- Overall Context
- Leading Health Challenges
- Health Situation and Trends
- Full Article
Nicaragua is a multiethnic and multicultural country located in the Central American Isthmus. It extends for 130,373.47 km2 () and is divided into 15 departments and two autonomous regions on the Caribbean coast. Its capital is Managua. It borders with Honduras to its north and with Costa Rica to its west; it has a coastline along the Pacific Ocean to the west and along the Caribbean to the east. It shares Pacific maritime boundaries with El Salvador, Honduras, and Costa Rica, and Caribbean boundaries with Honduras, Colombia, and Costa Rica.
In 2016, the estimated population was 6,327,924 inhabitants, of whom 59.6% were urban dwellers (), 51.0% were women, 42.0% were under the age of 15, and 5.0% were in the 65 and older group (). Figure 1 shows the changes in Nicaragua’s population structure between 1990 and 2015.
Figure 1. Population structure, by age and sex, Nicaragua, 1990 and 2015
Nicaragua’s population grew by 46.7% between 1990 and 2015. In 1990, it had a rapidly growing expansive structure, with a predominance of groups under the age of 15. By 2015, along with the aging of the population, the age groups older than 25 years of age increased more slowly, while the groups under that age took on a regressive structure, which is tied to a decreases in fertility and mortality rates over the last three decades.
Source: Pan American Health Organization, based on data from the United Nations Department of Economic and Social Affairs. Population Division. New York; 2015.
Indigenous groups and people of African descent comprise an estimated 8.6% of the population (), the main ethnic groups being the Miskito (27.2%) and Chorotega-Nahua-Mange (10.4%) (). Thus far in the 2015-2020 period, the population has grown at a rate of 1.04 per 100 population (), with a total fertility rate of 2.1 children per woman (), and a life expectancy at birth of 75.8 years for both sexes (78.9 for women and 72.6 for men) ().
The country has a mixed economy that relies heavily on the livestock sector. The structure and operation of the economy are the responsibility of the country’s four branches of government: Executive, Legislative (unicameral), Electoral, and Judicial. From 2006 to 2015, macroeconomic indicators showed an increase in real economic growth from 4.2% to 4.9% (), an increase in gross domestic product (GDP) from US$6.7863 to US $12.6925 billion (), increase in per capita GDP from US$1,203.7 to US$ 2,026.7 (), and a decline in the cumulative annual inflation rate from 9.4% to 3.1% (). As a result of macroeconomic management, total public debt in 2015 was US$ 5.7535 billion (47.6% of GDP) (), while foreign public debt was US$ 4.8044 billion (39.8% of GDP) ().
Violence and Security
The country has a public safety model based on shared responsibility between the individual, the family, and the community, coordinated with all institutions and focused on social prevention of violence and crime. This resulted in a positive trend in several indicators per 100,000 population between 2007 and 2015: the police force grew from 164 officers to 237, homicides fell from 13 to 8, thefts with intimidation decreased from 120 to 61, and thefts of all types declined from 491 to 162. Sex crimes fell from 86 to 45, injuries dropped from 331 to 87 each year, and the risk of being a victim of crime dropped to one crime for every 66 people (). These figures represent a reduction in mortality from assaults (X85-Y09) between 2005 and 2013 from 10.5 to 6.37 per 100,000 population (). According to public perception, the three main security problems in the country are thefts (63.7%), gang violence (31.5%), and armed robbery (21.9%), which, despite improvements in recent years, stem from to the lack of a police force (54.4%), alcohol and drug use (7.1%), poverty (4.8%), and drug trafficking (0.9%) ().
Leading Environmental Problems
Until 2010, the mean temperature in the country increased from 0.2 to 0.9ºC in the Pacific and Northern regions, and rainfall decreased by 6.0% to 10.0% in the Pacific area (). Dry zones increased as a result of climate change, which affected 45.0% of the population in 94 municipalities with average or high risk. As a result of this, it is estimated that by 2050, quality of life will decrease for 87.0% of the total population living in 139 municipalities (97.0% of national territory) ().
Nicaragua is a member of the World Trade Organization, and is a signatory to customs unions and free trade agreements with several Central America countries, China, the United States, and the Dominican Republic, as well as preferential trade agreements with Venezuela and Colombia. These agreements translate into greater trade and investment flows and fewer trade and capital restrictions. In 2016, the country ranked 97th in the globalization index, with a score of 53.8 (). It ranked 85th in economic globalization, but 110th in the social area, which reflects the use of communication, telecommunication, and Internet technologies. The lowest level of globalization was the degree of cooperation with other countries (127th of 207 countries). As a consequence of globalization, between 2011 and 2015 imports increased from US$53 million to US$75 million in processed foods, from US$50.5 to US$62.9 million in sweetened beverages, and from US$45.3 to US$58.1 million in baked goods (), reflecting a shift in Nicaraguan food consumption patterns.
