El Año Del Humo
Nicaraguan Health Care in Context
Moira Wood
Biomedical Anthropology
Dr. Thomas Williamson
01 May 2013
Wood 2 How I Got Here
When I was offered the opportunity to return to Nicaragua after five years, I was elated
by the prospect of going back to the community where I had lived as a High School student, and
staying with my host family once again. I first went abroad when I was 16, and I spent the
summer living and volunteering in the rural Nicaraguan community of La Barranca. I lived with
a host family for the eight weeks that I was there, and they quickly became a second family to
me. I volunteered at the local clinic and taught basic health practices and hygiene in the primary
school. This experience initiated a passion for health care and Latin America.
Along with my volunteer experience with health care in Latin America, I spent the month
of January 2012 studying Revolutionary History in Cuba, which also provided me the chance to
examine firsthand their politicized health care system. The following fall I participated in a
semester program studying Social Change in Central America, where I spent five weeks in
Guatemala, four weeks in El Salvador, and six weeks in Managua, Nicaragua. After completing
these 16 weeks of study, I extended my stay in Central America by an additional six weeks
before returning to the US. I spent that time by returning to my first home-away-from-home in
La Barranca, Nicaragua. I lived with my same host family, and volunteered daily in the same
clinic, observing its operation, as well as interviewing community members on their perception
of the health care system in Nicaragua.
Upon returning to the US, I began researching the same Latin American health systems
that I had observed and experienced, and what I discovered was fascinating. As I investigated
the countries in which I had lived, I was continually making international health care
comparisons in my mind. So I expanded my research to include cases that examined Latin
America as well as examples from France, Japan, and the UK, commonly recognized as some of
Wood 3 the best health care systems in the world. Such international analysis of industrialized and
developing health care systems, and having a basic understanding of each system's unique
strengths and weaknesses, enabled me to hold a critical eye to each of these health care systems.
My research emphasizes historical, political, and anthropological examinations of these health
care systems, supplemented by understanding acquired through my course of study, and
compounded by participant observation while abroad. My studies have supported my efforts to
compile a detailed dissection of these health care models, as well as an analysis of the inevitable
shortcomings of all health care systems.
The Search for Health Care Excellence
The ideal health care system has been sought for a century, and the search continues. In
their quest, large research institutions often look for equilibrium between quality and access.
Even the most highly respected health systems, however, could benefit from reexamination,
given that "no ideal health care system exists and each system has its shortcomings" (Graig 168).
All of these individual systems, as well as their international interplay, offer intriguing
comparison. I have chosen to focus my investigation, however, on the two systems with which I
have personal experience: United States and Nicaragua. These two countries, while different
historically, economically, socially, and politically, are both striving to create a health care
system that best serves its citizenry. Since "each nation's health care system is a reflection of its
history, politics, economy, and national values" (Reid 16), a system that works in one nation
cannot necessarily be directly transplanted into another nation. Rather, modifications must be
made to adapt to the new cultural climate, and "by examining other people's experience you can
extend your range of perceptions of what is possible" (Graig 2) within one's own health care
Wood 4 system. Even with these cultural variables, the objective for most remains to support the best
health possible, even if perfection remains a fantasy. Nevertheless, as we will see with some
systems, including the US, when health care becomes a business, some of the idealistic
principles are lost in the pursuit of profit.
In Nicaragua, the phrase "el año del humo" literally means "the year of smoke" and is
used contextually to imply something that is unattainable, a hopeless dream. While a perfect
health care system may only be realized in "el año del humo", it is still imperative to understand
the victories and shortcomings of international health care systems. Before I can unfold the
Nicaraguan health care system with its historical and political intricacies, I must place it within a
global context, which requires an investigation into both its regional counterparts as well as the
global standard of developed nations. What is captivating with all of these examples is that in
addition to their successes, all continue to face challenges. Health care is complicated, requiring
competent delivery for an unlimited demand. The examples not only help to interpret the
national health care system in question, but, inevitably, help by providing sufficient context to
understand the system that currently exists in Nicaragua. I will explore the historical and
political economy that shaped the current health care system of Nicaragua and briefly show how
that development compares to that of other nations, in particular the US, a country intimately
entwined in Nicaragua’s past and present.
A Look at Biomedicine
It should be noted that I make no attempt to tackle the complicated realm of popular and
culturally-based medicine. Such an exploration would require a more comprehensive analysis
than I am qualified to give with my observational analysis and research of contemporary national
Wood 5 biomedical systems. Therefore, I make no attempt to touch on the traditional systems that exist
in all the countries examined, in which large populations participate.
Most of the world has
utilized forms of traditional medicine since before the conception of biomedicine. The most
popular examples of these practices today include traditional Asian medicine, Shamanism, and
homeopathic medicine. In the case of Latin America, the majority of non-biomedical systems
manifest itself in the historical practices of Indigenous communities. For example, in Guatemala,
many of the indigenous people seek medical healing through a Mayan Priest, and in multiple
contexts families prefer to employ their own remedies instead of seeking biomedical treatment.
My attempt is merely to dissect the present-day Nicaraguan health care system within a regional
and international context of other modern biomedical models.
Evaluating Health Care Systems
While a perfect health care system does not exist, there are certainly some that are better
than others, especially when examined alongside the slew of issues with which the United States
health care system continues to struggle. In 2000, the World Health Organization (WHO)
produced the World Health Report that analyzed and compared international health care systems;
national health care systems were ranked based on a variety of factors, including, for example,
maternal mortality and immunization rates. This report ranks the overall performance of the US
at 37th, and Nicaragua at 71st (and Costa Rica closely beating the US at 36th) (World Health
Report 211).
Criticism was leveled at the WHO, and discussion continues, regarding the
argument that there are multiple ways to analyze and compare health care systems. As I will
explore different components of a heath care system, and the report by WHO is not absolute, I
Wood 6 consult other wide-ranging performance reports, such as the one completed in 2012 by the
Commonwealth Fund.
A Look at the Industrialized World
Despite its flaws, the WHO report still remains the most widely supported and
referenced, and it ranked France as number one in overall performance (World Health Report
209). The health care system in France provides universal coverage, as every citizen qualifies
for state-funded insurance, though 95% of the population elects to enroll in private health
insurance due to its affordability. Public expenditure accounts for 77% of total health care
spending, mostly funded through taxes, and patient health records are streamlined and protected
though 'vital cards' that are electronic historical medical identities for every patient (TCF 139).
France's innovation with all patient records available through the 'vital cards' eliminates
the need to purchase electronic medical record software, and therefore cuts out that for-profit
industry that is proving to be expensive and problematic in the US. It also facilitates the speed
and quality of care between doctors and clinics, while in the US, impediments hinder care,
including the lack of medical record availability and sharing among medical care providers,
liability concerns, and processing costs.
