20 August 2015
Nicaragua and ALBA – working out a truly democratic health system

A country's health care system is a fundamental indicator of a society's well being and the legitimacy of its government. The evidence has long highlighted that universal public health care makes more equitable and efficient use of resources than private alternatives. Arguments for privatized health care were lost long ago in the face of socialist examples like Cuba and socialist-inspired examples elsewhere.


The fact that in the United States the stale, old, phony arguments about health care still continue shows how public policy debate in the U.S. has been completely corrupted by corporate interests. The only relevant debate over health care is how government can meet public health care needs in the most appropriate, effective, efficient and sustainable way possible. In most countries, the more important arguments happen from the top down. Nicaragua's case is different. Understanding why requires a look back at recent history.

The 1990 elections in Nicaragua put into power a U.S. backed right-wing government with a neoliberal agenda determined to cut back public spending across the board, including health care. Until 2006, Nicaragua's population underwent a 17-year-long neoliberal experiment in which, among many other things, their very health of the public was on trial. Like so much else in Nicaragua, by 2006, the public health system was in progressive decline, sliding towards total collapse.

But throughout that period, the health workers union Fetsalud and related labor unions defended as best they could the public health system inherited from the decade of revolutionary government from 1980 to 1990. They were supported in their effort by the mass network of community health promoters, brigadistas and midwives on which Nicaragua's health service depended during the revolutionary years. When Nicaragua's second Sandinista government took office in January 2007, President Daniel Ortega declared that public health and education would be free.

In retrospect, between 2007 and 2011 President Ortega's government very clearly carried out an urgent program of recovery and basic reconstruction from the destructive effects of 13 years of armed conflict and 17 years of neoliberal misgovernment. Since 2011, the public health system in Nicaragua has stabilized and improved incrementally with internationally recognized results, especially in preventive health care. Those results derive immediately and directly from the political decision to take advantage of Nicaragua's strong community organizations, precisely that inheritance of the first Sandinista Revolutionary government.

In the second Sandinista Revolutionary government, public health policy compensates for lack of material resources by mobilizing the nationwide community health network, rebuilt and reinforced since 2007. The most recent example has been Nicaragua's First National Congress of Family and Community Health held on Aug. 15 in the capital, Managua. A total of nine regional congresses, held across the country, preceded that national congress in a process intended to design the main elements of Nicaragua's health policy between 2016 and 2021.

Around 3,000 people participated in the overall process including health workers, community health promoters, community council representatives, medical students, medical staff from the Social Security system, youth representatives and other participants mainly from the non-governmental sector. Over 600 people participated in the Congress in Managua and were divided into working groups covering ten areas of health policy and care identified in the earlier regional congresses. The dominance of women in this programme was self-evident.

Veteran women health brigadistas of the Sandinista Revolution with 47 years promoting health care in their community shared their views and experience with high level administrators half their age. Health Minister Sonia Castro and her senior colleagues participated directly, hearing points and making contributions of their own. The head of the national health workers union, Dr. Gustavo Porras, a leading Sandinista legislator, also participated in the discussions as well as closing the final plenary session of the Congress. The resulting policy document reflects the developing needs of a health system completely transformed since 2006.

Anyone aware of Nicaragua's enormous economic difficulties might well have regarded President Ortega's 2007 declaration of universal free health care as quixotic, but they would have been wrong.

The key to Nicaragua's successful health policies, as in other areas, has been the more efficient use of resources and the articulation of needs with other government institutions, like the Ministry for Education, the Ministry of the Family, the National Preventive System for Disasters (SINAPRED), with local municipal authorities and, to a lesser but still important extent with non-governmental organizations. Of supreme importance were the new sources of cooperation in public health care opened up by membership of the Bolivarian Alliance of the Americas (ALBA).

The overall success of the Sandinista government's health policy has come into show time and time again, from its responses to natural disasters like Hurricane Felix in 2007, to persistent phenomena such as seismic shocks, drought and flooding, and to health threats such as the 2009 H1N1 influenza pandemic, or the severe outbreak of dengue fever in 2014.

In 2010, Mirte Roses, Regional Director of the Panamerican Health Organization confirmed that Nicaragua “is one of the countries with the highest vaccination covers...The level of social organization and participation in Nicaragua has been a fundamental factor because health workers collaborate very closely with community leaders and with society in organizing health responses.”

