"Solidarity" Health System
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The Nicaraguan health system is in a state of transition, and as a volunteer with the Centro de Salud in San Juan del Sur, Nicaragua I have a front row seat. The recently elected government is introducing a new health system called "solidarity" in an effort to both improve services, and increase access to win back the confidence of the Nicaraguan people. Changes include free medication and medical visits, and an overall shift in philosophy to preventative medicine through health education, and training programs for local health promoters or "brigadistas".
Marketing this change in policy is almost as big a job as getting health workers to accept and comply with it. The countries violent political history and the corruption in the national government have led the majority of citizens to shun social services, not only because they rarely exist but also because they tend to be corrupt and ill managed. For example the Director in San Juan explained to me that for years there was an unregulated market for medical services. Doctors accepted bribes, and charged unfair prices, leaving the majority of citizens without access to care. This practice has left a black cloud over government health services, and the population generally doesn’t visit their local Centro de Salud. Most are unaware of the efforts being made to transform the system and the changes in health policy being instituted.
To begin tackling this problem, the Ministry of Health has instituted a nation wide health census to assess the health risks and priorities throughout the country in order to guide future health policy. Each municipality must collect health data from each household, and send it to their respective department by July 18, 2009. The census is also an opportunity to inform citizens of the new health services available, and provide brief consults and health education at each visit. All of the data is gathered by the manual labor of nurses who walk house to house in each barrio of their municipality issuing the questionnaires. As you can imagine many of the nurses are not as supportive of this process as others, and internal compliance is one of the many challenges in the new system. But the information gathered for each family is valuable and ranges from daily medications and family planning methods, to presence of rats or cockroaches, and aches and pains.
The "solidarity" health system goes against the idea of "Pay for Performance", and instead the government intends to increase equity and access by subsidizing all health costs. Hopefully the drastic change in policy does not result in a drastic decline in quality of service. I think the census itself is a great way to guide health policy, but will admit that I’m skeptical that a complete census will be sent into the Ministry of Health within two months. I head out to gather health data in the community of Auxiladora next week, so I’ll find out how efficient, or inefficient it is soon enough.