These factors combine to create what the WHO has determined as the best health care
system in the world. For example, the report highlights the multifaceted nature of their health
care program, noting, "France does a better job than almost any other country both in
encouraging health and in treating those who get sick" (Reid 49). This duality of health care aim
is critical to their success.
Wood 7 Distinct from France, but still equally respected, the Japanese health care system is
ranked at tenth for their universal and an entirely public system. Japan's model stems from
principles set forth by Prussian Chancellor Otto von Bismarck who invented the welfare state
during the unification of Germany. In this model both the health care providers and payers are
private bodies, and such plans essentially function as charities as they provide coverage for
everyone and do not turn a profit (Reid 17). The Japanese use their health care system almost
three times more than those in the US, but it remains incredibly inexpensive for the patients, at
the cost to the health care providers themselves. This system benefits the patients with a lowcost and high-quality system with access for all, but the doctors, nurses, and other health care
employees pay the price through their diminished salaries (Reid 109). This diminished pay is
contrasted by the health care professionals working in the US, especially physicians, who
represent some of the most well paid professions in the country, and only adds to the cost of
health care in the US.
The United Kingdom, sitting at number eighteen has one of the simplest health care
systems, where all residents are covered under the National Health Service and all health
procedures are free. Britain’s National Health Service was inspired by social reformer William
Beveridge, and declares that health care should be provided and financed by the government via
taxes (Reid 17), which accounts for 76% of NHS financial support (TCF 32). The UK spends 9.6
of its GDP on health care, and patients never see a bill or co-pay, as medical treatment is
considered a public service (TCF 32). This same ideal is seen in Cuba's national health care
system, as well the US Department of Veteran Affairs.
Wood 8 An Investigation of the US
The US health care system is "the most complicated, the most expensive, and the most
inequitable health care system of any developed nation" (Reid 251) and unsurprisingly ranks at a
low 37th place in the global health care competition as evaluated by WHO. The US prides itself
in research advancements, scientific accomplishments, and prestigious medical training, and yet
studies show its citizens are not receiving the best care (Reid 252).
Many scholars have
observed, "the U.S. health care system is one of the most technically advanced in the world, but
increasing costs, declining access, and growing public dissatisfaction indicate that the system is
in crisis" (Graig 168) and requires immediate remedy.
The health care system in the US is fragmented, being composed of multiple public and
private sectors, and containing large gaps in coverage across its population. For example, as
T.R. Reid notes, "American health care is not really a system at all. It's a market" (Reid 171),
and therefore does not benefit everyone equally. Public programs such as Medicaid for the poor
and Medicare for the elderly cover only 27% of the population, while 16% remain uninsured,
and 29% are underinsured. Even with so many without access to quality and affordable health
care, in 2010, the annual-per capita health expenditure in the US was the highest in the world at
$8,233, accounting for 17.6% of the GDP (TCF 251). The puzzle is that the US spends the most
on health care, but still has astonishingly high rates of people unable to receive or pay for care; it
continually has one of the highest infant mortality rates and lowest life expectancy rates of
developed nations (Reid 256), which is directly attributable to the way in which the US manages
health insurance and the overall complexity of the health system (Reid 36).
While the "health care crisis" in the US is perceived as a modern phenomenon and a
problem that plagues the current generation, research reveals that citizens have been complaining
Wood 9 about the national system of health care since the 1950s. The manner in which these critics
describe the system of their time is identical to the grievances that are commonly heard today;
seemingly not much has changed since 1972 when Dr. Strickland stated "high cost seems to be
the most pernicious problem in American health care" (Strickland 113).
The health care revolution that took place in 1965 with the introduction of Medicare and
Medicaid increased the annual health budget for the Department of Health, Education, and
Welfare by $13 billion, but is stated that the "large additional expenditures have not brought
unqualifiedly better health for all people" (Strickland 14).
As acknowledged earlier, 45% of
citizens are under- or un-insured, and undocumented immigrants are ineligible for public
coverage, clearly outlining an undeniable problem within the system, that many “are not poor
enough to qualify for Medicaid and they are too young to qualify for Medicare, yet they lack the
sufficient funds to pay for the high costs of private health insurance coverage" (Graig 19). An
enormous gap remains today between those who need health care and their inability to pay for it,
and the US remains the only developed country examined where patients go bankrupt to pay for
health care (Reid 31).
As was true during the reforms of the 1960s, "numerous legislative proposals have been
advanced which essentially call upon the federal government to take a more active role in
correcting major weaknesses in our system of health care" (Strickland 23); the same can be said
for the reforms put forth by the Obama Administration in March 2010 with The Patient
Protection and Affordable Care Act. This health care reform imposes new restrictions on
insurance companies, and also mandates that all people have health insurance. This is done by
expanding Medicaid to cover all people with income below 133% of the federal poverty line,
providing insurance subsidies for low- and middle-income individuals, eliminating co-payments
Wood 10 for preventative care, providing more funding to community clinics, and imposing regulations so
that insurance companies cannot deny or reduce coverage. While this will greatly increase the
number of insured people, estimated to reduce the number of uninsured to 30 million by 2022,
and thereby the number of patients who can receive affordable care, it is still a long way off from
the universal coverage that the world's best health care systems offer (TCF 111).
A Look at Developing Latin American Nations
In analyzing health care systems in developed nations, the common thought is that
"industrialized nations all battle to balance the three shared concerns in modern health care: cost,
access, and quality" (Graig 3). After examining the health care system in Nicaragua, however,
which is not a developed nation but a developing one, I argue that they too strive for similar
fundamental principles in their health care system. The striking difference between these two
cases, however, is the additional challenge of being a developing nation means that the
infrastructure for reform and the funds to yield it are not readily available.
Reid states, "only the developed, industrialized nations - perhaps forty of the world's two
hundred countries - have any established health care payment systems. Most of the nations on
the planet are too poor and too disorganized to provide any kind of mass medical care" (Reid
19). This is the case throughout Latin America, as so few are covered by insurance or social
security, they must pay out-of-pocket for health care. Ironically, the US is a wealthy and a
highly developed nation, yet 17% of health care expenditures are financed by out-of-pocket
payments (Reid 20).
In order to place Nicaragua in the context of its more socio-economically comparable
neighbors, I will explore the current health care systems being implemented in Guatemala, El
Wood 11 Salvador, Costa Rica, and Cuba. I was fortunate enough to study in Guatemala, El Salvador, and
Cuba, and can therefore offer firsthand experience that at times reinforce and at other times
contradict the recent literature on Latin American healthcare.
I will begin my analysis of Latin American systems with Guatemala, a nation nursing the
wounds of a 36-year civil war, where an estimated 200,000 people were killed or missing. While
the conflict officially ended in 1996, the residual effects and the institutionalized discrimination
and repression of the indigenous population are still present today (Booth 116). Memories
remain fresh as the former President Efrain Rios Mott, who was the military dictator for 17months during the conflict, is currently on trial for crimes against humanity and genocide for his
association with the estimated 1,700 deaths of indigenous Guatemalans during his brief but
devastating rule (Malkin).