By 2013, Nicaragua’s health ministry reported that the universal cover of Nicaragua's population prevented  95 percent of the country's infant population from contracting 16 diseases.

Nicaragua's health statistics between 2006 and 2013 register dramatic improvements in relevant indicators. In 2013, the health ministry gave over 20 million patient consultations, three times as many as in 2006, with almost four times as many prescriptions and, most essentially, their relevant medicines. The increase in patients seen was accompanied by almost three times as many medical tests, including almost 6,000 magnetic resonance tests, compared with none in 2006. The number of surgical procedures carried out more than doubled while the number of people treated in hospital rose by well over half.

Women's health has been a priority of Nicaragua's developing health programs. Prenatal controls, the number of papanicolaou exams, attended births, and post-natal controls, have all increased by well over 50 percent since 2006. Maternal mortality fell to 53 per 100,000 live births by 2013 with the tendency indicating that figure will drop to 40 by the end of 2015. In 2011, the Panamerican Health Organization recognized Nicaragua's system of Casas Maternas, assisting women in remote rural areas to give birth in an attended setting, as a key element in the country's successful effort to reduce maternal mortality. The network of around 150 Casas Maternas covers the entire country.

Statistics mask the more important underlying day-to-day reality of the Nicaraguan government's integral vision of health care. That vision is most apparent in community based programs like the Casas Maternas themselves, or in the Integral Program of School Nutrition ensuring school children get at least one nutritious meal a day with programs like Love for the Smallest Children aimed at fomenting good parenting at a community level.

This includes the Everyone Has a Voice program attending people with different abilities and the life changing Mission Miracle program that has helped over 145,000 Nicaraguans improve or recover their sight since 2007. Both these last two programs are possible thanks to the indispensable role of ALBA's solidarity-based cooperation made possible by Cuba and Venezuela.

With all its achievements, Nicaragua's public health system faces both long standing challenges and developing ones too. It will take some time to achieve reductions in waiting lists, improve the culture of patient care, improve inter-institutional coordination and ensure in-depth training to guarantee medical skills of the highest quality. Of special importance is the continuing incorporation of historically disadvantaged communities on the Caribbean Coast into Nicaragua's public health system.

As infrastructure, equipment and training improve, the fundamental basis of Nicaragua's public health system will remain the commitment of the country's health workers and their community support network as well as strong coordination between central government institutions and local municipal authorities.

Health workers' leader, Dr. Gustavo Porras believes collaboration between the Health Ministry, public health workers and the population that has made it possible for Nicaragua to overcome so many difficulties and make dramatic improvements in its health indicators. Commenting on the importance of that united effort, Dr. Porras remarked, “So we have the government, health workers and the population. This unity in facing problems is vital and is the model we now have. Without that model we could do absolutely nothing.”

When international organizations recognize Nicaragua's public health system as a model for the region, they implicitly raise an obvious political question. Nicaragua's recent history is one of devastating armed conflict and natural disasters. From 1990 to 2006, its public resources were ransacked by an oligarchy of white-collar crooks under cover of gobbledegook neoliberal ideology.

Even so, Nicaragua's Sandinista government under President Ortega and his ministerial team, closely coordinated by Rosario Murillo, working through an adverse period of global economic recession, have rescued the country's health system and turned it around in just eight years.

At the same time, in wealthy Europe and North American countries, public health systems are suffering cuts and relentless assault under Western regimes stripped of democratic process by oligarchic elites.

By contrast, Nicaragua has developed a revolutionary democratic politics that are self-evident in public health policies devised and implemented directly by health workers and community health promoters, with women in the majority. One way or another this same process, decisively focused on the rights of the human person, is happening across policy areas throughout the region. In their different ways, Nicaragua and its fellow ALBA countries are consolidating their legitimacy by defending their country’s fundamental rights and that can be seen very clearly in the outstanding progress of their public health systems.

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"Tortilla con Sal is an anti-imperialist collective based in Nicaragua producing information in various media on national, regional and international affairs. In Nicaragua, we work closely with grass roots community organizations and cooperatives. We strongly support the policies of sovereign national development and regional integration based on peace and solidarity promoted by the member countries of ALBA."

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