Envío Digital
Central American University - UCA  
  Number 253 | Agosto 2002



We Were Sold (and Bought) A Health System That Doesn’t Work

Dr. Jaime Espinosa Ferrando, a public health expert and specialist in health systems and economics, shares with envío his reflections on Nicaragua’s health crisis.

Jaime Espinosa Ferrando

Although reflecting on health is a political and not just a technical activity in any country in the world, this is particularly true of today’s Nicaragua. Health is a political problem that has technical solutions, but we will make no progress if we fail to discuss what we mean by health and what we want for Nicaragua before designing those solutions.

What’s at issue in the
debate on free health care?

Today’s discussions are rather simplistically reduced to whether or not health services should be free, the quality of the attention that people receive in the hospitals and health centers, the supply of medicines in the hospitals. But the debate must be widened, made more complex, more in-depth. The health issue is not limited to access to services, the quality of attention or the availability of medicines.
The following is just one example of how incorrectly the debate is currently being presented. Among the demands most pushed by health workers’ unions now is insistence on free health services. But what does this mean in today’s Nicaragua? It has been proven that demanding free health services generally speaking does not amount to being on the side of society’s poorest sectors. An analysis of household surveys reveals that those with most resources actually take the greatest advantage of the free services available to us. This phenomenon is common to all countries in the world. When I studied in Europe, we were already analyzing as a classic textbook phenomenon the fact that those groups with more education are able to access more and better public health benefits than those in most need. As a student I thought this only happened in developed countries, but the same thing happens in Nicaragua for the simple reason that people with more knowledge and education know how to take better advantage of the opportunities presented to them, and those with a greater ability to communicate their needs get more attention. For example, if an educated woman turns up at a hospital she will talk with the director or some other person in authority and demand a certain service or go through the relevant procedures, while an illiterate woman will sit in a corner not knowing what to ask for or how to ask for it and at the end of the day nobody will have treated her. Poor people have learned that they have no right to anything and therefore don’t demand anything.

Incredible as it may seem, this same phenomenon is not limited just to the care provided in hospitals and health centers; it is also true of vaccinations. Those with least income also have the lowest vaccination coverage rates, despite the fact that the vaccination campaigns have been precisely designed to reach people who do not visit health system institutions, whether out of ignorance or the distances involved. The explanation is that the use of health services involves three fundamental factors that act simultaneously: income level, education level and accessibility of the services. Bearing all of this in mind, what are we talking about when cost-free status is demanded and required? What services should be free and for whom? When we decided in the eighties that all health services were going to be free, for example, heart and kidney transplants were implicitly included in this cost-free status. But this was merely theoretical because we had absolutely no practical capacity to provide such services. We resolved this problem by sending people abroad, and organized this most specialized, tertiary health level by relying on Mexico, Cuba and other countries that were providing solidarity as an answer to the Nicaraguan health system’s problems. Theoretically, people could demand this free attention, but in practice it was never open to everyone.

Health is a result of many factors

Health is the product of the relations within society between the environment, the way we live, education, culture, genetic conditions and the resources available to society to respond to people’s problems. All health problems are linked. A simple example is that people who live in houses with dirt floors are more inclined to fall ill than people who live in houses with concrete floors. The difference that a dirt floor or a concrete floor makes to contracting infectious and contagious diseases has nothing to do with health services, doctors or nurses. The same is true of potable water. Members of a community that has drinking water close by are less likely to get sick than those of a community whose water comes from a far-off river or other distant source. In the latter case, the water gets contaminated while being carried, by whatever is used to take it out or while transferring it from one receptacle to another. The more water is handled, the greater the possibility of contaminating it and thus of transmitting diseases.

Health also has to do with the country in which we live and its particular environment. And it has to do with given conditions within that country. A good example in Nicaragua is dengue and hemorrhagic dengue, two epidemic diseases found in our environment. Proportionally speaking, not in terms of absolute numbers, people in higher income groups are more likely to die of dengue and hemorrhagic dengue in Nicaragua because the mosquitoes that transmit the diseases live in clean water rather than dirty water. There is much more clean water in households with more resources because they have big gardens with many plants, several toilets, perhaps a fountain or even a swimming pool...