The tragic history of Guatemala has a direct effect on the health care that is available
today, and access continues to be determined by race and socio-economic status. Health care
infrastructure in the rural areas of the nation remains either under-funded or non-existent, and
indigenous populations inhabit the majority of these communities. For example, 54% of the
national population of 13 million lives in rural areas, 41% of the population is indigenous, and
67% are not registered for Social Security (Country Coop. Guat). If one lives in an urban area
however, one would have access to a health care system composed of three major components:
public, private non-profit, and private for-profit. The public sector is the governmental branch,
the Ministry of Public Health and Social Welfare, funded by national taxes and foreign aid. A
diverse web of national and international non-governmental organizations organizes the private
non-profit sector, and the private for-profit sector is composed of a myriad of hospitals and
clinics authorized by the Ministry (PAHO 6).
Wood 12 The process of health care reforms began at the end of the war with the Health Services
Improvement Program in 1996, and since then efforts to increase access have continued. Total
health expenditure rose from 4.7% of GDP in 1999 to 5.4% in 2003 (Country Coop. Guat).
Together with the implementation of Comprehensive Health Care Systems, which is a public
emphasis on primary care for women and children in underserved populations, the population
covered by public services increased to 3.3 million of Guatemalans (PAHO 7).
Medical
anthropologist Dr. Bruce Barrett observes that the Guatemalan health care system is "commonly
known to be centralized, bureaucratic, understaffed and underfunded, but the official health
system does have an extended reach: 216 health posts, 184 health centers without beds, 32 with
beds, and 35 hospitals" (Barrett 77). While large sectors of society continue to be marginalized
and without access to health care services, improvements since the war cannot be minimized as
they have had a huge impact in humanizing Guatemalan health care.
Similar to Guatemala, the health care system in El Salvador operates within the three
categories of public through its Ministry of Health, and private for-profit and private non-profit
organizations. In 2010, during the first leftist government in the country's history, led by the
revolutionary president Mauricio Funes, the FMLN (Farabundo Marti National Liberation Front)
embarked upon the biggest change to the nation's health care system with the implementation of
a National Integrated Health System. This new program attempts to integrate existing programs,
as well as create Community-Based Family Health Teams to grant access to those currently
living without health care, which was estimated to be as high as 47% of the population before its
implementation (Acosta 190). Before the program was put into practice, health expenditure was
a mere 1.7% of GDP, and since has continued to slowly increase over the years, with its current
percentage at 6.9% (Country Coop. ES).
Wood 13 Despite these much needed improvements, 41% of the population continues to have
limited access to biomedical health services, and 78% have no form of insurance. When 39% of
the population lives in rural areas in the most densely populated country in the region, it is very
difficult to create an infrastructure in which those inhabitants can have daily access to quality
health care. However, if Salvadorian politics continue on their current trajectory, it may be
realized in the coming years (Country Coop. ES).
Distinct from El Salvador and Guatemala, Costa Rica never had an intense period of
repression and revolution, and in comparison has had a comparatively tranquil history. Costa
Rica is an indispensible example for our purposes because, while it lies on the Central American
Isthmus with Nicaragua, El Salvador, and Guatemala, it is the richest Central American nation
and never experienced the historical repression and revolution from which the other nations,
including Cuba, are still trying to recover. While such stability aids in the formation and
maintenance of infrastructure such as health care, Costa Rica has traditionally had a more
bureaucratic, top-down health care system. The national health system began being productive
with US financial support after WWII, and then passed the National Health Law in 1973,
guaranteeing health services to every citizen (Barrett 75). Costa Rica spends 10.9% of its GDP
in health care expenditures; while there exists both private and public systems, because everyone
is guaranteed access to free health care and only 34% of the population lives in rural areas, it is
more straightforward for the government to provide health care (Country Coop. CR).
The success seen in Costa Rica can be attributed to its stable political history and having
a strong foundational infrastructure, while neighboring Guatemala's civil war ended as recently
as 1996 and is just now beginning to rebuild. When looking at statistics, the literary rate in Costa
Rica is 95.9% of the adult population, while in El Salvador it is 82% and Nicaragua it is 76.7%;
Wood 14 access to potable water is available to 99% of the population in Costar Rica, 78.7% in El
Salvador and 74.5% in Nicaragua. Costa Rica's statistics dwarf those of its neighbors, separated
by a national border that actually improves life expectancy; the average for Costa Rica is 79.3
years, El Salvador is 71.7 and Nicaragua is 69.5 (Country Coop. CR, ES and Nic).
While these data points are striking, Costa Rica's health care system still has some
shortcomings. The public system covers 82% of the population, which is impressive, but not the
100% it promises (Country Coop. CR).
Moreover, "out-of-pocket expenses still constitute
almost a quarter of total health expenditure. While this is lower than in most low- and middleincome countries, it still means that vulnerable sections of the population may not be adequately
secured" (Global Health Watch 87). While Costa Rica has better outcomes than its regional
counterparts on most points of evaluation, and has a health care system that is commonly
compared to those of industrialized nations, ranking better than that of the US (World Health
Report 211) it is still lacking in its commitment to 100% coverage. This may be realized with an
increase in government funds allocated to health care in the coming years.
Cuba is notable in any health care discussion as the country rebuilt itself after the
revolution; it survived one of the worst economic crises in history, and now has one of the most
comprehensive, completely free health care systems in the world. This discussion is particularly
significant in the analysis of the Nicaraguan health system, as the Sandinista revolution and its
subsequent triumph drew its inspiration from the success of the Cuban revolution with regard to
health care reform. As a socialist nation and with the same regime in power since the revolution
in 1959, Cuba's health care system is solely composed of the governmental public sector, and is a
guaranteed right for all citizens.
Wood 15 Cuba's health care system is a fascinating case study as it is "notable for achieving
developed country health outcomes despite [having] a developing country economy" (Dresang
299). A common argument is that the implementation of "health care as a human right" is costly,
but Cuba spends 10.6% of its GDP on health care expenditures, and the US spends 17.9%, and as
mentioned before, the US makes no such promise of quality or access to care (World Health
Statistics). In fact, Cuba spends annually 4% per person of what the US spends on health care,
meaning that the US spends 25 times what Cuba does in a public system and yields poorer
results (Dresang 301).
This is made more impressive by the fact that the successful revolution spearheaded by
Fidel Castro necessitated the reconstruction of the country, as it became a socialist nation. If that
was not sufficiently challenging, the fall of the Communist Bloc, on which Cuba was dependent,
compounded by the US embargo policies, brought on a decade of severe economic depression,
euphemistically referred to as the "Special Period". Despite these considerable obstacles, Cuba
managed to survive, and create a world-class health care system. As a socialist country, input
and participation of communities was essential for the implementation and success of programs.
