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The true cost of “free” healthcare

Deteriorating public hospitals without medicine are hiding behind the official discourse of free healthcare in Nicaragua

With a bottle of acetaminophen syrup, two envelopes with oral serum and a small piece of paper without a letterhead that reads “Anginovag spray”, Amanda Hernández and her two-year old baby left the Manuel de Jesús Rivera Children’s Hospital, known as “La Mascota” in Managua. It was two in the morning on October 10, and her little girl was crying non-stop with a fever that exceeded 40 degrees Celsius.

The hospital did not charge her anything for the consultation, but Hernández resents that the doctor “only looked at the girl” with the light of a cell phone, asked her “a couple of things” and prescribed acetaminophen for the fever. “That’s no good,” she says without hesitation about the care she received. The woman claims that she took the girl to La Mascota Hospital because it was a medical emergency, but that she usually allocates part of her monthly income to pay for a private pediatrician to ensure better care.

Upon leaving the hospital, the woman, feeling desperate with her crying baby, boarded the first cab she could find and asked to be taken to “any pharmacy” to buy the medicine that the doctor wrote down on the clandestine piece of paper. She had no trouble finding the drug and was not asked for a prescription when they sold it to her.

“Medicine for the poor! Medicine for the humble! Medicine for the workers! Medicine for the people,” President Daniel Ortega exclaimed in his July 19, 2020, speech, for the occasion of the 41st anniversary of the popular Sandinista insurrection that overthrew the Somoza dictatorship in 1979. Ortega appeared after an absence of 38 consecutive days, as the SARS-CoV-2 coronavirus began to spread in Nicaragua and the Ministry of Health (Minsa) provided “succinct” information with “insufficient” data to make an assessment, the Pan American Health Organization (PAHO) said at a press conference.

Hernández, however, had to pay for the medications and specialized tests that she did not find at the hospital, where she was not charged for her care, but also does not feel that she was really cared for.

According to data from the General Budget of the Republic, the State of Nicaragua invests a total of 19.5 córdobas (less than sixty cents) on the purchase of medicines per month per citizen. In the second poorest country in Latin America, the amount is barely enough to buy ten pills of acetaminophen, a drug prescribed to relieve pain and fever, but which in Nicaragua is prescribed for almost every ailment.

The amount each Nicaraguan spends out of pocket on health care – even though it’s officially free – is above the continent’s average. According to the report “State of Health in the Americas,” published in 2019 by the Pan American Health Organization (PAHO) with data from 2016, until that year Nicaraguans paid 32.2% of medical expenses out of their own pockets, surpassing the average for the Americas which is 23.9%.

The latest Living Standard Measurement Survey, conducted by the National Institute of Development information (Inide) in 2016, also reveals that health spending represents 4.3% of total consumption by Nicaraguans.

Overall, the budget of the Ministry of Health in 2020 amounted to 16,022 million córdobas (467.4 million dollars), of which 14,039 million (87.6%) was used for administrative expenses and only 1,983 million (12.4%) was used for the construction of hospitals and other Minsa projects. This investment represents 19.8% of the total General Budget of the Republic, which this year amounted to 80,901.6 million cordobas.

More coverage does not guarantee access to health care

In order for Nicaraguans like Hernández and her baby to have access to health services free of charge, as the government proclaims, it is not enough to build public hospitals. There are economic, cultural, geographic and even political barriers that determine that the population’s access remains limited, despite the increase in health coverage.

Dr. Miguel Orozco, former director of the Center for Research and Studies in Health (CIES) of the National Autonomous University of Nicaragua (UNAN – Managua), explains that “health services can be free”, but if they are offered “at a time or distance that causes out-of-pocket expenses” this prevents the population from taking advantage of the free services offered.

The lack of medicine in public hospitals is one of those economic barriers that limit access to healthcare in Nicaragua. The Anginovag alone, prescribed to Hernández on that little piece of paper without a letterhead by the doctor at La Mascota Hospital, has a value of 250 córdobas (more than seven dollars), according to the latest price list authorized by the Ministry of Industry, Development and Commerce (Mific). A cost that the population has to assume.

Hernández recalls that the doctor gave her the slip of paper and told her that “it is forbidden to prescribe something that we don’t have” in the public hospital. Giving out prescriptions without medicine goes against Ortega’s speech: “Medicine for the people!”. That is why some doctors choose to prescribe medicine that way, on papers without the Minsa stamp.