Health is also related to how well health services are organized to answer the population’s needs. I’m much more likely to die if I have a heart attack talking about these issues in Managua than in New York City, because most listeners there will have received training in cardiopulmonary resuscitation, an ambulance will arrive in under seven minutes and will bring qualified personnel and specialized equipment to treat me on the spot. In Managua, probably nobody would have the training to help me, while I’d be lucky to get to hospital in 15 minutes, not by ambulance but by any available vehicle. Thus the probability of falling ill and the ways of dying are related not only to individual socioeconomic conditions but also to the social and economic conditions of the country we live in, the work we do and the education of the people around us. Living in a poor society without resources not the same as living in a wealthy society where resources are available to people when they need them. Of course genetic factors also influence the development of certain diseases, as do eating habits, which have a great effect on the health of the given population. So when we talk of health, we must bear in mind a wide range of factors rather than reducing the debate to the issue of services, hospitals and doctors.

Who’s responsible for a health system?

Health systems are the way in which society organizes its human, material and financial resources to place them at the public’s disposal and respond to people’s health needs. The different forms of organization are designed by the state, the market and different private or community initiatives. It’s up to the state to regulate all of the different forms designed and determine how all of these forms are going to be organized as a whole. It is also the state’s responsibility to guarantee that everyone’s right to health care is respected, although this does not necessarily imply that the state has to provide it. If the Nicaraguan state guarantees the right to property this does not mean that it has to give each Nicaraguan a piece of property. The state guarantees the right of every Nicaraguan to education, but this does not mean that it has to provide every Nicaraguan a complete education.

We thus come to the question of responsibilities. The state’s responsibilities are understood in different ways in different countries, according to how the population has assumed the task of organizing itself, derived from its political philosophy. Certain countries assume that the way to guarantee the right to health care is for the state to have the fundamental responsibility for the citizenry’s health, be the main provider of health services and have total control over health service provision. The best example of this in Latin America is Cuba, where the state uses family doctors to provide health services to the family nucleus and has a very well organized and developed tertiary care system with a high degree of medical technology aimed at responding to rehabilitation and recuperation needs. In France, the state declares that all citizens have the right to health care. In fact their rights have been increasing in this area and France has just defined a new one: the right not to feel pain. The state has even got involved in this area, exercising control and legislating to ensure that the first mission of any health worker is to stop a patient from feeling pain. But at the same time France is one of the countries where private medicine has most weight, even more than in the United States where the state directly finances 42% of health service provision. In France, most of the health services and the professionals are private. Hospitals and other structures depend on the state but are administered from a private perspective with most services paid for by the people through a variety of different mechanisms.

Cuba is a third world country and yet has impressive health indicators. They are very similar to those of Costa Rica, another third world country but with a very different political and social model. Costa Rica’s public health spending is lower than Cuba’s, but this doesn’t mean that its system is necessarily more efficient. The Cubans have organized things in one way and the Costa Ricans in another. The Cubans have taken exceptional decisions in public health. Seeking to create a self-financing system, they sell health education, specialized medical services, medicines and medical apparatuses throughout the world, including developed countries such as Norway and Sweden and Arab countries. They also offer all kinds of medical services, some of them highly sophisticated, on the island. They have thus created a cost-effective health project, developing it along very different lines to those of the rest of Latin America. Costa Rica does not share this particular conception; it doesn’t have the same kind of technical development or biotechnology, nor does it produce medical apparatuses and or sell services abroad. But its population’s health care is completely guaranteed throughout the national territory and its health indicators are comparable to those of Cuba. They are two different political models that have reached similar levels with very positive results for their respective populations.

We mustn’t forget that the per capita production of both Costa Rica and Cuba is several times higher than Nicaragua’s and that their societies therefore have far more resources available than ours. Both countries also successfully eliminated illiteracy many years ago, which is another great difference with respect to Nicaragua, where over a third of the population is illiterate.

