Delivery of Care

If your memory serves you well

A visit to a health center in Nicaragua offers a refresher course in how primary care works, what it can deliver, and what it cannot do

Photo by Michael Fine

The community health clinic delivering primary care in San Juan Del Sur in Nicaragua.

By Dr. Michael Fine
Posted 4/23/18
The Nicaraguan health system is built upon a system of clinics delivering primary care at the community level. It is affordable and effective, but it alone cannot fix the health consequences of poverty.
What can be learned from the way that other countries deliver primary care, whether in Nicaragua or France, Israel or Sweden? What can be done to make Rhode Island a more attractive place for primary care providers, including doctors, nurses and physician assistants? How will the opening of the new Neighborhood Health Facility in Central Falls reshape the equation around primary care? How does the growth of health equity zones fit into the economic development concept of an innovation economy?
The current demographics in Rhode Island reveal two significant trends: the birth rate is falling, and the number of residents over 65 is increasing. What hasn’t been reflected in the state budgeting process is how those trends will reshape the demands on the delivery of primary care, requiring more expensive, complex care as chronic diseases peak in an older, frailer population. Our systems of health care and hospitals have been built upon 20th century assumptions of employment, housing, family and transportation that no longer exist. Any 21st century innovation economy needs to address the needs of an aging population and the way people over 65 can be valued contributors.

SAN JUAN DEL SUR, Nicaragua – When I visited Nicaragua last week, I remembered three things.

The first thing I remembered is that everyone who designs a health system ends up coming up with the same system, except for us in the U.S.

Nicaragua is the second poorest country in the Western Hemisphere – only Haiti is poorer. The minimum wage is only $1.66 an hour, or $3,320 a year; so most people live outside the formal economy.

Too many Nicaraguans live on incomes of about $400 or $500 a year. Nicaragua spends 9 percent of its GDP on health care, about half of what we spend in the U.S. on a percentage basis [about 18 percent].

Their GDP is a tiny fraction of what ours is, so while we spend about $11,000 per person per year on health care, they spend $540 per person per year. But, they have a primary care system that takes care of everyone in Nicaragua for free, and we don’t.

A system of primary care
Nicaragua’s health care system was created after the Sandinista Revolution, in 1979; it is built on a system of primary care centers. Friends and colleagues from Rhode Island helped to build one of these health centers, in a little town called Niquinohomo in 1986.

I recently visited the Hospital Primario Gaspar Garcia Laviana, the primary care center of San Juan del Sur, to see what that primary care system looks like.

This health center, named for a Spanish poet priest who took up arms to fight for the poor and was killed in battle in 1979 by the armed forces of the dictator Somoza, is everything I think a health center serving a community of 15,000 people should be.

It sits on a little rise next to the main street, so you have to pass it and acknowledge its importance as you come into the town. It has the right composition of health professionals – doctors and nurse practitioners – five of whom do general medicine, three for maternity care, one pediatrician, one internist and at least one dentist [my newly acquired Spanish was good enough for to understand most, but not all, of what I heard].

The ambulances and EMS service are part of the health center. They focus on prevention. When I visited, it was National Immunization Day [which is actually a month – April 2-29).

There is a room at the heath center devoted to epidemiology – to tracking, identifying and working to control the spread of infectious and chronic disease in San Juan del Sur.

I got to see and meet with the three or four nurses devoted to this work, which they do using paper records, not computers.

The health center facility is cramped and a little dark – but they are building a beautiful replacement for it just a block away.

And, they do things here that we just don’t do in health centers in the U.S. – they deliver about 300 babies a year, right there in the health center, because they believe that birth, like death, is a normal part of life and not a disease.

There is a house, called Casa Materna, a block away, where women in the late stages of complicated pregnancies come to stay in the weeks before they are ready to give birth, so they can be less stressed and can be close to maternity care as soon as they need it.

At the health center, they also have a few rooms devoted to treating more serious, urgent conditions, such as severe dehydration, where they use intravenous medications and can hold people overnight to treat them.

Affordable and effective
Even though Nicaraguan politics have become messier and more disappointing than ours, I would give my eyeteeth to get a health care system organized like the one in Nicaragua. It is what every other country does that has health care that is affordable and effective.

But Nicaragua’s public health outcomes still lag far behind what should be achievable with a health care system like this. Their infant mortality rate is three times what ours is, but is a third of what Haiti’s is, and about the same as the infant mortality rate in other Central American countries like Honduras, El Salvador, and Guatemala. [The infant mortality rate in Costa Rica is similar to ours, but Costa Rica is a much wealthier country.]

Life expectancy lags a little behind ours, but it is similar to their Central American neighbors. Which made me remember the second thing: that health care systems alone can’t fix the health consequences of poverty.

The third thing I remembered is that our medical cost inflation is 4 to 5 percent a year. Which means our yearly cost increase per person per year is very near to the yearly total health expenditure in Nicaragua. So I also remembered just how much we waste.

Which made me remember to work harder on fixing our health care mess we have. Because if we don’t fix this expensive mess soon, we are going to end up impoverished like the Nicaraguans, with a whole complex set of public health failures but without the resources we need to provide optimal health for all Americans.


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