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—from Epidemiological Bulletin, Vol. 24 No. 1, March 2003—
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Figure 1: Population structure, by age and sex, Nicaragua,
2000
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For the period 1995–2000, life expectancy at birth was 68.4
years, the birth rate was 35.3 per 1,000 population, and the fertility rate
was 4.4 children per woman, being greater in rural areas. However, the annual
rate of population growth slowed 2.7% over the period 1995 to 2000. Emigration
and internal migration have a strong impact on the country’s economy. According
to the National Quality of Life Survey conducted in 1998 by the National Statistics
and Census Bureau (INEC), as of 1998, 47.9% of the population was living in
poverty and 17.3% was living in conditions of extreme poverty. The survey also
showed that the illiteracy rate was 23.4% in 1998.
The three cornerstones of the Government’s social development
strategy are the furtherance of economic growth, particularly in rural areas;
the promotion of spending on social programs for the poor that are designed
to reduce their vulnerability to economic, social, and environmental risks;
and the building of a stronger social safety net for vulnerable groups in order
to break the vicious cycle of intergenerational poverty.
The size of the economically active population (EAP) as of 1998
was estimated at 1,728,900 individuals, 11% of whom were unemployed. Unemployment
more heavily affects women (in 1999, 14% of the EAP in urban areas and 30% of
the EAP in rural areas). In July 1999 the Ministry of Labor reported that 56%
of the urban gainfully employed EAP earned less than US$ 9.20 per month, while
the cost of the basic basket of goods was US$ 13.30. Only 17% earned more than
US$ 19.40 a month. A mere 12% of female workers had monthly incomes of over
US$ 19.40.
Efforts to downsize the national government are a pivotal part of the structural adjustment process. The assistance furnished by the international community was crucial to renforce coverage levels for top-priority social services in the wake of Hurricane Mitch. Per capita GDP stood at US$ 455.80 for the period from 1991 to 1998. It grew at an average rate of 3.2%.
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Figure 2: Gross domestic product, annual growth,
Nicaragua, 1990-1999
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The general mortality rate was 26.5 per 100,000 population in 2000. Infectious diseases fell from fourth to fifth place among the leading causes of death in the last two years, with the number of deaths attributable to this cause down by nearly 50% from 1996. The number of deaths attributable to external causes rose in 1998 in the wake of Hurricane Mitch.
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Figure 3: Estimated mortality, by broad groups of
causes and sex, Nicaragua, 1995-2000
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Specific health problems
by population group
Children (0–4 years): The infant mortality rate for the period from
1997 to 2000 was 45.2 per 1,000 live births. The leading causes of death among
children under one year of age during this period were respiratory and cardiac
problems originating in the perinatal period, pneumonia, diarrhea and gastroenteritis,
bacterial sepsis of the newborn, and congenital malformations. The leading causes
of death among children 1- 4 years of age were pneumonia, diarrhea and gastroenteritis,
and transport accidents.
Schoolchildren (5–9 years): The leading causes of
reported deaths in 1999 and 2000 were transport accidents, pneumonia, accidental
drowning and submersion, and accidental exposure to other unknown factors.
Adolescents (10–14 years and 15–19 years): The
fertility rate for adolescents in 1999 was 152 births per 1,000 teenage girls
of childbearing age (15–19 years of age). Thus, 3 out of every 10 births
involved teenage mothers in this age group. The leading reported causes of deaths
among adolescents in 1998 were: death associated with natural disasters, pesticide
poisoning, and accidents. Youths between 15 -19 years of age comprised 30% of
cases of acute pesticide poisoning.
Adults (20–59 years): The family planning service
coverage level nationwide was 21% in 1999. According to ENDESA-98, the rate
of contraceptive use in Nicaragua was comparatively high: 68% of all women of
childbearing age reported having used some form of birth control at some point
in their lives. In terms of maternal mortality, the nationwide Maternal Mortality
Surveillance System showed fluctuations, with rates of 102 per 100,000 in 1998,
and 133 per 100,000 in 1999. Maternal deaths stemmed from obstetrical problems,
with the leading causes being hemorrhages caused by placenta retention, pregnancy-induced
hypertension, sepsis, rupture of the uterus, and abortions.
The Elderly (60 years and older): The number of elderly
was estimated at 4.7% of the population for the year 2000, with males accounting
for 45.4%. The age group 75 and over made up 1% of the total population.
Workers’ Health: An estimated 24,000 children 10-14
years of age were working at jobs in the informal sector, with another 6,000
employed in the formal sector. Between 90% and 100% of farmers and farmhands
are exposed to some type of pesticide every year. Official statistics for 1999
put the work-related pesticide poisoning rate at 5 cases per 10,000 population.