We should reiterate quite clearly that differences in health indicators are not determined by one hospital more or less, but in people’s lifestyle and education level. There is an almost exact relationship between a mother’s educational level and the survival of her children. There is a greater probability that children of illiterate mothers will die during their first year than those of mothers who know how to read and write. The difference in probability between the children of illiterate mothers and those of university-educated mothers is greater still. In health, not everything depends on the political model; it also depends on the model of society as a whole and particularly the national income distribution model. The following three factors need to be linked together to produce good results: a more educated society, greater available resources and the political will to redistribute the resources and guarantee the whole population its basic rights.

What health rights must be guaranteed?

How society is organized to guarantee health also depends on how we interpret people’s right to health. What does this right oblige us to guarantee? Although this is a question of ongoing debate, certain fundamental concepts have been established.

The right to life

The first and most essential is that all inhabitants of this planet have the fundamental right to life, the unalienable right to have their life respected. This means that they must be protected from anyone trying to kill them and that their life should be saved if they suffer an accident. These are not health problems; they are undebatable ethical problems related to the right to life. What must a state do to guarantee everyone’s right to life? In addition to organizing a good public security system, it must also organize public health in such a way that no one is turned away in an emergency. Guaranteeing this right one way or another will depend ultimately on regulations, laws, controls, supervision, etc.
In Nicaragua, quite simply, the system doesn’t function. Certain kinds of emergencies are even rejected. And this isn’t just a recent thing; it’s something that we have inherited. The Roberto Calderón Hospital was formerly called the Manolo Morales Hospital because its namesake, a Social Christian activist and health workers’ union lawyer, was rejected by hospital after hospital in the seventies after suffering a heart attack, because his problem didn’t fit the hospital’s particular profile. He was only accepted in the hospital that until recently bore his name and there he died. The situation hasn’t changed and many people are still shunted from one hospital to another. Many women arrive at different hospitals and health centers with dangerously dehydrated children only to be rejected because the women don’t have the means to pay or because the center doesn’t deal with that particular problem.

Reproductive rights

One of the fundamental rights that guarantee the right to life is the right to be born. The state must concern itself with the pregnancy and birth of its citizens; it must protect reproductive rights. This debate should not focus on who provides the services, but rather on what should be guaranteed. In Nicaragua, we discuss it the other way round: instead of discussing rights, we argue over how to organize ourselves to guarantee the services that are supposed to guarantee the rights we have never even discussed.
If the state is responsible for protecting the population’s reproductive rights as an essential way to guarantee the right to life, then we face a big problem in Nicaragua. Here we do not have a lay government as set out in the Constitution; it is guided by a confessional, religious, Catholic mentality. Societies need lay governments. History has demonstrated that it is the only way for a state to function adequately. It wasn’t necessary just to put an end to the religious wars between Protestants and Catholics, but is still necessary to resolve the many other problems facing the population, providing the same opportunities for all, regardless of their religious beliefs. All individuals have the right to their own religious conscience and to decide whether to use the resources that the state puts at their disposition. But just because ministers belong to a certain religion doesn’t give them the right to impose their way of thinking on everybody. Doing so violates our right to think and act freely in religious terms on a daily basis.

The Nicaraguan state does not promote the use of contraceptive methods because it believes this violates Catholic Church precepts, which dominate the philosophic and religious conscience of state officials. The same is true of using contraceptives to prevent AIDS and of sex education in schools, which is essential to guaranteeing reproductive rights. In the field of education, Catholic religious precepts are further complicated by Victorian prejudices. It is considered bad and dangerous to talk about sex and further believed that young people’s sexuality is a private issue that should only be dealt with by the family, not by the state. Thus, between precepts and prejudices, our children are left unprotected when they reach adolescence, without the necessary instruments or training to deal with the social reality or their roiling hormones.
What is really behind the state’s failure to assume responsibility for sexually educating its young citizens is a conception that children belong to their families alone and that only parents have the right to make life and death decisions about their children until they are of age. And yet this conception has supposedly been left behind. What happened to the rights of children and adolescents? What happened to the right to information, which is the main reproductive right of all human beings? We must first be informed; what we then do with that information is the exclusive responsibility of each human being. All people have the right to make their own decisions, but the state is responsible for facilitating all information possible.

