HEALTH CARE AND REVOLUTIONIN NICARAGUA

The state of health care in Nicaragua prior to the revolution and

FSLN first steps in developing a revolutionary health care system.

HEALTH CARE – RIGHT OR PRIVILEGE?

• How you answer this question shapes the fundamental nature of health care.– If you view healthcare are as a commodity then access is a privilege. If

you can afford it, you can have it.

– If you view healthcare as a public good it is not a commodity and access should be available to all.

• In the United States we currently view healthcare as a commodity, with some exceptions.

• 4 models can provide perspective in discussing healthcare systems worldwide.

HEALTH CARE SYSTEMS – 4 BASIC MODELS

• Beveridge– Health care is provided and financed by the government through tax

payments

• Great Britain, Spain, most of Scandinavia and New Zealand. Cuba represents the extreme application of the Beveridge approach; it is probably the world’s purest example of total government control.

• Bismarck– Uses an insurance system usually financed jointly by employers and

employees through payroll deduction

• Germany, France, Belgium, the Netherlands, Japan, Switzerland

HEALTH CARE SYSTEMS – 4 BASIC MODELS

• National Health Insurance– Has elements of both Beveridge and Bismarck. Uses private-sector

providers, but payment comes from a government-run insurance program that every citizen pays into.

• Canada, Taiwan and South Korea.

• Out-of-Pocket– Perhaps 40 of the world’s 200 countries have established health care

systems. The remainder follow an out-of-pocket model.

– The basic rule in such countries is that the rich get medical care; the poor stay sick or die.

THE NICARAGUAN HEALTH CARE SYSTEM

• We’ll look at 3 time periods:– Pre-revolution (the 1970’s)

– After the victory of the Sandinistas (July 17, 1979)

– Today (2017)

• Current health care is covered in a follow-up presentation.

BEFORE THE REVOLUTION

• Average life expectance was 53 years (in 2015 was 75 years).

• 1/8th of all babies died in first year– Main causes of infant death:

• Diarrheal diseases

• Pneumonia

• Tetanus

• Measles

• Whooping cough

• Over 50% of children malnourished.

BEFORE THE REVOLUTION

• Periodic polio epidemics.

• Estimated 90% of health resources directed to 10% of the population.

• 28% of population had effective access to any modern health services.

SYSTEMIC FACTORS CONTRIBUTING TO HEALTH CRISIS

• Poverty

• Landlessness

• Inadequate food supply

• Illiteracy

• Poor housing and sanitation

• Lack of clean drinking water

ADEQUATE FUNDING IN THE 70’S

• Pre-revolution there were sufficient funds, including foreign aid.

• The heath care system was fragmented, with multiple agencies.

• Severely imbalanced – 60% of all health resources concentrated in Managua. 25% of population in Managua.

• Corruption drained funds.

• Focus was on providing care to the affluent.

FETSALUD – HEALTH WORKERS UNION

• Formed in 1974 – Predominately a non-physician union organized by hospital staff*.

• Organized several strikes in hospitals during Somoza's final years.

• August 1978 – FETSALUD hunger strike– National Guard – restrained in acting against health workers until now -

unleashed

– Union leaders jailed, murdered or ‘disappeared’

– Many health workers left the country due to political harassment or lockouts

SOMOZA BOMBS HOSPITALS

• During the last months of the war:

– Hospitals were targeted by Air Force bombings and artillery strikes.

– 4 public hospitals destroyed

– 5 other hospitals damaged

SOMOZA FLEES NICARAGUA, FSLN VICTORIOUS

• 17 July 1979 Somoza flees the country.

• 19 July 1979 FSLN forces enter Managua, Government of National Reconciliation takes power.

• 10 August 1979 MINSA inaugurated.

CREATING A ‘HEALTH SERVICE FOR ALL’

• Within 3 weeks of the victory the new government inaugurated the United National Health System.

• This shifted control of most hospitals, clinics and the social security system to MINSA bringing together scattered elements of the health care system.

• Minsa established a focus on services to– Urban and rural laborers

– Small scale farmers

– Women and children

SHIFTING THE HEALTH MODEL

• Prior to the revolution health care followed an institutional model.– Technical orientation.

– Doctors, Hospitals, Experts.

– Curative, not preventative.

– Focus on medical control and supervision

POPULAR HEALTH MODEL

• The popular health model adopted after the revolution– Cultural authority and social responsibility for community health care

shifts from professionals to the community.

– Organizational responsibility for oversight of the health delivery system is expanded to include the popular health councils, not just clinic staff.

– An expanded role and coverage given to the health brigadista.

– Focused more on the dissemination of health knowledge and preventative programs in non-clinical setting.

SIX PRINCIPLES FOR HEALTH ORGANIZATION1. Health is a right of every individual and a responsibility of the State

and the Popular Organizations.

2. Health services ought to be accessible to the entire population, geographically, economically and culturally.

3. Health services should function to integrate the physical, mental and social dimensions of health and to address the conditions of work and residence as they affect health.

