The public health system needs to opt for prevention, education and quality

An assessment of the current status of Nicaragua’s public health system: its focus on cure rather than prevention, the politicizing of health care and its staff, the failure to provide ongoing public and staff education, and the many ways the system could improve the quality of this critical human service.

Leonel Argüello Yrigoyen

Compared with the three governments that preceded it, we can see that the current government has definitely increased the public health coverage, upped the number of medical consultations, issued more medicines—although not without continual ups and downs—done more laboratory tests and imaging tests such as X rays or CT scans and improved the waiting times in some Managua hospitals. Despite all these advances, however, the public health system remains more focused on care than prevention, as demonstrated by the recent dengue epidemic.

Epidemics test a health system’s prevention procedures and, at the same time, show how well-oiled its information system is in anticipating which epidemic is about to break out. The art of epidemiology is to anticipate epidemics, just as the art of a cardiologist is to anticipate heart attacks. Success doesn’t lie in caring for dengue or heart attack cases, it’s in preventing them from happening.

Lifestyle changes are
more important than doctors

Different studies on the determining factors that maintain or damage health have indicated that people’s lifestyles are more important than doctors, hospitals and even the health system as a whole. These studies show that a better life¬style—avoiding obesity, eating right, exercising, attending to hygiene, not smoking—can reduce mortality by up to 47%. Nonetheless, under 2% of the health budget is spent on health education and more than 90% of the health system’s spending only reduces mortality by 11%.

Hygiene and food are the two pillars of good health. A wise saying from centuries ago about food says the key to good health is to breakfast like a king, lunch like a prince and dine like a pauper, which is very true, because for adults food eaten at night only makes them fat. Another, more modern saying advises that good health comes from eating less, socializing with others more and burning up a lot of shoe leather. Prevention is the key: the most effective way to improve a population’s health is by encouraging healthier lifestyles and regular check-ups. However, health budgets in Latin America usually dedicate a meagre 1.5% to educational campaigns promoting healthier lifestyles.

Prevention is better than cure

Health systems opt for care because it’s easier. Taking the prevention path, educating about healthier lifestyles, is more complex because it’s a cultural struggle against years and years of deeply rooted unhealthy habits, and because campaigns offering information about healthy foods aren’t enough, they should also promote the fact that healthy food ends up cheaper and is accessible to people with limited means.

But while prevention is more complex, it’s also more effective and has a permanent impact on health. Promoting healthy habits reduces mortality and also morbidity. We know that food is crucial in order to grow and develop and to maintain good health. We know that obesity automatically causes many diseases, because more weight creates a greater risk of diabetes, more problems with arthritis or osteoarthritis of the knees, high blood pressure because the heart has to pump more blood around a bigger body… Obesity is a growing problem in Nicaragua through poor diet, made worse by a sedentary lifestyle. At a health fair held in Ciudad Sandino with women from the municipality in which we weighed them, took their blood pressure and did other tests, we found that 70% of the women were overweight. We reckon that the percentage is similar in men because they not only eat the same but also drink more beer, which is fattening. Increased obesity is already being reflected in a progressive increase in chronic diseases, which are more expensive for both the population and the government because they are incurable and require a lifetime of medication.

Nicaragua’s health system is dealing with the damage rather than promoting the factors that avoid it. Most of the resources allocated to health are dedicated to care, not prevention. While it’s true that the health system has given more medical consultations in these last seven years than any previous government, the population’s health would be no better even if there had been still more consultations, especially if they don’t include an educational aspect rather than just handing out prescriptions and pills. A health worker must essentially be an educator. And a health system must be constantly educating if it wants to improve the population’s health and avoid damage, not just deal with it.