However, studies conducted in various parts of the country estimate annual incidence
rates for pesticide poisoning at from 3% to 9% of exposed farm workers.
The Disabled: The National Rehabilitation Program operated
by the Ministry of Health estimated the percentage of the population with some
type of disability at 12.1% in 2000. The most common types of reported disabilities
were visual impairments (63.9%) and hearing impairments (9.2%). The leading
causes of disabilities were problems at birth (10%), disease (29%), war (3%),
and accidents (12%).
By type of health problem
Natural disasters: The worst disaster during this period was Hurricane
Mitch, which struck the country in October of 1998. It caused 2,823 fatalities,
with another 885 persons reported missing, and damaged 49 municipalities. The
most recent disaster was the earthquake that struck the city of Masaya in July
of 2000, with a death toll of nine.
Vector-borne diseases: The largest number of malaria cases
(76,269) was reported in 1996, with an annual parasite index of 18.4 per 1,000
population. There was a downward trend in malaria cases over the 1997–2000
period. The number of cases of P. falciparum malaria nationwide fell 67.2% over
the period. The risk of contracting dengue quadrupled in 1998, with an incidence
rate of 28.1 per 100,000 population. Circulation of cases of dengue fever serotypes
3 and 2 were confirmed and 432 confirmed cases of dengue hemorrhagic fever were
observed. A nationwide entomological survey was conducted from 1998–1999
to establish the prevalence of triatomine infestations in 14 departments (125
municipalities, 31,466 dwelling units), finding prevalence rates of 1%–10%.
A seroprevalence study of 11,375 blood samples collected from schoolchildren
between 7 and 14 years of age found 387 cases of Chagas’ disease (3.4%).
Diseases preventable by immunization: Nicaragua has successfully controlled the spread of diseases preventable through immunization by achieving and maintaining high vaccination coverage levels over the past few years and introducing new vaccines (the MMR vaccine in 1998 and the pentavalent vaccine in 1999). Vaccination coverage for different biologicals ranged from 90% to 100% in 1999 and 2000. There were a total of 132 clinically diagnosed cases of pertussis over the 1997–2000 period. The last registered case of neonatal tetanus dates back to 1997. Vaccination coverage for women of childbearing age is over 95% in most municipalities around the country. There were 37 cases of non-neonatal tetanus reported over the period from 1997 to 2000, the majority of which involved persons over 15 years of age whose occupations put them at a higher risk of exposure. Haemophilus influenzae type b vaccination coverage among children under 1 year of age was already greater than 90%. H. influenzae type b comprised 56% of all cases of bacterial meningitis, which meant that nearly 200 cases a year could have been prevented through immunization.
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Figure 4: Vaccination coverage among the population
uder 1 year of age, by vaccine, and tetanus toxoid coverage among women
of childbearing age, Nicaragua, 2000
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Intestinal infectious diseases: After Hurricane Mitch,
there were outbreaks of cholera, with 1,451 reported cases (28.2 per 100,000
population) and 36 deaths (0.7 per 100,000 population), for a fatality rate
of 2.4%. Only 12 cases and 1 death were reported in 2000. Acute diarrheal diseases
are one of the main types of notifiable diseases. Children under 5 years of
age are hit hardest by these diseases, accounting for 73% of the total reported.
The morbidity rate was 484 cases per 100,000 population in 1997 and 415 in 1998,
with mortality rates around 7 per 100,000 in the same years.
Chronic communicable diseases: Tuberculosis is endemic
in the country, the incidence rates fluctuated between 13 and 111 per 100,000
population. In 2000, there were 2,396 cases, 1,467 positive by microscopic examination.
The population 15–24 years were hardest-hit, accounting for 26% of all
cases of tuberculosis.
Acute respiratory infections: Acute respiratory infections were the most common
notifiable disease with an incidence rate for the 1997–2000 period of 2,658
per 10,000 population. Children under 5 years of age were the hardest-hit, accounting
for 57% of all treated cases of the disease. The mortality rate was 6.47 per
100,000 population, with the hardest-hit group that of children under 1 year
of age, which accounted for 55% of all fatalities.
Zoonoses: Two cases of human rabies were reported in the
1997–1999 period, both caused by wounds inflicted by wild animals. Vaccination
coverage for canine rabies improved to over 85% countrywide. A leptospirosis
epidemic was reported in 1998 in the wake of the flooding caused by Hurricane
Mitch, with 705 suspected cases reported.
HIV/AIDS: The total cumulative number of cases of infection by HIV/AIDS over the period from 1987 to the year 2000 was 643 with 294 AIDS patients, of whom 164 have died. The hardest-hit was the 20–44 age group, 81% of all cases, while 74% of all cases were males. The leading mode of transmission was by sexual contact, (88% of all cases, 64% by heterosexual contact), with 9% attributable to intravenous drug use, 2% to mother-to-child transmission, and 1% to blood transfusions.