Control of epidemics

In addition to providing emergency treatment and guaranteeing reproductive rights, it is also essential for the state to protect everything related to the control of epidemics, which includes the fight against epidemic diseases. It is up to the state to respond to the hostility of the environment and to dangerous working and living conditions that could cause illnesses. Today, the state tends to minimize or even hide information on epidemics so as not to affect the country’s image or discourage tourism. But any tourist with any sense already knows that this is a tropical country in which dengue and malaria are endemic. Tourists don’t expect dengue to have been eliminated, what they do expect is a dengue control program that reduces their risks to a minimum. This control, for the genuine benefit of both Nicaraguans and tourists, rather than the country’s image, should be the Nicaraguan state’s main concern.
Finally, the state must be responsible for guaranteeing treatment of chronic diseases such as diabetes, hypertension and degenerative diseases, which affect a great many people. In Nicaragua, chronic mental diseases are not suitably attended due to the lack of a correct flow of supplies for those affected. Meanwhile, many diabetics die or often have unbalanced sugar levels because the country lacks insulin, in turn because the state doesn’t take responsibility for ensuring adequate insulin supplies. It guarantees parliamentary representatives two US$50,000 vehicles during their term, but cannot guarantee the monthly amounts of insulin needed in the country, which works out to exactly the same price as one of those vehicles.

Emergencies, reproductive rights, chronic illnesses and epidemics are the four fundamental rights linked to the right to life that we should discuss before proposing how to finance the state’s responsibility for them, provide access to services that guarantee them, guarantee the necessary medicines and organize the system so it can respond adequately.

Who pays for what?

The state finances all of this through taxes, contributions by companies or out of the pockets of individuals. It is also externally financed through loans or donations to the state. Either I pay directly, the state pays directly, or social security pays because I make monthly contributions to it directly or through or my company. The health service companies can be public, private, mixed, NGO-run, etc. In Managua I can go to a private hospital and pay, a private service that handles social security claims and pay through my social security or a public hospital and still have to pay for a significant part because the Health Ministry cannot cover it all and tells me as much.
There’s a rule that states that the more direct the form of paying the less equitable the service, because those with more get more. Wealthy people buy more services and better quality medicines whenever they like, while those with no money quite simply don’t buy them. The services that spread the liability most equitably are those provided by social security. In social security systems, everyone—whether they are sick or well—contributes money and the service provided for a sick person is paid for out of that common pool. In other words, I pay in advance when I’m well rather than pay when I’m ill. I also pay in proportion to my income yet receive equal service to someone whose contribution was greater and another whose contribution was less.

The Nicaraguan state health budget has been progressively reduced since 1983, the year of the country’s highest health budget ever. The reduction has been so big that the budget is currently 40% less than in 1983, while the population has increased by 40% over the same period. This impressive per-capita budgetary reduction means that the amount of money invested in every Nicaraguan has fallen from $50 to $16 between 1983 and today. This provides a precise measurement of the crisis. While the state was able to pay for doctors, nurses, medicines and the maintenance of hospitals and health centers with the $50, it is currently limited to paying doctors’ wages. In all countries where the health budget is reduced, it ends up concentrated on providing doctor’s salaries, because they are one of the most inelastic budgetary factors. In Haiti, 89% of the health budget goes towards paying their salaries, leaving only 11% for maintenance, repairs and purchasing supplies. Haiti therefore depends on foreign cooperation and donations to cover its costs. We have the same problem in Nicaragua, with 80% of the health budget dedicated to salaries as compared to 60% during the eighties.