The habit of eating fruit

For example, eating fruit is very important for health and in Nicaragua we’ve been losing the habit of eating it and making cold drinks from it through the glut of Coca Cola and other carbonated drinks. How many NGOs and governmental institutions now offer these drinks in their workshops instead of fruit juices because it’s easier and faster? A lot of fruit is wasted in different parts of Nicaragua because we’ve stopped eating it. Perhaps, instead of letting it go to waste, these fruits could be dehydrated and sold as dried chewy fruit; I think kids would like them, and they’d get all the nutrients of ripe fruit. Projects of this kind are within the purview of the health and education ministries. This government could do it because it has organized people, enough resources and power; the issue is whether it also has the will.

Short, specific and
effective health messages

There’s no end of messages that could make a significant contribution to improving the population’s health if used in continuous campaigns in all the media. One such message would be to stress the importance of washing one’s hands with soap and water. I dream about billboards throughout the country showing people washing their hands. Studies show that you can reduce the risk of diarrhea by 45% and respiratory diseases by 50% just by washing hands with soap and water. If we can so drastically reduce the most common diseases in the country just by doing this, aren’t ongoing campaigns about washing hands worthwhile? Soap is cheap and we’ve got water. it doesn’t take a genius to understand the importance of something so simple, because we eat and prepare food with our hands, use them to clean up after defecating and touch people and everything else with them. Hands can save and they can kill; blessings and dangers are in our hands.

Let’s look at other short and important messages: Want to lose weight? Walk every day or do any exercise for more than 30 minutes and you’ll burn fat. Or this one: Don’t eat beans and drink coffee at the same time because the coffee inhibits the iron in beans from being absorbed. Or this one: Putting a few drops of orange or lime in the beans helps you absorb the iron from the beans better. Or this: Take your blood pressure in both arms after being seated for five minutes; the arm where the pressure comes out highest is the one you should always take it from.

Other messages warn about risks, such as this caution: If you see small white patches with no sensation on the skin, look for a doctor and suspect leprosy. Or this: If the diarrhea doesn’t stink, it’s cholera. Or this one: Bleeding during pregnancy or after childbirth, full alert. The objective of these messages is for the general public to learn the warning signs and danger symptoms so they can seek medical help in time, and the earlier the better.

Given the publicity going the other way, other important messages could be: No child needs brand-name infant formula; s/he only needs mother’s breast milk for the first six months. Another: Breast milk doesn’t need to be refrigerated and can be drunk by the child during the day if the mother expresses it. Another: After breastfeeding for six months children don’t need formula; they can drink the same liquid milk as adults.

Messages in favor of good health have to be very concrete. “Live clean, live nice” is too general because everyone has different ideas of what’s nice and what’s clean. A family with a dirt floor thinks of clean differently than a family with a concrete or tile floor. Furthermore, this message was useless in preventing dengue because the mosquito that transmits dengue doesn’t develop in filth but in clean water. Messages about health must be very direct, clear and specific; people have to be clearly told that if they get fat they’re at risk from diabetes, high blood pressure and arthritis…

Companies bombard our cell phones with foolish messages that are of no use whatsoever. I’ve tried to get them to send messages like these that contribute to health education but they won’t accept them even though such simple messages can make important changes in the population’s health, because we get most diseases through ignorance. Obviously those responsible are those of us who, institutionally or personally, know how to prevent these diseases and promote good health but aren’t constantly and appropriately sharing what we know with the public.

Curable cancer is killing women

We know that cervical cancer and breast cancer are the two leading causes of death in Nicaraguan women. We also know that cervical cancer is preventable and 100% curable if detected in time. If a Pap smear reveals that the woman has a precancerous lesion, it can be burned with cold or heat, thus saving her life in a procedure that takes ten minutes in an outpatient clinic. In breast cancer, if ultrasound imaging or a mammogram detects it in time, the treatment is effective and we can prevent mortality in about 50% of cases. We know this but because of lack of education, many of our women are dying from preventable problems. Campaigns have been made about these two kinds of cancer but they’re fleeting. Health education must use ongoing campaigns because they are about trying to eradicate unhealthy culturally-embedded patterns. And in these campaigns, as with all health issues, the work has to be done skillfully, not politically. Political campaigns for women can be conducted, and hundreds of Pap smears or mammograms can be taken, without checking the results afterwards. In order to be effective, the cycle in public health programs has to be completed, ensuring that the smears are taken, that there are people who can read and interpret the results and, if there are cancer symptoms, they’re capable of doing something about it. And this whole process must be very streamlined because cancer doesn’t wait.