Health Policies, Plans, and Programs
The National Human Development Plan (PNDH) establishes objectives for the transformation and human development of the population, and contains a strategy based on 12 guidelines that combine the continuation of established policies with the incorporation of new priorities, in order to address urgent needs and achieve the productive and social transformation of the country (). As part of this strategy, various social programs have been implemented, including Usura Cero [Zero Usury], Hambre Cero [Zero Hunger], and Amor para los más Chiquitos y Chiquitas [Love for the Smallest Ones], as well as programs related to the right of the elderly to live in protective environments, and others aimed at improving the living conditions of the most vulnerable sectors (). The health policy focuses on restoring the right to a healthy environment through preventive health measures and free, quality, comprehensive, and integrated services, by implementing the Family and Community Health Model. This model promotes the inclusion of individuals, families, the community, and other social actors, thereby ensuring a systematic and comprehensive social response approach to endemic and epidemic problems ().
Social Determinants of Health
Nicaragua’s human development index fell from 0.619 in 2010 to 0.604 in 2014 (), putting the country in the medium category for this indicator. In addition, social inequality at the national level fell from 0.40 in 2005 to 0.38 in 2014, according to the Gini coefficient (). Between 2009 and 2014, the general poverty rate dropped from 42.5% to 29.6%, thereby achieving Target 1A of the Millennium Development Goals (MDGs). This was due to the decline in extreme poverty from 19.0% to 8.3% over the period from 1993 to 2014 (), as well as in the three areas of unmet needs with the greatest impact on households: economic dependency (23.0%), inadequate housing (10.8%), and overcrowding (10.6%) ().
With regard to labor, in 2010 the open unemployment rate was 7.4%, and 53.7% of the economically-active population was underemployed (). Among employed people, 18.8% were covered by social security (), with an increase in the number of people with coverage from 420,316 to 773,409 () and the number of active employers from 15,065 () to 32,738 over the period between 2006 and 2015 (). During this period, the average wage for formal employment rose from C$4,823.6 to C$8,696.6 (), while the estimated cost of the basic basket of goods was C$12,364.45 in December 2015 (). In 2014, the breakdown of total household spending was 42.3% for food, 17.7% for housing, 5.3% for health, 5.0% for education, and the remaining 29.7% for basic services, goods, transportation, and personal items, etc. ()
Total public expenditure on education as a percentage of GDP rose from 3.0 to 4.7% between 1999 and 2012 (), which helped the country achieve MDG Target 2A through social investment, increasing the net rate of enrollment in primary schools from 76.0% to 90.0% over the period from 1993 to 2015. By 2015, the estimated literacy rate was 83.0% (), with a total of 732,000 illiterate adults (). Between 2005 and 2013, the percentage of children who entered first grade and completed sixth grade increased from 47.0% to 57.0%, and the national rate of grade repetition fell from 10.5 to 6.3%. In addition, the average number of years of schooling in the total population rose from 5.6 years in 2005 to 6.8 years in 2012 ().
As a result of the Drinking Water and Sanitation Program (), the indicators of MDG Target 7C were achieved. Between 1990 and 2015, drinking water coverage increased from 73.0% to 87.0%, and sanitation coverage expanded from 44.0% to 68.0% (). Another social investment of major importance was the expansion of road infrastructure during the period from 2005 to 2015, when paved roads increased from 2,032 km () to 3,883.78 km, which facilitated the population’s access to social services and led to improvements in production and trade dynamics ().
The Health System
Nicaragua’s health system includes both the public and private sectors. The public sector is made up of the Ministry of Health, the Nicaraguan Social Security Institute (INSS), and the medical services of the Nicaraguan Army and National Police Force. The Ministry of Health is the policy-making entity and the main provider of services covering 65% of the population, while the INSS covers 18%, and the Interior Ministry and the Army provide 6.0% of coverage. Private institutions and nongovernmental organizations cover the remaining 11%. Between 2005 and 2015, the Ministry of Health expanded its network of services from 1,092 to 1,401 health facilities, with a total of 5,143 beds in the public sector in 2015 (8.1 beds per 10,000 population). In addition, there are 171 maternity centers with 2,064 beds and 6,619 basic health centers responsible for the work carried out in the communities ().
Leading Health Challenges
There are persistent challenges related to the targets of MDG 7, all linked to climate change and variability, indoor air quality, noise pollution, and improvements in water and sanitation services (access, quality, and continuity). Other health challenges stem from epidemiological transition and an increase in non-communicable diseases and their risk factors. In terms of nutrition and food security, systems and methods used to produce foods for domestic consumption and export must be adapted in response to climate change problems.
In 2016, the estimated prevalence of diabetes was 8.1% (9.0% for women and 7.2% for men). This disease accounted for 6.0% of all causes of death in the country, with a total of 880 deaths (both sexes) in the 30-69-year age group, and 730 deaths in the 70 and older population. There were 1,470 deaths attributable to hyperglycemia among 30-69-year-olds, and 1,350 in the 70 and older group (). In 2009, the prevalence of hypertension in Managua was 7.7% for Stage I and 2.8% for stage II, while the figure for prehypertension was 33.2%. In 2015, the prevalence of hypertension was 4% in people over 60 years of age.
Law 760/2011 on Health Careers establishes a set of standards that regulate the income, development, training, evaluation, promotion, and discharge of people working in the area of health under the Ministry of Health. From 2005 to 2015, the Ministry of Health’s labor force expanded from 21,728 to 32,122 employees (), with 9.3 physicians per 10,000 population in 2015, 7.5 nursing staff, 6.3 nursing aides, and 7.1 technical health care staff () (see Table 1). Despite the increase in human resources, gaps persist in terms of ensuring complete family and community health teams in all the country’s sectors.