Minsa’s coverage is also limited to 65% of the population, according to the 2017 Health in the Americas report. The other 45% of the population has to pay to be treated in the private health subsystem; 18% by the Nicaraguan Institute of Social Security (INSS); 6% by the Ministry of the Interior and the Nicaraguan Army, and the remaining 11% goes to private institutions and non-governmental organizations.

Human resources are also scarce and have little credibility. The report read by Ortega on July 19 says that the Minsa has 36,983 health workers, of whom only 6,182 are doctors and 11,050 are nurses. This means that, for a population of 6.48 million, there are ten doctors and eight nurses for every 10,000 inhabitants, details the Minsa’s Map of Ailments.

However, the Nicaraguan leader assured that “because we had all these capabilities installed, and which we continue to install, is that we have managed to successfully address this pandemic,” of the coronavirus. An achievement that has not even been seen, according to Ortega, in “the great world powers.”

In April 2018, citizens’ protests against the Ortega government erupted, demanding a reform of the Social Security system to which the government responded with violence, leaving 325 murdered between April and September of that year. In addition, national and international organizations reported dozens of missing persons, thousands wounded, more than 800 political prisoners, of whom more than one hundred are still in government prisons, and approximately one hundred thousand exiled due to political persecution.

In the context of the protests, dozens of wounded people arrived at public hospitals, where the government allegedly gave the order not to attend to them, according to the Annual Report 2019 of the Inter-American Commission on Human Rights (IACHR). However, there were doctors who refused to comply with the order or joined in on the complaints, so the Minsa fired more than 400 health workers, including specialist doctors and sub-specialists, “for providing care to the opposition demonstrators” according to the Nicaraguan Medical Unit’s complaint to the IACHR.

Since then, the Ministry has continued to kick out workers who are not politically sympathetic to the government party. The latest dismissals were 20 doctors who demanded protective equipment against the SARS-CoV-2 coronavirus pandemic, which according to official data has left 162 dead and 5887 sick from March 18 to December 9, 2020, but it is estimated to be 18 to 36 times more deaths, according to reports by the COVID-19 Citizen Observatory, a network of doctors and volunteers who independently monitor the impact of the pandemic, and investigate and analyze excess mortality.

Orozco is a public health expert and was dismissed from CIES, controlled by the government through UNAN-Managua, for expressing his views on the official response to the pandemic. The specialist assesses that the main weakness of the public health system lies in “the mistrust that the population has in the human resources (professionals and support staff) and in the services provided”.

Health workers do not have good working conditions, Orozco says. The pandemic exacerbated the lack of protective equipment and the supply of medicines, so hospitals “far from representing a factor of protection and tranquility have become an opportunity for contagion and frustration, since what is needed is not found”, he adds.

Another weakness in the public health system, emphasizes Orozco, is “the lack of cohesion and synchronization between the different levels of care. This, he points out, can manifest itself in “the long waiting lists for specialized examinations and elective surgeries that end up becoming emergency surgeries,” because they were not performed in the corresponding time, but rather only until the patient presents complications.

The political barrier to accessing health

In the western part of the country, 98 kilometers from La Mascota, at the Hospital Escuela Óscar Danilo Rosales Argüello (Heodra), in León, the discourse of free health is frequently heard.

A sign with a photograph of the governing couple stands out at the northwest entrance of this old building, embedded in the center of the warm city, with the slogan “Long live the Sandinista Revolution 2020” the flag of the governing Sandinista National Liberation Front (FSLN) and a drawing of a “tree of life”, which is a symbol of the government.

The Heodra is the most tangible example of the political barrier that limits access to public health in Nicaragua. This hospital, which has been in operation for 54 years, was the genesis of the mass layoffs against health personnel in 2018. In July of that year, ten doctors, twelve nurses and thirteen other health workers at Heodra were arbitrarily dismissed by the hospital’s director, Judith Lejarza Vargas, who informed them that the dismissals were for “political” reasons, including caring for injured opponents or joining anti-government protests. Since then, patients in western and northern Nicaragua have had to wait longer for their highly complex surgeries, because they fired a dozen specialists and subspecialists for partisan reasons, without taking into account that most of them had more than 17 years of experience.

Dr. Javier Pastora, former head of the Department of Surgery and Gastroenterology at Heodra, emphasizes that “it is completely false” that there is free healthcare. “Health always has a cost and that cost is paid by people’s taxes. It is because of those taxes that the people of León hope that the government will finally build the new Heodra, a project that has existed on paper since 2014 and is issued as an introduction for large state investments to expand health coverage.