At 9%, the proportion of the GDP being spent on health is the same as before, if not more. But the real amount of money is less and the system has more people to cover. Today’s crisis lies in the fact that the state has increasingly fewer tax resources for financing the health needs of a population that grows by over 3% a year. In 15 years, there will be 5.4 million Nicaraguans compared to under 3 million in 1983. The population is extremely young and growing fast and the resources available are increasingly limited, which is why economists argue that the capacity to provide health services is closely linked to the capacity to produce resources. Concentrating on material production, export capacity and increased productivity is thus linked to the possibility of transferring resources to the public sector to offer better health services. But as we haven’t been able to produce more, our economy has failed to overcome the crisis and the state guarantees less and less, the state has "solved" the problem by handing over responsibility for health to people themselves, opening up the health market to create greater supply. But this isn’t going to solve anything, because the main problem is that 70% of Nicaraguans live in poverty, 40% of them in extreme poverty, and they have no money to pay for the services offered in either the public or private health sectors.

A recent study covering the last 20 years in Nicaragua analyzed how public sector health responsibilities have been transferred to the private sector and compared the number of consultations per year by the country’s inhabitants. It was observed that while 60% of all health activities generated by the public sector had been transferred to the private sector, the per capita services received fell by exactly the same percentage, 60% fewer. The fact is that all national activities are interlinked, so if there are no resources to produce, there will be neither companies nor people to pay taxes or consume, and if not enough people are paying taxes there won’t be enough money for health services. Bearing this vicious circle in mind, it is a fallacy to say that privatizing the services can solve the problem. People who cannot be treated by the public services cannot afford to pay for private services. Privatizing does not solve the problem, it just provides an answer for limited sectors of the population that are demanding and can pay for better attention.

The illogical medicine crisis

Current public health spending is essentially divided between personnel and supplies. Most of the spending on personnel goes for doctors’ salaries, which are determined by the state and not by the law of supply and demand. Of the total spending on supplies, 80% is earmarked for medicines, whose prices are defined by the international market for finished products and raw materials, which also establishes how such products can be acquired. Since the production of medicine in Nicaragua is so rudimentary that it scarcely even exists, almost all of the medicines we need must be bought on the international market, where purchases and sales are determined by scale: the more you buy the lower the price. There is a link-up between the different steps involved in purchasing and selling medicines. Thus the medicine-producing plants plan their production annually and buy their raw materials six months in advance so as to produce determined amounts and assign fixed tasks for each of their lines of production. The most favorable prices are obtained by buying at the right time, which is three months before the end of the plan. But if you buy at the wrong time, the prices are incredibly high. An aspirin bought on time and in bulk, for example, could cost a cent while one bought at the wrong time and in small amounts could cost as much as a dollar.

In 1982, Nicaragua’s Ministry of Health had 84 registered medicine importers. Of those, only a dozen were big ones that represented the big pharmaceutical firms. The rest were small importers such as big pharmacies or certain traditional importers of a specific product. At the time, the economy had serious foreign currency restrictions and the state thus controlled foreign currency and established the priorities for its use, which included the purchase of agricultural inputs and medicines. The ministry soon discovered that the importers were overcharging for the purchase of medicines in order to sneak foreign currency out of the country undetected. The most serious side of this was that this method of capital flight was jacking the price of medicines up four to ten times higher than in the rest of Central America.

Instead of applying sanctions, the ministry decided to take charge of purchasing all the medicines the country needed. Without dissolving the private importers, it formed a series of medicine importing companies and grouped them together into a corporation known as COFARMA, which ended up buying $40-50 million worth of medicine a year. Today, the public and private health sectors invest only $20 million in medicine combined. COFARMA managed to increasingly reduce prices for both the public and private sectors because we bought in bulk following an annual bidding process and we bought on time.

With the political and ideological changes introduced in 1990, it was decided that the "state monopoly" had to end and the medicine market had to be freed up to make it more "efficient." The thinking behind this was that open markets reduce costs and are more efficient. The new government dismantled COFARMA overnight, resulting in an immediate rise in the cost of medicine, ultimately fivefold or more, and purchases became increasingly inefficient and anarchic. With the liberalization of the market, Nicaragua went from paying $4.5 to paying $14 for a kilogram of medicine on the international market.

