How public/private medicine works in Nicaragua

We have had a few articles about specifics of medical care in Nicaragua but the big picture really hasn't been covered well. While not much different than many other places, Costa Rica being a good example, it is very different from the US or Canada. It's not just the pieces but how they interact that needs to be understood.

First, there is the government-supplied part which consists of health clinics and hospitals. There are multiple government hospitals in Managua and regional ones in other cities such as Estelí (San Juan de Dios). That infrastructure is supplemented by health clinics. For example, there is a clinic in Estelí but also one in the community of San Nicolas with a population of about 7000.

Service is free to anyone in the hospitals and clinics. There are, however, costs for supplies. Usually that means a trip to the pharmacy near the hospital or clinic. There is also free ambulance service supplied by the Red Cross. Blood is handled through the Red Cross where it is typical for them to encourage your friends and family to make donations.

There are some private but free clinics, usually run by some sort of non-profit. For example, there is a clinic at a catholic school (whose name I forget) in the south of Estelí. They are free (that particular one actually charges a one cordoba administrative fee) and typically staffed by volunteer doctors. Their particular approach is to have an assortment of doctors there on a schedule who will take a fixed number of appointments.

There are then lots of doctors in private practice as well as privately-run hospitals and other services. For example, while there is no MRI in the Estelí public hospital, there is a private company that has one in town.

Finally, there is INSS which is a government-run insurance plan that employees are supposed to be enrolled in. They have separate clinics in many areas and offer a higher level of care than the "free" options.

That pretty much covers the pieces but how they interact is what is typically not understood. First, many private doctors have "hours" at the hospitals. They also use the public hospital facility for their private patients. (I don't know how this works but I speculate the doctors contribute some hospital time and, in return, get some hospital time for their patients.)

As an example, Claudia Molina is a eye, ear, nose and throat specialist in Estelí (and a good doctor in my opinion). She has her private practice, works at the public hospital and volunteers in the clinic I mentioned above.

This "work together" situation goes even further. For example, my aunt was in the public hospital and needed an MRI. The hospital arranged for her to get it done at the private place in Estelí. Her only "cost" was transportation (which was me with my pickup). That same aunt needed to see a specialist at a different time. There wasn't one in Estelí so the hospital set up an appointment with one one for her in a public hospital in Managua. Her expenses, once again, were the cost of the bus trip.

I have another friend covered by INSS. The INSS clinic is a separate (from the hospital) building on the grounds of Hospital San Juan de Dios. It includes patient rooms and such but uses the hospital operating rooms.

As I said, there are no fees associated with the public clinics and hospitals. There does, however, seem to be advantages gained by knowing how the system works. I would call this "very Nicaraguan". Service can be improved by how you ask, who you ask and who you know.

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Leon, jodido

From what I can piece together of what I know about sick care (health care is a universal misnomer) here in Leon, it seems like I've been living in a different country from what you describe, Phil. There is only one 'hospital' here, Heodra. It's a roach hotel, unspeakably filthy & overcrowded. Yes it's 'free', but it's not uncommon to find relatives of patients begging for money for prescriptions (showing the paper) in nearby Central Park. After my other sis'n-law gave birth there, she had to sleep on the floor for lack of beds in the maternity ward. When my wife gave birth in Managua, years before we met, she went three times to the public hospital Lenin Fonseca. She was turned away the first two times, even after her water had broken. Many 'doctors' in these places are effectively interns. Errors are common.

I am not aware of any free clinics here in Leon. There are free 'centros de salud' with a couple doctors & nurses that mostly weigh babies & give 'em shots, but their facilities for treating adults are minimal; they're sent to Heodra. There is one that does routine blood & urine analyses (small fee) for job seekers - beside a bill of health, a current police report is usually required to apply. The old hospital (actually collapsing) behind the newer Red Cross blood building has a few doctors and a lab, but sends patients requiring attention to Heodra. There is also a free sanitorium for isolating & treating tuberculosis patients (ca.50), near the by-pass highway (Managua-Chinandega).

