Healthcare, a Sick System in Nicaragua

Valeria Manuel Pitt, 49, -a substitute judge of the community of Miskitos in Sangnilaya or Aguas Claras, municipality of Puerto Cabezas in the northern Caribbean coast of Nicaragua- lives off of agriculture and selling coal. In January, her one-year granddaughter had difficulties to breathe, diarrhea, fever and vomit. She had to take her by bus to the hospital in the region’s capital because the ambulance never arrived. The bus only makes one trip a day. It departs the community at six a.m. and arrives in its destination at eight o’clock. In winter, the road is so damaged that the journey might even take three hours, an extended hassle while transporting a sick person.

The girl was admitted to hospital for three days. She was given acetaminophen and saline instead of not the medication she needed. Valeria says that she received a prescription, she does not remember the names nor quantities of the medications, she only know that the pharmacist said the bill amounted to “85 dollars”. This is a lot of money for her because she lives in poverty. She does not have a steady income and she makes a living selling coal, for which she charges 2.5 dollars a bag, which means that she had to sell 34 bags of coal on that day to cover the cost of her granddaughter’s treatment (regardless of the slow production process).

“When you go to the hospital and they don’t have the right medicine, you get a prescription and you have to go to the pharmacy and purchase it yourself. If you don’t have a family member in the city (Puerto Cabezas), you have to pay for a hotel and the cost increases”, she adds.

This is one of the many stories that illustrate the reality of public health services in the northern Caribbean coast of Nicaragua. It resembles that of the rest of the country, which is headed for public elections on November 7th. The Sandinista leader, Daniel Ortega, is seeking his fourth consecutive term in the executive branch, portraying free-of-charge healthcare as one of his electoral campaign axes. However, underneath this triumphalist speech, the system’s diagnose is disheartening.

Testimonies reveal weaknesses in medicine supply, deteriorated facilities, lack of human resources and disorganized installation of a hospital infrastructure that is presented by the government as “the largest in Central America”, which has expanded at the expense of a debt that has amounted to approximately 237.61 million dollars between 2007 and the first semester of 2021, per data of the National System of Public Investment (SNIP, for its Spanish acronym), almost 50 percent of this year’s health budget.

There are different ways to get to Prinzapolka, Puerto Cabezas and Waspam, three of the poorest municipalities in the Caribbean coast of Nicaragua. By sea, river or roads, the landscapes look like a postcard: a scenery with coconut palm trees, pine trees in valleys with wooden houses inhabited by citizens who live in oblivion and in total inequality. A deliberate visit of these routes means at least a week of strolling through each community.

In the framework of the special feature #NicaraguaNoCalla, CONNECTAS and ONDA LOCAL visited the medical centers in these municipalities. In the region, at least 69 percent of the population lives with less than three dollars a day, according to recent information revealed by Instituto de Investigaciones y Gestion Social, a local institute working in the area. The region is also prone and vulnerable to natural disasters. Moreover, in these three municipalities 90 out of the existing 185 communities do not have healthcare centers and people completely rely on natural medicine.

Long distances and a diverse geography -amidst rivers, forests, widely-spread towns, and destroyed roads for land communication- make it difficult to access healthcare services. Sagnilaya, a rural village in Puerto Cabezas populated by Miskitos, has a three-small-room medical center that does not provide service on a daily basis. Last January, upon our visit, the people explained to us that the nursing staff would come back the next day because they had to go to the capital to conduct administrative procedures.

Sangnilaya’s medical center was replaced in 2008 by the State’s Fund of Emergency Social Investment (FISE for its Spanish acronym) and financed by the mayor’s office of Puerto Cabezas and the Inter-American Development Bank. Thirteen years later, it looks abandoned, its walls are dirty, the paint is corroded, the ceiling is falling off, and the latrine does not have a roof or a door. The center is small, and on the day of the team’s visit no one attended, in part because it was closed and also because the community prefers to self-medicate with home remedies and to visit the center only for emergencies.

The reality of those who attend is the shortage of medicine supply. “Before, the government sent enough medication to cover health problems, but now supply is low and it is not enough for the entire population. The medical center services five communities aside from Sangnilaya; it is just insufficient”, asserts Valeria, whose granddaughter is now fully recovered.

