TO THE PEOPLE OF NICARAGUA AND TO THE WORLD
A SINGULAR STRATEGY
-- WHITE BOOK --
- Strengthening Health 2007-2020
- Preparation for COVID-19
- Actions agains COVID-19
I. PUBLIC POLICIES ACCORDING TO NATIONAL NEEDS AND POPULAR INTERESTS
- COVID-19 is here to stay
- Balance between Economy and Public Health.
II. CURRENT SITUATION
- About COVID-19 and other causes of mortality in Nicaragua
- Nicaragua's situation in the regional context
- What does Nicaragua attribute to COVID-19?
III. PREPARATION OF NICARAGUA BEFORE COVID-19
- Preparation of medical personnel and community networks for the COVID-19 pandemic in Nicaragua
IV. ACTIONS TO FACE THE PANDEMIC
V. HOW NICARAGUA IS IN A BETTER POSITION TODAY TO DEAL WITH THE PANDEMIC THAT IN 2006?
- The Family and Community Health Model (MOSAFC)
- Main advances in the installation of the health system
VI. HEALTH EXPENDITURE
VII. CRITICISM FOR NICARAGUA´S RESPONSE TO COVID-19
- Supporters of lockdowns
- The continuity of the coup
- About accounting of cases
VIII. ORGANISATION OF THE NICARAGUA HEALTH SYSTEM
- Territorial organisation of the national health system
- Organisation of the Family and Community Health Model
- Information on and for the population: National Health Map of Nicaragua
- Causes of hospitalisation in the general population
- Chronic diseases
- How to access the National Health Map in Nicaragua
- Hospitals built in Nicaragua since 2007
We present to the Nicaraguan people and the international community the “NICARAGUAN WHITE PAPER ON THE COVID-19 PANDEMIC: A SINGULAR STRATEGY”, which contains an analysis of public policies, presenting a vision of the Nicaraguan health model, as a unique model in the world, based on the reality and conditions of the country, which serves persons, families and communities with a proactive approach and proactive measures. Within this model, we have a balanced strategy between the Pandemic and the Economy, vigorously fighting COVID19 without closing our economy.
The policy is based on the fact that 40% of the population lives in the countryside and 80% of urban workers belong to the informal sector, and earn their livelihood day to day. At the same time, we are defending the recovery of an economy weakened by the attempted coup d'état of April 2018, which continues to be attacked by false news campaigns (“fake news”) and disinformation, as well as illegal and coercive measures. The country has been well prepared for this fight against COVID-19, due to:
1) The strengthening of the health system (2007-2020);
2) Preparation from January 2020, two months before the appearance of the first case; and,
3) The measures taken.
Strengthening Healthcare 2007-2020
Nicaragua is in a better position today to face the pandemic, compared to the 16 years of the neoliberal period, with more modernized health infrastructure (18 new hospitals), more trained personnel (36,649 health workers in 2020 compared to 22,083 in 2006; 6,045 doctors in 2020 compared to 2,715 in 2006) and emblematic solidarity programs that demonstrate the sacred commitment of the Government of Reconciliation and National Unity (GRUN) to restore rights to the population ("All with a Voice", "Love for the Smallest and Youngest", "Operation Miracle"), based on the organization of the Family and Community Health Model (MOSAFC), working together with the community network and with an increased investment budget (USD 468.6 million in 2020 compared to USD 111.9 in 2006).
Preparation for COVID-19
When the COVID-19 outbreak occurred in Wuhan, China, on the 21st January, the Ministry of Health (MINSA) held a Press Conference to warn the population about the risk, and communicate preventive measures. This was almost two months before the first case occurred in Nicaragua on the 18th March.
Since the declaration by the World Health Organization of COVID-19 as a Public Health Emergency of International Importance (ESPII), on the 30th January, 2020, Nicaragua established an Inter-Institutional Commission, to ensure a comprehensive approach.
On the 9th February, MINSA released a “Protocol for the Preparation and Response to the Risk of Coronavirus Virus (COVID-19) in Nicaragua”, to ensure monitoring and early detection of suspected and confirmed cases. Preventive measures were established to reduce the transmission of the virus and a permanent communication plan was implemented, aimed at the population, as education and border control actions have been carried out, always based on the WHO/PAHO Protocols.
The Protocol also designated 19 Hospitals to be specialized in COVID-19, one of them, the Nicaraguan-German Hospital, exclusively for respiratory diseases, detailed measures for greater preparation of primary care units for addressing respiratory symptoms at the national level, training of public and private personnel, and the acquisition of protective equipment. Nicaraguan authorities also established a follow-up capacity for contacts. Thus, Nicaragua was prepared before the appearance of the first case of COVID-19 in the country on March 18.
Actions Against COVID-19
As part of the Protocol designed by MINSA in response to the Coronavirus pandemic and COVID-19, in Nicaragua, 470 people with suspected COVID-19 or who have had contact with confirmed cases in the country have been cared for and carefully and responsibly followed up.
Likewise, more than 42,000 international travelers were subject to monitoring for 21 days to detect possible cases of COVID-19. This monitoring is given to travelers, suspected cases and contacts of positive cases, including daily controls by at the Healthcare Center closest to their home, from which the medical personnel decide daily on the correct course of action: continued follow-up, hospitalisation or discharge, as the case may be.
More than 4.6 million home-to-home educational visits have been made to date in a country of 6.2 million inhabitants, by 98,224 volunteers to promote family and community health.
In addition to an intense information campaign in the media about prevention measures, disclosure of symptoms and action against the disease, a National Information Center has also been created that has a free telephone line where trained personnel and doctors clarify any doubts that the population may have, and guide them on how to adequately respond to the pandemic.
In addition, there is a disinfection program for public transport units, both collective (buses) and selective (taxis); popular markets, government buildings and study centers at all levels, preschool, primary, secondary and public universities.
The Ministry of Education and the National Council of Universities, in coordination with the Ministry of Health, have also adapted their physical facilities, designed prevention protocols and adjusted their study programs to include preventive health talks and reinforcement of healthy habits for all their students.
In summary, Nicaragua, the second poorest country in Latin America and the Caribbean, has been prepared to face the COVID-19 pandemic and any other similar one, as well as being prepared to face natural disasters, whether due to the climate - such as hurricanes and droughts -, geological phenomena - such as earthquakes or volcanic eruptions -, mainly for reasons of its own health response model, which is eminently preventive in nature and based on the active participation of the family and the community, but also because it has invested a fundamental part of its scarce economic resources in the construction of new health units and in the modernization of existing ones, as well as in the numerical growth and continuous improvement of its medical, nursing and technical personnel, in addition to its more equitable distribution throughout the national territory.
