Download Nicaragua

Continuing Promise 2011: Host Nation Health Brief
Republic of Nicaragua
Provided to enhance participant experience and sense of competence
during the mission
Information current as of June 10, 2011
Please send suggestions for improvement to [email protected]
The NCDMPH is a center of the Uniformed Services University of the Health Sciences
Demographics/Cultural Breakout:
Population: 5.66 million people, world rank 108/237. (yr:2011)[1, 2]
o Proportion living in urban setting: 57% (yr:2010)[2]
o The median age of the population of Colombia is 22.9 (22.1 for males, 23.7 for
females) years with roughly 31.7% between the ages of 0-14, 63.8% between the
ages of 15-64 years of age and 4.5% being 65 years and older. (yr:2011)[2]
o One major city: Managua 934,000, also Nicaragua’s capitol. (yr:2009)[2]
Ethnicity[2]:
o Mestizo (mixed Amerindian and white) 69%
o White 17%
o Black 9%
o Amerindian 5%
Language[2]:
o Spanish (official)
o Literacy rate*: 67.5% (67.2% for males, 67.8% for females). (yr:2003)
Religion[2]:
o Roman Catholic 58.5%
o Evangelical Protestant 21.6%
o Moravian 1.6%
o Jehovah’s Witnesses 0.9%
o Other 1.7%
o None 15.7%
* There are no universal definitions and standards of literacy. Unless otherwise specified, all rates are based on the
most common definition - the ability to read and write at a specified age[2]
Socioeconomic standing:
GINI
70
60
50
40
30
20
10
0
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Billions
GDP
$300.00
$250.00
$200.00
$150.00
$100.00
$50.00
$0.00
*GDP of the US is 2293 times greater than Nicaragua’s and is over 2,200 times that of Haiti for comparison.
GDP-H
20.00%
15.00%
10.00%
5.00%
0.00%
HDI
1.0
0.9
0.8
0.7
0.6
0.5
0.4
0.3
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USNS COMFORT (T-AH 20) DEPLOYMENT APR-AUG 2011
GINI[3]
GDP[4]
GDP-H[5]
HDI[6]
Jamaica
45.5
$13.74 billion
4.7%
0.688
Peru
49.6
$153.5 billion
4.3%
0.723
Ecuador
46.9
$56.5 billion
5.8%
0.695
Colombia
58.5
$283.1 billion
6.1%
0.689
Nicaragua
43.1
$6.375 billion
8.3%
0.565
Guatemala
55.1
$40.77 billion
7.3%
0.560
El Salvador
52.4
$21.8 billion
6.2%
0.659
Costa Rica
48
$35.44 billion
8.1%
0.725
59.2
$6.593 billion
5.3%
0.404
45
$14.62 trillion
15.7%
0.902
Country
Haiti
United States
GINI: This index measures the degree of inequality in the distribution of family income in a country.
The index is calculated from the Lorenz curve, in which cumulative family income is plotted against
the number of families arranged from the poorest to the richest. The index is the ratio of (a) the area
between a country's Lorenz curve and the 45 degree helping line to (b) the entire triangular area
under the 45 degree line. The more nearly equal a country's income distribution, the closer its Lorenz
curve to the 45 degree line and the lower its Gini index, e.g., a Scandinavian country with an index of
25. The more unequal a country's income distribution, the farther its Lorenz curve from the 45 degree
line and the higher its Gini index, e.g., a Sub-Saharan country with an index of 50[3].
GDP: This entry gives the gross domestic product (GDP) or value of all final goods and services
produced within a nation in a given year[4].
GDP-H: Percentage of GDP that is spent on health[5].
HDI: The Human Development Index (HDI) is a composite statistic used to rank countries by level of
"human development" and separate "very high human development", "high human development",
"medium human development", and "low human development" countries. The Human Development
Index (HDI) is a comparative measure of life expectancy, literacy, education and standards of living
for countries worldwide. It is a standard means of measuring well-being, especially child welfare. It is
used to distinguish whether a country is a developed, a developing or an under-developed country,
and also to measure the impact of economic policies on quality of life[6].
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Health Indicators (yr: 2009):
Immunization Coverage*
Nicaragua
Latin America
US
99%[1]
N/A
93%[7]
Measles
99%[1, 8]
93%[8]
92%[7, 9]
Diphtheria, Pertussis, and Tetanus
98%[1, 8]
92%[8]
95%[7, 9]
98%[1]
N/A
N/A
Polio
BCG Vaccine for Tuberculosis
Immunization Coverage (Year 2009)*
90%
70%
50%
Nicaragua
Polio
Latin America
Measles
DPT
US
BCG
*in the pediatric population.