The promise of the new Heodra is so recurrent that the former Minister of Health, Sonia Castro, arrived twice in Leon to lay the first stone of the hospital. The first time in March 2017, and the second in June 2019, when construction finally began, five years after it was announced in the state propaganda media.

Hospitals under construction

In times of the pandemic, the expansion of public health coverage in Nicaragua stands out in the official media, even though some are projects that predate the appearance of covid-19, and have been dragging on. The new Heodra alone is one of four regional hospitals under construction, according to the Report on Investment in Infrastructure and Equipment of Health Units, published on the Minsa website. The other projects under development are: the Chinandega Departmental Hospital, also in the west; the Luis Alfonso Moncada Departmental Hospital, in Nueva Segovia, and the Nuevo Amanecer Regional Hospital, in the North Caribbean Coast Autonomous Region (RACCN).

The same Minsa report details that since Ortega returned to power in 2007 to 2020, only two national hospitals have been build: the new Fernando Vélez Páiz Hospital (whose previous building was severely damaged by the Managua earthquakes in 2014), which is completely public, and the Solidaridad Hospital, which operates as a Provisional Medical Clinic (CMP). In addition to these, there is also the Boaco Departmental Hospital, in the center of the country, and 16 primary hospitals in different municipalities.

Dr. Pastora recognizes that the construction of primary hospitals “is something positive” that contributes to “decongesting regional hospitals” such as Heodra, and increases the coverage of the public health subsystem; however he questions that the attention they provide is “quite limited” because only some types of “basic surgeries” can be performed.

Dr. Orozco agrees that the construction of primary hospitals, maternity homes and health centers “is part of a necessary strategy to improve coverage for rural populations. However, he emphasizes that in those areas “access (to the health service) is more difficult due to the distances to be covered and the cultural barrier”.

Although there is no known recent study on access to health care in rural Nicaragua, Dr. Orozco explains that the greatest out-of-pocket spending for the population “is concentrated in communities where there is less information about health care options.

The Minsa’s public-private business

Unlike the care that Amanda Hernandez and her two year old baby received at La Mascota Hospital, medical care is not “free” at 15 Minsa hospitals. These operate as Provisional Medical Clinics (CMP), where until December 2018, they provided care for 199,453 insured persons, according to the latest Statistical Yearbook of the Nicaraguan Institute of Social Security (INSS). The patients that Minsa treats privately are mainly health workers, insured by the INSS, and people that are “recommended” by other state institutions or members of the governing Sandinista National Liberation Front (FSLN).

Solidaridad Hospital in Managua is one of Minsa’s CMPs and the medical care provided there contrasts with the service that is provided publicly by the same institution. The infrastructure is relatively new, the human resources are properly trained, the patients do not have to wait long for the surgeries and the attention “is not bad”, according Dr. Nubia Olivares Muñoz, anesthesiologist and specialist in Pain Clinic and Palliative Care, who worked in the department of Oncology at that hospital for over a decade.

On the other hand, unsatisfied with the care she received at La Mascota, Hernández took her baby to a private pediatrician. “There (at the private clinic) they checked her properly, saw that she had a respiratory infection:, and changed her treatment: “Just one of the syrups cost me more than 1000 cordobas,” she says.

According to the INSS yearbook, 27% of the 755,874 people insured in 2018 were treated at the Minsa Social Security Clinics. The other 73% were treated at 21 Health Service Provider Institutions (IPSS). Among those is the network of Medical Services S.A (SERMESA), which is owned by the insurance company, as is the case of the Alejandro Dávila Bolaños Military Hospital of the Nicaraguan Army and the Carlos Roberto Huembes Hospital of the National Police.

The work environment in this Minsa CMP is similar to that of public hospitals, explains Dr. Olivares. Here, too, the discourse of free healthcare for the people is repeated and “you can’t talk against the party (FSLN)” because you would be fired as she was for demanding protective equipment at the height of the SARS-CoV-2 coronavirus pandemic.

An example of that party loyalty is that last March, when the first cases of covid-19 were reported in the country, the nurses at Solidarity hospital were not wearing masks because “they were scolded by their supervisors,” she recalls. The Ortega government ordered them “not to alarm the population” and make it seem to the rest of the world that the impact of the disease has been minimal, since his administration has “strengthened” healthcare service, comparing it to or placing it above “the most developed countries”, because, he says, in Nicaragua “it is better”, because health “is free”.

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