Regarding women’s health, I don’t want to pass over the regrettable fact that Nicaragua continues to penalize therapeutic abortion. Although not many women have died as a result, the life of every woman has value. Some of the Health Ministry’s institutions have continued to practice therapeutic abortions and others haven’t, thus discriminating against women who weren’t able to access the ones that do. This is tragic in a so-called secular State because a State that isn’t secular is always discriminatory.

Coordinating efforts

It’s impossible to prioritize all the health problems at the same time. But it is possible to prioritize prevention and education. The art of governing, of those who govern, is to unite all public and civil society efforts to educate about prevention and so address the greatest number of priorities. But when efforts aren’t coordinated—which is what’s happening now in Nicaragua—the priorities can’t be addressed, or even identified. The government’s connections with national organizations and international and national cooperation have dwindled from what they were in 2007. And in Nicaragua nobody achieves anything working alone. We have to understand that we must all head towards the same goal. If there’s one thing we learned from the 1980s and continue to see when we do community work, it’s that health is the goal that most unites the population.

Unfortunately, community work has been confused with party political work in today’s Nicaragua, and this has negative consequences. It’s sad, because the Ministry of Health should keep itself as a prestigious and credible institution. If people stop seeing it as credible, they won’t take their children to be immunized…

There are worrying signs. For example, during the recent dengue epidemic, some people wouldn’t let those who came to fumigate against mosquitos or treat the water with Abate (aka Temphos) into their homes despite the fact that we were in a full-blown epidemic. This resistance was a warning sign to the health system that something is failing: was it just people’s ill manners or was it that people saw those who came to their houses as party activists and some didn’t want to let them in? Let’s hope the Ministry of Health will heed a warning like this so that workers’ efforts can have a greater impact on health.

Let’s prioritize quality

The health system’s challenge of quality is unresolved. Just because the entire Nicaraguan population goes through 40 medical consultations and gets prescriptions and pills doesn’t mean its health is improving.
It’s time for the health system to prioritize quality. Constant ongoing training of the health personnel is crucial to improving the quality of health. There should also be linkages between the ministries of health and education, so children can be taught from an early age to know how to prevent diseases. Quality begins in school through constant educational campaigns focused on prevention, on encouraging lifestyle changes in order to have a healthier life. Education in prevention must be done with patients, the family, the community and society as a whole, and on all media, not only those of the government.

Quality is often bypassed in the health personnel’s attitude. Because they’re public servants, they’re supposed to serve the public that goes to them for help. But to be able to do it well, serving others must be gratifying, while what we see today in many cases is that they’ve been forced to try to improve the quality of the service, pressured by top-down orders and commands… And that has then been replicated in the health staff’s relationship with the public. People are won over by being taught and made aware, by affection and dialogue, not force. People aren’t an army. They can be turned into an army if and when necessary, but you have to know people, work with them, see how they view things, see what we can learn from them, and offer them useful messages… Quality is lacking when the doctor doesn’t touch the patients, doesn’t talk to them or listen to them... Failing to do so creates a dearth of humanism, of professional ethics. The health staff have to be educated in the vocation of service, made aware of what it means to be public servants, not employees of a government much less of a party.

Quality in the health system isn’t just about how well we finished our training as a doctor, nurse or lab technician. It’s about the on-going training we continue to receive once our initial training is completed, because once we complete our training we’re only starting to learn. Ensuring ongoing learning is even more important for health professionals than for other professions because we have lives in our hands. It is absolutely essential because the speed of technological innovation is changing medicine every four or five years. But while quality requires that health system personnel be involved in ongoing training programs, they couldn’t do it now even if it were available because they’re forced into activism and under pressure from the excess of extra tasks.