Table 1. Density of human resources for health (per 10,000 population), Nicaragua, 2005-2015
|Technical health care staff||5.9||5.8||5.9||6.6||6.8||6.4||6.9||6.9||6.9||7.0||7.1|
a Includes the following categories: social services nurses, specialist nurses, general nurses, nursing department managers, nursing section managers, nursing department assistant managers, and general nursing supervisors.
Source: Dirección General de Recursos Humanos, Ministerio de Salud. Fuerza laboral por perfiles 2005-2015. Available on: http://www.minsa.gob.ni/index.php/repository/Descargas-MINSA/Divisi%C3%B3n-General-de-Recursos-Humanos/Fuerza-Laboral-por-Unidad/Fuerza-Laboral-Por-Perfiles-Periodo-2005-2015/.
Health Knowledge, Technology, and Information
Decree No. 5/95 created the Nicaraguan Council of Science and Technology (CONICYT) in 1995, an institution that carries out its activities in accordance with component nine of the 2012-2016 National Health Development Plan. Between 2005 and 2013, science and technology indicators trended upward, from 0.8 to 1.6 per 1,000 people with degrees in science and engineering, from 14 to 26 per 1,000 population working in science and technology, from 0.05 to 0.09% of GDP for spending on research and development activities, and from 40 to 70 for the number of indexed scientific publications per million population (). Progress in infectious disease research has been facilitated by agreements between the Ministry of Health and the Sustainable Sciences Institute in Managua and the University of California in Berkeley. The most important contributions involved innovations in health informatics and the development of installed capacity at the National Laboratory of Virology in the Socrates Flores Health Center and the Manuel de Jesús Rivera Children’s Hospital. The Ministry of Health has 19 mobile clinics that provide dental, gynecological, cardiovascular, and natural medicine health care. The Ministry’s telehealth program and its Community Information System, which coordinates health management activities from within the communities, are provided through free cellular communication service.
The government’s Web-based Health Information System contains vital statistics modules (births and deaths) that are incorporated into the central database of the national civil registry in Nicaragua. In 2016, this system provided training on clinical records, hospital management, and primary health care modules. The lack of full-time software development staff limits any progress in the construction of this system, and pending challenges include linking platforms and coding the Epidemiological Surveillance System in the National Diagnostic and Referral Center. As of the end of 2016, work was still being done on the design of the national kidney disease registry and the registry of maternity centers. Improvements in training programs for health care personnel on the International Classification of Diseases, the correct way to fill out death certificates, and checking the consistency of systematic registries and clinical records have reduced the underreporting of mortality from 47.1 in 1990 to 24.8 in 2012. In 2015, the percent usage of infrequently used codes was 15%, and 1.2% for ill-defined causes ().
The Environment and Human Security
Natural and Manmade Disasters
The annual deforestation rate in 2010 was 70 per 1,000 hectares, 100% caused by humans. From 2007 to 2012, the total burned forest area decreased from 57.5 to 22.5 per 1,000 hectares per year (). This has led to a 42.0% reduction in the flow of underground water, and ensuing interruptions in drinking water service in the months of November and April (). Drinking water for household use supplied from underground sources accounted for 70.0% of the total, while the remaining 30.0% was from surface or subsurface sources. Estimated water consumption for industrial use accounted for 14.0% of total annual extraction. ()
Twenty-three percent (23%) of the volcanoes in Central America are located in Nicaragua. In the period from 1993 to 2012, 44 recorded volcanic events caused US$224.61 million in economic losses, with 69% of the population and 68% of GDP exposed to two or more meteorological risks (). Decree No. 53/2000 established regulatory provisions to enforce Law 337 on the creation of the National System for Disaster Prevention, Mitigation and Response (SINAPRED), which is based on a community, inter-agency, and intersectoral organization model, leading to the implementation of the Hyogo Framework for Action. The Hospital Seguro frente a Disastres [Safe Hospitals during Disasters] initiative applied the Hospital Safety Index to 25 health care facilities, and included academia in the training and certification of evaluators and the development of technical guidelines for hospital design and construction.
Drinking Water and Sanitation
Climate change has affected the continuity of water service and led to improper storage in the home, which has in turn contributed to the prevalence of diarrheal and arboviral diseases. Between 2011 and 2012, the prevalence of diarrhea by water supply source ranged from 13.0% in children living in households that obtained drinking water from private taps to 18.0% in children who got their water from public taps (). From 1997 to 2012, there were a total of 7,879 deaths from water-related diseases, 54.3% of which occurred in males and 45.6% in females. Six out of every 10 deaths were in the 0-4-year age group, and of those deaths, 70.0% occurred in 39 municipalities located in areas where water service interruptions had lasted more than eight hours (). Between 2007 and 2010, the majority of primary care visits were for water-related diseases: diarrhea and gastroenteritis of presumed infectious origin (58.0%), anemia (14.0%), scabies (8.0%), giardiasis (2.0%), amebiasis (2.0%), and to a lesser extent ascariosis. Nationally, the prevalence of soil-transmitted helminth infections was 18.8% in schoolchildren between the ages of 3 and 14, primarily in the North Atlantic (63.0%) and Río San Juan (43.9%) regions, and the highest parasitic intensity was due to Trichuris (3.7%) and Ascaris (13.6%) in the Nicaraguan Caribbean area ().