One of the most effective of these programs is the Family Doctor Program, which trained
community members to be health care professionals, ensuring that every barrio had local access
to health care (MacDonald 180). This was a successful way to "effectively resolve health risks
during the crisis" and proves that "in times of socio-economic constraints, as well conceptualized
public health policy can play an important role in maintaining the overall well-being of a
population" (De Vos 469). Cuba's success in the face of difficult odds has fostered an intense
pride in their health care system and even become a symbol of their revolution. Achieving the
Wood 16 reputation for a health care as one of the best in the world is made more remarkable having been
accomplished by a country of little economic means.
Community-Based Programming
A common denominator for all of these countries continues to be that there are simply
not enough resources to fund the programs that are necessary to create and maintain a healthy
population; there are not enough human and financial resources to provide continuous access to
all regions of the country. Interestingly enough, multiple counties, and all the Latin American
countries that I have studied, have met this challenge with the same solution: community-based
health initiatives.
These programs mandate participation in the health care system at the
community level, from training and staffing health centers with community members, to
facilitating brigades for vaccination of clean water sources. When the government lacks the
financial recourses to fund a national health care system, they call upon the human recourses of
their citizens to pick up the slack. While this model is hardly enough to provide the sufficient
medical attention that all individuals require, it still improves upon the existing system, and is
therefore better than having no system at all.
An Investigation of Nicaragua
Nicaragua has a national history similar to that of Guatemala, El Salvador, and Cuba, in
that all countries had revolutions stemming from the repression of the people. This is not unique
to Latin America, but a sequence of events that can be seen across the world and spanning
centuries. One aspect that makes Nicaragua's history distinctive is what occurred after the
revolution, when the revolutionary FSLN party overthrew the Somoza dictatorship and
Wood 17 maintained power for close to a decade before they were voted out of office and replaced by a
conservative government in the 1990s. Since then, Daniel Ortega and the Sandinistas have
returned to power, but have engaged in seemingly corrupt and fraudulent activities.
Unfortunately, over the years, the revolutionary party has morphed into a dictatorship similar to
the one they successfully ousted in 1979 (Booth 87).
The current political climate in Nicaragua is one of skepticism and mistrust, and is
rapidly turning into a situation reminiscent of the suppression witnessed through Castro's regime
in Cuba. Even so, much of the population continues to credit programs of the revolutionary
government, as over their combined 15 years of power the Sandinistas have been
overwhelmingly pro-poor, and have advocated for 45.8% of the nation's almost 6 million citizens
who are living below the national poverty line (Country Coop. Nic).
Under the Somoza regime, health care and all other social services were, for all practical
purposes, were non-existent. One only received care and benefits if one was a member of the
president's National Guard, who served as Somoza's personal army during this 60-year military
dictatorship. In 1979 only 28% of Nicaragua's population had regular access to medical care, as
compared to the 70% in 1982 (Halperin 389). During this time, the health care system was
composed of 23 separate entities, a completely disjointed system to which few had access
(Donahue 259). A USAID report completed in 1976 states that the "'hospitals are obsolete,
dilapidated, dingy, overcrowded, unsanitary, and lack many essentials to the physical comfort,
safety, and well-being of patients'"(Morgan 287). With the overthrow of Somoza in 1979, the
FSLN took on a $1.6 billion national debt, and was responsible for rebuilding the postrevolutionary country (Booth 77). One of the most effective solutions to equalize societies where
one group has been socially, economically, or politically oppressed, is to start with those poor
Wood 18 and marginalized peoples, implementing public health programs and addressing primary health
care needs (Elling 23). Expert in Global Health Policy, Thomas Bossert asserts, "Immediately
after the victory of the Sandinista forces in 1979, health was proclaimed a major national priority
and the fragmented health sector was unified into a single system under the Ministry of Health"
(Bossert 73).
Given the circumstances, the Sandinistas were incredibly successful at achieving this
goal; within three years of the revolution, there was a marked improvement in national health
infrastructures, with the number of health care units increasing from 224 nationally in 1978 to
483 in 1983, the immunization rate increased from 10% of the population in the mid-1970s to
75% in 1983 (Barrett 76). The government implemented a "literacy crusade" coupled with
immunization brigades that brought health care programs to rural parts of the nation that had
been neglected for the last century. Indeed, as John Morgan states, "The government more than
tripled the public expenditures for health in the first three years of its administration and public
spending for health services rose from 6 to 17 per cent of the national budget" (Morgan 290).
This newly created infrastructure came at the cost of multiple international loans and
stipulations, but it remains impressive that the FSLN was able to create a national health care
system under the circumstances. These gains in health care are all the more impressive when
one considers that Nicaragua suffered a devastating earthquake in 1972 that destroyed the capital
city of Managua, inherited the debt left of the Somoza dictatorship, and bore the costs of fighting
the Contra War with the US in the 1980s. These unfortunate and costly circumstances required
enormous funds from a nation that was already the poorest in the region. But even in the face of
these seemingly insurmountable challenges, Nicaragua was able to maintain a relatively stable
national health system throughout the 1980s.
Wood 19 Nicaragua achieved these health care gains by following examples of other health care
revolutions through the "deemphasis on centralized high technology and corresponding emphasis
on the extension of preventive services into underserved areas, using paraprofessional health
workers" (Morgan 291).
The importance put on community programming demanded the
participation of all citizens and greatly reduced governmental costs, with the fringe benefit of
creating national unity. Nicaragua emphasized four health care initiatives in order to create an
affordable national system, and these ingredients for success were preventative care, popular
participation, increased professional and paraprofessional training, and integrated planning
(Morgan 291). As in Cuba, the government called upon committed participation of its citizens to
create community health programs that were largely implemented by local members of the
community trained in basic health procedures. This was instrumental in the rural areas of the
country, so that while there may not have been easy access to doctors, there was local access to
those trained in fundamental medical and emergent care.
Columbia professor Dr. Garfield expresses that community health programs were not the
only borrowed concept, but that similar to socialist revolutions in other countries, the Sandinistas
went through two distinct stages in the development their health programming. "The first was a
rapid expansion in coverage of conventional care, responding to prerevolutionary goals and
plans. The second was the reformulation of health plans in response to the revolutionary
economic, political, and social environment" (Garfield 234).
He maintains that much of
Nicaragua's programming was taken from Cuba's health care implementation after their socialist
revolution in the 60s, as during the first stage, the "Cuban medical model stood out very
prominently. This was a state socialist model of central management for equitable distribution of
scarce health resources" (Garfield 241). Both Cuba and Nicaragua implemented the most cost
Wood 20 effective program by emphasizing public health through preventative medicine via community
participation, instead of the very expensive and less-sustainable system of technical medicine
focused on treatment. Nicaragua drew on the accomplishments of other socialist revolutions,
especially with regard to health care, and then adapted such principles to what would work
within their specific context. It remains notable that "despite two wars, a ruined economy, a
series of natural disasters, the Sandinistas established and maintained a health system that met
the basic needs of most people" (Garfield 232).