Additionally, before the appearance of COVID-19 itself, the responses given by the Government of Nicaragua have been made in coordination with the regional authorities of SICA and with the cooperation of sister nations such as Taiwan, Cuba and South Korea.
Nicaragua therefore ratifies its confidence in the success of its policies based on defending the health and life of families and communities, with its active participation in the prevention of diseases, epidemic and non-epidemic, but also in protecting the family, community, local and national economy, which has allowed, and will continue to allow, new achievements in the fight against poverty and for the human development of the country, even in adverse times of economic crisis and climate change, and even in the face of COVID-19
I. PUBLIC POLICIES ACCORDING TO NATIONAL NEEDS AND THE INTERESTS OF THE PEOPLE
Countries must implement policies based on their national reality and the interests of their citizens. "One size fits all" strategies based on the same policy for any country, independent of its reality, invariably fail in many countries.
Nicaragua's model is unique because it is based on the reality and conditions of the country. That reality is that 40% of the Nicaraguan population lives in the countryside, and it cannot be asked that these persons stay at home adhering to quarantines, because they have to go out to look for firewood to cook, to look for the water they consume, milking the cows or searching for eggs, selling their products, preparing the land for planting in these months of April and May, and then planting, among other activities.
The reality of Nicaragua is that 80% of urban workers are from the informal sector and the vast majority earn their daily living by selling something or providing services, but if they do not work and do not earn, they do not eat.
The International Labor Organization (ILO) states that 1.6 billion of the 2 billion informal sector workers in the world are going to have significant reductions in their income in these months. In just the first month of the crisis, global revenues in this sector decreased by 60%. This is due to the disastrous impact of containment measures for the informal sector. In Nicaragua there will be a partial reduction in income, due to a drop in economic activity in general, but it will not be due to government action or because their right to work has been hampered. Rather, the government is defending the interests of informal workers, peasants, and all poor people, as well as the national economy, with the unique strategy of fighting the Coronavirus.
Nicaragua was growing 5% annually in a period of 7 years before 2018, the third highest growth in Latin America and the Caribbean, but decreased by 4% in 2018 and 3.9% in 2019. This is due to the economic consequences of the failed coup attempt sponsored by the United States, whose declared policy at the highest level is to overthrow the governments of Venezuela, Cuba and Nicaragua. The coup plotters and the entire imperialist apparatus of social networks, corporate news, "fake news" and daily lies demand a complete closure to weaken the economy and the government, while painting abroad a fictitious situation of chaos in Nicaragua. Faced with these attacks, the economy must be cared for to avoid an increase in poverty with all that this represents in terms of health, morbidity and mortality.
In addition, it should be noted that the failed coup attempt in April 2018, had direct economic consequences totalling US$200-231m, plus US$1,453.6m in damages to national economic activity. The losses were due to roadblocks set up on roads and streets, preventing the transit of goods and people, and the closure of businesses, in some cases partial and in others definitive, causing more than 157,000 unemployed.
The economic activities most affected by these destabilizing actions were Hotels and Restaurants (-20.2%); Construction (-15.7%); Commerce (-11.4%); Livestock (-5.4)%; Financial intermediation (-5.4%), and Transport and communications (-3.5%).
Thus, active insured workers by the Nicaraguan Social Security Institute (INSS) decreased by 157,923 affiliates, totalling 755,874 workers. The main reductions of those insured were in the activities of Commerce (-69,318), Community, social and personal services (-36,590) and financial services (-16,266).
Deposits in banks decreased by -20.7% and the Loan Portfolio decreased by -9.2%.
Likewise, exports fell by –270 million USD and Foreign Direct Investment (FDI) contracted by - 63.2%.
Consequently, the Gross Domestic Product (GDP) registered a reduction of -4.0% in 2018 and -3.9% in 2019, which imposed a brake on the average growth achieved in the period between 2010 and 2017 (+ 5.1%).
Meanwhile, the losses and damages for the Ministry of Health are significant: 18 buildings, including 4 hospitals looted and invaded, 2 looted and destroyed SILAIS headquarters (Local Integral Attention System), 1 looted maternal home; 107 vehicles destroyed of which 15 totally and 92 partially, of which 64 were ambulances; as well as equipment such as dental, ultrasounds, mobile clinics, medicines, all looted and/or destroyed, all of which directly affect health services and their quality.
This is not the only time that Nicaragua has adopted unique policies according to the interests of the Nicaraguan people, in contrast to most of the world.
In 2015, for example, at the 21st Climate Summit in Paris, Nicaragua did not sign the “Paris Agreement”, because the proposals of the Intended National Determined Contributions (INDC) of 2015 were not going to be enough to achieve the goals of the same Agreement to reduce the world average temperature at the end of the century to +1.5 celsius or even to +2 celsius, but, with these proposed reductions it would reach +3.7 celsius world average.
Since this world average could be expressed as +4 celsius to +6 celsius in tropical countries, in deserts and even more in arctic latitudes, Nicaragua decided not to sign the document. An increase of +4 celsius or more would have a catastrophic impact on production and life in Nicaragua, specifically in the reduction in yields in the production of basic grains and in the reduction in water in a country that has an agricultural cycle dependent on seasonal rains, as well as a dry corridor with a tendency to become increasingly arid.
By 2017, there was a consensus among the countries of the world that the 2015 INDCs were insufficient and more ambition was required to achieve the objectives and goals of the Paris Agreement. Thus, Nicaragua became a signatory and ratified the Paris Agreement, to demand greater ambition, especially from the countries that are the largest emitters, in order to achieve the objective of stopping the rise in the world average temperature in a maximum of +1.5 celsius.
In 2017 the world came to adopt the Nicaraguan position. And with the increasing abandoning of “lockdowns”, all the countries of the world will have to combine defense against the Coronavirus with the functioning of society, just as Nicaragua and Sweden have done from the beginning.
COVID-19 is here to stay
Dr. Mike Ryan, Executive Director of Emergencies at the World Health Organization, said on May 1: “I think it is important to put this on the table. This virus can become another endemic virus in our communities. And this virus may never go away." Others estimate that COVID-19 may become seasonal. On the 16th May, British Prime Minister Boris Johnson warned that there might never be a vaccine, as has been the case with HIV-AIDS. In all these cases, countries have to learn how to defend themselves against the virus and function at the same time. This also applies to the “next pathogen” in the saga of the fight of our immune systems with bacteria resistant to antibiotics and virus mutations.