Yamileth Obando Leman, a resident, agrees with Valeria. “The clinic is there, but it is not helpful because medication is scant… people from many communities come, so supply is not enough”, she reiterates.

The health situation of this community demands attention, according to Valeria, diseases such as malaria and diarrhea are out of control and have become an issue in the northern Caribbean coast. On the day of the visit in January, the lack of visits to the medical center was be explained by the fact that people in the community know it is closed, those who live farther take the risk of finding its doors closed.

According to the Ministry of Health’s (MINSA) National Health Map, P. vivax malaria was the main epidemic disease in 2020 in the municipalities of Puerto Cabezas, Prinzapolka and Waspam, in the northern Caribbean, with 12,223 cases. Another disease that ravaged these municipalities was diarrhea, with 420 cases, becoming the third cause of hospitalization and the sixth cause of death with 23 cases.

The medical center barely services sick people, Valeria complains, she explains that for serios illnesses, the center “contacts Puerto Cabezas, but unless the patient is pregnant, the ambulance does not come and patients have to find the way to get there(...) Here if you don’t have money, you die because you can’t leave”. Paradoxically, the vehicles of the Ministry of Health (MINSA), including ambulances, are used for partisan activities of the Sandinista National Liberation Front (FSLN, for its Spanish acronym), as evinced in the Facebook of the Northern Caribbean Regional Government, controlled by that party.

Free and universal access to healthcare is an institutional policy of the MINSA. Ortega insists that the neoliberal governments (1990-2006) dismantled the public system and privatized health.

“The budget for medication was minimum. Patients had to bring alcohol, dressings and sheets(…) Hospital infrastructure was in ruins. Laboratory exams, treatments and surgeries cost thousands of cordobas, which made it impossible for poor families to access services”, reads the 2022-2026 National Plan Against Poverty, the cover of which depicts a doctor with a red and black handkerchief vaccinating a woman, whose hand is gesturing the “V” for victory and the number 2, the box of the FSLN party as well as the initials of Daniel Ortega Saavedra (in Spanish).

The document adds that, starting in 2007, when the Sandinista ruler got back to power, free and universal access to healthcare would be guaranteed. Per records of the Ministry of Treasury and Public Credit (MHCP, for its Spanish acronym), the MINSA’s budget tripled between 2006 and 2020, from 180 million to 529.88 million dollars, nevertheless, this budget did not help overcome the low investment per capita of the medication item, which is equivalent to 74 dollars in 2021.

The report Outlook on Health: Latin America and the Caribbean 2020 (“Panorama de la salud: Latinoamerica y el Caribe 2020”) by the Organisation for Economic Co-operation and Development (OECD) and the World Bank, with indicators for 33 Latin American countries, showed that the “out-of-pocket expenditure” -assumed directly by users without the state financing- in Nicaragua’s health sector represents an average of 3 percent of what is usually spent; in municipalities as poor as Waspam, Puerto Cabezas and Prinzapolka, this becomes a major difficulty.

For doctor Carlos Hernandez, member of the Multidisciplinary Scientific Committee, a group of health practitioners reunited in the context of the Covid-19 pandemic and that has been critical of the government, one thing is to have a no-charge policy in public health services and a different one is to make it free. “Maybe the medical center provided two weeks of medicine, but the patient has to buy medicine for other two weeks”, he explains.

Yorleny Lisayda, 30, an auxiliary nurse with straight hair, born and bred in the community of Yulu -where the riches were planted in Yulu or mahogany trees- is in charge of attending to the medical center. The building has two rooms and it shares the plot of land with a little stilt house. She considers her work difficult because the medical center is ridden with limitations. With conviction, she mentions that she works overtime, sometimes without proper compensation, and that she uses all of her mobile’s data plan helping people.

Yulu is in the Miskito territory of Twiwaupasa, the most striking thing there upon arrival -aside from the poverty- is the state of neglect of the medical center. Things are so bad that community members have lost faith in things changing for them or the center. It is not listed among the 807 medical centers that, according to the MINSA, have been refurbished in the country, nor on the list of those to be refurbished. Here, even posters of Ortega and Rosario Murillo (commonplace in public institutions in other regions, especially the capital city) and the red and black flag of the FSLN are absent.