The health staff is overworked…

Health activism is currently mixed with party activism. There’s a lot of commanding and controlling, with new campaigns started and then interrupted for another new activity. This happens constantly, and it wears down and exhausts the health staff. It’s an activism more motivated by political pressure than skilled leadership. And without skilled leadership, focus is lost.

Just like the teachers, health workers are overwhelmed, and for the same reasons. They have their daily work to which the government is currently adding a load of other tasks, subjecting them to permanent activism. They’re sent to make home visits, to treat patients in their homes, to look for cases of hypertension; they’re asked to do overtime because of the dengue epidemic; they’re told to clean the centers; they’re assigned a certain number of patients every day; they’re sent to demonstrations, meetings and party activities… Medical brigades are sent out to rural areas. Everyone acting like Ché Guevara makes no sense… And furthermore, how much do these brigades cost? I’m one of those who believe it would be better to make creative use of what we already have than using brigades.

The Ministry of Education has finally acknowledged that it has underutilized buildings and is going to use them to start up the rural high school program. That’s very positive. Let’s hope the Ministry of Health also acknowledges it has underutilized buildings, which could be used for three shifts of surgery to reduce the waiting lists, three shifts for consultations, for health education. Why build more schools when most of them are empty after midday because there’s no afternoon shift? Something similar happens in the health units, especially in the hospitals.

To make good use of what’s already there, there has to be more linkage with the community, for example to use these buildings for clubs for diabetics, for people with hypertension… Making the most of what’s already there requires coordination with all the civil society organizations that deal with some aspect of public health.

Currently many programs are initiated but then aren’t given continuity or don’t finish. What’s worse, the health system doesn’t seem to learn. The first step to learning is wanting to learn but the government doesn’t seem to want to learn. The second step is opening up, being receptive and learning from others. But when suggestions are made about the quality of the health system or it’s pointed out that human relations could be improved or protocols aren’t being complied with or a procedure wasn’t done properly—all of which has to do with quality—the government interprets it as an attack and views those commenting or criticizing as enemies, instead of thanking them. The third step is creating a climate of freedom where everyone can contribute and is involved in the solutions. When the government doesn’t permit opinions, the health personnel are afraid to comment or say what could be done to make improvements for fear of losing their jobs.

…and underpaid

Health personnel are also very poorly paid. Nicaragua pays its doctors and nurses the least of any Central American country. Next in line is Honduras, which pays over twice as much. A general practitioner in Nicaragua earns the equivalent of about US$700 a month; a consultant about US$1,200 and a nurse about US$300. In Honduras, a general practitioner earns some US$2,000, almost three times as much as here. Despite these low salaries, people stay in the Ministry of Health because there aren’t many alternatives. They would earn less working for the social security medical companies and if they want to go private it would cost them a lot of money to open their own practice. It’s lucky for the Ministry of Health that so little other work is available; otherwise many would leave because of the low salaries. But although they remain there—and I believe many have a genuine vocation for service—the work pressures and environment aren’t right; people are dissatisfied and this affects the quality of the service provided.

Quality also requires that health personnel work in a friendly environment. It’s negative to work in an environment where you’re uncomfortable, under pressure, where those in charge shout at you and order you about disrespectfully. One of the challenges facing the Ministry of Health is the way its workers are treated, because those mistreated in their work environment aren’t predisposed to treat well those who are looking to them as public servants.

IDB’s transition health project

There’s currently a US$35 million Inter-American Development Bank project to compensate about 2,000 health workers who are over 60 years old for retiring voluntarily, and 4,000 new workers will be hired from the FSLN’s Family Cabinets to provide health care to the population in the so-called «dry corridor» where the very poor rural population lives. This is all we know about this transition process in the health system. Naturally, it’s good to have more people working in places where they are so desperately needed but they must be well trained for this work. Because this project hasn’t been well explained, it’s created uncertainty, fear… and of course rumors. Some people say it’s designed for the government to be able to put in “its people.” That isn’t the problem so much as whether these people have the needed requirements, skills and abilities for the positions and work entrusted to them and will be willing to receive continuous training to improve further.