Nicaragua and Sweden represent alternatives to total lockdown in a developing country and a developed country, respectively. Dr. Ryan noted: "Sweden represents a future model if we want to return to a society where we have no lockdowns." This is increasingly important given the astronomical cost of lockdowns. Nicaragua is the same example as Sweden, but among developing countries.
The total lockdown is actually partial in every country. The police, the army, the provision of food and medicine, the entire value chain and logistics that this implies, the communication networks and the internet, transport, electricity, water, waste collection, the media, the Government must always be kept running. All persons with essential functions, which are numerous, have to function to preserve civilized life.
Balance between Economy and Public Health
Farmworkers, informal workers, small and medium-sized enterprises, and the national economy are being protected. Nicaragua's position does not choose between public health and the economy: both are absolutely necessary for the health of society. A balance must be sought between all policies.
Nicaragua sees the example of societies that have carried out strong lockdowns that have gone from prosperity to the worst depression in their history in just two months, due to government policies with no balance between public health and the economy. The fact that the United States has gone from unemployment rates of 3.5% to 25% (38.5 million unemployed workers as of May 21) will have a worldwide impact, causing a deep depression. There are even J.P. Morgan predictions of -14% GDP at the close of the second quarter of 2020.
Preliminary data for the first quarter of 2020 from the pandemic response actions through the “Lockdown” indicate that the United States GDP fell -4.8%, the largest quarterly decrease in GDP since the fourth quarter of 2008 during the global financial crisis, when the United States economy contracted -8.4%.
Estimates from, the Economic Commission for Latin America and the Caribbean (ECLAC) indicate that the region's GDP will fall -5.3% in 2020 and that approximately 29 million people in Latin America could fall into poverty, reversing trends in the reduction of huge income inequality in the region.
The IMF projects that the world economy will suffer a sharp contraction of -3% in 2020, much worse than that registered during the financial crisis of 2008– 2009. On the other hand, according to the OECD estimate, current containment measures could reduce world GDP by 2.0% per month, or an annualized rate of 24%, approaching a level of economic contraction that had not been experienced since the Great Depression of the 1930s.
According to the Central American Integration System (SICA), through the Central American Economic Integration Secretariat (SIECA) together with the Executive Secretariat of the Central American Monetary Council (SECMCA), the updated scenario with the perspectives collected as of April 2020 estimates a decrease of -6.9% in Central American GDP for 2020 and an inflation rate of 0.6% for the region. For 2021, the decrease in regional GDP would be -1.4% and the estimated inflation rate would be 1.9%.
Faced with such unfavorable scenarios at the regional level and the world in general, the Government of Reconciliation and National Unity (GRUN), has not declared a quarantine, nor closed the economy.
Given the national and international situation, Nicaragua will seek a balance between public health and a healthy economy.
II. CURRENT SITUATION
According to data from the Ministry of Health (MINSA), Nicaragua has had, as of May 19, 279 cases of persons with COVID-19, of which 63 cases are active, while 199 patients have recovered and 17 have died (see Illustration 1), being that these cases present pre-existing co-morbidities.
470 persons have been cared for and given responsible and careful follow-up. The cases have presented as outbreaks through clearly established contacts, who are followed-up.
About COVID-19 and other causes of mortality in Nicaragua.
According to data from the last six years, the main causes of mortality in our country have been acute myocardial infarction, malignant tumors and diabetes mellitus. In the last three years chronic kidney disease has had a high incidence of death.
In Graph 1 we can see how deaths in general have remained in the range of 8,500-9,000 deaths annually and in 2020 they have decreased, compared to the same period in 2019.
Similarly, in Graph 2 it can be seen that, in 2020, the death rate per 1,000 inhabitants is the lowest in the last 6 years.
On the other hand, deaths from pneumonia stood at 309 as of May 15, 2020, a higher number than in 2017-2019, but less than in 2016.
The Pneumonia rate for every 10,000 inhabitants in 2020 is similar to the rates that were registered in 2015 and 2016, but it is lower than those presented in 2018 and 2019.
Of course, we must remain on high alert, but as of May 19, 2 months after the first case, the situation of the pandemic is under control in the country. One reason for this is the strengthening of the health system from 2007 to the present and the preparations for COVID-19 from January 2020, as well as the actions taken to confront Coronavirus and COVID- 19.
Nicaragua's situation in the regional context
As of May 20, according to data from the Central American Integration System (SICA), Nicaragua, with 279 cases, is the country with the second-lowest incidence of COVID-19 among SICA countries, which have a range that reaches up to 13,477 cases (Dominican Republic), and also has the lowest rate of confirmed cases per million inhabitants in the region (see Illustration 1 and Illustration 2). According to these same data, Nicaragua, with 17 deaths, has the third-lowest number of patients who died from COVID-19 among the countries of Central America and the Dominican Republic, which have a range that reaches 446 deaths (Dominican Republic) (see Illustration 1).
Illustration 1.COVID-19 in Central America & Dominican Republic
Illustration 2. Confirmed cases per million inhabitants in Central America and the Dominican Republic. Source: Own elaboration based on data from SICA-CEPREDENAC.
What does Nicaragua allocate to fighting COVID-19?
In Nicaragua, the Ministry of Health has been providing epidemiological monitoring to each person with epidemic diseases typical of the period: Dengue, Malaria (vivax and falciparum), Chikungunya, Zika, Pneumonia, Tuberculosis, H1-N1, Leptospirosis, Chagas Disease, as well as chronic diseases. Cases with respiratory problems, including cough and fever, are given special attention and follow-up are being given to determine if they need greater vigilance according to their condition for Chronic diseases: Diabetes mellitus, chronic kidney disease, stroke, hypertensive disease, chronic obstructive pulmonary disease, pneumonia, among others.
With these multiple conditions, the Ministry of Health searches for the person's epidemiological link, to determine if they have had contact with persons who have traveled to countries with patients who tested positive for coronavirus or if they have had contact with persons who have presented symptoms of COVID-19.