The auxiliary nurse experiences the system’s precariousness firsthand. The health system categorizes the facility where she works as a sub-facility -a place that is enabled to service several communities nearby- but she believes it lacks the characteristics of a sub-facility, it does not have a laboratory, a professional nurse, a primary care physician, an ambulance and a shelter home. Medications are insufficient, and the area has a prevalence of deadly diseases such as malaria, diarrhea and skin ailments.

“An auxiliary nurse does not have the same capacities as a professional nurse. There used to be a professional nurse here, but she was relocated to Puerto Cabezas in April 2020 due to a malaria pandemic. I was left with a social service medic (…) in case of an obstetric complication with a pregnant woman, what can an auxiliary nurse do? She can hold up, but not much more!”, she adds with a self-critical tone.

For Yorleny, the fact that the medical center lacks an ambulance generates a lot of difficulties and risks the lives of pregnant women and of sick patients that need to be transferred to the hospital in Puerto Cabezas. When there are serious cases, she calls the hospital in Puerto Cabezas and asks for an ambulance, but it takes at least three hours to get there, although the medical center is less than forty kilometers away from Puerto Cabezas.

Yorleny complains that, instead of improving the center, they have removed some of its capacities. “We used to have an ambulance that had been gifted by China Taiwan. But they took it from us and gave it to Puerto”; she states that on a given working day, as in other communities, few patients come and the only woman in sight walked away when she say the journalists team.

Sotero Winter, exwihta or community judge in Yulu, is sitting in his house garden after a visit to the medical center. It did not go as expected: he received bad news. “We have been told there is not enough medication to treat every patient. This is one of the problems we have right now, and we are asking the government to help us with medication to treat our community and its problems”.

The consumables sent by the MINSA are not enough and fail to meet the demand of a population exceeding 2,500 people. Yorleny makes miracles, as in the Bible’s miracle of the five loaves and two fish. She is given a thousand acetaminophen tablets for the month. The nurse estimates that, prescribing half the recommended dose, 10 acetaminophen tablets of 500 milligrams for an adult, her supplies could last for 100 patients. Usually, the indication is for a tablet every six hours, so the treatment would last three days, but these are mathematical calculations instead of her pragmatism talking.

“What I want is more medical consumables. Sometimes I want to give some to my patients but there is not enough. The doses cannot be diffused, even if I want it to”, she explains referring to the real circumstances she faces as a practitioner; this has actual consequences on patients, some relapse due to mistreated diseases.

In the banks of the river Coco or Wangki, one of the most fast-flowing of the country in wintertime and at the border with Honduras, reality is the same as in Sangnilaya and Yulu, despite the fact that there is a primary-level hospital in the municipality of Waspam (Remolino de Aguas) whereas there isn’t one in the aforementioned communities.

The river is the main transportation route, but it is only navigable in the summer by small boats and wooden rafts. The journey from one of the communities to the municipal capital of Waspam can take somewhere between eight to twelve hours. More torture.

Adrian Sierra Bucardo, regional council member of the Yapti Tasba Masraka Nanih Aslatakanka (YATAMA) or Children of Mother Earth indigenous party, summarizes the health situation as “disastrous”. For him, Waspam’s “Oswaldo Padilla” first level hospital is in reality a “mini hospital”, it does not have the capacity to service the entire municipality.

“There are several medical centers throughout the municipality, the service is awful due to lack of medication and of medical staff”, he adds. In communities in Waspam, in case of emergency, if people don’t have the necessary resources they die and never make it to the hospital, Sierra comments.

Transportation is scarce and expensive. “The minimum fare -of a private trip- to get from a community in Rio Coco to the hospital at de Waspam is of 10,000 cordobas (285 dollars)… and when you get there, service is still appalling”, Sierra complains.

The community of Asang Rio Coco, indigenous territory of Li Lamni, is located 120 kilometers away from the municipality of Waspam, in the high part of the river Wangki, explains Pitter Hendy, 32, substitute judge of the community. The boat makes only two trips per week. From Asang it departs each Monday to Waspam and returns on Wednesday, it departs again on Thursday and returns on Saturday. The roundtrip costs 40 dollars in the public boat.

Sometimes, evacuating a sick person entails renting the entire boat at exorbitant process, states Pitter. If you don’t have a family member in Waspam, the budget increases approximately by 25 dollars per day, considering the cheapest lodgings and food.