The medicine market is an imperfect market. In a perfect market supply and demand are balanced and the market permanently informed. The central element of the market is information: consumers know what they want to buy, know exactly what they are buying and can choose from among different offers to end up with the most suitable one. This is not the case with health and medicine. When one visits a doctor, the doctor says what one has and what one should take to cure it. Sick people lack the information that would allow them to compare and decide. While the doctor has the information, based on scientific considerations that might differ from doctor to doctor, the patient goes to the market to buy the product. This makes the market highly imperfect, which means that there is no room here for free market dogma. This has been demonstrated all over the world and in hundreds of reports produced by the World Health Organization, the Pan American Health Organization (PAHO), independent groups and classical, neoclassical and Marxist economists. Everyone knows that in the case of medicines it is essential to consider economies of scale and market imperfections.

But do we know about this in Nicaragua? There is currently a serious medicine shortage in the country’s public hospitals and health centers, which is at the center of the current political debate. Leaving aside the issue of corruption, the new health minister found herself facing the reality behind the 40% savings on the health budget paraded as a success by her two immediate predecessors. In reality this "success" was because they had stopped buying medicines for years, thus accumulating an enormous deficit. The new minister’s only solution was to go out and buy medicine. But she didn’t have $50 million to spend and the state has lost not only its awareness of the need to purchase massively to get the economies of scale, but also its experience of the mechanisms necessary to do so. The urgency of the situation forced the ministry to go out and buy here, there and everywhere. The result has been dozens of purchase orders and a continuing shortage, when efficiency requires a single purchase order that should have been submitted in September last year, because any order placed in the world medicine market after November is automatically inefficient. The inefficiency of the current purchases is not due to corruption or ill will, but to ignorance and the desperate need to resolve a problem of shortages that also has ideological roots.

Ideology and health care

The dominant ideology that lauds and imposes the free market has a lot to do with the current inefficiency, which Nicaraguans are constantly forced to face. When they go to a public health center the most they can hope for is to be seen by a doctor and receive a prescription. But that’s as far as the service goes, because the health center lacks the medicines to treat their illness. Only the plethora of private pharmacies offer the medicines and at a high and inefficient price that most users of public services cannot remotely afford. This problem could be solved by setting up non-profit state-supplied pharmacies that sell their medicines at low prices. This viable formula would allow people to buy what they need and currently can’t find in the public health system at more favorable prices. It would also improve relations between the state and its citizens. So why hasn’t it been adopted?
In the eighties the Ministry of Health created popular pharmacies along exactly these lines. The main reason for not re-launching this initiative and reinstalling such pharmacies today is basically ideological. In the nineties, Nicaragua not only underwent a profound change of political regime, but was also subjected to the ideological influence of very important economic changes being implemented throughout the world. For a number of years, the dogmatic idea that the state was such an inefficient administrator that it had to be removed was already being imposed. It was the communist utopia’s image of the withering away of the state seen from the other extreme! This idea was gradually modulated until it was stated that the state should be limited to regulating or facilitating. But the idea of state inefficiency was maintained and consequently state companies started to be privatized within a more general framework known as state "modernization." Modernizing fundamentally meant transferring what was previously public responsibility to the private sector, particularly the provision of services. There was fierce opposition throughout Latin America to the privatization of health services. In El Salvador and Puerto Rico, the medical schools themselves—in other words, the doctors—opposed privatization and fought for reforms to the health system that defended people’s rights. In Nicaragua, FETSALUD, the state health care workers’ union, which includes doctors, led that fight.
As the opposition of the population and the health unions stopped the rapid privatization of the health services in Nicaragua, one of the new government’s first measures was to close down the popular pharmacies. Now that there is a demonstrated theoretical need to recreate this kind of pharmacy to provide some response to a system that lacks resources, ideology is dominating and it is said that there is no longer a place for such things within the modernization of the health sector. The reasons given are that the ministry must be limited to a regulatory and controlling structure and that the apparatus that produces health services should be transferred to the municipalities and administered differently. Before that decentralization happens, popular pharmacies and other initiatives of that type are rejected despite their obvious advantages. The state rejects out of hand many solutions based on past experiences that would have an evident impact and immediate effectiveness for the simple reason that they no longer "fashionable."
The World Bank and Inter-American Development Bank (IDB) have provided loans to finance the "modernization" processes throughout Latin America, including Nicaragua. The money used to modernize the Nicaraguan health sector in recent years has been spent with notable inefficiency. All analyses concentrated exclusively on the technical aspects of the processes financed reveal an impressive squandering of money because there are no results and all indicators are negative. All of the money invested in training human resources, for example, has been effectively lost due to political polarization. The 600 administrative health ministry workers laid off for purely political reasons during the changes of government in both 1990 and 1997 meant the waste of between US$2 million and US$5 million in training financed by the international organizations.