The Ministry of Health follows up on patients who have symptoms of respiratory failure, in order to make a diagnosis if it is COVID-19 or is a process triggered by their chronic condition, for which they may have suffered decompensation for any reason. Worldwide, pneumonia and seasonal influenza have a mortality of 3.5 million persons, in Nicaragua 1,251, while by COVID-19 there are 320,000 deaths worldwide, and in Nicaragua 17 as of May 19.
One person may have COVID-19 but die of an acute heart attack, as well as one who is with COVID-19 and died of COVID-19 from the condition of the upper lung, typical of viruses that cause Severe Acute Respiratory Syndrome (SARS), such as SARS-CoV-2 produced by COVID-19.
III. PREPARATION OF NICARAGUA BEFORE COVID19
Our country has been prepared since January to face the COVID-19 pandemic, although the first case was not reported until March 18, 2020.
Following the COVID-19 outbreak in Wuhan, China, the Ministry of Health (MINSA) held a Press Conference on January 21, to warn the population of the epidemiological risk and to communicate the first prevention measures. This was almost two months before the presentation of the first case in Nicaragua, on March 18. Following the declaration of the World Health Organization of COVID-19 as a Public Health Emergency of International Importance (ESPII), on January 30, 2020, Nicaragua established an Inter-Institutional Commission, to ensure a comprehensive approach to the pandemic.
On February 9, MINSA released a "Protocol for the Preparation and Response to the Risk of Coronavirus (COVID-19) in Nicaragua", with the accompaniment of PAHO-Nicaragua, to ensure monitoring, early detection of suspicious and confirmed cases, preventive measures were established to reduce the transmission of the virus and a permanent communication plan aimed at the population was implemented. In addition, education and border control actions have been carried out, always based on the WHO / PAHO Protocols.
This Protocol includes 19 care centres for patients with COVID-19, and designates the German-Nicaraguan Hospital to be fully dedicated and equipped to treat respiratory diseases. The prepared centres have equipment, medications, and supplies to deal with COVID-19, with a capacity of 11,732 general hospital beds and 562 intensive care beds.
In addition, the country has 449 ventilators, 954 vital sign monitors and 574 suction units to care for all kinds of diseases and illnesses. There is also a national reference laboratory, which has Level 3 WHO Biosafety recognition. Likewise, Nicaragua has an Early Detection Ring at the country's border crossings and airports, using state-of-the-art technology with thermal imaging cameras that detect people with symptoms characteristic of COVID-19.
Along these same lines, Nicaragua has promoted a vaccination campaign, where 1.2 million doses have been applied against pneumonia and seasonal influenza to reduce the number of cases of respiratory diseases.
A nutrition census has been carried out, where 1,386,351 boys and girls have been measured and weighed. Children with malnutrition are attended with a family accompaniment plan and food reinforcement with micronutrients. Some of these meals offered in schools as a reinforced school snack, with particular attention in the territories included within the Dry Corridor.
66 mobile clinics have been distributed in the various SILAIS, as a way to further carry medical care to the most vulnerable population.
Preparation of medical personnel and community networks for the COVID-19 pandemic in Nicaragua
Actions have been directed to strengthen prevention, epidemiological monitoring, and preparation for care, according to the recommendations of the World Health Organization and the Pan American Health Organization.
The COVID-19 Preparation and Response Protocol, referred to above, contains detailed measures on epidemiological surveillance, laboratory procedures and sampling, organization of health services, inter-institutional organization, communication plans, etc.
Likewise, 158,000 health volunteers (community health workers and networks, religious leaders, teachers, public health personnel) have been trained in the 153 municipalities of the country. Currently 50,000 visits are made each day, with 4,631,314 visits counted as of May 20, 2020, as part of the coronavirus prevention campaign.
A total of 9,006 people from different government institutions (MINED, City Halls, DGA, MIFAM, OIRSA, IPSA, INTUR, MINGOB, PN, Army, ENACAL) were trained in the 13 entry points of the country, in addition to 1,591 people corresponding to airlines and land transport companies.
A total of 15,367 health personnel from the public sector and 1,610 health personnel from the private sector were trained in the Protocol for the Preparation and Response to the Risk of Introduction of the Coronavirus.
Further to this, our country has been visited by the Henry Reeve Cuban medical brigade, who came to share their experience and knowledge regarding the coronavirus pandemic. The Cuban brigade, made up of virologists, epidemiologists and clinical doctors, presented its protocols and the entire catalog of drugs with which it has managed to fight coronavirus and other diseases in countries around the world. In addition to sharing their own experiences with Nicaraguan authorities, the expert doctors made a national diagnosis of the situation of the primary health care system of the country's health model.
As part of its integrationist approach, Nicaragua actively participates in all the activities coordinated through the General Secretariat of the Central American Integration System (SICA), within the Regional Contingency Plan “Central America united against the Coronavirus COVID-19” to address the pandemic.
In this sense, on the 12th March, the presidents of Central America (with the exception of President Nayib Bukele, of El Salvador), participated in a virtual conference to coordinate actions in the face of the pandemic. Additionally, the Nicaraguan Government held two meetings with its border neighbors (Costa Rica and Honduras) to coordinate efforts in the face of the pandemic.
IV. ACTIONS TO FACE THE PANDEMIC
There is a comprehensive approach to both the public and private systems, institutional and community epidemiological surveillance at entry points to the country and at the level of health units, timely detection, early diagnosis and medical care of suspected and confirmed cases, ensuring medical attention, with the aim of reducing complications and mortality in seriously ill patients.
Both suspected cases and travelers in quarantine are monitored daily by the health personnel of the Health Post or Health Center closest to their home, registering their vital signs and clinical progress daily. The need, or not, of the continued monitoring, transfers to hospitals or medical discharge, as the case may be, is then evaluated on a daily basis.
A National Information Center was installed, with which the population can establish contact through the toll-free telephone line 132 and in which timely attention and information are provided. The Information Center has 150 operators, who attend 24 hours a day, 7 days a week and can be accessed from any telephone line, be it fixed or mobile. In the first month of its operation, more than 110 thousand calls were received and registered.
The Information Center has areas for receiving, supervising, monitoring cases and specialized medical personnel who make the pertinent connections with MINSA at the national level. They also have a statistic area where calls are monitored.
In addition, a disinfection program is being carried out for 10,000 public transport buses and 23,000 selective means of transport (taxis) daily, more than 10,000 schools weekly and 130 popular markets with a frequency of 3 times a week in the most visited markets in Managua, and twice a week in the rest of the country.