Staffing for the medical center in Asang is not permanent. “They bring a nurse every six months, then they send another one. We don’t have a professional nurse here, they send interns. There is shortage of medication, the Ministry of Health barely supplies any. The center is very small and the community is large, a total of 1,668 people live here, and people from neighboring communities come here looking for medication”, Pitter adds.

Away from Waspam at eight hours of river journey and another hour by bus, the community of Francia Sirpi faces the same problems as the neglected Caribbean. Inhabited by 448 families, this place belongs to the Miskito territory Wangki Twi-Tasba Raya, which has been subject to violence perpetrated by armed settlers or third parties seeking to take control of the land, driving forced displacement and damages to emotional health, per the Inter-American Commission on Human Rights.

The capacity to service the entire population is also absent here. The health unit was built in 2005 by the government of former president Enrique Bolaños. The community requires a larger one with a laboratory, female-oriented room, and with lodgings for the health practitioners to rest, says Emilia Pedro, denizen of the community.

Despite the current government taking pride in the fact that they are building hospitals, this community has been managing an expansion of the medical center for more than five years. Although she does not remember it exactly, Emilia says that works began to expand the unit, but it was left unfinished without explanation. Only some holes remain -filled with water at the moment of this interview- intended to hold the pillars of the new building.

A likely repair of the medical center was contemplated in the government’s 2007-2012 Public Investment Plan, but not much has changed in the area: reality is deplorable. At national level, zooming out on the public system, many places live under the same circumstances and other areas have works in progress that are being developed at the expense of the country’s indebtedness.

Vulnerable Health Infrastructure

Nicaragua had 1,092 health units in 2005, most of which were in bad shape, as referred to in the 2022-2026 Plan Against Poverty. It adds that between 2007-2020, the “largest public health infrastructure in Central America” has been built with the construction of nineteen new hospitals and the refurbishing of 46, construction and refurbishing of 1,259 medical centers, 192 health centers and 178 mother’s houses. Also, the health system has been improved with 66 mobile clinics.

Nevertheless, specialists consider that disorganized growth of the service network, lacking accessibility criteria for remote places is an ongoing issue in Nicaragua. “Where and following which criteria were those hospitals built?”, asks economic consultant Maykell Marenco in a tweet in which he evaluated the health system with these criteria: lack of beds, quality of the service and overcrowding levels in hospitals. According to the government, enormous network of centers is in place, and they brag about having 10,685 hospital beds, a number that is still insufficient to service the population.

The precarious health infrastructure in the northern Caribbean coast has been severely affected by hurricanes Eta -category 4- and Iota -category 5- which hit the area on November 3rd and 16th 2020, respectively, revealing the infrastructure’s vulnerability. The State reported damages of around 2.35 million dollars in the northern Caribbean and 12.6 million at national level.

In the community of Haulover, municipality of Prinzapolka, both hurricanes stroke and destroyed the medical center. Prior to these natural phenomenon, the community was a strip of land with a gorgeous view to the Caribbean Sea on one side and to the Haulover lagoon to the other. The fury of the hurricanes formed a small island, dividing the community in two. There are two ways to get to Haulover by boat: through the sea or through a channel that leverages the area’s rivers and lagoons, its wharf is known as Lamlaya.

“We don’t have a clinic now, it was left in ruins. A social medic from here was transferred to Alamikamba and we only have a community nurse. She cannot manage alone, she needs a doctor or a professional nurse to respond to emergencies. Sometimes you go and medication has run out; in this situation, people cannot buy any”, Jacqueline Budier, a community member, explained.

According to the MINSA, service will improve with the construction of the Nuevo Amanecer regional hospital at Bilwi, which has a projected investment of 74.47 million dollars, and intended to service northern Caribbeans. Its construction is foreseen to conclude on December 31st, 2023, but for communities such as Yulu, Francia Sirpi, Asang, and Haulover, the lack of access remains invariable and costly.

The repression exercised by the government of Ortega conspires against the interests of the population. The Nuevo Amanecer hospital is financed in part by the Central American Bank for Economic Integration (CABEI) with 52.97 million dollars. Cofinancing of the hospital was guaranteed with a donation of 21.5 million dollars from the Kingdom of the Netherlands, but cooperation was halted in 2018 due to the repression conducted by the Nicaraguan regime.

