Contracting for health services: an evaluation of recent reforms in Nicaragua

Nicaragua has embarked on a reform of the way in which publicly provided medical care is organized and financed. A principal feature of the reforms includes a decentralization of decision-making authority coupled with an increase in local accountability. Local decision-making authority has been increased by allowing managers more freedom to allocate inputs. Accountability has been strengthened by stipulating what is expected of hospitals and health centres in the form of performance agreements, and tying rewards (i.e. bonuses) to the satisfaction of these requirements provides incentives. This paper provides a critical assessment of these reforms, and presents some early evidence of their effects.     

Health services reforms: political and managerial aims--an international perspective

Health policy everywhere is in flux. In marked contrast with the impenetrable orthodoxy and inaction characteristic of past decades, health policy currently is in the midst of large-scale upheaval. Many of the fundamental assumptions and principles that long guided health-sector development are in the process of being turned upside down. Whether a country is rich or poor, it matters not. Virtually every country either has or is contemplating major reforms in its provisions for the organization and financing of health services. Moreover, the differences in health services structure which divided nations, are becoming smaller--to the point where formerly shunned international exchanges now are considered useful mediums for the exposition of common tensions and the exploration of choices for adapting health care to complex and new economic realities.     

Health for all in Nicaragua

The state of health care in Nicaragua can be attributed in part to the interaction between 'revolutionary' and 'counter revolutionary' forces. Since 1979 development of primary health care has been rapid and ambitious. Nicaragua's early successes in the pursuit of 'Health for all by the year 2000' have been widely reported and rightly acclaimed. Since 1983, however, these advances have been difficult to maintain, leading to stasis and deterioration in the health system. The contribution of various factors to the current health status of Nicaragua is examined.     

Health and medicine in Nicaragua

A mass of statistics indicates that the health of the nation as a whole has benefited under the Sandinistas' unified health system. Nevertheless, many physicians and the principal coalition of opposition parties that will oppose the Ortega regime in this month's election advocate replacing it with a three-tiered system aimed at different segments of the population.     

Planning for primary health care in Nicaragua: a study in revolutionary process

Recent changes in the political economy of Nicaragua have resulted in significant advances in public health. The improvements are due to changes in the health system which include comprehensive health planning, regionalization of health services and popular participation in health education and mass drug administration programs. Traditional structural approaches to the study of national health systems can benefit from an analysis of the process of change. The research reported herein focuses upon struggles between instructional actors who would professionalize primary health care and those who promote popular participation in the planning and execution of primary care programs. An analysis of decision-making within the Sistema Nacional Unico de Salud illustrates the process whereby a health system undergoes structural change from within. The Nicaraguan case suggests that the changing configuration of health systems is a dynamic process and the result of negotiation among several constituencies amid changing conditions in the world system. The role of a government seeking to democratize health delivery within a socialist political economy is to create and promote constituencies for the popular model and thereby institutionalize the debate.     

Health effects of the war in two rural communities in Nicaragua. Nicaragua Health Study Collaborative at Harvard, CIES, and UNAN.

We report on a pilot study to assess the effects of low intensity war in Nicaragua on the health of the civilian population. The study compared data from two regions in Nicaragua, one in an area of intense conflict, the other further removed from the war's violence. Information was obtained from a questionnaire administered to female heads of randomly selected households; structured interviews with community leaders and health workers; group discussions with community residents; and a review of regional and municipal death records. Height and mid-upper arm circumference of children were measured, and immunization records reviewed. The war has had a serious negative effect on the lives of the civilian population in both the war zone and the non-war zone, with the effects most severe in the war zone. In both communities, over half of the respondents reported the death of a friend or relative. In the war zone community, over one-fourth of respondents reported attacks on family members in non-combat situations around their homes. Death by firearms was the leading cause of death in persons over age 6 in the war zone. Vaccination coverage, nutritional indices, and familial disruption were worse in the war zone community. The findings suggest that continued funding of the Nicaraguan contra forces by the United States may be harming the ostensible beneficiaries of that policy, and that use of such low intensity conflict as a foreign policy tool should be questioned.     

War-related changes in health and health services in Nicaragua

The low-intensity war against Nicaragua from 1983 to 1987 has had a wide reaching impact on health, health services, and health economics in that country. Beyond the death of individuals and destruction of facilities, economic embargo and contra destruction have cost the health system about 200 billion cordobas between 1981 and 1987. This is approximately equal to the value of 2 years of the entire health budget. The war has resulted in decreased accessibility and availability of services, leaving about 10% of the population without access to modern health facilities. Perhaps 10% of the demand for acute care services is generated by the war, which has resulted in a reorganization of surgical and medical services. Long term care needs for psychiatric illness and rehabilitation services are far more extensive. Population movements and resettlement, where preventive care has been unavailable, are associated with epidemics of malaria, diarrheal diseases, measles, leishmaniasis, meningitis, and tuberculosis. Health services remain a high priority of the government as health care is viewed as a way to reduce the untoward effects of the war on the general population. Nonetheless, the indirect effects of the war have been detrimental to the system. Negative effect include the loss to the system of health professionals and rampant inflation. These forces contribute to the weakening of primary health programs and the reorientation of the national system into hospital based, curative medical services.     

Disability support services and the reforms

Features of disability support service provision in New Zealand are examined. Factors influencing the restructuring of the disability support services are identified in the context of international comparisons. Reference is made to the debate on the health/welfare interface, policy trends that have favoured a shift from institutional to community care and the need to contain escalating public health service expenditure. Changes to the disability support services under the new Regional Health Authority structure are outlined. Thereafter, the influence of the reforms in redressing the problems inherent in the long-term care services is analysed, as well as the possible consequences of the changes.