As part of the coordinations carried out by the Inter-Institutional Commission, the Ministry of Education and the Ministry of Health, in addition to the National Council of Universities (CNU), disinfection of all public study centers was carried out along with the installation of disinfection trays and sinks. Alcohol gel dispensers were installed at the entrance of educational centers, as well as the formulation of prevention and action protocols, the training of teaching and non-teaching staff, the adequacy of physical facilities and finally, the organization of conversations with students about preventive health and reinforcement of healthy habits, all to ensure the continuity of classes safely for the entire community.
Similar measures have been carried out in all State institutions, particularly those where a large number of the public are served, where even waiting rooms and service windows have been adjusted to guarantee distance and physical barriers to reduce possible risks of infestation. Private companies and other civil society entities have adopted global standards of personal and collective hygiene, as well as measures for personal distancing.
• 19 hospital care units have been established for COVID-19 and primary care units have been prepared for the care of respiratory symptoms at the national level.
• The attention and follow-up of reported COVID-19 cases and their contacts, has been ensured.
• 42,236 travelers who have entered the country have been followed up by health personnel, who remain in responsible and careful shelter for 21 days.
• Three cycles of home-to-home visits have been carried out by brigades from the Ministry of Health and the community network, which now total 4.631 million visits nationwide, explaining protection measures that promote health in the family, in the home and community.
• A National Information Center has been established, which, through a free telephone line, provides the population with accurate and timely attention and information on any concern they have about the pandemic.
• A disinfection program is being carried out for collective and selective means of transportation (buses), as well as educational centers and popular markets.
• In coordination with the Ministry of Education and the National Council of Universities (CNU), disinfection and adaptation of study centers has been carried out to safely receive students, protocols for prevention and action against Coronavirus have been designed, teaching and non-teaching staff have been trained and content on preventive health and reinforcement in healthy habits has been included in educational curricula.
Nicaragua ensures, through our health model, the principles of freedom, solidarity and equality, and assumes the principles of accessibility, comprehensiveness and continuity in the process of health care, maintaining efforts and measures to mitigate the socioeconomic impact of COVID-19.
V. HOW NICARAGUA IS IN A BETTER POSITION TODAY TO DEAL WITH THE PANDEMIC THAN IN 2006:
Starting in 1990, three successive right-wing governments applied and carried out the neoliberal and privatization policies designed by the International Monetary Fund (IMF) and the World Bank (WB), which caused serious damage to the social programs previously established.
Health policy in the neoliberal era (1990–2006) promoted ideas focussed on the individual instead of society, reducing social spending on health, and privatizing hospitals and social insurance. From this period, the Ministry of Health ceased to be, in practice, the governing institution of health, and instead several “systems” and actors appeared, including companies, NGOs and the State offering health services (or projects) dispersedly; the preventive health approach was replaced by a curative approach.
Numerous economic efforts have been made by the GRUN to raise the Nicaraguan people from the place of enormous poverty in which the colonial, neocolonial and neoliberal regimes have left them throughout their history.
In 2007, with the return to the Presidency of the Republic of Commander Daniel Ortega Saavedra, through the GRUN, the institutional framework around health took another turn, with the family and community health model, in addition more GRUN participation in social security clinics and the importation of medicines.
In several indicators, Nicaragua has achieved results applauded by international organizations that are members of the United Nations System, such as:
• the reduction of maternal mortality, from 92.8 deaths in 2006 to 29.9 deaths per 100,000 live births in 2019;
• the reduction of infant mortality, from 29.0 deaths in 2006 to 11.4 deaths of children under one year of age per 1,000 live births in 2019;
• the reduction in chronic child malnutrition, from 21.7% in 2006 to 11.1% in children under 5 in 2019;
• the reduction of general poverty, from 48.3% in 2005 to 24.9% in 2017, and;
• the reduction of extreme poverty, from 17.2% in 2005 to 6.9% in 2017.
Despite the neoliberal counter-reform of the period 1990-2006, in which an attempt was made to totally privatize health, all medical personnel trained during the 1980s in the values of health as a basic and inalienable right, resisted, and when the Sandinista Front returned to power, it was in a position to implement the successful family and community health model that today tests the emergency of COVID-19.
During the last 13 years, the Sandinista government has built 18 hospitals: 15 primary, 1 departmental and 2 national, all of them operating free of charge. In the medium term, there is a projection to build 15 more hospitals, six of which are already under construction, including two large ones: the one in León and the one in Nueva Segovia.
Likewise, in the last 13 years Nicaragua has increased its health personnel: in the year 2,006 there were 22,083 health workers, going to 36,649 in 2020, among doctors, nurses and technicians.
In addition to this, there are 143 health centres and 1,333 medical posts distributed throughout the country. In 2006 there were 50 maternity houses and currently Nicaragua has 178 maternity houses; In the last 13 years, 128 of these houses have been built throughout the country. In 2006, 9,205 pregnant women were housed in maternity homes and in 2019 66,175 women were housed. This has led to the fact that in 2006 maternal mortality has gone from 92.8 deaths per 100,000 live births to 28.9 in 2020.
There are also 66 mobile clinics, a massive program that actively visits communities every week to provide free information and medical care to the population. In 2019, 1,959,506 services were performed in these mobile clinics.
To all this, we must add the recent inauguration of a modern molecular biology laboratory capable of analyzing tests for various diseases, including COVID-19. This laboratory is the second most advanced in the region.
Furthermore, since late 2018, Nicaragua has had a drug plant with the capacity to produce 12 million influenza vaccines per year and which plans to produce the Cuban drug Interferon Alfa-2B successfully used to treat patients with COVID-19.
Several months before the alert by COVID-19, the Government, in July last year, had already declared an epidemiological alert to combat the aforementioned diseases. In fact, for many years Nicaragua, due to its very conditions, has lived in a permanent situation of epidemiological alert that the authorities are facing together with the communities, which has given the country better levels of health at the population level and extensive experience with these types of threats.
Due to its own characteristics, Nicaragua is obliged to have an alert system against all kinds of threats that include epidemiological, climatic (for example, hurricanes), tectonic (seismological and volcanic) situations, and for many years it has been carrying out massive civil defense exercises that involve millions of citizens.
In terms of infrastructure, the health system in Nicaragua has 77 hospitals, of which 19 were prepared to serve COVID-19 patients, with a capacity of 11,732 general hospital beds and 562 intensive care beds. Of these 77 hospitals, from 2007 to the present day 18:15 primary, 1 departmental and 2 national hospitals have been built, all of them operating free of charge.
