Country Report: Nicaragua
Nicaragua is located in Central America and borders Honduras, Costa Rica, and the Atlantic and Pacific Oceans. It is divided administratively into 15 departments, 2 autonomous regions, and 153 municipalities.
Between 1990 and 2016, its population grew by 54%, reaching 6.3 million in 2016. In 1990, the population pyramid was expansive but has since become stationary in the population under 20 years of age.
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%).
The total fertility rate is 2.1 children per woman, and life expectancy at birth was 75.8 years (78.9 for women and 72.6 for men) in 2016.
In the period 2006-2015, real economic growth increased from 4.2% to 4.9%, at the expense of the agricultural sector, with an increase in per capita gross domestic product (GDP) from US$ 1,203.70 to US$ 2,026.70 and a decline in the cumulative annual inflation rate from 9.4% to 3.1%.
- Health system achievements include the enactment and implementation of 146 laws and 85 legislative decrees, which have strengthened institutional capacity and leadership in the health sector.
- Implementation of the Family and Community Health Model and its intersectoral and interinstitutional coordination, along with the renovation of health infrastructure and technology, have improved access and coverage in health services networks through an integrated approach.
- Between 2005 and 2015, the Ministry of Health substantially increased its workforce and network of facilities.
- The increase in human resources education and the implementation of a Health in All Policies approach (adopting an intersectoral methodology in line with national policy) have been essential for promoting health in the population.
Figure 1. Distribution of the population by age and sex, Nicaragua, 1990 and 2015
Proportional mortality (% of all deaths, all ages, both sexes), 2014
Source: Pan-American Health Organization, World Health Organization, and PAHO Health Information Platform (PHIP).
SELECT BASIC INDICATORS
Source: UN Population and Statistics Divisions, 1990; PAHO Health Information Platform (PHIP), 2013, 2014, and 2015.
SOCIAL DETERMINANTS OF HEALTH
- The human development index was 0.604 in 2014 and the Gini coefficient, a summary measure of income inequality, improved from 0.40 in 2005 to 0.38 in 2014.
- Between 2009 and 2014, the general poverty rate fell from 42.5% to 29.6%. Between 1993 and 2014, the extreme poverty rate fell from 19.0% to 8.3%.
- In 2010, the unemployment rate was 7.4%, and 53.7% of the economically active population was underemployed.
- Between 1993 and 2015, enrollment in primary education rose from 76% to 90%, and an overall literacy rate of 83.0% was achieved.
- Between 2005 and 2012, the average educational attainment (population-wide) increased from 5.6 to 6.8 years of schooling.
- Between 1990 and 2015, drinking-water coverage increased from 73% to 87% of the population and sanitation coverage, from 44.0% to 68.0%.
- Between 1993 and 2012, a total of 44 volcanic events were recorded; 69% of the population was exposed to two or more hydrometeorological risks.
- An objective of the National Human Development Plan (PNDH) is the transformation and human development of the population. The strategy of the PNDH is based on 12 guidelines that combine the continuity of existing policies with the integration of new priorities. Some of its objectives are aimed at improving the living conditions of the most vulnerable sectors of the population.
HEALTH SITUATION AND THE HEALTH SYSTEM
- The maternal mortality ratio improved from 160 deaths per 100,000 live births in 1990 to 36.9 per 100,000 in 2014. The leading cause of death was puerperal hemorrhage.
- Between 2006 and 2012, several maternal health care coverage indicators improved, including early diagnosis of pregnancy (from 38.4% to 49.1%), antenatal check-up coverage (from 91.0% to 95.1%), postpartum follow-up coverage (from 47.6% to 69.3%), and in-hospital deliveries (from 62.8% to 75.2%).
- Between 2001 and 2012, the infant mortality rate fell from 41 to 20 deaths in children under 1 year of age per 1,000 live births, at the expense of late post-neonatal or child mortality, while the neonatal mortality rate declined modestly, from 8 to 7 per 1,000 live births.
- Between 2006 and 2012, chronic malnutrition in children under 5 declined from 21.7% to 17.3%, and global malnutrition, from 5.5% to 5.0%.
- In that same period, overall vaccination coverage held steady at around 85.0%. A reduction in third-dose DTP and pentavalent vaccine coverage was observed, from 95.1% to 94.3%, while third-dose coverage of the polio vaccine increased from 95.1% to 95.8%. Coverage for the tuberculosis vaccine (99%) and the MMR vaccine (88.2%) remained stable.
- In 2012, 54.7% of adolescents had experienced health problems in the last 30 days. The leading causes of outpatient visits were disorders of the respiratory system (47.6%), the genitourinary system (9.6%), and the digestive system (7.5%). Among adolescents, 4.8% displayed stunting, 4.7% were obese, and 19.5% were overweight; 67% had some mental health disorder.
- The main reasons for outpatient visits in adults aged 60 and over were hypertension (31.0%), diabetes mellitus (28%), and rheumatoid arthritis (15%); 13.5% of adults in this age group reported some type of disability.
- 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.