Nicaragua has one of the youngest populations in the Region, with a demographic dependency ratio of 54.1 for both sexes () and a growth rate per 1,000 population that declined from 1.3 in 2010 to 1.0 in 2015 (). It is estimated that by the five-year period from 2050 to 2055, there will be an equal number of people over the age of 60 years and under 15. In 2010, there were 12 older persons for every 100 adults aged 50 to 64; starting in 2050, this parent support ratio will rise to 20, with the same trend continuing until 2085 when there will be around 59 people aged 80 years or older for every 100 adults aged 50 to 64 years ().
The country contributes migrants and is also part of the migrant corridor in Central America. Climate change, the lack of food security, and unemployment are causes that have influenced the migration of one million Nicaraguans (48% living in Costa Rica and 42% in the United States), who contribute 9% of GDP in family remittances (). The social impact of migration can be seen in terms of family disintegration. From 2006 to 2012, female heads of household increased from 30.7% to 36.3% (); the percentage of children living with only one parent rose from 36.6% to 38.9%; the percentage of children living without either parent grew from 8.4% to 9.0%; and the percentage of women with two or more marriages climbed from 25.3% to 28.5% (). Estimated migration rates trended downward, from 6.6 per 1,000 population between 2000 and 2005 to 4.5 in the period from 2010 to 2015 (). Internal migration caused by the boom in the reactivation of African palm and cocoa production and fishing as well as land disputes in the Northern and Southern Atlantic autonomous regions are key determinants in the emergence of epidemic outbreaks and the reintroduction of malaria in municipalities that had been free of the transmission of this disease.
Monitoring the Health System’s Organization, Provision of Care, and Performance
From 2000 to 2013, GDP rose from US$ 3.9381 billion to US$ 10.8747 billion; health expenditure as a percentage of GDP decreased from 7.0 to 6.2% (), private expenditure fell from 46.6% to 40.5%, and total expenditure on per capita health swelled from US$ 53.9 to US$ 113.4 (Figure 2) ().
Figure 2. Gross domestic product (GDP) and total expenditure on health as a percentage of GDP, Nicaragua, 2000-2013.
Health Situation and Trends
Health of Population Groups
Maternal and Reproductive Health
The country achieved MDG Target 5A by decreasing the maternal mortality ratio from 160 to 36.9 per 100,000 live births between 1990 and 2014 (). In absolute numbers, 37.5% of deaths occurred during pregnancy and 62.4% after childbirth, hemorrhaging being the main cause of maternal mortality. In addition, MDG Target 5B was achieved by increasing the rate of early detection of pregnancy from 38.4% to 49.1%, prenatal check-ups from 91.0% to 95.1%, and puerperal care for mothers from 47.6% to 69.3% between 2006 and 2012. Births that took place in health care facilities increased from 62.8% to 75.2%, while births attended by specialists in gynecology/obstetrics rose from 48.2% to 69.6% in each year compared. In 2012, 30% of births were by cesarean section, with an upward trend in cesarean birth rates from 2006 to 2012 as follows: from 56.1% to 77.2% in private hospitals, from 45.9% to 65.4% in private clinics, from 25.2% to 36.1% in the Ministry of Health network, and from 44.1% to 51.4% in the INSS sector ().
In the period from 2006 to 2012, the unmet need for family planning decreased from 10.7 to 5.8, which led to an increase in the number of women using modern birth control methods from 69.8% to 77.3%, and from 72.4% to 80.4% for all methods (). In addition, Ministry of Health financing to meet total contraceptive needs rose sharply from 1.0% in 2006 to 74.0% in 2011. Furthermore, in 2012 the availability of at least three to five drugs to treat problems related to reproductive health and maternal health problems increased to 99.6%, which resulted in more lives being saved in health clinics (). Between 2001 and 2012 the gap in absolute inequality of care for women based on educational level narrowed: the lack of coverage of four or more prenatal check-ups for pregnant women fell from 32% to 12%, and the rate of unattended births fell from 51% to 25% ().
The country achieved MDG Target 4A by reducing the infant mortality rate (children under 1 year) from 41 to 20 per 1,000 live births, and child mortality from 53 to 25 per 1,000 live births between 2001 and 2012 (). In 2012, the risk of death in childhood was 1.41 times higher among children of teenage mothers and two times higher in rural areas than in urban. Perinatal mortality per 100 live births from 2006 to 2012 fell from 20 to 16 nationally, from 22 to 17 in rural areas, and remained stable at 18 in urban areas; it dropped from 15 to 14 per live births among teenage mothers, and from 30 to 21 in women with no education (). In terms of reducing absolute inequality gaps based on the mother’s educational level, the neonatal mortality rate decreased from 8 to 7 per 1,000 registered live births, but did not fall based on place of residence, in which case it increased from 3 to 5 deaths ().