In the medium term, there is a projection to build 15 new hospitals: 6 are currently being built in different parts of the national territory, including two large ones: one in the Department of León and the other in Nueva Segovia; and 8 other hospitals in short-term projects; 8 hospitals in projection and design: 1 in Wiwilí, in the department of Jinotega; 1 in Mina el Limón in the department of León and in Managua the Rehabilitation Hospital "Aldo Chavarría", will be moved to another place, in order to modernize it in terms of rehabilitation. In Bilwi, Puerto Cabezas, located on the North Caribbean Coast of Nicaragua, a departmental hospital will be built and there are improvements in the Bluefields hospital, located on the South Caribbean Coast of Nicaragua, but also a hospital will be built in the municipality of Paiwas, Mulukukú.
Similarly, the construction of the Los Chiles Community Hospital has begun, in the Municipality of San Carlos, bordering Costa Rica. 80 projects are currently being carried out by MINSA, expected to be completed in their entirety in the year, such as the new Jorge Sinforoso Bravo Health Center in Granada that began construction in 2019 and will conclude in 2020 and Maternal Homes in El Cua, Pantasma and Bluefields.
Likewise, with 82 clinical laboratories and 14 epidemiological laboratories, one of them is the National Center for Diagnosis and Reference, one of the best in the Central American region, in charge of carrying out tests and studies to attend and prevent epidemics such as influenza, dengue and coronavirus
Additionally, Nicaragua has the most modern linear accelerator against cancer in Central America, which has made a qualitative leap for patients with this disease.
The Family and Community Health Model (MOSAFC)
The Family and Community Health Model (MOSAFC) is the health instrument that gathers the political and economic vision of the State within the field of the health sector. It focuses on caring for families, people and the community as a continuous process, with interrelated moments of promotion and protection of their health, recovery and rehabilitation when the population or person becomes ill or suffers disabilities, all with a comprehensive preventive approach and actions aimed at the person, the family, the community and the environment around them.
This Model generates initiatives for change in the culture and structure of the health sector to satisfy the needs and the exercise of human rights, contributing to improve their quality of life throughout the life cycle.
The Nicaraguan Family and Community Health Model, which is based on the active participation of the community, has facilitated the development of activities to ensure, as a priority of our government, measures aimed at protecting the population in terms of morbidity and mortality.
Within this plan, as fundamental elements, a comprehensive approach to both the public and private systems is established, as well as institutional and community epidemiological monitoring at entry points and at the level of health units, timely detection, early diagnosis and medical attention of suspected cases and confirmed, ensuring medical attention, with the aim of reducing complications and mortality in seriously ill patients.
Along with the development of this material base, the Family and Community Health Model of the Government of Reconciliation and National Unity (GRUN), formulated conceptually as early as 2008, has a broad social infrastructure in the form of sectoral, municipal, and departmental networks and national that articulate public, community and private health resources that for years have been promoting all kinds of health days, especially to prevent epidemic diseases such as dengue, zika and chikungunya.
The objectives of this model are to improve the health conditions of the population, generating timely, effective, quality and warm activities capable of generating positive personal, family and community changes, with an emphasis on prevention and health promotion, satisfying the needs of the population's health services, protecting the population from epidemics, improving the quality of services, responding to the expectations of the population in receiving quality health services, with human warmth, strengthening the articulation between the different members of the health sector, as well as inter-institutional and inter-sectoral coordination.
Main advances in the installation of the health system
Since January 10, 2007, the first action that our President Commander Daniel Ortega directed was the faithful compliance with the Constitution of the Republic of Nicaragua in relation to free universal health, that is, for all Nicaraguans.
In this context, since 2007 to date, Human Rights in Health have been restored in terms of maternal and infant mortality, prenatal care for pregnant women, construction of Maternal Homes, the Love for the Youngest Program, the Operation Miracle Surgery and the All with a Voice Program. These advances can be noted in the comparison made in relation to the figures that existed in the period of neoliberal governments to the figures that exist in Commander Daniel's current presidential period from 2007 to date.
As for Programs created by the Good Government of Commander Daniel and Comrade Vice President Rosario Murillo (they did not exist in neoliberalism), we have:
• Love for the youngest: 565,259 home visits to families with children under 6 years of age.
• All with a Voice: 2019: 369,637 visits in their homes to people with disabilities
• Operation Miracle: 2019: 13,747 cataract and pterygium surgeries to regain vision.
• Regarding Nutritional Census Data we have:
- Childhood chronic malnutrition: In 2006: 21.7% in children under 5 years of age; in 2019: 11.1% in children under 5
• Vaccination Campaign Data:
- During the National Vaccination Campaign from April 20 to May 8, 2020, the total goal of doses to be vaccinated was 1,998,142 doses, applying 2,067,111 doses, with compliance of 103.5%;
- The goal of Vitamin A was to administer 1,112,483 doses, 1,112,483 doses were applied, with 100% compliance;
- The goal of Antiparasitics to be administered was 1,573,519 doses, 1,573,519 doses were applied, with 100% compliance;
- During the undertaking of the Vaccination Camaign 11,285 open vaccination posts were reported, with a total of 36,767 participants, 14,844 health workers, 18,041 resources from the community network and 3,882 resources from other institutions and organizations;
- 4,631,314 house-to-house visits have been made nationwide, on protection measures that promote health in the family, at home, and in the community.
VI HEALTH EXPENDITURE
Health spending, both current spending and capital spending, has increased substantially in the last decade. In both the 1980s, and 1990s and the early 2000s, spending was extremely low. It is from 2007 onwards when spending in the Health Sector in Nicaragua increased. Investment has been made in better infrastructure in the health sector through the construction of new public hospitals and the rehabilitation of existing ones. In 2006, the per capita expenditure of the Republic Budget assigned to the Ministry of Health was $ 32 40 per person for one year. In 2007 it went to 37, in 2008 to 41 and in 2018 to $ 70 per capita (which would remain for 2019). In other words, the allocation for the Ministry of Health has been more than doubled in terms of the budget for investment by each Nicaraguan. If we compare the Current and Capital Expenditure we obtain that in 2006 said allocation was C $ 3,283 million (111.9 million dollars) while in 2020 C $ 16,048 million (USD 468.55 million dollars) have been budgeted, almost 5 times that of 2006.