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Nicaragua
1
Leading Causes of Death
(Overall: Adults)
2
3
Infant Mortality Rate
(Per 1000 Live Births)
(yr:2009)
Mortality Under 5 Years
of Age (Per 1000)
(yr:2009)
Child Malnutrition
Stunting
(% Under 5yrs)
Access to Improved
Water Source (%)
Proportion of Deliveries
Attended by Trained
Professional
(yr:2001)
Physicians Per 10,000
Inhabitants
(yr:2001)
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Ischaemic Heart
Disease
(yr:2002)[10]
Cerebrovascular
Disease
(yr:2002)[10]
Lower Resp.
Infections
(yr:2002)[10]
Latin America &
Caribbean
(Developing
Countries Only)
US
N/A
Cardiovascular
Disease
(yr:2007)[11]
N/A
Cancer
(yr:2007)[11]
N/A
Cerebrovascular
Disease
(yr:2007)[11]
23[8]
19[8]
7[12]
41[8]
23[8]
8[12]
21
(yr:2009)[8]
14
(yr:2009)[8]
3
(yr:2000)[11]
87%
(yr:2008)[13]
N/A
99%
(yr:2010)[5]
81.5%[13]
N/A
99.4%[14]
6.2[13]
N/A
27.9[14]
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Current Health System:
Most health care in Nicaragua is provided by the Ministry of Health (MINSA)[15, 16]. Since 2004,
MINSA has embarked on a 10 year program designed to decentralize the Nicaraguan healthcare
system, with the intent of giving local health agencies and organizations increased decisionmaking authority[15]. In general, Nicaragua has seen improvement in its health care system in the
first decade of the 21st century, and this improvement has been comparable to that of other
Central American (CA) nations. Nicaragua, however, spends a higher percentage of its GDP on
health care than any other CA nation, without having superior outcomes[15]. Challenges remain
in healthcare equity, effectiveness, and efficacy. In the case of both the rural and urban poor, for
example, Nicaragua lags behind other CA nations in providing access to care[15]. Only 9% of
Nicaraguans have any kind of health insurance; consequently most Nicaraguans receive care
from MINSA facilities or from the Nicaraguan Social Security Institute (INSS), a private
healthcare organization[15]. MINSA has over 1000 facilities, including 33 hospitals, 177 health
centers, and 872 health posts[15]. The main barriers to access are long distances to medical
facilities, lack of access to medications, and high medication costs. Medication costs take up by
far the largest share of health care expenditures by the poor. Only 50% of injured/ill
Nicaraguans seek care because of these barriers[15]. Preventive care is almost unheard of, with
only 3.7% of the population receiving any preventive services[15]. In 2011, Nicaragua had 3.7
physicians per 10,000 people, compared to the CA average of 22.5 per 10,000[17].
Current Health Status:
Hurricane Mitch, which hit Nicaragua in October 1998, seriously damaged much of Nicaragua’s
infrastructure. Nevertheless, since 1990 there has been significant improvement in many of
Nicaragua’s health status indicators. Infant mortality has fallen from 70 per 1,000 live births in
1990 to 23 per 1,000 live births in 2009, which is somewhat better than the decrease across CA
over the same similar time period (55%)[8, 15]. The maternal mortality ratio is currently 1.0 per
1,000 live births, which is slightly higher than the Latin America and Caribbean average of 0.85
per 1,000 live births reported by the WHO[18].
HIV/AIDs is a bright spot for Nicaragua, which enjoys the lowest HIV prevalence in CA at
0.2%[19]. Although HIV is more common in men, the gender gap has been shrinking in recent
years. About 1/3 of children between the ages of 12 and 59 months are anemic[15]. Deaths
among young children are most commonly due to prematurity, pneumonia, congenital anomalies,
and diarrheal diseases. Adult deaths are most commonly due to cardiovascular disease,
malignancy, injuries, and respiratory infections[20].
Tropical diseases are certainly found in Nicaragua. Malaria is still encountered, although the
incidence has fallen markedly since 1996 and currently stands at 7.6 per 1,000 persons per year.
15% of cases are due to Plasmodium falciparum, which is chloroquine-susceptible in Nicaragua;
the remainder of cases are generally P. vivax[21]. Also present are dengue, filariasis,
leishmaniasis, onchocerciasis, and Chagas’ Disease. Visitors are at risk of contracting Traveler’s
Diarrhea. Yellow fever is not currently found in Nicaragua[22].