In this same period (2006-2012), the number of children who completed the vaccination schedule declined from 85.0% to 84.0%, with a higher incomplete vaccination rate (24.5%) in 18-29-month old children whose mothers had no education (). If this result is disaggregated by specific vaccines, a reduction in coverage levels from 95.1% to 94.3% was seen among those who received three doses of the DTP/pentavalent vaccine, but an increase for other vaccines, as follows: from 95.1% to 95.8% in those who received three doses of the polio vaccine, from 98.3% to 99.1% for the BCG vaccine, and from 87.6% to 88.2% for the MMR vaccine (measles, mumps and rubella), for each year compared (). In 2015, 11.0% of the municipalities had less than 80.0% coverage for the DPT3 vaccine.
Other children’s health strategies that showed improvement in the period analyzed were the administration of iron (liquid or tablet), which remained at 46.0%, while the treatment of intestinal parasitoses increased from 65.8% to 67.3% ().
In 2012, the recorded incidence of acute diarrheal disease in children under the age of five at the national level was 15.4 annual cases per 100 children, with 16.0 cases in rural areas, and 17.2 cases in children of mothers with no education (). It was observed that 60.5% of children with acute diarrheal disease received oral rehydration salts, which is more than 50.0% higher the figure reported in 2001. In addition, inquiries for a health care provider to treat diarrhea increased from 43.1% in 2006 to 52.6% in 2012 (). According to epidemiological surveillance data provided by the Ministry of Health, in 2015 there were 284,080 reported cases of diarrhea, for a morbidity rate of 552.46 per 10,000 population ().
The incidence of acute respiratory infections in children under the age of 5 in 2012 was 28.5 annual cases per 100 children at the national level, with 30 cases in rural areas, 37 cases in the Caribbean coastal region of Nicaragua, and 31 cases in children of mothers with no education (). These figures increased the percentage of children with symptoms of acute respiratory infections for whom the care of a health provider was sought, from 64.1% to 67.4% between 2006 and 2012 (). In 2015, a total of 1,582,445 events from acute respiratory infections were recorded in the Ministry of Health’s surveillance system, for a rate of 3,077.43 per 10,000 population ().
In the same period (2006-2012), the percentage of children who were breastfed within the first hour of birth remained stable at 54%, rising to 80% for children who were breastfed during the first day of birth (). In 2012, the percentage of children who were breastfed in the first hour of life was 61.0% for children in rural areas, 47.0% for children in urban areas (), 68.9% for children whose mothers had no education, and 72.8% for children born at home ().
Health of Adolescents
In 2016, adolescents aged 10 to 19 years comprised 20.0% of the total population (50.2% in the 10-14-year age group and 49.7% in the 15-19-year group), 51.0% of them males (). In 2012, 73.3% of the female adolescent population was unemployed and the 40.7% who were employed had unskilled, poorly paid manual jobs; of that group, 79.0% were able to spend their money as they pleased (). Of the total adolescent population (either sex) in 2015, only 2.1% were found to be directly insured by social security and 10.1% were classified as beneficiaries (). With respect to health care expenditures, 65.3% reported that their health care was completely free, 16.8% were covered by insurance 17.2% paid out-of-pocket, and 0.5% used another method of payment ().
In 2012, 54.7% of adolescents had had health problems in the previous 30 days, 7.5% of this group requiring hospitalization. The most frequent causes of ambulatory diseases in the 15-19-year age group were disorders of the respiratory system (47.6%), the genitourinary system (9.6%), the digestive system (7.5%), and infectious diseases (6.4%). Of the adolescents who presented health problems, 50.6% went in for a medical consultation at a health center, 21.4% went to a public hospital, and 5.0% visited a private health provider.
That same year, 4.8% of adolescents were found to have stunted growth, 4.7% were obese, and 19.5% were overweight (). With regard to mental health, 67% of adolescents were found to have signs of mental health problems, 38.0% suffered from severe depression, and 20.0% did not have anyone they could trust to talk with about their life problems (). The number of adolescents who were already mothers increased from 18.3% in 2006 to 19.7% in 2012 (). In 2015, out of a total of 141,017 live births, 23.5% were to mothers between the ages of 15 and 19, and 1.14% to mothers aged 10 to 14 ().
Health of Adults
In 2015, 46.1% of the adult population was overweight (40.7% for men and 51.3% for women) (), while 15.5% of the total population was obese (9.7% for men and 21.1% for women) (). Per capita alcohol consumption was 5 liters/year and 10.0% of the population said they drank, with the highest consumption (56.7%) in the 25-34-year age group (). Some 78.2% of the population said they knew that alcohol was consumed in public in their neighborhood or in the vicinity (). In 2011, between 20.0% and 30.0% of the country’s total population said they smoked, with a 25.1% rate of tobacco use among 13-15-year-olds (30.4% in males and 20.5% in females) ().
Health of the Elderly
In the period from 2005 to 2016, the population aged 60 and older grew from 5.0% to 8.0% with respect to the country’s total population (), and the number of people who received an old-age pension from social security increased from 36,976 to 117,031 (). From 2005 to 2015, the number of primary care medical consultations at Ministry of Health facilities increased from 394,752 to 950,214, accounting for an average of 8.5% of all consultations. The main reasons for these visits were essential hypertension (31.0%), diabetes mellitus (28%), and rheumatoid arthritis (15%). On average, 13.5% of people over 60 years of age had some type of disability, which is significantly higher than the 3.3% disability rate in 40-59 year old adults (). In 2013, the main causes of mortality in older women were ischemic heart diseases (512.94 per 100,000 population), diabetes mellitus (291.79 per 100,000), and cerebrovascular diseases (243.01 per 100,000). In men, the main causes were ischemic heart diseases (623.43 per 100,000 population), cerebrovascular diseases (272.98 per 100,000), and diabetes mellitus (260.33 per 100,000) ().