The weight of the
international financing agencies

While the lack of a civil service law to protect technical workers contributes to this important waste of human and economic resources, the international financing institutions have inexplicably never pressured for approval of such a law with the same determination shown over other issues. Entering the health service or being promoted within it should be based on experience, length of service and training, but here there is no health promotion ladder and it is not even contemplated. You get in or get promoted because you’re a friend of the nephew of the brother of the politician of the moment and the powers that be see you as politically reliable according to their interests.

The multilateral organizations have played a fundamental role in all national decisions. The main problem is not so much that they insist on their own particular recipes, but that they also muck around in the kitchen. They don’t just ask us to do something; they insist on how it should be done. And our governments are increasingly incapable of negotiating with these powerful entities or representing the population’s needs. This is more than evident in the case of Nicaraguan health care.

A group of public health experts that formed during the sixties in Nicaragua was responsible for designing and developing the public health model that started to be implemented in the seventies. We had the first program-based budget in 1965, although it took until 1981 for this to be repeated. There were already growth plans for the health sector in the sixties. The main projects for the sector’s infrastructure growth were designed in 1975 and the financing for them was successfully negotiated with the IDB in 1977. In other words, the explosion of health services during the revolutionary eighties had actually been negotiated from 1975 to 1979 between that era’s health authorities and the IDB, which at the time was also imposing a health care model that stressed secondary, or hospital, attention. The revolutionary government transformed that project and expanded it to set up 400 primary attention units (health centers and health posts). One way or another, then, there has always been a continuum and everything has had a precedent, because the international organizations working in the health area have always had a presence and an influence in the country and been imposing their own models.
When the World Bank launched the great program to modernize the Nicaraguan state in 1990, one of the main components was the modernization of health. By that time the Bank had learned from experiences in the Ivory Coast and Venezuela, where the modernization processes had been endangered by the uprising of poor people against draconian adjustment programs that included massively reduced health spending and restrictions on consumption. It had added social compensation policies to its adjustment policies that were mainly aimed at allowing the poorest sectors to survive the economic transition. The first thing the World Bank tried to do in Nicaragua was break the ideological model that went with the health system. But this has still not been achieved despite all the efforts. They did not succeed because a model can’t be broken when there are no resources to do so and when breaking it depends on a population that has no resources to find alternatives in the new privatized model. Given a population with income levels three or four times higher, less unemployment and more equitable income distribution, the World Bank’s models would probably have worked better and been more easily implemented in Nicaragua. It is very surprising that with the country in such a harsh crisis the state so quickly decided to dismantle the previous model instead of protecting the poorest population and relying on more efficient use of the limited resources available to it.

The first thing dismantled was the regionalization of health, and for ideological reasons, as maintaining it was seen as preserving the Sandinista model. With IDB support, PAHO made us change from regionalization to departmentalization through the creation of the Local Integral Health Attention Systems (SILAIS). The scheme originally had a municipal logic, but they remained in the departmental capitals because of a lack of resources to take them further down the ladder and because there was no real will to decentralize down to the municipal level.

There is another side to this particular coin. Which groups are currently most opposed to the health decentralization processes? The unions. Why? Because decentralization means they would lose control over the sector and therefore lose power. At the moment they are automatically imposing their agenda, and the only thing that guarantees them the negotiating power to continue doing so is maintaining the system as it is, with them representing 60-70% of the 23,000 health workers.

