements. With outside intervention, the Nicaraguan

government launched educational campaigns with the remnants of the “Brigadistas” to

educate populations on the contributing factors of diarrhea and how death from the disease

occurs 18. The campaign utilized promotional posters, community forums, and various other

media outlets to bring forth attention on the disease. Information on boiling water before

consumption, simple hand washing hygiene practices, and how to prevent fecal

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contamination of local water sources were the primary spotlight. However, a significant

focus was also placed on educating mothers on understanding dehydration and

consequences of it during the disease process 19. Of course, educational campaigns can

only go so far to and affect those willing to listen. Like in many other countries, there is a

large distrust in the local and federal government within Nicaragua. Some indigenous tribes

and rural populations rejected these practices and still heavily contribute to the disease

burden 14.

As access to safe water is a considerable international concern many outside

organizations, spearheaded by the World Health Organization’s safe water campaign, have

attempted to provide safe drinking water to rural communities over the decades.

International governments, international non-governmental organizations, and religious

missionaries have made successful attempts to build deep wells with safe drinking water for

communities still using open or unsafe sources. The favorable responses from communities

and support by government officials for this practice have contributed largely to the reduction

in disease burden we see today 9.

The food sovereignty campaign in Nicaragua launched in 2007. The system was

intended to help reduce hunger levels by having continual access to plentiful, healthy, and

affordable locally produced food 20. This was accomplished through dispersion of land to a

collection of small local land holdings, redistribution of indigenous lands back to the people,

and the creation of cooperatives 20. Agroecology education practices have been

implemented by the Nicaraguan government to core curriculums in schools in order to assist

in dispersal of knowledge of plant and animal farming practices. This network has created a

series of small-scale producers freely contributing to an intra-community trade network to

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ensure access to food for all. Excess food not immediately utilized in the local area is

integrated into the agribusiness model in which small-scale farmers can contribute to the

country with financial incentives. In communities where this practice has been integrated,

the malnutrition and subsequent diarrheal deaths have waned 20.

The greatest challenge to solve the underlying issues causing diarrhea in Nicaragua

has ultimately come down to finances. Being the second poorest country in the Western

hemisphere, funds have been strictly controlled and tightly allocated throughout the country

for decades 21. Nicaragua uses the greatest good approach to management of medicine

and infrastructure. Diseases of affluence, which occur more frequently in Nicaragua’s urban

populations, have garnered most the attention and funding in the last few years as their

burden has dramatically increased 21. Even though drastic improvements have been made

over the last three decades in bringing down mortality rates from diarrhea, it will still remain

a rampant problem until governmental funding acknowledges its shortcomings and provides

access to safe water, hygiene, healthcare, and nutrition to all rural communities.

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