Health of Workers
In 2005, there were 17,026 reported accidents and occupational diseases, which doubled in 2015 (37,930 reported cases) (). That year, the accident rate was 53 per 1,000 insured exposed workers, the disability rate was 35 per 1,000 accidents, and mortality was 1.3 per 1,000 accidents. A total of 63% of occupational injuries and diseases were due to poor posture in the workplace ().
Health of the Disabled
Between 2009 and 2010, 179,138 homes were visited and 126,316 people with disabilities were censused, which revealed a disability rate of 2.5 per 100 population. Of the total number of people with disabilities, 25.9% were intellectually disabled, 12.7 had a sensory disability, and 10.1% had an auditory disability 10.1%. Disabled children and adolescents accounted for 24.1% of the total number of people with disabilities (). Between 2003 and 2010, the number of special education schools increased from four to 26, and the number of regular schools that served students with some type of disability swelled from 800 to 12,542. In the health sector the number of physiotherapy centers increased from four to 38, and centers with rehabilitation services rose from eight to 22. There was also an increase in special pensions for victims of war, rising from 20,484 pensioners to 32,361 over the period from 2005 to 2015 ().
From 2005 to 2013, the crude death rate for both sexes rose from 117 to 123 deaths per 100,000 population, for a total of 123 years of life lost per 1,000 population. During this period, the three leading causes of death remained the same: ischemic heart disease (from 36.7 per 100,000 population deaths in 2005 to 47.9, in 2013), cerebrovascular diseases (from 22.4 to 22.8 per 100,000 population), and diabetes mellitus (from 19.7 to 28.7 per 100,000 population). With respect to medically preventable deaths, in 2013 the estimated mortality rate for perinatal disorders was 32.2 per 100,000 population, 20.2 for diabetes mellitus, and 19.9 for ischemic heart disease (). Infectious diseases such as influenza and pneumonia and intestinal infections were the leading causes of child mortality, while the predominant external causes in schoolchildren and young adults were motor vehicle accidents and adult assault. The leading causes of death in the elderly were non-communicable chronic diseases ().
There is still a high incidence of communicable diseases in Nicaragua (see Table 2). Between 2005 and 2015, the morbidity rate from confirmed classical dengue increased from 3.38 to 7.94 per 10,000 population (with four serotypes in circulation) (). In the case of Chagas disease, the predominant vector was Triatoma dimidiata, and the morbidity rate rose from 0.01 to 0.44 per 10,000 population between 2005 and 2013. Leishmaniasis continues to be endemic and there were 2,900 reported annual cases of the cutaneous, mucosal, and atypical cutaneous forms of the disease. Children under the age of 10 accounted for 45.0% of cases, and 83.0% of the total number of diagnosed cases were determined through laboratory criteria. In 2015, the rate of cutaneous leishmaniasis was 3.44 per 10,000 population (). The morbidity rate from Leptospirosis increased from 0.16 per 10,000 population in 2005 to 1.11 in 2015 (), and a total of 1,206,720 inhabitants were considered at risk of contracting that disease. Canine rabies predominated in rural areas, and in 2014 a total of 21 municipalities had a vaccination coverage rate of less than 40.0%.
Table 2. Incidence of communicable diseases (per 10,000 population), Nicaragua, 2005-2015
|Confirmed classical dengue||1,738||3.38||5,156||10.03||4,081||7.94|
|Acute diarrheal disease||203,263||395.29||279,183||542.94||284,080||552.46|
|Acute respiratory infection||1,103,024||2,145.09||2,069,686||4,024.98||1,582,445||3,077.43|
Source: Dirección General de Vigilancia de la Salud, Ministerio de Salud. Boletín Epidemiológico de la Semana 52 del 2005, 2010 y 2015 Nicaragua: Ministerio de Salud.
As for the country’s achievements in the area of neglected diseases, in 2011 Nicaragua obtained international certification for interrupting transmission of Trypanosoma cruzi by the Chagas disease vector Rhodnius prolixus. Furthermore, in 2005 the country achieved MDG 6 as a result of halting and beginning to reverse the incidence of malaria. In 2014, there was a 95.1% reduction of malaria (1,163 reported cases), with a 28.0% annual average reduction using the annual parasitic index and a 27.0% as measured by the slide positivity rate. However, in the last two years (2015-2016) there was a 50% increase in the number of cases, predominately from Plasmodium vivax infection. The number of annual cases recorded in the year 2016 tripled with respect to 2015 (2,309 positive cases in 2015 vs. 6,283 in 2016), primarily from the Plasmodium vivax infection (79% of cases).
The country succeeded in reducing the prevalence of tuberculosis (TB), which declined from 103 to 68 between 1990 and 2013, for an incidence of 44.7 per 100,000 population for all forms, with the human immunodeficiency virus (HIV) present in 0.02% of positive cases out of the total number of TB cases. Between 2005 and 2013, multi-drug resistant tuberculosis was confirmed through susceptibility testing in 113 cases per 100,000 population, with an annual average of 13 diagnosed cases between 1997 and 2005. HIV testing increased from 31.9% in 2007 to 73.2% in 2013, with respect to all reported cases of TB in 2013.