It would also be good if the wisdom and experience of the older professionals isn’t lost in this process because as both individuals and institutions we always learn from our elders. This should be a transition that doesn’t lose the experience of those leaving; those who’ll hopefully train and equip the newcomers well for these areas. I say this because doctors trained in Western medicine usually don’t know much about alternative medicine techniques, which is very useful and much simpler and cheaper. With the training I received, if I’m without medicines I don’t know what to do with someone who has high blood pressure because I don’t know which plant lowers it. Nor do I know acupuncture or acupressure, or how to use energy to stabilize a patient. Through economic necessity, all these alternative medicine methods were introduced into Cuba. In Nicaragua we have no reason to wait any longer. We know Nicaragua’s ten main health problems, so we should be able to figure out both the conventional and the alternative responses.

When a drug isn’t what it claims to be

The pharmaceutical industry’s considerable influence in the media also has to be taken into account. People get very enthused about one pill or another and, in a system like the current one, which is more concerned about care than prevention, they can become convinced that medication is cure. When going to a health center, most people don’t say “I’m going to get cured”; what they usually say is “I’m going to look for a pill.” And sometimes they go in search of “that yellow pill that worked for me before…” Or else they’re looking for an injection, which also is very popular.

All Nicaragua’s governments have been corrupt about purchasing medicines, authorizing or denying them entry into the country. There’s also been very little control and monitoring of the medications that do enter. It’s the Ministry of Health that grants authorization and it should be responsible for checking every three or six months that the authorized drug works as it claims. We’ve done some research that proves that between 20% and 30% of nationally produced and imported drugs don’t contain the components they say or don’t have them in the quantities they say or don’t dissolve when they say they’ll dissolve… That’s why it’s important for the Ministry of Health to monitor drugs and, when prevention is prioritized, to promote the rational use of medicines.

Doctors and patients alike have come to associate pills and injections with curing, without modifying our lifestyles. That’s why people keep going back to the doctor with the same problem seeking the same solution, which doesn’t resolve anything because the patient isn’t doing anything different. And why not? Often because people aren’t informed. It’s the Health Ministry’s responsibility to continuously provide us with information so we can improve our health. Informed people are smarter and healthier.

The information system

Promoting prevention, education and quality is also associated with the health system having a good information system. And for it to be good, the system must do research on a regular basis so its actions are founded on data. Some research is indeed done in Nicaragua. For example, one investigation found that 10% of the population of Managua has diabetes which, in numbers, would be over 100,000 diabetics. But the health system’s records don’t have this figure; theirs is a lot lower, because the health system never collects all the information, nor does it have efficient coordination with those who do have it. The issue gets even more complicated because Nicaragua’s health system has information it doesn’t make public. In health matters, providing information at all levels is vital because otherwise a false sense of security is created and people don’t respond to appeals for their own safety or the need for community help.

To have good information, you have to encourage sources to share it. During the revolution, I encouraged private doctors to gather information and they gave it to us in exchange for vaccines and medicines, especially for tuberculosis. In Nicaragua a sector of private medicine has grown, and is growing every year, that has information. I don’t know if it would share it with the Ministry of Health. The Ministry has to manage its own information, that of the Police, Army and Social Security medical companies and also that provided from samples by private practices. With this it could have an idea closer to reality.

Incentives for false data

President Bolaños’ administration initiated a heinous system for gathering information in the education system: teachers were given financial incentives if they guaranteed that children were in school. Honest teachers told the truth but many didn’t because they didn’t want to lose the money they received. That introduced a perversion into the information system until in the end all teachers began to lie to the system to keep the incentive.

This government doesn’t use those incentives in the health system, but does give directives that certain diseases aren’t to be mentioned or certain figures showing problems should be altered or that the information simply be kept secret, which is a crass mistake in public health.

Today, the incentive for not telling the truth is to avoid being fired from your job. This is ridiculous and promotes inefficiency and ineffectiveness. Covering up the truth for political reasons doesn’t lead anywhere; or rather it leads to a deterioration in the health system, which I’m sure isn’t what either the institutions or the government want.