4. Health care ought to be delivered in a multi- professional team effort.

5. Health activities are to be planned.

6. The community ought to participate in all activities of the health system.

FIRST STEPS• Consolidation of 23 separate semi- autonomous institutions under

MINSA.

• Construction of new facilities:– 1979 < 200 health centers and posts

– By 1984 > 300 new health centers and posts built

• Literacy and Health Brigades– National Literacy Campaign

• Recruited & trained 100,00 volunteers, mostly high school and university students

– 15,000 Literacy volunteers trained by MINSA in first aid, sanitation and malaria control• Worked as rural Health Aids and helped construct new health posts

FIRST STEPS

• Creation of Division of Education and Popular Communication in Health (DECOPS) – Formed the Popular Health Councils at local, regional and national levels.

– Organized 4 popular health campaigns in 1981

• Anti-polio

• Environmental sanitation

• Anti-dengue

• Anti-malarial

1981 ANTI-MALARIA CAMPAIGN

• During these ongoing campaigns up to 10% of the population were mobilized as health volunteers.

• Mass organizations – groups of community residents with common interests or similar backgrounds.

– Sandinista Defense Committees

– AMNLAE

– ATC

– And more

MASS ORGANIZATIONS AND THE POPULAR HEALTH COUNCILS

• Popular Health Councils facilitated interactions between health professionals and people throughout the levels of health care organization.

HEALTH BRIGADISTAS

• November 1981 training of 8,000 ‘Brigadistas de Salud’ (Health Workers) was initiated.

• Training in primary health care for mothers and children and first aid.

• Training of brigadistas intensified during 1983 and 1984.

• Brigadistas trained other brigadistas creating a multiplier effect.

• The Brigadista model surfaced tensions between professional, institutional model and the popular health model.

INSTITUTIONAL/PROFESSIONAL RESPONSES

• This transition to a popular health model heightened tensions between professional and popular objectives.

• In response MINSA opened a 2nd medical school in Managua and expanded enrollment from 200 to 900.

• Throughout this post-revolutionary period these tensions were present in the health care system.

• Note that private practice by physicians has always been present.

THE LEVELS OF TECHNICAL EXPERTISE WITHIN THE SYSTEM

• Hospitals – Urban areas (Managua, Leon, etc)

• Health Centers– Present in larger villages, towns and cities.

– Services Provided:• Gynecological

• Pediatric

• Internal medicine

• Obstetrics care

– At least 1 doctor.

– Some lab services.

– Some health centers had beds.

THE LEVELS OF TECHNICAL EXPERTISE WITHIN THE SYSTEM

• Health Posts– Villages less than 5,000

– Services provided:

• Common illnesses

• Prenatal checkups

• Well child

• Minor first aid

– Staffed by a Nurse or Auxiliary Nurse.

– Visited by a Dr 2 or 3 times a week.

IMPACTS (BEFORE THE CONTRA WAR)

• Estimated that some regular access to medical care rose to 80% (28% prior to revolution).

• Increase in available hospital beds.

• Construction of new health centers, largely in rural areas.

• Increase in health literacy across the population.

• Reduction of incidences of polio, malaria and diarrhea.

THE CONTRA WAR AND ITS IMPACT.

• More than 30,000 (some estiamte 50,000) Nicaraguans killed.

• Health volunteers and health workers killed.

• Health volunteers and health workers kidnapped and tortured.

• Health posts destroyed.

• Construction of many new health posts abandoned.

• Diversion of funds to fight the war.

ON REVOLUTIONARY MEDICINE – CHE GUEVARA

• The principle upon which the fight against disease should be based is the creation of a robust body; but not the creation of a robust body by the artistic work of a doctor upon a weak organism; rather, the creation of a robust body with the work of the whole collectivity, upon the entire social collectivity.

REFERENCES/SOURCES• Bossert, T. J. (1981). Health policy making in a revolutionary context: Nicaragua, 1979–1981. Social Science & Medicine.

Part C: Medical Economics, 15(4), 225-231.

• Donahue, J. M. (1986). Planning for Primary Health Care in Nicaragua : A study in revolutionary process, 23(2), 149–157.

• Donahue, J. M. (1986). The Profession and the People: Primary Health Care in Nicaragua. Human Organization, 45, 96–103. Retrieved from http://www.sciencedirect.com/science/article/pii/0277953686902418

• Garfield, R. M., & Vermund, S. H. (1986). Health education and community participation in mass drug administration for malaria in Nicaragua. Social Science & Medicine, 22(8), 869–877. https://doi.org/10.1016/0277-9536(86)90241-8

• Garfield, R. M., & Taboada, E. (1984). Health Services Reforms in Revoiutionary Nicaragua. American Journal of Public Health, 74(10).

• Garfield, R., & Williams, G. (1989). Health and revolution: the Nicaraguan experience.

• Segall, M. (1983). On the concept of a socialist health system: a question of marxist epistemology. International Journal of Health Services, 13(2), 221-225.

• Wendt, C., Frisina, L., & Rothgang, H. (2009). Healthcare system types: A conceptual framework for comparison. Social Policy and Administration, 43(1), 70–90. https://doi.org/10.1111/j.1467-9515.2008.00647.x