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Health Beliefs and Culture
Providers treating patients in Nicaragua may encounter a number of culture-bound syndromes.
One of these is Grisi siknis, which is generally characterized by anxiety, nausea, dizziness,
irrational anger and fear, punctuated by frenzied periods in which the sufferer apparently loses
consciousness, believes him/herself to be beaten and sexually assaulted by a demon, and then
runs away[23]. Nicaraguans do not generally believe that Western medicine is helpful for
treatment and will seek the remedies of Miskito herbalists or witch doctors. Notable cases of
Grisi siknis occurred in 2009[24, 25]. Other syndromes found in Nicaragua include ataque de
nervios, bilis/colera, nervios, susto, and mal de ojo. Most of these syndromes are similar in
some ways to DSM-IV anxiety disorders, except for mal de ojo, which refers to a susceptibility
to misfortune[26].
Physician-patient relationships in Nicaragua are characterized by interactiveness and respect[27].
Nicaraguans do not appreciate being rushed while seeing a provider. In all cases use patients’
titles and last names (i.e. Señora López rather than Verónica). When addressing a Nicaraguan in
Spanish using a pronoun, use formal pronouns (i.e. usted) rather than familiar pronouns (i.e. tu).
Nicaraguans, particularly females, are generally quite uncomfortable discussing sexual/genital
issues, abortion, and domestic violence[27]. They are very modest about exposing their private
parts. In such cases, it may be helpful for the provider to be of the same sex as the patient.
Family Life/Structure:
Extended family units are very important in Nicaragua, but also very important are the madrina
(godmother) and padrino (godfather)[28]. Godparents may be key in allowing a Nicaraguan to
move from a lower to a higher socioeconomic status. Nicaragua continues to have a strong
culture of machismo, and male Nicaraguans may use violence to enforce their will in family
life[28]. Because of the high level of poverty, children often enter the workforce at an early age
and are expected to contribute to the economic survival of both nuclear and extended families[28].
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United States Agency for International Development (USAID) Involvement in Health[29]:
USAID assists the Nicaraguan Government on various issues on justice and governance, which
also includes economic growth, improving health and education services, and expanding access
to social services (i.e. health care, education).
http://www.usaid.gov/locations/latin_america_caribbean/country/nicaragua/
Current NGO Involvement**[30]:
Action Against Hunger: Action Against Hunger fights hunger through the prevention, detection
and treatment of malnutrition, especially during and after emergency situations of war, conflict
and natural disaster. To tackle the underlying causes of malnutrition and its effects, we use our
expertise in nutrition, food security, water and sanitation, health and advocacy. Integrating our
programs with local and national structures helps ensure long-term sustainability.
http://www.actionagainsthunger.org/
Management Sciences for Health (MSH): Management Sciences for Health (MSH) is a
nonprofit international health organization composed of nearly 1,300 people from more than 60
nations. Their mission is to save lives and improve the health of the world’s poorest and most
vulnerable people by closing the gap between knowledge and action in public health.
http://www.msh.org/
Operation Smile: Operation Smile provides safe, effective and free cleft lip and cleft palate
repair surgery for children born all over the world. They are an international medical
humanitarian organization dedicated to raising awareness of this life-threatening issue and
providing lasting solutions that will allow children to be healed, regardless of financial standing,
well into the future.
http://www.operationsmile.org/
Pan American Health and Education Foundation (PAHEF): PAHEF works with the Pan
American Health Organization (PAHO) and other strategic partners in the Americas to mobilize
resources and jointly address key health, education, and training priorities. http://www.pahef.org/
World Kids Foundation: Fosters sister-school relationships around the world to create crosscultural dialogues, break down multi-cultural barriers, improve student decision making, and to
recognize specific students with special needs (medical or personal).
http://www.worldkidsfoundation.org/
Grupo Fenix: The mission of Grupo Fenix is to contribute to the wellbeing of rural
communities, creating an awareness of sustainable lifestyles through technical and cultural
exchange, promotion, and research in the field of renewable energy. http://www.grupofenix.org/
**Only listed NGOs in country found by web search that were identified to be working in this country. Web search
strategy noted in Appendix A.
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Habitat for Humanity: Habitat for Humanity seeks to eliminate poverty housing and
homelessness from the world and to make decent shelter a matter of conscience and action.
http://habitat.org/
Fundación A. Jean Brugger: The Fundación’s mission is to identify, improve, and expand
educational opportunities in partnership with the community of San Juan del Sur.
http://www.fundacionajbrugger.org/en/home.php
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Resources:
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
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18.