VI. CRITICISM OF NICARAGUA´S RESPONSE TO COVID-19
There are three lines of criticism of the Nicaraguan government's management of the COVID-19 pandemic:
1) of the supporters of total closings or “lockdowns”;
2) from the coup opposition who want to see in the pandemic an opportunity to weaken the Government and the national economy; and
3) controversies regarding the accounting of cases, since the Ministry of Health only accepts as COVID-19 those verified by means of laboratory tests or by clinical opinion.
Given the similarity of symptoms with pneumonia and seasonal influenza, which are much more frequent in the world and in Nicaragua, there is a tendency for many people to attribute to COVID-19 any death caused by diseases of the respiratory tract.
Supporters of Lockdowns
Countries that have completely closed their economies are uncomfortable with the example of countries that do not apply a draconian closure and do not destroy their economies to face the pandemic; rather, they create a balanced environment with respect to the global economic crisis, protecting the interests of the peasants, the informal sector and the poor in general, as well as the national economy. The Nicaraguan economy was growing by 5% on average until 2018, being the third highest growing economy in Latin America and the Caribbean, then it had a decrease of -4.0% due to the attempted coup d'état in that same year and from -3.9% in 2019.
Taking drastic closure measures would have a debilitating effect on the economy; even more, it could be catastrophic. Rather, the government must have policies to deal with the pandemic and lay the groundwork for economic recovery at the same time. All the countries that are emerging from closures face this same problem, of how to combine the fight against the Coronavirus with the functioning of society, many of them with the complications of rising unemployment, the bankruptcy of small and medium-sized companies, the needs of emergency subsidies and the need for stimuli to stop the fall in GDP in these countries. There is no doubt that we are living a “world war” against the COVID-19 pandemic and that this is only surpassed by the pandemic of manipulation and disinformation of the major media in the world.
The Continuity of the Coup
Misinformation terrorism, conceived from the United States and which the media in many countries, including those in Costa Rica, carry out to the letter, is brutal, criminal and xenophobic. Nicaragua is the example of unfounded attacks regarding what happens to the pandemic. Lie after lie, from media such as Teletica, Repretel and La Nación, whose owners represent the Costa Rican oligarchy, blatantly lie against this sister Nicaraguan nation.
One of the most recent is an information from the American television channel CNN about El Salvador and that Repretel misrepresents and puts it as if it happened in Nicaragua. In the same way, videos made in Ecuador, Bolivia and other 43 nations are used by these media to make people believe they are from Nicaragua.
This behavior of generating false news is the same as that of the attempted coup in 2018. With the current pandemic of COVID-19, the coup leaders of Nicaragua and their sponsors of the covert action agencies of the United States. They have lashed out with a massive disinformation campaign, with the same practice of daily lying to the Nicaraguan people trying to undermine confidence in the government, they have seen the pandemic as a great opportunity to scare and misinform the population, viralizing videos of a cemetery in Guayaquil saying that it is in Nicaragua and putting together artificial psychodramas, spreading the false information that there will be a quarantine with a curfew to try to provoke panic purchases, while projecting abroad a vision of chaos in the country. It does not work internally, since the entire population observes the normal functioning of the country.
Likewise, they criticize the government for not establishing a quarantine, not closing borders, not prohibiting the entry of foreigners into the national territory, or suspending the school year in public sector schools and universities, all with the purpose of weakening the economy.
About Accounting of Cases
Regarding the controversy over the number of victims and given the similarity of symptoms of those who died from respiratory diseases, it is worth reiterating that annual deaths from pneumonia and seasonal influenza in the world are 3.5 million and in Nicaragua 1,251, while the number of deaths in the world by COVID-19 is 320,000 and in Nicaragua, 17.
VII. ORGANIZATION OF THE NICARAGUAN HEALTH SYSTEM
The Nicaraguan National Health System is made up of the public and private subsystems. The public subsystem is made up of: The Ministry of Health, the Nicaraguan Social Security Institute, the Army Medical Corps and the Medical Services of the National Police. The Ministry of Health is organized into 19 Local Systems of Comprehensive Health Care (SILAIS) which have functions of provision of services, 46 administrative and stewardship of health.
Ilustration 3. Local Systems of Integral Medical Attention (SILAIS) of Nicaragua
Likewise, it develops comprehensive actions of promotion, prevention, cure and rehabilitation, aimed at people, family, community and environmental control. Vaccines are also applied to prevent 16 diseases, anti-epidemic activities and actions to fight maternal and infant mortality. In addition to promoting emblematic and solidarity programs such as Amor para los Chiquitos ("Love for the Youngest", aimed at children), the Todos con Voz program ("All with a Voice", aimed at people with disabilities) and Operación Milagro ("Operation Miracle", eye operations).
The network of public health units nationwide has 77 hospitals, 143 health centers, 1,333 health posts, 5 specialized centers, 178 maternity homes with 2,365 beds and 91 houses for people with special needs. For the transfer of patients, nationwide there are 404 ambulances, 6 water ambulances, and for the care of individuals and families living in areas of difficult access, there are 74 mobile clinics.
Through the service network, people have free access to laparoscopic surgery, mammography, ultrasounds, cytology, cryotherapy, chemotherapy, laboratory tests, electroencephalogram, electrocardiograms, X-Rays by remote control, magnetic resonance imaging, tomography, and a linear accelerator for treatment cancer patients.
Also, the integration of natural medicine in public health services is promoted, for this it has the Institute of Natural Medicine and Complementary Therapies, which has 16 subsidiaries and 188 Clinics throughout the country. In addition, there are 70 pain management clinics and progress has been made in the Caribbean Coast in the cultural adaptation of health care, recognizing diseases of cultural affiliation such as the Grisi Siknis or Pauka Alkan.
In Nicaragua, for every 10,000 inhabitants there are 12 hospital beds, 10 doctors, 8 nurses and 9 nursing assistants.
Territorial Organization of the Health System
Illustration 4. Territorial Organization of the Health System
Each SILAIS typically corresponds to a department of the country's political division, except in the cases of the Autonomous Regions of the North Caribbean Coast (RACCN) and the South Caribbean Coast (RACCS) which, for reasons of length and limitations of communication channels, have been divided into two SILAIS.
Thus, in the RACCN there are two SILAIS: Bilwi, which includes the municipalities of Waspán, Prinzapolka and Puerto Cabezas; and SILAIS de Las Minas, which circumscribes the municipalities of Rosita, Bonanza, Siuna, Mulukukú and Paiwas.
