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C O N F I D E N T I A L SECTION 01 OF 09 MANAGUA 000344
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DEPT FOR WHA/CEN AND WHA/FO - GSNIDLE
DEPT ALSO FOR PM/WRA - RICHARD KIDD AND MARK ADAMS
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SOUTHCOM FOR FPA
AFMIC FOR LCDR GOTTLIEB AND MSG EISENMAN
E.O. 12958: DECL: 03/24/2028
TAGS: MARR MASS MOPS PHUM NU
SUBJECT: NICARAGUA MANPADS: RECOMMENDATION FOR SUPPORTING
MINISTRY OF HEALTH ASSISTANCE REQUEST
REF: 2007 STATE 138325 AND PREVIOUS (NOTAL)
Classified By: Ambassador Paul A. Trivelli for reasons 1.4 b & d.
1. (C/NF) SUMMARY. Between March 3 and March 13, 2008, a
two-person team from the Armed Forces Medical Intelligence
Center (AFMIC) was in Nicaragua to assess the condition and
capacity of the Nicaraguan health sector. This mission was
in support of ongoing U.S.-Nicaraguan bilateral discussions
regarding Nicaraguan President Daniel Ortega's proposal to
destroy 651 of Nicaragua's remaining stockpile of 1,051 Man
Portable Air Defense Systems (MANPADS) in exchange for
humanitarian medical equipment and supplies from the United
States. One of the tasks of the AFMIC team was to evaluate
the request for assistance put forward by Nicaragua's
Ministry of Health (MINSA) with an eye to determining the
value of possible packages that the USG could put forward in
response to the MINSA request. Three possible options with
rough cost breakdowns are detailed in the report appendix
below.
2. (C/NF) Over the course of 10 days, the evaluation team --
comprised of two AFMIC medical administration experts, one
USAID Health issues specialist (a Nicaraguan MD) and Embassy
personnel -- visited hospitals, health clinics and medical
facilities in 10 of Nicaragua's 13 provinces, including both
the North and South Atlantic Coast Autonomous Regions (RAAN &
RAAS). Following is the final report of the assessment team.
This report is for internal USG-use only. We will provide a
shorter, executive summary of the report to the Ministry of
Health.
3. (C/NF) BEGIN REPORT TEXT.
RECOMMENDATIONS FOR SUPPORTING THE NICARAGUAN MINISTRY OF
HEALTH REQUEST FOR ASSISTANCE
Purpose: The purpose of this report is to provide the United
States Department of State and the Government of Nicaragua
with possible courses of action in supporting a request for
assistance from the Nicaraguan Ministry of Health.
Scope: The health care system in Nicaragua consists of
private hospitals, social security hospitals and the public
health system under the cognizance of the Ministry of Health
(MINSA). The public health system primarily consists of
hospitals, health centers and health posts. Hospitals are
classified as department hospitals, regional hospitals, and
national referral centers.
Our assessment was conducted in the allotted time by
concentrating on representative hospitals, health centers and
an epidemiological laboratory located throughout the 13
departments and two autonomous regions of the country.
Key Assessments:
-- The medical infrastructure is severely degraded due to
age, over-use and lack of financial resources. As a result,
there is a shortage of supplies, equipment and trained
personnel throughout the public health system. These
deficiencies most likely contribute to the higher mortality
rates in select groups.
-- The country's power grid is unstable, is prone to multiple
daily power fluctuations, and appears to be damaging
sensitive electronics contained in biomedical, medical
support, and administrative equipment.
-- Medical personnel in Nicaragua consistently demonstrate an
excellent clinical acumen and resourcefulness. With a
shortage of diagnostic and monitoring equipment, they are
forced to rely on their clinical skills. While clinically
very capable, the shortage of equipment limits their ability
to provide what is considered good-quality standard of care
as commonly accepted by the Pan-American Health Organization
(PAHO), World Health Organization (WHO), and in the United
States.
-- Although MINSA has both a five-year and fifteen-year
health plan, MINSA officials were not able to articulate the
plan to us nor could they provide details about short term,
mid-term and long term goals. A budgeting plan to support
their stated goals was not evident. As a result, MINSA's
ability to prioritize requests and develop efficient
system-wide improvements is limited.
-- The Government of Nicaragua regularly receives assistance
from other countries, non-governmental organizations (NGOs)
and other entities. These donations, some of which are
short-lived, are helpful but do not appear to be coordinated
into a any larger health system improvement plan. Many of
these donations are in the form of older outdated equipment
and arrive without supplies, training, or support.
DISCUSSION
----------
According to the WHO, Nicaragua spends 12 percent of its
national budget on health care. This government spending
comprises 47.1 percent of the total health care spending in
the country. The remaining portion of health care spending,
52.9 percent, comes from private contributions. WHO
indicates the Nicaraguan government spends $31.6 (U.S.
dollars) per capita on health care
The Ortega administration has directed MINSA to ensure that
all Nicaraguans have access to health care, regardless of the
citizens, ability to pay. At this time, they have yet to
implement a new and increased budget to support that policy
decision. Reporting from Sistemas Locales de Atencion
Integral en Salud (SILAIS) departments and hospital
leadership shows the 2007 expenditures exceeded the projected
budget by more than 10 percent, and a projected budget for
2008 that has yet to be established and funded.