"Due to serious violations to human rights committed by government officials and paramilitary police groups, the government of the Kingdom of the Netherlands has suspended cooperation with the government of Nicaragua pertaining to the construction of the hospital in Bilwi, Nicaragua", reads the press release posted in the embassy’s website. It adds that the decision was made “due to complaints regarding the obstruction and serious delays in access to healthcare for people in manifestations (opposition) in Nicaragua".

Construction and refurbishing of the country’s health infrastructure is dependent on external cooperation, as stated before. Between 2008 and 2021, the Inter-American Development Bank (IDB) and the CABEI became the leading financers of Nicaragua’s hospital network and have sustained their support to the regime of Daniel Ortega, despite the serious situation of human rights and the Dutch people’s firm stance in the matter.

The government claims that eight new hospitals are under construction and that fifteen medical centers are being refurbished at the moment, yet under-execution of the works is one of the factors impacting the system. Only one of the promised hospitals was inaugurated last August.

For doctor Carlos Hernandez, specialist in public health, “results are not measured in the number of appointments, in the amount of buildings; those are just steps forward, the key is to focus on how many diseases and deaths we prevented. We have been shown pompous reports centered on infrastructure and technology improvement, but results are seldom discussed”, he manifests.

Hernandez acknowledges evident progress such as improved and expanded infrastructure and health personnel, improvements in life expectancy at birth and decrease in mortality of specific groups, especially among children. But some concerns persist in terms of the overall population’s health. “The country’s mortality due to Covid-19 is high. Dengue is out of control and there are more cases of malaria, chronic disease prevention policies are missing”.

31,911 people died in Nicaragua in 2020; 6,573 more than in 2019, the main causes of death were: acute myocardial infarction, diabetes mellitus and pneumonia. Independent medical organizations question authorities’ credibility, they claim that Covid-related deaths have been covered up with diagnoses such as atypical pneumonia. As of July 20th, 2021, the MINSA had reported a total of 7,313 positive cases of Covid-19 and 194 deaths, the lowest figures in Central America per their own data.

Staff Deficit, Another Symptom of the System’s Poor Health

Although the World Bank estimates that there is a doctor per thousand habitants in Nicaragua, the MINSA’s statistics show that the work force went from 22,083 health practitioners in 2006 to 36.649 in 2020, including doctors, nursing personnel and technicians.

“There are less and less doctors”, complains Ricardo Pineda, a member of the Medical Association of Nicaragua (AMN, for its Spanish acronym), one of the 24 organizations that were affected by the removal of their legal status by the National Assembly last July 27th, in a clear act of retaliation against the specialists for having condemned the ill management of the pandemic of Covid-19 in Nicaragua.

Despite the official discourse citing increases of personnel, the reality is that it has been dwindling since the beginning of the government’s’ repression in 2018. According to the Medical Unit of Nicaragua (UMN, for its Spanish acronym), at least 468 healthcare personnel, including specialists, nurses and technicians have been laid off for supporting anti-government protests and for reporting the government’s negligence in responding to the pandemic of Covid-19. Moreover, approximately 400 doctors have left the country since April 2018, Pineda adds. In addition to the deaths of healthcare personnel caused by the pandemic, Observatorio Ciudadano reports 150 deaths among the health staff that can be attributed to the virus.

“Human resources are declining and experienced professionals cannot be substituted overnight”, says Pineda, he mentions that the Nicaraguan heath system has suffered irreparable damage from the moment in which medical centers were filled with political activists, whose last priority is the health of the population. These are dangerous activists whose work is to silence people. The threat of being laid-off is commonplace”, Pineda deplores.

While the MINSA removes valuable human resources from the health system, in the northern Caribbean and in places that are distant from cities, the population cries out for more medicine, doctors and professional nurses, and for better medical centers. The auxiliary nurse at Yulu’s medical center, Yorleny Lisayda Roy Reymundo, asks Ortega to change his strategy and to supply more medical consumables to meet the population’s demand.

Doctor Hernandez believes that the current health model reveals Nicaragua’s deficiencies and suggests the urgent need to seriously evaluate the system in order to improve it and thus save lives. In his opinion, the country should shift from a curative model to a preventive model.