Nicaragua: A Brief History of the Current Health Care Situation

Nicaragua has followed a troublesome path in the area of healthcare for its 5.3 million inhabitants. In the Somoza years, before the Sandinista regime, the majority of the economically disadvantaged Nicaraguans had limited access to modern health care. In the 1980’s, the Sandinistas instituted policies that created a unified health system and created outreach clinics designed to bring primary and preventative care to the underserved. Vaccination and sanitation programs were instituted, community health volunteers were trained, and oral rehydration centers were established. New hospitals were built and medical school enrollment was increased. Nonetheless, civil strife took its toll on the system, resulting in war injuries and shortages of medicines and basic medical equipment.

Over the past 15 years, since the Sandinistas left power, there continues to be a lack of budgetary resources, resulting in limited access to health care by the majority of the population. Inequalities in Nicaraguan society are reflected in the current three-tier health care system in which the wealthy are treated in private hospitals or travel abroad for their care, select workers and members of the military are cared for in social Security and military facilities, and the large majority of the population, around 90%, are treated in public facilities that are under-equipped, understaffed and poorly maintained.

Orthopaedic Volunteerism in Nicaragua

Several organizations, including Operation Rainbow and Orthopaedic Overseas, have sponsored missions to Nicaragua. Information gleaned from various participants in these missions, mainly in Managua and Leon, confirms the general statements above. My own experiences in Leon at the Hospital Escuela Oscar Danilo Rosales Arguello (HEODRA) in the summer of 2004 parallel those of UCSF residents who have worked in the Hospital Antonio Lenin Fonseca in Managua. Both of these facilities are teaching hospitals of the Universidad National Autónoma de Nicaragua (UNAN). Orthopaedic care in the large public teaching hospitals is rendered by part-time orthopedists who must work in private clinics to make ends meet. In Leon there was a three year orthopaedic training program that included 3 residents per year. The residents in Leon were paid a paltry salary of about $200 a month to begin with, with salaries available for only one resident for the second and third years of training. Many residents quit due to lack of financial support. In Leon, there was only one third year resident in training in 2004. These doctors were eager to learn, and had access to the internet where they were made well aware of techniques and technology available in the rest of the world. Contact with practitioners in private clinics confirmed the disparity in resources available to them in HEODRA - the lack of equipment, drugs, supplies, implants, and radiographic studies, to name a few.

Orthopaedic Surgical Training in Nicaragua
Observations and Recommendations
July 9-13, 2007

Harry E. Jergesen, M.D. and Gabriel J. Martinez-Diaz, B.S.

Sponsored by Orthopaedics Overseas (OO) and
the Institute for Global Orthopaedics and Traumatology (IGOT)

We visited orthopaedic training sites both in Managua and Leon over the course of a five day visit.  The purpose of the trip was to gather information about the current status of the various training programs and to learn about changes in training that are presently being proposed.  The overall goal was to identify strategies with our hosts that might increase the effectiveness of efforts to create sustainable improvements in orthopaedic education and musculoskeletal care in Nicaragua.

We gathered information by speaking to groups of orthopaedic teachers and residents, both inside and outside the hospital setting.  We also talked to the Dean of the Faculty of Medicine in La Universidad National Autónoma de Nicaragua (UNAN) Managua, Dr. Freddy Meynard, and, later in the week, to a representative of the Dean of the Faculty of Medicine of UNAN-Leon, Dr. Rudolfo Peña.  Finally, we met with the President and Board of Directors of the Asociación Nicaragüense de Ortopedia y Traumatologia (ANOT), the Nicaraguan national orthopaedic association.  These interchanges allowed us to more fully understand the current status and most significant challenges that face orthopaedists-in-training in this resource-constrained country. 

Dr. Freddy Meynard (left), Dean of the Faculty of Medicine at UNAN Managua and members of the hospital leadership at Hospital Fonseca in Managua explained the orthopaedic training process to Dr. Harry Jergesen (second from left).

Orthopaedic residents at the Hospital Roberto Calderon in Managua

The meetings we had resulted in several recommendations that our hosts and we felt would set the stage for improved orthopaedic education, promote more productive interchanges with outside groups, and provide a clear understanding of the areas of musculoskeletal care that most need to be addressed from a public health point of view.

Patients in Nicaraguan public hospitals like this young girl in Hospital Velez Paiz in Managua are cared for with compassion despite the lack of material resources

RECOMMENDATIONS:

1) Orthopaedic training in UNAN should be four years

2) A uniform resident training curriculum and educational objectives should be established for all training sites.

3) A collaborative resident rotation schedule should be established between UNAN hospitals to insure exposure of each resident to all critical areas of orthopaedic training.  To add to this, combined conferences and educational rounds and lectures should be scheduled to bring residents and teachers from the various hospitals closer together in their training.

4) MINSA (Ministerio de Salud) and UNAN should provide resources to improve the knowledge base and mentoring skills of orthopaedic educators in each of the training hospitals.

5) MINSA and UNAN should continue to support appropriate outside projects designed to improve the delivery of orthopaedic care in all of the UNAN training hospitals.  Until government funding becomes available in the future, this may well involve coordinating efforts from outside organizations to assist in improving instruction, in documenting areas of need to justify funding from foreign sources, and in providing material support where it will do the most good.
     We sensed widespread agreement that sporadic short-term missions from overseas to date have not provided the sustained, long-term benefit and stimulus for improvement that is needed.  The timing of missions is inconsistent, the degree of educational interchange is variable, and the non-uniform distribution of the visits leaves some locations without access to outside contact. We believe that it is appropriate to ensure that these efforts are evenly distributed between the participating UNAN training hospitals. As an organization separate from the individual training sites, ANOT, in collaboration with the training site directors, may well be the ideal entity to broker overseas interchange agreements to ensure that they achieve maximum impact and fair distribution.

6) Partnership agreements with outside educational institutions, such as IGOT, OO or university-based orthopedic departments, should be encouraged in order to promote the educational agendas in the public teaching hospitals.

7) We suggest that the elected leaders of ANOT, in conjunction with MINSA and UNAN, help to organize new collaborative efforts between the training sites. As emphasized above, we suggest that ANOT take a lead role in directing the assistance efforts of foreign organizations to ensure that they are more evenly distributed between the training hospitals and that they provide educational support of the type that is most beneficial to their patients, residents and staffs.