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20.
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22.
23.
24.
25.
World Health Organization, Nicaragua, Country Statistics. 2009.
Central Intelligence Agency. The World Factbook: Nicaragua. 2011 May 26 [cited
2011 June 10]; Available from: https://www.cia.gov/library/publications/the-worldfactbook/geos/nu.html.
Central Intelligence Agency, Distribution of Family Income - Gini Index. 2011.
Central Intelligence Agency, GDP (Official Exchange Rate). 2011.
Boerma, T. and C. AbouZahr, World Health Statistics 2010. 2010, World Health
Organization.
United Nations Development Programme (UNDP), International Human Development
Indicators. 2010, Human Development Reports,.
World Health Organization, United States of America, Country Statistics. 2009.
World Bank, Nicaragua Health, Nutrition, Population (HNP) at a Glance. 2009.
World Bank, United States Health, Nutrition, Population (HNP) at a Glance. 2009.
World Health Organization. Mortality Country Fact Sheet 2006: Nicaragua. 2006 [cited
2011 June 10]; Available from:
http://www.who.int/whosis/mort/profiles/mort_amro_nic_nicaragua.pdf.
Centers for Disease Control and Prevention. Leading Causes of Death. 2011 May 23
[cited 2011 June 10]; Available from: http://www.cdc.gov/nchs/fastats/lcod.htm.
You, D., G. Jones, and T. Wardlaw, Levels & Trends in Child Mortality Report 2010.
2010, Inter-agency Group for Child Mortality Estimation (IGME).
Pan American Health Organization. Country Health Profile: Nicaragua. 2001 [cited
2011 June 10]; Available from: http://www.paho.org/english/sha/prflnic.htm.
Pan American Health Organization. Country Health Profile: United States of America.
2001; Available from: http://www.paho.org/english/sha/prflusa.htm.
Angel-Urdinola, D., R. Cortez, and K. Tanabe, Equity, Access to Health Care Services
and Expenditures on Health in Nicaragua, in HNP Discussion Papers. 2008, World
Health Organization.
Program for Appropriate Technology in Health, The Nicaraguan Health System: An
overview of critical challenges and opportunities. 2011.
World Health Organization, General Health Statistical Profile -- Nicaragua. 2011.
World Health Organization, et al., Trends in Maternal Mortality: 1990-2008. 2010.
UNAIDS, Annex 1: HIV and AIDS Estimates and Data, 2009 and 2001, in UNAIDS
Global Report 2010. 2010. p. 201.
World Health Organization, Estimated Proportional Mortality (%), Nicaragua, 2004, in
WHO Global Infobase. 2004.
World Health Organization, Malaria Profile: Nicaragua, in World Malaria Report. 2010.
Centers for Disease Control and Prevention. Health Information for Travelers to
Nicaragua. 2011 [cited 2011 June 10]; Available from:
http://wwwnc.cdc.gov/travel/destinations/nicaragua.htm.
Dennis, P., Grisi Siknis Among the Miskito. Medical Anthropology, 1981. 5(4): p. 445505.
Brote de locura colectiva ataca a indigenas miskitos de Nicaragua. 2009, Caracol Radio:
Bogota.
La Prensa: Grisi siknis ataca otra vez en la RAAN, in Managua. 2009.
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26.
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Hall, T.M. Glossary of Culture-Bound Syndromes. [cited 2011 June 10]; Available
from: http://homepage.mac.com/mccajor/cbs_glos.html.
Harrison, J.K. Medical Culture in Latin America. Available from:
http://www.wfu.edu/~harrisjk/.
University of Pittsburgh. Nicaragua: People, Culture, and History. 2004 [cited 2011
June 10]; Available from: http://www.ucis.pitt.edu/clas/nicaragua_proj/society.html.
United States Agency for International Development (USAID). Nicaragua. 2011 [cited
2011; Available from:
http://www.usaid.gov/locations/latin_america_caribbean/country/nicaragua/index.html.
Humanitarian Organizations. [cited 2011 June 10]; Available from:
http://www.nicaliving.com/node/8562.
Prepared by: Laurie Chow, MA, MPH
Marion A. Gregg II, MD, MPH
LCDR MC USN (UMO)
Shane C. Steiner, MD, MPH
Maj, USAF, MC, FS
Approved by: Kenneth Schor, DO, MPH
CAPT MC USN (Ret)
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