Pan American Health Organization

Nicaragua

  • Overall Context
  • Leading Health Challenges
  • Health Situation and Trends
  • Prospects
  • References
  • Full Article
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Overall Context

Flag of NicaraguaNicaragua 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.

Demographics

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 Economy

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) ().

Globalization

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.

Chronic Conditions

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.

Human Resources

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

  Years
Practitioner 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015
Physicians 5.0 4.9 5.3 6.5 7.0 7.3 8.2 8.6 8.9 9.0 9.3
Nursing staffa 4.1 4.5 5.2 5.8 5.9 5.9 6.5 6.8 6.9 7.1 7.5
Nursing aides 7.4 6.9 6.5 7.1 7.1 6.7 7.2 6.9 6.5 6.3 6.3
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
Dentists 0.4 0.4 0.4 0.5 0.5 0.4 0.4 0.4 0.4 0.4 0.4
Others 16.8 16.9 17.6 20.0 19.0 18.8 21.3 21.5 21.1 20.7 20.7
Total 39.6 39.5 41.0 46.4 46.3 45.6 50.5 51.2 50.7 50.5 51.3

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 ().

Aging

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 ().

Migration

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.

Source: General Planning and Development Division, Ministry of Health. Cuentas Nacionales en Salud. Nicaragua: Ministry of Health; 2015.

Prospects

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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Reference/Note:

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.

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