This period of great progress under the new administration began to wane at the start of
the Contra War in 1984. The US was opposed to Nicaragua’s socialist revolution and the Regan
administration did everything in its power to ward against a communist epidemic in Latin
America, deeming it unacceptable to have communist regimes in its "own backyard" (Booth 81).
The war demanded much of the nation's human and financial resources, cutting funding to many
social welfare programs, and much of the health care began to focus on victims of the conflict.
The Contra War caused the destruction of 67 schools, 125 social service buildings, the closing of
106 health units, and the death of 127,000 people, which at the time meant 1 in 38 Nicaraguans
lost their lives due to the conflict (Donahue 262, Pebley 61)
In the 1990s, Daniel Ortega and the FSLN party were voted out of office largely due to
the costs of the Contra War and the promise that the election of the US-backed candidate,
conservative Violeta Chamorro, would lead to the end of the conflict. While the Sandinistas had
implemented a myriad of pro-poor programs, such as facilitating the development of
cooperatives among small farmers, and affordable food and housing programs, due to the cost of
the Contra War against the comparatively unlimited funds of the US, the country was continuing
to sink into debt, and Chamorro had the promise of US aid and assistance in job creation.
Wood 21 Therefore the opportunity to end such structural and human destruction was taken by the
Nicaraguan voters, even at the cost of nearly all social programs that were implemented during
Sandinista rule.
Garfield argues against such claims of social progress made during the 80s, stating that
regardless of allegations of a unified national health system, by 1989 Nicaragua essentially had a
two-tired system: services in rural areas were provided by public facilities, staffed by
professionals doing social service, local auxiliary staff, or volunteers, and urban options included
public and private doctors, health centers, pharmacies, and hospitals. Followed by the default
privatization of some of these services in the neoliberalism era of the 1990s, which created a
third tier of the Nicaraguan health care system (Garfield 238). In Nicaragua, therefore, the
options for private healthcare are numerous, and offer a shorter wait time and a more
comfortable ambiance for a price. The public facilities include local health clinics as well as the
larger urban hospitals. The state hospitals are extremely specialized, and each place serves a
very particular role. These public facilities tend to be of modest means, understaffed and
overcrowded, with long waiting lines for exams and consultation. There are also non-profit,
non-governmental options, such as the Clinic at Nueva Vida, and privately funded Women’s
Center at Acahual, which I was able to visit.
This clinic provides technically ‘private’
healthcare, but at a ‘public price’. Such operations are made possible by loans, fundraising,
international aid, and small donations by patients, averaging C50 Córdoba per visits, which is the
equivalent of $2.05 USD. The patient has the choice to either tolerate sub-par public services or
pay for more amiable treatment in private facilities, but in either case, it cannot be stated that
Nicaragua offers free care under an integrated national system.
Wood 22 While these programs are imperative, when the majority of funding rests in the hands of
international donors, the system is not sustainable and is constantly in threat of being shut down
if such aid should stop. What remains a striking symbol of the lack of affordable and accessible
health care to Nicaraguans is that in the rural community of La Barranca, the sporadic visits form
international medical brigades has a huge impact on community health. Their community clinic
receives brigades an average of twice a year, and these visits from Japanese dentists and German
ophthalmologists are the only time the community receives dental and ophthalmological care.
With the change in power, the 90s were a decade of economic conservatism, where three
successive leaders found the socialist programs put forth by FSLN superfluous governmental
expenses. The International Monetary Fund subsidized these ideas; in order to combat the debt
accumulated during the Contra War. Nicaragua took loans from the IMF, which came with the
stipulation of Structural Readjustment Programs. The concept of SRPs is to lessen national debt
as fast as possible by reducing governmental expenditures. The most expensive government
programs, however, are those that support health care and education, so the neoliberal policies
that were intended to help reduce the national spending in the 90s directly caused an increase in
poverty. What is more, Nicaragua was unable to adhere to the strict repayment schedule, causing
the debt to increase through penalties and interest. Even with this history, Nicaragua as a poor,
debt-ridden country did not have many other options, and Ortega signed Nicaragua's fifth
agreement with the IMF in 2007 (Booth 89).
In addition to partnership with the IMF, during the 90s Nicaragua was also receiving aid
and advisement from other international entities such as the World Bank, the World Health
Organization, especially the regional branch: Pan American Health Organization, UNICEF, and
UNDP. While much of international aid is greatly criticized, Donahue argues that in the case of
Wood 23 Nicaragua, support from these organizations was necessary for survival during the war and
continued development during the 90s. He states that in the case of Nicaragua, "international
health organizations share a common purpose with he development aspirations of the Nicaraguan
government" (Donahue 266). Despite a popularized belief that such programs are a propagation
of imperialist attitudes, Donahue believes that WHO and UNICEF formed a partnership with
MINSA (Ministerio de Salud) to create effective national programming.
The government portrays a very realistic account of the nation's health care system,
admitting to the shortcomings, and proposing ambitious solutions. In MINSA's annual reports
and programming plans, they openly state the statistics that express the country's poor economic
status, and how the health system suffers from that deficit. The report completed in 2008
enumerated that 20% of children under five years are chronically malnourished, 26% of the
population live in areas vulnerable to malaria, diabetes prevalence has increased from 8.9 per
100,000 in 1992 to 18.98 in 2005, and the minimum salary does not afford even the basic food
basket (Rep. de Nic. MINSA 8-12). The Ministry makes no excuses and declares that food
insecurity is a direct result of under- and un-employment, and that the limitation in the public
health sector is due to a limitation in resources, and that the nation must search for new avenues
in funding to improve their system (Rep. de Nic. MINSA 8-16).
Another WHO report was completed in 2012 analyzing the Nicaraguan health financing
system, and suggesting various recommendations for improvement.
It states, "the health
financing system suffers from many institutional and organizational deficits such as gaps in
resource mobilization, non-conductive cross-subsidies from the government to the social health
insurance scheme, and inefficient purchasing mechanisms" (Mathauer 4). Their comprehensive
suggestions include increasing resource mobilization, eliminating health segmentation of the
Wood 24 health financing system, and strengthening strategic purchasing of the Ministry of Heath and
Institute for Social Security (Mathauer 20-22). Due to the fact that 78.25% of the economically
active population is without social security, these changes in infrastructure will streamline the
Nicaraguan health system, but such changes take time to implement, and the reality of health
care access in Nicaragua cannot wait, as people need care and services now (Rep. de Nic.
MINSA 8).
Field Notes
During my six weeks of living in the rural community of La Barranca observing the
Nicaraguan health care system, it was fascinating to see how the system in that community
differed from what I had experienced in the capitol of Managua six weeks prior. After the
extended time of participant observation, I became accustomed to the health care system. As my
observatory role began to reel routine and the system became normalized, I had to remind myself
to not lose critical sight of the situation at hand. I would get used to the hours of waiting by
suffering patients, and if they were not seen, asked to come back the next day. Given that it was
their daily reality, the patients appeared to by un-phased by the long waits and the limited care,
and I too became accustomed to this phenomenon. They adjusted to the circumstances and
showed up at the clinic at 7:00 am when it opened at 9:00 in an attempt to improve their spot in
line, hoping they could spend just one day waiting as opposed to multiple.