- Diseases of the circulatory system caused 27% of deaths, followed by external causes (13%) and neoplasms (10%).
- The leading causes of death from chronic noncommunicable diseases are ischemic heart disease (47.9 per 100,000 population), cerebrovascular disease (22.8), and diabetes mellitus (28.7).
- Between 2005 and 2015, the morbidity from confirmed cases of dengue increased from 3.4 to 8.0 per 10,000 population. Between 2005 and 2013, the incidence of Chagas disease also increased, from 0.01 to 0.44 per 10,000 population.
- Leishmaniasis continues to be a controlled endemic disease, while leptospirosis incidence increased from 0.16 to 1.11 per 10,000 between 2005 and 2015.
- Canine rabies is still present in some of the more rural municipalities.
- In 2005, the incidence of malaria began to decline; however, in 2015-2016, a 50% jump in cases was observed.
- The TB incidence rate in 2013 was 44.7 cases per 100,000 population. Between 2005 and 2013, 113 cases of multidrugresistant TB were recorded.
- Human immunodeficiency virus (HIV) continues to affect mainly the young and economically active population. It is estimated that 10,036 adults and children were living with the virus in 2014. Sexual transmission accounted for 98.0% of cases.
- In 2016, the prevalence of diabetes was estimated at 8.1% (9.0% in women and 7.2% in men); 6.0% of all deaths in the country are related to this disease. The prevalence of hypertension in 2010 was 7.5% for stage I and 2.4% for stage II.
- Between 2005 and 2015, the road traffic accident rate doubled. There were 35 cases of secondary disability and 1.3 deaths per 1,000 accidents, while mortality was 10.2 per 100,000 population.
- The prevalence of disability in 2010 was 2.5%, with intellectual impairment accounting for 25.9%; sensory impairments, 12.7%; and hearing impairment, 10.1%.
- Between 2006 and 2012, indicators of domestic violence (verbal, psychological, physical, and sexual) fell by 25%. Nevertheless, a 2012 survey confirmed that 67.3% of women aged 15-49 had experienced some type of physical or sexual violence at some point in their life.
- In 2012, 46.1% of adults were overweight and 15.5% were obese (9.7% of men and 21.1% of women).
- In 2014, the overall prevalence of smoking was 14.2% (18.5% in men and 9.7% in women; 25.1% in young people). Annual per capita alcohol consumption was 5 liters, and 10% of the population self-reported alcohol intake.
- The health system is composed of a public sector and a private sector. 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 Police.
- The Ministry of Health is the health authority and main service provider, covering 65% of the population; the INSS covers 18%, and the Ministry of the Interior and Army services, 6.0%. The remainder of the population is served by private institutions and nongovernmental organizations.
- Between 2005 and 2015, the Ministry of Health service network was expanded by approximately 50%, reaching a total of 5,143 hospital beds (8.1 per 10,000 population) in public facilities.
- In that same period, the supply of health workers also increased by 50%. In 2015, there were 9.3 physicians, 7.5 nurses, 6.3 nursing assistants, and 7.1 health technicians per 10,000 population.
- In the period from 2000 to 2013, total expenditure on health in relation to GDP rose from US$ 3,938.1 billion to US$ 10,874.7 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 health per capita swelled from US$ 53.90 to US$ 113.40.
- Partnerships between the Institute of Sustainable Sciences in Managua and the University of California at Berkeley with the Ministry of Health have furthered advances in infectious disease research.
- The Government’s Web-based Health Information System contains vital statistics modules (births and deaths), whose data are entered in the central database of the national civil registry in Nicaragua. In 2016, this system provided training on the clinical records, hospital management, and primary health care modules.
ACHIEVEMENTS, CHALLENGES AND PERSPECTIVES
- In 2011, Nicaragua obtained international certification for the interruption of Trypanosoma cruzi transmission by Rhodnius prolixus, the vector of Chagas disease.
- The Water and Sanitation Program has substantially increased coverage, leading to the achievement of the corresponding Millennium Development Goals.
- The National Human Development Plan of Nicaragua establishes guidelines aimed at the human development of the population. Regarding the living conditions of the most vulnerable sectors, the health policy focuses on restoring the right to a healthy environment through preventive health interventions and the delivery of free comprehensive, integrated, high-quality services through the Family and Community Health Model.
- The Family and Community Health Model guides sectoral health action by engaging individuals, families, communities, and other social actors to promote a comprehensive systematic social response to endemic and epidemic problems.
- Continuing education for human resources is key to handling technology transfer, responding to public health demands, and implementing the national health strategy. The lack of full-time software development staff limits progress in the construction of the health information system, and pending challenges include linking platforms and coding the Epidemiological Surveillance System at the National Diagnostic and Referral Center.
- Greater capacity-building is needed for intersectoral intervention to control dengue, Zika virus, and chikungunya under the Integrated Management Strategy for Arboviral Disease.
- Tackling these challenges will require better information systems, health analysis, and documentation of best practices; evidence generation; and knowledge management through cooperation networks.
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