There are many clinics in Leon, some quite well equipped (operating rooms &c.). In the past two years, all save one were bought by 'La Fraternidad' (and they're putting pressure on that one). Nicas here tell me that Ortega owns the 'La Fraternidad' system. Their logo is a blue key with colored boxes. All patients are insured or pay cash (quite reasonable for gringos accustomed to having their savings accounts operated on before being allowed to see a doctor.)

Most commonly, the insurance is INSS, somewhat different from US social security in this regard. All employees have 6.25% of their wages deducted for INSS. (They say it'll soon go to 7.5% soon.) That is, of course, employees of businesses with payrolls & gov't audits. The quality of care is limited, at times inadequate. My young sis'n-law recently gave birth (Caesarian) in 'hospital La Fraternidad'. (They call themselves a 'hospital', but Nicas here say it's a clinic, that there's only one hospital, the public Heodra.) After the operation she became severely anemic. Only after her brother who had given blood went to the Red Cross and had a pint sent to her at 'La Fraternidad' did they give her a transfusion. The facilities are new, clean & large, but crowding is evident everywhere I turned. She shared her room with one bathroom with four others having (or having had) Caesarians, a continuous rotation (normally leaving the day after).

Much of Nicaragua's economy is still 'open market' & 'black market'. Street vendors & stall 'owners' pay fees to police/municipality, but much is 'corrupt', outside of any reliable accounting. Those folk don't pay into INSS; they are eligible for INSS 'insurance' only if old enough or incapacitated. So til then they go to the public hospital, Heodra, or a 'centro de salud'. All Nica families know folk remedies. Generic drugs here are cheap. Tell a local pharmacist what ails ya & she'll recommend something that'll work (no prescription needed for antibiotics, sulfa-drugs and some CNS pain killers).

To my knowledge, all doctors in Nicaragua are required to donate half of each week to charity work, to free public hospitals & clinics, where they exist. My wife's gynecologist spends her mornings at one such clinic in Chichigalpa. She also has a shared office, in a mini-complex of doctors' offices, where she does vaginal exams & minor procedures. Her typical fee is $16 (400 cords) for the exam and a half-hour (or more), relaxed 'consultation'. Being a doctor in Nicaragua is not exactly a lucrative profession. When I had had a minor operation 4 years ago, I visited a few doctors to learn their fee, and picked the one I judged to be most competent (& forthcoming). He scheduled the operating room at a clinic; I paid the clinic directly. With private room & anesthesiologist coming in from Managua, the total cost was less than my Stateside insurance's deductible.

Between Chichigalpa & Chinandega is Pellas' San Antonio sugar refinery & the FdC distillery called 'El Ingenio' by Nicas here. Thousands & thousands work there, all contributing to & covered by INSS. It has its own hospital. But occasionally their patients come into Leon for procedures not available there. There are several excellent X-ray (dental &c.) & ultrasound labs and routine chem- & micro-analyses labs here. Endoscopic surgeries have become more common here recently.

More than a service level issue?

Before I get into the question, it is true that the government non-hospital facility is called a "Centro de Salud". I said "clinic" which will have a different connotation for some. What is available there seems to vary greatly but it is generally a place to get care -- however limited -- rather than an administrative office.

Now, unless I am missing something, your main distinction is really about what is available in León vs. Estelí rather than "how the pieces fit together". I am a bit surprised at what you describe in León based on what I see in Estelí. There is certainly nothing luxurous about the hospital in Estelí (nice facility but understaffed and certainly like a roach motel in parts) but it's there. And there is another hospital (Adventist) in the center of town across the street from where the old hospital was located.