Mixing politics with data

I think the information available to the Ministry of Health today isn’t analyzed properly because when politics is mixed with data they get entangled. Analysis should be skilled; you have to be able to believe in the numbers. If we don’t believe in them they have be researched; the political focus given to this data comes later. If we don’t analyze the information, prevention will fail, because, as I said, the art of analyzing numbers is to prevent what’s could happen. There are very few new diseases in Nicaragua; the ones we’re dealing with are always here or are old recurrent ones. In Nicaragua we know we could have a recurrence of cholera, and the reason we know that is that we’ve had it already, we have the conditions for it; not all neighborhoods have a constant water supply and the water isn’t always drinkable… The only thing missing is patients showing up with cholera for the epidemic to start.

Sentinel sites

A proper, effective information system must aim to inform the general public and the health staff about what’s going around in the country at any given time: which virus, which bacterial infection and what antibiotics they respond to. This is the information the Ministry of Health should be providing about viruses, bacteria, medicines that work and those that don’t, and the measures that have to be taken to prevent and deal with the given disease. The methods for learning this are quite simple. For example, one is to identify three pilot schools in Managua and ask them for regular reports on how many children are sick and from what, how many children have stopped going to school and why… By processing this information you can know what’s happening in the rest of the country. Based on these sentinel sites and these warnings it’s possible to know what to do and to act in time.

It’s important enough to reiterate yet again: the art of public health is to prevent diseases from occurring, not attend to them once they have. From this point of view, hospitals are nothing more than an expression of failure. Of course, hospitals are necessary for patients where prevention didn’t succeed, but they are also an indication that neither community work nor primary care is working.

Volunteers are a proven asset

Community work, whether in health or other issues, must be voluntary to be effective. This was proved in Nicaragua in the 1980s and continues to be proved today everywhere. What survives is what’s done voluntarily, because what we do voluntarily we do for enjoyment, and when we like what we do, we’ll keep on doing it. When they pay us for what we do, we stop doing it when they stop paying us because it makes people feel exploited.

We’re now noticing that involvement in community health work, the movement of health volunteers, has been dropping because people view this work as party oriented and understand that health shouldn’t belong to a political party. When this work is oriented by party considerations, the community divides and involvement dwindles.

Rational use of resources

Quality health systems also demand a rational use of resources. If an MRI is done for every headache, it’ll cost the system a fortune. Today, because the system is so focused on care, there are already people asking for a scan or a complicated examination for any ailment. The few or many resources a health system has must be geared towards the greatest risks and the groups at greatest risk.

I don’t know how many resources are spent on stool tests in Nicaragua. People go to the doctor because of a digestive upset; the doctor sends in the sample and patients often don’t return for the results. It wastes time and resources. Wouldn’t it be more rational to do some research to determine which parasites are the most common in the country and identify which is the most effective medicine against them? With this information, anyone who comes with any symptom could take the drug and save on the test.

In the throes of the dengue epidemic, why do constant blood tests if the person coming to the health center has all the obvious symptoms of dengue? Saving these resources is also opting for quality health.

In conclusion, the health system we have in Nicaragua today has advanced in some ways and regressed in others, but it will regress even further if it doesn’t have the capacity to learn, doesn’t want to learn, doesn’t understand that quality means questioning itself in order to improve and doesn’t really want to be revolutionary, which means being able to identify things in order to change them every day. We need a health system able and willing to learn from others and to coordinate with all who work in health, able to understand that critics aren’t enemies but rather have a contribution to make to the raison d’être of a health system.

The prime objective is that people have a better quality of life. And for that, the health system needs to opt for prevention, for education and for quality.

Leonel Argüello Yrigoyen is a general practitioner specializing in epidemiology. He worked in the Ministry of Health for over 10 years in the 1980s then directed national and international NGOs for 19 years. He now heads the Nicaraguan Society of General Medicine (SONIMEG).

Print text

Send text