Despite what I considered to be serious problems with the administration of medical care,
when I would interview community members about what they thought of their clinic and the
Nicaraguan health care system in general, they offered no criticisms. People unanimously
seemed to believe the health care system served its purpose, and appeared to resign themselves to
Wood 25 the shortcomings. When I was able to talk about health care in a more informal setting, however,
such as over a meal or relaxing in the hammock, I discovered what people really felt about it.
They expressed their complaints about the long wait, how it is terribly understaffed and
underfunded, how the promise of health care for all is false, and how the clinic is only open at
the whim of the nurse. They explained how in order to get quality care, they had to travel to a
larger city and go to a private clinic, which is an expense that is difficult to afford.
The Health Center in my community of La Barranca was technically open daily from
8:00 am - 3:00 pm, but in reality, this was rarely the case. The one doctor gave consults to
patients back-to-back until they were all seen, or until she decided she was done, which was
usually around lunch. Often patients would come in the afternoon to see if she was still seeing
patients, and she would consistently turn them away, and instruct them to come back the
following morning. The nurse registered all the patients, staffed the pharmacy and administered
injections to mothers and children. In my observations, the heath care demand deserved at least
a five person staff, but just the two the one nurse and doctor had to do everything.
The pharmacy is mostly stocked with acetaminophen for pain, inflammation, and fevers,
amoxicillin for bacterial infections, and oral rehydration therapy. Anything beyond these three
antidotes must be bought in the neighboring city. When supplies became scarce, they put in
requests to the local SILAIS, the regional MINSA office, but it often took days to process and
receive, so in the interim prescriptions needed to be bought in the nearest pharmacy. If any tests
were needed, those too need to be done in the nearest hospital or clinic. In the case of La
Barranca, most people usually went to Nandaime, which had private and public hospitals and
clinics, as well as pharmacies and testing centers. Nandaime is about a 20-minute taxi ride, and
medications can be expensive; often tests had to be done at a private facility in order to receive
Wood 26 faster results. Even if one were to go to the public hospital, the hospital does not necessarily
have enough materials for everyone, so one is often instructed to buy specific medical supplies
before arriving. As a result of travel and extra medical supply costs, this supposedly free public
system with universal access and coverage becomes exceedingly expensive and time intensive.
In my interviews with health care providers and patients of the Nicaraguan health care
system, there was a unanimous opinion that those living in rural areas had a lack of access to
health care facilities due to location and overall diminished financial means. It was also widely
stated that heath care facilities in both rural and urban areas are under-funded and under-staffed
and the citizens are suffering from the deficit, but that the system they have is better then
nothing. While this humble perspective is understandable, given that a partial or broken system
is preferable to none at all, do Nicaraguans not have the right to demand more, to mandate a level
of care that surpasses mediocrity?
Nicaragua Today
When a society makes the promise to supply free and accessible health care to all
citizens, these hope are quickly dashed when "free health care for all" is based on a system of
health care centers that cannot meet the needs of the community.
Harvard Professor Dr.
Kawachi attributes this deficit to the globalized effects of neoliberal policies through the
capitalist market, saying that "unbridled competition threaten the health of us all" (Kawachi 201).
It is difficult to implement expensive social programs without the necessary funds, but the
current international domination of capitalism directly contributes to the continued poverty of
underdeveloped nations, and only continues to get worse. For example, as Kawachi states, "the
income ratio between the richest and poorest countries increased from a three-fold difference in
Wood 27 1820, to an over seventy-five fold a century and a half later" (Kawachi 5). In this analysis, it
seems that the only way in which small, poor, and developing countries can provide an improved
health care system for their citizens is if capitalism was not the leading world economic force.
In lieu of socio-economic reconstruction of the world's order, a plethora of interest
groups in Managua do not accept the reality of the un- and under-employed, homeless,
undernourished, and undereducated populations that are often pushed to the periphery and
demand that the government provide improvements in social programming. Much to the dismay
of the current government, these groups such as the Movimiento de Renovación Sandinista,
Nicaragua 2.0, and many others are bringing these social issues to public attention (Booth 94).
While MINSA has been very vocal about the health issues that the country continues to face, the
FSLN wants to be responsible for the solutions, and not under the public scrutiny of public
policy groups. As Garfield explains, however, understanding how governments should be
spending their money proves difficult, where "investments in medicines, doctors, and hospitals
are less efficient in improving the quality of life than spending on food, latrines, and basic
education. Expansion of health services, however, visibly responds to the desires of the people
and the interests of the government" (Garfield 236). Both during the revolution and still today,
the people of Nicaragua are demanding investments in health in order to improve health care
access and meet the wishes of the citizens.
These sentiments are repeated by Dora Maria Tallez, who was the Minister of Health in
the early years of FSLN power from 1979-1984. She believed that it is "the responsibility of the
government to provide health care, but only to the degree that the people are willing to take part.
Health is a shared responsibility of the government and people. Our responsibility is to respond
to people's concerns and focus their resources" (Garfield 239). I believe that the revolutionary
Wood 28 government in the early 1980s achieved this, but with the strain of the contra war, and neoliberal
practices implemented during the 1990s and the current FSLN powers morphing into a
dictatorship, the original aspirations of the revolution have been lost.
Conclusion
Health care can never be evaluated within a vacuum, as every system is restricted by a
budget and burdened by the political history, all of which are unique to each specific country.
Reports prepared by the World Health Organization and the Commonwealth Fund provide
illuminating statistics and an objective dissection of a nation's health care system, but as we have
seen with all of the national health systems examined, and especially that of Nicaragua, statistics
reveal little about the cultural context and reality in which these systems operate. As Stern
states, "medicine cannot develop and never has developed in isolation, that the nature of its role
and its achievements are circumscribed by the soil in which it is rooted" (Stern 216). While
every nation is striving to create a health care system that is the most cost effective and best
serves its people, that "perfect system" looks different in every context. While points for
improvements can be taken from other health care models, they will always be most relevant to
the country in question.
The fact remains that a health care system like that of Nicaragua, one that legally
guarantees but does not actually deliver universal access, is falling short, not of an international
standard, but of a national goal. How they are to achieve this goal remains the critical issue.
Similar to Guatemala and El Salvador, Nicaragua was burdened during the 1980s with the dual
curse of being a poor country and attempting to recover from years of government
mismanagement and revolution. As outlined before, the programs put forth by the FSLN, like
Wood 29 that in Cuba, were incredibly impressive as they improved the national health system while
maintaining as fiscally conservative as possible. But with the neoliberal structural adjustment
programs implemented during the 1990s, and the now repressive regime has continued to sink
Nicaragua into debt as social welfare programs deteriorate.
