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Health Services and Resources

Sep/22/2009

Organization of Services for Care of the Population

Water Supply and Sewerage Systems. The water available for human consumption is sufficient to meet the population’s needs. In 1996, 82.4% of the urban population and 30.1% of the rural population had drinking water service. In rural areas, the coverage level has not increased since 1992 because the services and the population have grown at about the same rate. Although much of the urban population continues to be served through household connections, 23.4 % receive water from public hydrants. The number of urban and municipal water supply systems has remained at 148. In 1990, 70% of these systems obtained water from underground sources; the remaining 30% used surface sources.

The Nicaraguan Institute of Water Supply and Sewerage Systems (INAA) administers 19 sewerage systems, of which only 7 have their own treatment facilities (stabilization ponds). Lack of treatment and improper final disposal of wastewater pose a serious risk to the environment and to human health. In the city of Managua, for example, domestic and industrial wastewater is discharged on the banks of Xolotlán Lake without any treatment.

During the 1981–1992 period, the percentage of the population with sewerage services in urban areas decreased from 32% to 29.9%. However, in 1996 the proportion rose again to 32.6%.

The estimated number of housing units in the country, as of 1992, was 621,926, of which 46.6% received drinking water from water supply systems administered by INAA, 21.5% from excavated wells, 12.7% from rivers and ponds, 15.5% from public hydrants, and 3.9% from cistern trucks. As for disposal of excreta and wastewater, 21.9% of the housing units were connected to sewerage systems, 8.1% had cesspools or septic tanks, 55.7% had latrines, and 14.2% had no system.

Solid Waste Disposal. Urban sanitation services for collection and final disposal of solid waste are supplied in 69 of the 143 municipal city seats, which, in terms of urban population coverage, represents approximately 35%. With a daily per capita production of solid waste equivalent to 0.5 kg, it is estimated that the urban population produces 1,272.5 metric tons of waste per day; if only about 35% of that amount is collected and eliminated, then there are 827 metric tons of waste in urban areas that are not being properly removed. The waste collected is not being properly disposed of because appropriate environmental impact assessment criteria and techniques are not being applied for selection of sites for municipal waste dumps. In addition, waste disposal is largely unregulated, and only 13% of waste dumps have been certified as sanitary sites. Solid waste is disposed of in open-air dumps, with no planning or control, and no treatment, recovery, or recycling methods are applied.

Environmental Protection. There has been a progressive deterioration of natural resources in rural areas, mainly because of aggressive development of new agricultural lands, use of forest lands for agricultural purposes, felling trees for fuel, lack of legislation on use of land and natural resources, and inappropriate farming techniques. It is estimated that deforestation affects some 100,000 hectares of forest per year.

Organization and Operation of Personal Health Care Services

With the exception of some remote areas, the coverage of health services is adequate. The health center is the most frequent source of outpatient care. Health posts, which were designed to be the first point of contact at the primary care level, are used very little, probably because of a lack of personnel and insufficient drugs.

For operation of the SILAIS, the country has 873 service provider units at the primary care level, including 708 health posts, 165 health centers, and 589 beds. At the secondary care level, there are 24 hospitals with 3,930 beds for acute cases and 4 hospitals with 407 beds for chronic cases, for a total of 4,337 hospital beds (1 bed per 968 population).

During the five-year period between 1991 and 1995, the number of patient visits to primary and secondary health care facilities rose from 4.9 million (1.2 visits per person) in 1991 to 6.5 million (1.5 visits per person) in 1995, an increase of 30%. During the first three years of that period, the primary care level accounted for 70% of the total care provided, and in 1995 it accounted for 75%, which appears to indicate greater use of this level; the remaining 25% of care was provided at the secondary level and includes emergency care.

Maternal and child health care showed an increase in absolute figures, consistent with the growth in the target population. Although the number of first prenatal visits decreased 4 % overall, the number of first prenatal visits in the first trimester of pregnancy increased 3%, and total prenatal visits showed an upward trend, with relative growth of 29%.

The percentage of hospital deliveries was 45.0% in 1995, lower than the figure of 46% registered in 1991. The highest percentage during the period was achieved in 1993, when 49 % of births took place in health care institutions.

In 1995, visits to monitor growth and development increased 20% for children under the age of 1 year and 48% for children aged 1–5 years, as compared to 1991.

Inpatient services (as measured by hospital discharges) increased from 228,000 in 1991 to around 278,000 in 1995. In 1995, acute-care hospitals accounted for 87% of total discharges. The use of bed resources in these hospitals has improved markedly, as evidenced by the fact that the occupancy rate increased from 63.7% in 1991 to 74.2% in 1995, with no increase in the number of beds in these centers since 1992. Hospital discharges per 100 population rose from 5.6 in 1991 to 6.2 in 1995; childbirth was associated with approximately 30% of all discharges.

An increase in major surgeries took place as a result of improvements in operating rooms in 16 hospitals in the country. A noteworthy development was the introduction of outpatient surgery services in hospitals. Previously, the vast majority of surgical procedures were carried out in operating rooms, but beginning in 1991–1992 some procedures began to be performed in delivery and emergency rooms. The most common procedures are laparoscopies for sterilization and ophthalmologic surgeries, but cesarean sections, appendectomies, and herniorrhaphies are also performed.

The number of laboratory tests increased from 3.4 million in 1991 to 5.0 million in 1995, including tests performed at both the primary and secondary levels of care, although the secondary level accounts for a greater proportion (59% of the total number).

Geographic access to health services is acceptable in urban areas. In Managua, only 13% of the population lives more than 30 minutes’ walking distance from a health unit. The figure is 8% in other urban areas of the country. In rural areas, the situation is radically different: the percentage of the population that lives more than two hours’ walking distance from a health unit is 33% in the case of hospitals, 22% for health centers, 10% for health posts, and 26% for private physicians.

A growing market of private services exists, but the Ministry of Health continues to be the main provider of services for the Nicaraguan population as a whole. A study of health care financing options identified a sizable private sector that provides care that is more costly but of better quality. Although the social security system offers medical services to approximately 5% of the population, its resources are insufficient and the basic basket of services that it provides is limited. Social security affiliates who have more serious health problems must seek care in health facilities of the Ministry of Health, but there are no agreements for the transfer of funds, so delivery of these services constitutes a de facto subsidy of the social security system.

A study demonstrated that many users pay directly for a significant proportion of the total cost of health services, even in the public sector. Widespread payment for private services, direct payment to public health care providers, and frequent purchases of drugs and supplies by users of public services result in significant out-of-pocket expenditures, which are an important source of health care financing without which the public sector would face tremendous fiscal pressure and users would receive even fewer services. The weight of these economic contributions, however, is not distributed evenly or equitably. In poor rural areas of Nicaragua, families tend to suffer more illness but seek less medical attention than those in urban areas who have higher incomes. In the rural population, the increase in payment for services in public facilities has led to a significant reduction in the use of these services, which has been only slightly offset by patients seeking care from other sources. In the urban population, on the other hand, especially in Managua, similar relative increases have led to changes in the mix of the public services used as well as greater substitution of care from other sources and only a small reduction in overall use of services.

Source: new.paho.org

Pan American Health Organization