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Figure 5: AIDS incidence, by sex, with male-female
ratio, Nicaragua, 1994-2000
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Nutritional and metabolic diseases: ENDESA-98 found one
out of every three children malnourished and 9% of all children severely malnourished.
The percentage of children in rural areas suffering from some degree of malnutrition
was 32%, compared with 19% in urban areas. The mortality rate for all forms
of malnutrition was 11 per 100,000 in 1998. Though iodine deficiency is not
a public health problem in Nicaragua, thanks to the fortification of salt with
iodine, there are high-risk groups in the South Pacific region where the prevalence
of goiter in certain communities is over 20%. The nationwide prevalence rate
for anemia in children between the ages of 12 and 59 months was 28.4% with an
average hemoglobin level of 10.6 mg/dL.
Diseases of the circulatory system: Cerebrovascular disease
accounted for 31.7% of deaths due to diseases of the circulatory system in 1992–1993.
Hypertension was responsible for 12.6% of deaths attributable to this group
in 1998.
Accidents and violence: The leading causes of death in
the year 2000 were transport accidents (9.5 per 100,000 population), suicides
(7.3), and homicides (6.6). According to ENDESA-98, 29% of the married or in-union
women surveyed had suffered sexual or physical abuse at some time. There were
2,473 reported cases of attempted suicide by pesticide poisoning over the period
between 1997 and 2000, with a case fatality rate of 25.5%. Women accounted for
44% of these cases.
Oral health: In 1997, of the 233 communities covered by
a study on fluoride content of drinking water, only 12% had water supplies with
optimal fluoride levels (0.5–1.0 mg/kg). The total prevalence rate for
dental caries in children between 6 and 15 years of age was 85% with diagnosis
of mild fluorosis in 2.6%, while only 0.8% of the children studied had moderate
to severe fluorosis.
The Response of the health system
National health policies and plans
The National Health Policy 1997–2002 is an extension of the commitment
of social policy to alleviate poverty and to improve service coverage, particularly
for the poorest and most vulnerable segments of society. There are five separate
health policies, aimed at modernizing the health sector, strengthening the Ministry
of Health, improving hospital care, formulating new public health strategies,
and modernizing the social security system. A number of initiatives designed
to strengthen the steering functions of the Health Ministry were initiated based
on technical instruments such as the health system profile, health analysis,
and the Ministry of Health’s investment plan for 2000–2002.
The health system
Institutional organization: The health sector encompasses both the public
and private sectors. The public health sector consists of the Ministry of Health;
the Nicaraguan Social Security Institute; and the health services operated by
the Ministry of Government and by the Ministry of Defense. The divisions of
the Comprehensive Local Health System (SILAIS) represent the Ministry of Health
in technical and administrative matters at the departmental level. The private
sector includes hospitals, clinics run by health insurance management companies,
and nongovernmental organizations.
Developments in health legislation: The National Health
Policy 1997–2002 calls for revising and updating of the existing legal
framework through the passage of a number of laws and regulations, including
the General Health Act, the Unified Health System Act, the Social Security Act,
the Drug and Pharmacy Act, food monitoring regulations, regulations for the
control of pesticides and toxic and hazardous substances, regulations governing
ionizing radiation, regulations for professional health practice, and regulations
under the Health Administrators Law.
Organization of regulatory actions
At the primary care level, in 1997–2000, coverage was provided by the different
health delivery networks: public networks, 60%; INSS networks, 10%; private
networks, 20%; and other networks, 10%. The private sector provides curative
care to the insured population (15% of the EAP). The Ministry of Health is the
leading health service provider at both the primary and the secondary care levels.
At the primary care level, it operates health centers (some with beds and some
not) and health posts. Secondary care level offers general and specialized medical
care and outpatient and inpatient care in basic areas. The private health sector
consists of eight hospitals, private medical and dental practices and clinics
providing outpatient care, clinical laboratories, and diagnostic imaging centers.
Insurance management companies provide insurance plan members with prescribed
curative services outsourced by the INSS. Insurance management companies have
begun offering prepaid plans to expand their service offerings.
The Regulations Office also investigates and responds to complaints
with respect to the handling or treatment of patients in public health care
facilities and conducts audits to control the quality of health care. The Office
of Environmental Health monitors water quality through sampling procedures conducted
at specific points of the water supply network. The Ministry of Environment
and Natural Resources is also involved in regulatory activities, exercising
its powers under Law 290. However, the regulatory framework for environmental
protection is lacking, and the country has no systems in place for the assessment
of environmental risks. The Ministry of Environment and Natural Resources and
the Ministry of Agriculture and Forestry is putting into place programs designed
to protect natural ecosystems, with the emphasis on soil and water conservation.