The concentrated HIV epidemic continues to affect the young and economically active population, with an estimated 10,036 adults and children living with HIV in 2014, contracted primarily through sexual transmission, which accounted for 98.0% of the cases. The prevalence of the disease in men who have sex with men was 7.9 per 100,000 population, 2.3 per 100,000 population in sex workers, and 0.15 per 100,000 population in pregnant women (). The most common sexually-transmitted infections (STIs) among sex workers were herpes simplex type 2 (75.7%), bacterial vaginosis (36.7%), and trichomoniasis (30.1%). In the Nicaraguan Penitentiary System, the HIV infection rate was 546 per 100,000 population, and the syphilis infection rate was 35,930 cases per 100,000 prisoners. Of this population, 67.5% engaged in sexual relations with non-regular partners and only 15.9% used condoms. According to a sentinel site study conducted in 2014, out of 2,241 pregnant women, 3.4% had a history of some type of STI, which is more than the 2.0% recorded in 2012. The breakdown of STIs is as follows: vaginal discharge (41.8%), candidal vaginitis (22.8%), condyloma (21.5%), gonorrhea (5.1%), and syphilis (1.3%); 7.6% of the respondents did not fill out the questionnaire (). Of the total number of STI consultations in the country, the principal reasons were candidiasis (46.0%), urogenital trichomoniasis (16.7%), nonspecific trichomoniasis (9.1%), candidiasis in other sites (8.3%), congenital syphilis (3.1%), gonococcal infection (2.9%), and herpes infections (2.4%). STI consultations accounted for an average of 1.0% of all general consultations, 68.7% for females, and 31.2% for males.
Chronic, Noncommunicable Diseases
The general prevalence of Stage I and II hypertension in 2010 was 7.5% and 2.4%, respectively (), while estimates of the risk of contracting cancer before the age of 75 were 13.8% for men, and 15.1% for women (). In 2012, 98% of women aged 15 to 49 knew about the Papanicolaou test and 80.3% had had one done, with the time elapsed since the last cytology screening for 50.2% of them ranging from 0 to 11 months. Between 2005 and 2013, mortality from malignant neoplasms of the uterus increased from 8.6 to 10.4 per 100,000 population, and the rate of chronic respiratory diseases also rose, from 10.3 to 13.4 per 100,000 population ().
Chronic malnutrition in children under 5 declined from 21.7% in 2006 to 17.3% in 2012, and global malnutrition fell from 5.5% to 5.0% during the same period (). In 2012, there was more chronic malnutrition (22.8%) and global malnutrition (7.5%) in children born in the 24- to 47-month birth interval than in those born in the 0- to 23-month interval, or 48 months or more (). Furthermore, children born to teenage mothers suffered from more chronic malnutrition (18.0%) and global malnutrition (7.1%) than those born to mothers between the ages of 25 and 29 (). Between 2006 and 2012, the number of low-birth-weight children rose from 8.7% to 9.6% (), although the absolute inequality gap in the period from 2001 to 2012 fell from three low-weight births to one, depending on the mother’s educational level ().
The prevalence of chronic malnutrition among schoolchildren was 33.2% and 42.3% for 8- and 9-year old children, respectively, while the prevalence rates in 6- and 7-year-olds were 13.1% and 22.8%, respectively (). The average height of 7-year old girls was 115.8 centimeters, a 5.0 cm difference from the standard height established by WHO, while the average height of boys of the same age was 116.5 cm, a 5.2 cm difference from the reference standard ().
Accidents and Violence
A total of 552,000 vehicles were registered in 2014, 47.0% of which were driven in Managua, with an average of 21,138 traffic crashes per year at the national level. Most (57.2%) of the common causes of accidents were due to either not keeping a safe distance, making improper turns, or drifting into another lane (). On average, these accidents resulted in the death of one child every six days and two people daily, causing an increase in mortality (V00-V98) from 9.8 to 10.2 per 100,000 population over the period from 2005 to 2013 (). According to public perception, the four biggest problems affecting road safety in the country were failure to obey traffic laws (22%), inadequate road infrastructure (21%), the lack of traffic lights or traffic signs (21%), and poor driver education (19%). ()
Between 2006 and 2012, the prevalence of verbal and psychological violence by an intimate partner fell from 21.2% to 16.2%. Physical violence rates ranged from 8.0% to 6.1% and sexual violence from 4.4% to 3.5% for the years compared. In 2012, it was found that 67.3% of women between the ages of 15 and 49 had suffered physical or sexual violence by an intimate partner, while the prevalence of emotional abuse by a partner in the 12 months prior to the Nicaraguan Demographic and Health Survey (DHS 2011) ranged from 19.3% among women in urban areas to 11.9% in rural areas (). Of the women surveyed, 20.8% reported three or more instances of controlling behavior on the part of their partner: 11.7% had to request permission to seek health care, 15.4% were restricted from family contact, and 20.0% were restricted from seeing their friends. The triggers leading to violence were intoxication or drug use (33.1%), followed by jealousy (19%) (). More than one-fifth (21.4%) of women considered violence toward them a safety issue, which makes intimate partner violence the country’s fifth leading safety problem for the population (). Another forms of violence include harassment by an intimate partner and violence by a stranger or a partner. The maximum expression of such violence is femicide, which in 2015 took the lives of 53 women, mainly at the hands of unknown men or their own partners.