With SILAIS appeared the first IDB projects and accompanying World Bank consultants, who arrived in Nicaragua proposing the need for a better redistribution of the limited resources available, based on the country’s epidemiological characteristics and the people’s poverty. This seemed an excellent idea: the eighties discourse turned into a World Bank manual! But there was just one small problem: the infrastructure of the previous model was still in place and there was no possibility of moving it towards the people most in need. It soon became very clear that the new model was not moving in the direction that the World Bank wanted. Furthermore, the health model in the eighties was conceived with the idea that the country’s economy would grow by 5% or more a year and with a certain population distribution. Ten years on, the country was in ruins and people were already located in a different way, among other factors because the war had displaced some 250,000 Nicaraguans from their homes and migration had altered the organization of the cities, thus changing the geographical priorities.

Unable to move the model in the required direction, the IDB fired off another broadside by ordering the privatization of social security. This isn’t an issue of discussing whether privatizing pensions is a good or a bad thing. The problem is that it only serves the 8% of wage earners in Nicaragua whose employers participate in the social security system while the rest of the wage earners have no access to the new system. In other words, the new system only serves an elite sector of the country’s workers.

In the new health model imposed on us, the World Bank has even proposed decentralizing the health ministry’s own purchases of medicines to supposedly make them more efficient. It has suggested that each hospital invite bids independently and that each hospital go to the market to buy medicines. If the ministry’s purchases are already inefficient, just imagine what would happen if it was left up to the hospitals! The international organizations also ordered the government to approve a general health law, which is badly drawn up, containing such basic mistakes as the confusion in the first chapter between the concepts of "system" and "sector." In response to a question about how this error went undetected, given that "sector" is an economic concept and "system" a classification of relations and links among different elements, one person gave the following answer: "The thing is that system is a Marxist concept."
The general health law was drafted in the World Bank itself to ensure that it included the concept it was demanding: that public health services only be guaranteed for those living in extreme poverty. While that’s not actually realistic, let’s say that they are guaranteed. What do I do with the rest of the population? What about the rights of all other Nicaraguans? If I reduce the health problem to extreme poverty, I’m reducing it to 40% of the population, when 70% are below the poverty line. Do I just forget about the rest, along with the reproductive rights of all women and girls, attention to chronic diseases and emergency attention?
The model that the World Bank sold to us and that Nicaragua bought is extremely limited, while the World Bank loans granted to set up this model have been very inefficiently used. As long as there is no serious discussion about this we’re not going to make the remotest progress in health matters and the health of the Nicaraguan population will just continue deteriorating.

This boat is going down and the philosophy of every man for himself is on the rise. In today’s Nicaragua, you go to a hospital and it doesn’t have any resources, plus you could find yourself stuck with an insufficiently qualified and almost certainly underpaid health professional. This situation is spreading such despondency that the hospitals and health centers have been losing their professionalism, interest and sense of service. What else is a female health professional going to feel after years of struggling against the lack of the most basic supplies, such as cotton, gauze and sutures, while at the same time being threatened with losing her job? In addition, she has no possibility of developing. Thousands and thousands of Nicaraguans are currently trapped in a vicious circle with no possibility of escape. People born into extreme poverty and who learn to live with it, for whom it is already part of their culture, survive as best they can and might even be happy, because happiness is a very relative thing. But what happens to people who fall into extreme poverty after their families fought for two or three generations to get out of the countryside so their children could study and become technicians, and slowly slipped back into poverty through no cause of their own, having already known another level of life and embraced other expectations? Such people will become resentful members of society, will never be happy and have no possibility of escaping. One almost unknown but highly alarming statistic is that 20-30% of Nicaraguan doctors today are living below the poverty line and almost 5% live in extreme poverty. And this doesn’t include nurses, auxiliaries or laboratory technicians, who are even worse off. Many of these impoverished doctors work in the public health system. How are they going to attend the population with any spirit of dedication?

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