I believe one change that could have a huge positive impact on the Nicaraguan health
care system is to simply revert back to some of the programs they had previously prioritized in
the 1980s. One of the reasons the revolutionary health care reforms were so successful was that
they called upon the citizens to implement them, such as by using the community-based
programs discussed before, and placing a greater national emphasis on public health initiatives.
For example, vaccination brigades allowed for children to be vaccinated before they were
susceptible to these widespread diseases, and the foundation for community clinics is that
patients have access to health care, to treat symptoms before they metastasize to full-fledged
infections. In addition, these community clinics offered brief tutorials of how to spot symptoms
of common afflictions, such as dengue or dehydration, as well as facts about breastfeeding and
sexually transmitted diseases (Garfield 215). If public health education were to become a
priority again, not only in health care facilities but also in Nicaraguan schools, such preventative
health care measures hold the potential of having a significant impact on the health of the nation.
Such public health programs are not only the most cost-effective, but also the most efficient way
to promote healthy living, prioritizing education as a cheaper alternative to treatment.
This public health programming would be more cost efficient for the government in the
long term, but it would require a redirection of funds from urban hospitals to rural clinics. This
is an issue that I would like to investigate more thoroughly, as it seems to me that the rural clinic
is neglected compared to the fiscal attention given health care facilities in urban centers. Given
Wood 30 that 57% of the population lives in urban areas, this gap is understandable, but it leaves the
remaining 43% of the population without quality health care, as seen in La Barranca (Country
Coop. Nic).
This greatly ignored rural population is also the sector of society who has
historically had the least access to financial resources (Booth 92). I contend that it is precisely
due to the low economic status of the rural populations that they deserve increased access to
health care and education, and that preference should be given to the marginalized masses. I
would have liked to investigate this issue specifically, to discover the historical discrepancies
between rural and urban access to health care and how to address them.
Another topic that I would have loved to explore is the difference between the
governmental promises in regard to health care and all social systems, and the reality of what
programs were actually implemented. Coupled with this, I would like to study how effective
these social programs actually are. For example, in Nicaragua, there seemed to be huge gaps
between the programs that the government promised and the programs that were actually put into
practice, not to mention the question of whether these social programs had any tangible affects
(Booth 112).
I am certain in my belief that health care should be universal, and that every person
should have free access to quality care everywhere in the world, especially in the regions such as
Nicaragua that are particularly burdened by their history. Until such a dream is realized, I
appreciate how many people have found creative ways to make a less-than-perfect system
suffice. But these innovations are not enough for the masses; they are not adequate to provide a
standard of living with access to adequate health care. No health care system is perfect, and even
those in the most advanced societies are riddled with challenges and shortcomings.
Such
deficits, however, become intolerable when the quality or length of life is reduced due to a lack
Wood 31 of access to quality and affordable health care. I hope that one day the population will not have
to creatively adapt to health care shortcomings, and that such a utopia of affordable health care
for all may be realized before "el año de humo".
Wood 32 Works Consulted
Arriagada, Irma, et al. Politicas y programas de salud en America Latina. Problemas y
propuestas. Santiago de Chile: Naciones Unidas, 2005.
Arrieta, Alejandro, Ariadna García-Prado, and Jorge Guillén. "The Private Health Care Sector
and the Provision of Prenatal Care Services in Latin America." World Development 39.4
(2011): 579-87.
Barten, Françoise, et al. "Democratic Governance - Fairytale or Real Perspective? Lessons from
Central America." Environment and Urbanization 14.1 (2002): 129-44.
Birn, Anne-Emanuelle, Sarah Zimmerman, and Richard Garfield. "To Decentralize or Not to
Decentralize, Is That the Question? Nicaraguan Health Policy under Structural
Adjustment in the 1990s." International Journal of Health Services 30.1 (2000): 111-28.
Bitran, Ricardo. Reformas recientes en el sector salud en Centroamerica. Santiago de Chile:
Naciones Unidas, 2004.
Davis, Karen, and Cathy Schoen. Health and the War on Poverty. Washington D.C.: The
Brookings Institution, 1978.
Donahue, John. "The Politics of Health Care in Nicaragua before and after the revolution of
1979". Human Organization 42.3 (Fall 1983). 264-72.
---. "Planning for Primary Health Care in Nicaragua: A Study in Revolutionary Process." Social
Science & Medicine 23.2 (1986): 149-57.
---. "Studying the Transition to Socialism in the Nicaraguan Health System." Medical
Anthropology Quarterly 15.3 (1984): 70-71.
---. "The Political Economy of Responsibility in Health and Illness." Social Science & Medicine
40.1 (1995): 47-53.
Ertler, Wolfgang, et al. "The Social Dimensions of Health and Health Care: An International
Comparison." Research in the Sociology of Health Care 5 (1987): 1-62.
Espinoza, Eduardo Antonio, et al. El Sistema Local de Salud de la Zona Norte de San Salvador
1992-1997: Una Expereinca Innovadora en Salud. San Salvador: Ministero en Salud
Publica, 2008.
Farmer, Paul. Pathologies of Power: Health, Human Rights, and the New War on the Poor.
Los Angeles: University of California Press, 2003.
Garfield, Richard. "Revolution and the Nicaraguan Health System." Medical Anthropology
Quarterly 15.3 (1984): 69-70.
---. "Health and the War against Nicaragua, 1981-84." Journal of Public Health Policy 6.1
(1985): 116-31.
Green, Linda. "Consensus and Coercion: Primary Health Care and the Guatemalan State".
Medical Anthropology Quarterly New Series 3.3 (1989): 246-57.
Hahn, Robert A., and Marcia C. Inhorn. Anthropology and Public Health: Bridging
Differences in Culture and Society. 2nd ed. New York: Oxford University Press, 2009.
Herrera-Valdes, Raul, and Miguel Almaguer-Lopez. "Strategies for national health care systems
and centers in the emerging world: Central America and the Caribbean. The case of
Cuba". Kidney International 68.98 (2005): 66-68.
Kim, Jim Yong, et al, eds. Dying for Growth: Global Inequality and the Health of the Poor.
Monroe, Maine: Common Courage Press, 2000.
Latin American and Caribbean Health Sector Reform Initiative. Cuentas Nacionales de Salud:
Nicaragua (14). Washington DC: Pan American Health Organization, 1999.
Wood 33 Leon, Moises. "Perceptions of health care quality in Central America." International Journal
for Quality in Health Care 15.1 (2003): 67-71.
Linsenmeyer, W. S. "Foreign Nations, International Organizations, and Their Impact on Health
Conditions in Nicaragua since 1979." International Journal of Health Services 19.3
(1989): 509-30.
Lopes Beltran, Jose Francisco, et al. Estimacion del Gasto Nacional en Salud en El Salvador
Durante 1999; Cuentas Nacionales en Salud. San Salvador: Ministerio de Salud Publica
y Asistancia Social de El Salvador, 2009.