Between 1997 and 2013, there were 3,733 deaths of individuals diagnosed with a mental health disorder: alcoholic psychosis (91.2%), dementia (1.2%), depressive episodes (1.4%), and schizophrenia (0.8%). In the period from 2005 to 2013, mortality from mental and behavioral disorders (F00-F99) trended slightly upward, from 4.3 to 4.4 per 100,000 population (), while mortality from self-inflicted injuries fell from 7.2 to 5.9 per 100,000 population (). People admitted to health facilities had attempted two suicides per day (51.0% in men and 42.0% in adolescents); of those suicide attempts, 12.0% were successful and 71.0% were unsuccessful. The following pesticides were used in suicide attempts: Gramoxone® (24%), phosphine (18.0%), cypermethrin (14.0%), and Paraquat ® (10.0%) ().
Other Health Problems
It is estimated that 90% of the population has dental caries; 85.0% of children have them and by adolescence an average of four teeth are affected. Given this situation, National Oral Health Days were organized, with the goal of offering 16 health education classes annually at each school. The maxillofacial departments of hospitals saw an average of 30 patients per day for minor oral surgery. Between 2005 and 2015, the density of dentists per 10,000 population remained stable at 0.4 (), while mortality from lip, oral cavity, and pharyngeal cancer (C00-C97) rose from 0.56 deaths per 100, 000 population in 2005 to 0.76 in 2013 ().
In 2014, it was verified that 0.6% of the total population suffered from blindness: 60.0% from cataracts, 12.0% from diabetic retinopathy, and 10.0% from glaucoma (). The institutional response to this problem was an increase in the number of cataract surgeries from 600 to 1,221 in the period from 2006 to 2014, after screening 795 neonates, 35 of them receiving treatment through the Retinopathy of Prematurity Program in 2014. In the country’s hospitals, there were an average of 106,549 consultations for ophthalmological services, increasing from 15.5 per 1,000 population in 2009 to 23.12 in 2015. With regard to human resources, between 2005 and 2014, the number of physicians specialized in ophthalmology increased from 89 to 1,904 and 287 optometrists were trained.
Regarding kidney disease, in 2013, the prevalence of patients who received renal replacement therapy was 2.57 per 1,000,000 population, and 139 in patients under the age of 20; of these, 212 were treated with hemodialysis, 24 with peritoneal dialysis, and 21 had end-stage renal disease (). In 2015, the Ministry of Health’s installed capacity for serving patients with renal disease was 41 hemodialysis machines and 12 automated peritoneal dialysis machines (). From 2005 to 2013, the mortality rate from acute kidney failure and chronic kidney disease (N17-N19) increased from 13.4 to 23.8 deaths per 100,000 population (35.8 for men and 12.0 for the women in 2013) ().
Risk and Protective Factors
In 2014, a survey of secondary students showed 17.4% use of some type of tobacco product (21.9% for males and 12.6% for females), while the rate of smoking was 14.2% (18.5% for males and 9.7% for females). It was estimated that 38.7% of the students were exposed to tobacco smoke in enclosed public places and 59.7% of current cigarette smokers purchased them from shops, grocery stores, street vendors, or convenience stores ().
Nicaragua’s biggest challenges include ensuring continued joint efforts in the legislative area, strengthening the National Regulatory Authority, implementing public health laws, and providing continuing education for human resources through Nicaragua’s Virtual Campus for Public Health, which helps address technology transfer needs, maternal and neonatal health demands in terms of handling obstetric emergencies, newborn needs, and the implementation of the national sexual and reproductive health strategy. Work is also being done to strengthen partnerships and build capacities to ensure intersectoral intervention in the Strategy for Integrated Arboviral Disease Management, risk management in the event of natural disasters, and the inclusion of organized urban drainage systems and household sanitation risk management in local development plans. The country is also working to maintain basic skills in connection with the International Health Regulations, and comply with model intervention strategies for the prevention and treatment of chronic diseases. The linchpin of all these challenges is to strengthen information systems, health analysis, documentation of good practices, generation of evidence, and knowledge management, built through cooperation networks. It is also important to use mobile eHealth applications to disseminate information to inform the population about prevention and self-care measures.
Among the country’s achievements is the approval and implementation of 146 laws and 85 legislative decrees which have helped build institutional capacities and health sector leadership, the implementation of the Family and Community Health Model (with intersectoral and interagency coordination), the renovation of health infrastructure and technological equipment, an increase in human resources and training, and a health-in-all-policies focus, based on an intersectoral approach and in keeping with national policy. All of this has contributed to achieving the targets and indicators of the Millennium Development Goals.
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1. Globalization Index: this indicator evaluates the connectivity, integration and global inter-dependence of countries in cultural, ecological, economic, political, social and technological areas.
2. C$: Nicaraguan córdoba, the legal tender in Nicaragua divided into 100 centavos. The exchange rate in 2015 was US$ 1.00 = C$ 27,00.