The Estelí hospital is relatively new (I believe most of the money came from the Spanish government) and it is designated as a "regional hospital". I'm not sure what other regional hospitals exist. Do you know of one in your area, possibly in Chinandega?

the ``new``hospital

on the Pan am dates to the 90s and was a Spanish aid project. It has one interesting feature--a first world parking lot that you are not allowed to use because of local crime. When transporting a patient, you have to talk your way past the guard. Regular parking is on the mud/dust street outside the fence in plain view of the empty paved parking lot. I was so used to this drill that I was shocked that when we went to the emergency hospital in Boaco that the parking lot was actually used for parking.

Esteli has a second private hospital, a chain called ProFamilia. I believe it is an NGO-subsidized private outfit with branches in other cities. My wife went there for an out-patient procedure that required anethesia and a surgery that required a 2 day stay. I went there for a day for testing and IVs. All went well, much cleaner than the public hospital, but the lack of modern equipment was noticeable.

When I was discussing having my gall bladder whacked, my local doctor said there was one doctor locally who could do it orthoscopically at the local hospital and several in Managua. When I asked her which she would choose for herself, she enthusiatically said !!!Managua!!! (I had it done in the States, for a variety of reasons including costs and hidden costs).

``Socialism works fine until you run out of other peoples` money``

Margaret Thatcher

I must be special

Every time I have been there I got into the parking lot. Once was when I brought a person with hemoragic dengue from Santa Cruz to the hospital (which makes sense). I picked up and dropped off my aunt from the parking lot when I took her the the MRI place. Finally, I had a friend who was a patient in the INSS part. Told the guard that and he pointed to the building and waved me on.

When did you get married?

Yes it depends upon the location

First:
Submitted by Daddy-YO:...All employees have 6.25% of their wages deducted for INSS. (They say it'll soon go to 7.5% soon.) That is, of course, employees of businesses with payrolls & gov't audits. The quality of care is limited, at times inadequate...
Actually the 6.25% INSS plan is 1 of 4 plans - the other three require lower contributions and do not include the clinic benefits.
http://www.inss.gob.ni/index.php?option=com_content&view=article&id=13&Itemid=36
The local INSS people recommend the lower cost plans because the "The quality of care is limited, at times inadequate". About half of the employers here are doing that now - With the money you save you can pay for an employee's visit to a clinic, a private doctor, and/or medicine when the need arises so you don't have frivolous doctor visits as well. The INSS people also have the opinion that most of the INSS money never reaches the people so are not too enthusiastic about their own system.

Actually ...

. . . sis'n-law's employer Arnecon, now Yasaki, did not give her any choice. They handled all the paperwork with INSS. Such is the case with all their some 10,000 (now going to 8,000) employees. Could it be because they're a 'Zona Franca' employer?

Otherwise your suggestion would have worked well for her, because early on in her pregnancy she suffered from anemia, and was actually bed-ridden in the same clinic for a week but all they did was give her the same tiny folic acid-iron pills (Trinovit Kela) that she'd been taking. When she was released she went to an outside doctor who prescribed Unipharm's Intrafer F-800 capsules (also, folic acid & iron, + B-12). With those, her blood globulin count bounced back. Were the tiny 'free' pills at the INSS clinic too weak, or like other patients there commented, "Just chalk" "No vale nada". (A separate forum could treat the dangers of bogus medicines here, a country without adequate quality controls. Brands matter, assuming they're not Chinese counterfeits.)

She kept going to that outside gynecologist - which may have saved her life (details to follow in personal blog) - while still visiting the clinic for the regular check-ups.

Zona Franca

Wages and conditions are negotiated by unions and they have a sector of their own.

Its probably that the Union have negotiated the type of INSS plan they are on.

MINSA versus SILAIS

During the 1990s, healthcare shifted to a more private sector healthcare market including fees in public health facilities and the creation of the Sistema Local de Atención Integral en Salud (SILAIS), working under MINSA.

This privatization led to health inequities, particularly in poor and rural communities. When the FSLN regained power in 2007, they changed that and restricted the private sector health model being built and return it to a more central control.

User fees were removed and SILAIS was used to provide a Departmental "community outreach service" in each Department that performs hands on health care and prevention.