Mendez Larin, Hild Cecilia, et al. Caracterizacion del Sistemas de Salud de El Salvador. San
Salvador: Universidad de El Salvador: 2013.
Meyers, Alan, et al. "Community Health Assessment of a 'Repopulated' Village in El Salvador".
Medical Anthropology Quarterly New Series 3.3 (1989): 270-80.
Morgan, Lynn. "The Importance of the State in Primary Health Care Initiatives." Medical
Anthropology Quarterly New Series 3.3 (1989): 227-31.
---. "'Political Will' and Community Participation in Costa Rican Primary Health Care".
Medical Anthropology Quarterly New Series 3.3 (1989): 232-45.
Pan American Health Organization. Prefil de Los Sistemas de Salud: El Salvador. Washington
DC: PAHO, 2007.
Partnerships for Health Reform Project. Cuentas Nacionales de Salud: Guatemala. Informe
sobre Iniciativas Especiales 10. Bethesda, MD: Abt Associates Inc., 1998.
Ripp, Joseph. "Revolutionary Nicaragua: An Arena for Research in Medical Anthropology 15.3
(1984): 68-69.
Republica de Nicaragua Ministerio de Salud. "Fundacion Rectora de la Autoridad Sanitaria
Nacional en la Politica Nacional de Salud y Plan Nacional de Salud (2004-2015)".
Managua 2004.
---. "Plan Quinquanal de Salud 2005-2009". Managua 2005.
U.S. Department of Health, Education, and Welfare: Office of International Health:
Division of Planning and Evaluation. Syncrisis: The Dynamics of Health.
"Nicaragua". Washington: GPO, 1973.
Waitzkin, Howard, et al. "Social Medicine Then and Now: Lessons form Latin America".
American Journal of Public Health 91.10 (2001): 1592-1601.
World Health Organization. Costa Rica: health profile. Geneva: World Health Organization
Office of Publishing, 2012.
---. Country Cooperation Strategy At A Glance: Cuba. Geneva: World Health Organization
Office of Publishing, 2009.
---. Cuba: health profile. Geneva: World Health Organization Office of Publishing, 2012.
---. El Salvador: health profile. Geneva: World Health Organization Office of Publishing,
2012.
---. Guatemala: health profile. Geneva: World Health Organization Office of Publishing,
2012.
---. Nicaragua: health profile. Geneva: World Health Organization Office of Publishing, 2012.
Wood 34 Works Cited
Acosta, Monica, et al. "Sistema de salud de El Salvador". Salud Publica de Mexico 53 (2011):
188-96.
Barrett, Bruce. "Integrated Local Heath Systems in Central America". Social Science &
Medicine 43.1 (1996): 71-82.
Booth, John A., et al. Understanding Central America: Global Forces, Rebellion, and Change.
5th ed. Boulder, CO: Westview Press, 2009.
Bossert, Thomas. "Nicaraguan Health Policy: The Dilemma of Success." Medical Anthropology
Quarterly 15.3 (1984): 73-74.
De Vos, Pol, et al. "Public health services, and essential determinant of health during crisis.
Lessons from Cuba, 1989-2000". Tropical Medicine and International Health 17.4
(2012): 469-79.
Donahue, John. "International Organizations, Health Services, and Nation Building in
Nicaragua." Medical Anthropology Quarterly 3.3 (1989): 258-69.
Dresang, Lee, et al. "Family Medicine in Cuba: Community-Oriented Primary Care and
Complementary and Alternative Medicine," Journal of the American Board of Family
Medicine 18.4 (2005): 297-303.
Elling, Ray. Socio-Cultural Influences on Health and Health Care. New York: Springer
Publishing Company, 1977.
Garfield, Richard, and Glen Williams. Health Care in Nicaragua: Primary Care Under
Changing Regimes. New York: Oxford University Press, 1992.
Global Health Watch 3: An Alternative World Health Report. New York: Zed Books Ltd,
2011.
Graig, Laurence A. Health of Nations: An International Perspective on U.S. Health Care
Reform. Washington D.C.: Congressional Quarterly Inc., 1993.
Halperin, David, and Richard Garfield. "Developments in Health Care in Nicaragua". The New
England Journal of Medicine 307.6 (1982): 388-92.
Kawachi, Ichiro, and Bruce P. Kennedy. The Health of Nations: Why Inequality is Harmful to
Your Health. New York: The New Press, 2002.
MacDonald, Theodore. A Developmental Analysis of Cuba's Health Care System Since 1959.
Studies in Health and Human Services, Vol 32. Lewiston, New York: The Edwin Mellen
Press, Ltd., 1999.
Malkin, Elisabeth. "Ex-Dictator Is Ordered to Trail in Guatemalan War Crimes Case". New
York Times 29 Jan. 13: A4.
Mathauer, Inke, et al. "Health financing challenges and institutional options to move towards
universal coverage in Nicaragua". World Health Report (2010) Background Paper, 24.
World Health Organization Office of Publishing, 2010.
Morgan, John, ed. Third World Medicine and Social Change: A Reader in Social Science and
Medicine. Lanham, MD: University Press of America, 1983.
Pan American Health Organization. Health Systems Profile of Guatemala. Washington DC:
PAHO, 2007.
Pebley, Anne, and Luis Rosero-Bixby, eds. Demographic Diversity and Change in the Central
American Isthmus. Santa Monica, CA: RAND, 1997.
Republica de Nicaragua Ministerio de Salud. "Politica Nacional de Salud". Managua 2008.
Reid, T.R. The Healing of America: A Global Quest for Better, Cheaper, and Fairer Health
Care. New York: Penguin Books, 2010.
Wood 35 Stern, Bernhard. Society and Medical Progress. Princeton: Princeton University Press, 1941.
Strickland, Stephen P. U.S. Health Care: What's Wrong and What's Right. New York:
Universe Books, 1972.
The Commonwealth Fund. International Profiles of Health Care Systems, 2012. Washington:
The Commonwealth Fund, 2012.
The World Factbook 2009. Washington, DC: Central Intelligence Agency, 2009.
World Health Organization. Country Cooperation Strategy At A Glance: Costa Rica. Geneva:
World Health Organization Office of Publishing, 2012.
---. Country Cooperation Strategy At A Glance: Guatemala. Geneva: World Health
Organization Office of Publishing, 2007.
---. Country Cooperation Strategy At A Glance: El Salvador. Geneva: World Health
Organization Office of Publishing, 2010.
---. Country Cooperation Strategy At A Glance: Nicaragua. Geneva: World Health
Organization Office of Publishing, 2006.
---. The World Health Report 2000. "Health Systems: Improving Performance". Geneva: World
Health Organization Office of Publishing, 2000.
---. World Health Statistics 2012. Geneva: World Health Organization Office of Publishing,
2012.