The quality of food products is controlled through health inspection and monitoring
procedures and surveillance for foodborne disease. The Ministry of Labor is
in charge of formulating and coordinating occupational safety and health regulations
with relevant agencies and overseeing their enforcement in the workplace.
Evaluation of health technology: The equipment is insufficient
and its use is limited by lack of resources for operation and maintenance. In
2000, of all available equipment, 73% was used for diagnostic and treatment
purposes and in direct support of medical care; 82% was in hospitals but only
73% was in proper working order. The health centers and health posts had 18%
of equipment.
Organization of public health care services
Health analysis, epidemiological surveillance, and public health laboratory
systems: The national register is maintained by the National Vital Statistics
System (SINEVI), which records official morbidity (mainly hospital-data) and
mortality statistics with a one-year delay. The national and local epidemiological
surveillance systems covers 25 specific health problems subject to immediate
notification requirements, such as outbreaks of disease and disasters. Both
SINEVI and the epidemiological surveillance system data are used for strategic
planning and health service management purposes at the local and national levels.
Potable water and sewerage services: Potable water supply
was 89.4% in 1998, the urban coverage was 89.5% and the rural coverage 33.7%.
Of the samples collected in 1999, 4% contained over 50 fecal coliform bacteria
per 100 mL. The percentage of the population without access to adequate excreta
disposal service dropped to 21.1% in 1998. Only 4.7% of the urban population
was still without service, compared with 31.7% of the rural population. Only
34% of collected wastewater received any type of treatment. The urban population
generated an estimated 1,396 metric tons of solid waste in 1999, 65% of which
were not subject to proper disposal methods. A great deal of progress has been
made in the area of environmental protection legislation, with the passage of
the General Environment and Natural Resources Act, environmental impact assessment
regulations, the Law Governing Pesticides and Toxic and Other Hazardous Substances,
regulations governing effluents, and the act creating the Environmental Protection
Agency.
Organization of individual health care services
The primary health care network offers virtually all types of health promotion
and risk and disease prevention services as well as general curative care and
preventive and restorative dental care. The physical infrastructure administered
by the Ministry of Health consists of 996 health care facilities, 48.3% of which
are concentrated in the Pacific coast area. Managua has 11 hospitals, more than
a third of all hospital facilities. The INSS has no health delivery infrastructure
of its own, outsourcing health care services to public and private service providers.
Health supplies
Efforts to develop a pharmaceutical industry are based on the country’s
National Medicinal Drug Policy, whose strategies for the 1997–2001 period
focus on institution-building, promoting access to essential drugs, quality
assurance, and rational drug use. The essential drugs list for 2001 consists
of 345 active ingredients, with their generic names, and 509 drugs in their
various pharmaceutical forms. The list is used as a yardstick for the procurement,
distribution, and use of drugs in the public sector and the for-profit and not-for-profit
private sector. According to the Drug Regulations Office attached to the Ministry
of Health, as of the year 2000, there were 12,000 registered products, 255 drug
importers/distributors, 12 domestically owned pharmaceutical laboratories whose
output covered an estimated 20% of nationwide needs.
Human resources
In 1999, there were 23,285 health care workers, 32% of the government workforce,
of whom 47.4% were assigned to the primary care level and 52.6% to the secondary
care level. The wages of health care personnel consumed 60% of the Health Ministry
budget. In 2000 there were 5,656 registered general practitioners, 950 specialists,
323 professional nurses, 974 dentists, 1,042 pharmacists, 56 mid-level laboratory
technicians, and 21 radiologists. The number of nursing personnel in 1999 totaled
1,538, of whom 62% were assigned to the secondary care level, and 23% concentrated
in Managua. Of the auxiliary personnel, 52% worked at the primary care level.
In order to practice, health professionals must register their university degrees
with the Regulations and Accreditation Office attached to the Ministry of Health.
An estimated 90% of the nation’s physicians are registered.
Health sector expenditure and financing
Health resources are drawn from the public sector (41.5%), the private sector
(44.8%), and external cooperation (13.7%). Per capita health spending in 1998
reached US$ 45.1. The government allocation to the Ministry of Health for 1998
as a percentage of GDP was 3.2% in real terms, or the equivalent of 9.5% of
the general budget. International assistance to the Ministry of Health over
the period from 1991 to 1998 as a percentage of GDP was approximately 1.3%,
or the equivalent of 25.6% of its total budget. Household spending on health
as a percentage of GDP ranged from 2.5% to 2.8%.
Return to Index
Epidemiological Bulletin, Vol. 24 No. 1, March
2003