Illustration 5. SILAIS of the Autonomous Region of the North Caribbean Coast (RACCN)
Similarly, in the RACCS there are two SILAIS: the SILAIS Autonomous Region of the South Caribbean Coast, which includes the municipalities of La Cruz de Río Grande, Desembocadura del Río Grande, El 51 Tortuguero, Laguna de Perlas, Kukra Hill, Bluefields and Corn Island ; and SILAIS Zelaya Central, which includes the municipalities of El Rama, Muelle de losBueyes, El Coral and Nueva Guinea.
Ilustración 6. SILAIS of the Autonomous Region of the South Caribbean Coast (RACCS)
In turn, each municipality is divided into sectors. The Sector is defined as the Epidemiological, Social and Health Production Territorial Unit where promotion and prevention actions are developed in coordination with the network of community agents. It is a territorial health area where communities, neighborhoods or areas are grouped between 600 to 1,000 families, equivalent to 3,000 to 5,000 inhabitants, depending on the rural or urban case.
Organization of the Family and Community Health Model
In the country there are 5,806 base houses and as part of the Family and Community Health Model (MOSAFC) 2,766 Sectors are formed, attended by family and community health teams, which work together with 48,973 members of the community network, among which there are brigade members, midwives, volunteer collaborators, healers, sobadores, shamans, bonesetters and traditional doctors from the Caribbean Coast.
All this structure produces detailed information at the household level, numbering its inhabitants, and thus the health situation by household, sector, municipality, department and national level is known. This accumulation of information is fully available for anyone who wants to know it through an accessible and user-friendly web portal, known as the "National Map of Health in Nicaragua" (mapsalud.minsa.gob.ni) and which can be easily accessed from the page of the Ministry of Health (www.minsa.gob.ni).
Information on and for the Population: National Health Map of Nicaragua
Nicaragua has a web portal where all people can access and have information on the main illnesses, hospital admissions and causes of death at the national, departmental and municipal levels. This portal is known as the "National Map of Health in Nicaragua". The map can be accessed in two ways: mapsalud.minsa.gob.ni and through the MINSA page www.minsa.gob.ni.
There is a menu with updated national data for 2017, 2018 and 2019 and information in each of the areas to enter any SILAIS. For example, if we want to obtain specific information from a department, in this case Matagalpa, on the main page we click on the Map of Nicaragua on the department of Matagalpa:
Then we will obtain the tables with information from the municipality of Matagalpa from 2017 to 2019 as shown in the following tables.
Chronic diseases in the years 2017, 2018 and 2019, the most frequent chronic diseases in the department of Matagalpa were:
Causes of Hospitalization of the General Population
Likewise, in 2017 39,739 people were hospitalised, in 2018 38,234 people were hospitalised and in 2019 42,312 people were hospitalized, which represents an increase of 10.6% of people hospitalised in this last year compared to 2018 and the causes that most frequently required hospitalisation:
If we want more specific information about the Department of Matagalpa we can select on the map of the department, for example, we can select the municipality of San Ramón.
Then we will obtain the tables with information from the Municipality of San Ramón in Matagalpa from 2017 to 2019 as shown below.
Chronic diseases In the years 2017, 2018 and 2019, the most frequent chronic diseases in the municipality of San Ramón were:
If we want more specific information, we can click on the comparative statistical tables, for example, in the Public Health Services Network.
And we will obtain the following table:
In the same way we can click on Private Health Services Network.
And we will get the following table: Or we can see the information by Sectors, as shown below.
It then shows the map of the municipality of San Ramon with a list of sectors.
If we select for example Sector No 1, Lucrecia Lindo, we will obtain even more specific information:
Likewise, there are two additional sources of information at the municipal level, such as the Epidemiological Situation and the Todos Con Voz! program
In Epidemiological situation we find the following table:
And in Todos Con Voz we find a table with people according to their type of disability and below you can select the sector.
If we select for example Sector No 1, Lucrecia Lindo, we will obtain even more specific information:
How to Access the National Health Map in Nicaragua
Below is an instruction on how to access the National Map of health in Nicaragua, in the same way you can find it here http://www.minsa.gob.ni/pub/instructivo_mapa_padedamientos.pdf
Hospitals built in Nicaragua since 2007
2 NATIONAL HOSPITALS:
- 1. New Dr. Vélez Paiz Hospital, Managua municipality
- 2. Hospital Solidaridad CMP, municipality of Managua.
1 DEPARTMENTAL HOSPITAL
- 3. Boaco Departmental Hospital, Municipality of Boaco.
16 PRIMARY HOSPITALS
- 4. San Juan de Río Coco Primary Hospital - Madriz.
- 5. Primary Hospital Muelle de los Bueyes - Chontales.
- 6. Primary Hospital Heroes and Martyrs of San José de las Mulas, La Dalia, Matagalpa.
- 7. Carlos Fonseca Primary Hospital - Mulukukú - RACCN.
- 8. PrinzuPawanka Primary Hospital, Prinzapolka - RACCN.
- 9. El Sauce Primary Hospital. LeonDepartment
- 10. Chichigalpa PrimaryHospital. Chinandega Department.
- 11. Primary Hospital of San Francisco Libre, Department of Managua.
- 12. Primary hospital in El Jícaro. Nueva Segovia Department. 72
- 13. Corn Island Primary Hospital. RACCS
- 14. Tipitapa Primary Hospital.Managua Department.
- 15. Primary Hospital in San José de Bocay.Jinotega Department.
- 16. Primary Hospital of the Jinotega Previsional Medical Clinic (CMP).
- 17. Primary Hospital of San Juan del Sur. Rivas Department
- 18. Primary Hospital of San Miguelito, Río San Juan.
- 19. El CuaPrimary Hospital, Jinotega
7 HOSPITALS UNDER CONSTRUCTION:
- 20. Chinandega Departmental Hospital
- 21. Dr. Oscar Danilo Rosales de León Hospital
- 22. Ocotal Departmental Hospital, Nueva Segovia.
- 23. Nuevo Amanecer Regional Hospital of the North Atlantic Autonomous Region
- 24. San José de Matiguás Primary Hospital, Matagalpa
- 25. Los Chiles Primary Hospital, Río San Juan
- 26. Quilalí Primary Hospital, Nueva Segovia.
The following map shows the distribution of these Hospitals in the geography of Nicaragua. The national hospitals are indicated in red, the departmental hospitals in orange, the primary hospitals in blue and the hospitals under construction in green. The numbering indicated corresponds to the list presented above.