Lack of funding has led to a significant and prolonged
degradation of infrastructure and an inability to support the
national health system. In touring the different hospitals
and health centers several issues were immediately apparent:
-- The national power grid is unstable. All institutions
report frequent power fluctuations and outages. As a result
of these fluctuations and the lack of surge protection
equipment, many of these facilities have problems with
electrical circuit boards in medical and administrative
equipment. Combined with the lack of funding, this leads to
medical diagnostic equipment being either non-functional or
functioning at a marginal rate at best.
-- Most medical facilities have antiquated buildings and
infrastructure. Seventy-five percent of the oldest hospital
visited was built of adobe in 1863. The building is still in
use today. While it would be less expensive to build a new
building than to continue to maintain them, the funding does
not exist. Therefore, renovations are underway, but will do
little to improve conditions. While not all buildings are
this old, most show extreme signs of age and lack of proper
maintenance.
-- Extreme lack of medical monitoring and diagnostic
equipment brings additional constraints to providing health
care Most of the equipment currently in the inventory is
archaic. Most was donated by foreign countries and other
hospitals (from both inside and outside Nicaragua). Almost
all of it, with a few exceptions, has been used prior to
being donated. When this equipment breaks or needs
re-supply, the needs can not be met due to the age of the
equipment. In short, 1970,s replacement parts are no longer
available.
-- Hospitals and health centers may have only one or two
items of equipment that is normally standard in a hospital
such as ventilators, and other support equipment, including
sterilizers, which are broken or short in number. The
expenditures of manpower, to perform tasks manually, albeit
less effectively, increases the need to seek support wherever
it is available. This lack of equipment extends to their
epidemiological laboratories, decreasing the efficiency of
their surveillance program on a national level. There are
currently two epidemiological laboratories in the country and
MINSA would like to update the two and establish three more
in an effort to increase monitoring and prevention of
diseases.
-- Most medical property and biomedical equipment suffers
from an extreme lack of maintenance. The major reason is an
almost complete lack of preventative maintenance plans and
trained biomedical repair technicians. Well-qualified
maintenance specialists are also almost non-existent. Those
who are trained in biomedical maintenance received training
over a decade ago on what we previously described as
archaic/antiquated equipment. Equipment provided by
Venezuela is being donated with specialists who are charged
with training the Nicaraguan users. This training has yet to
begin.
The need for a long range plan for rebuilding the entire
public health infrastructure cannot be over-emphasized. In
order to develop a national plan and acquire sources of
funding, short-range, mid-range and long-range goals need to
be identified, articulated and then supported by a realistic
financial plan. In talking to MINSA and hospital personnel,
there seems to be some obstacles to developing such a way
forward.
-- The entire health system needs to be rebuilt. This is an
overwhelming prospect for a country facing increasing
inflation and lacking a robust gross national product.
-- With the new health care model promising free health care
to all patients, there is a high rate of usage at public
facilities, including patients from neighboring countries,
which increases the strain on an already over-stressed system.
-- Hospital directors do appear to have a sense of where they
need to start improvements if funding were available and do
have a means of prioritizing their needs.
-- MINSA, which has responsibility for the entire public
health system, appears to be overwhelmed and claims
everything is a priority. They are unable to articulate a
plan for prioritization of needs. Instead, MINSA
representatives continuously emphasize that previous
administrations are the cause of the current poor state of
the Nicaraguan medical system. Their solution is for
everything to be provided at once.
In spite of an inadequate work environment, shortage of
funding, antiquated equipment, and a lack of sufficient
professional staff, the capable and professional medical and
nursing staff involved in the public health system do provide
the very best direct patient care possible under
circumstances. The lack of modern diagnostic and monitoring
equipment forces these professionals to rely on their
clinical acumen almost exclusively. They have proven
extremely adept and resourceful at doing so. It must also be
emphasized that the quality of care available at public
hospitals in Nicaragua is far below the standard of care
available at modern private facilities within the same
border. A few examples include:
-- Physicians reported the lack of ventilators continues to
be a contributing factor to many deaths within the hospitals.
There is a need for many more ventilators and when one is
not available, ventilation must be accomplished manually.
This is not as efficient or effective.
-- Without diagnostic and monitoring equipment, it very
difficult to diagnose and treat patient conditions regardless
of how simple or complex.
-- In neonatal intensive care units, there are very few
heating lamps that work, making it almost impossible to
adequately heat infants.
-- The laboratory equipment that does exist requires manual
intervention to complete tests. This leads to inefficiencies
and human mistakes not common in more modern automatic
equipment. One piece of equipment was dated 1922.
Regardless of the challenges in the Nicaraguan public health
care system, there are numerous international donations and
efforts underway to assist MINSA and the citizens of
Nicaragua. While this assistance is desperately needed,
there does not seem to be a plan in place for determining the
most efficient use of donated resources. Examples include
the following:
-- Venezuela recently finished donating a modern diagnostic
wing ($2.4 million) to a hospital in Managua. The Venezuelan
government also promised to build a second diagnostic wing on
another hospital in the country.
-- Japan built an entire hospital in 1998 and provided
subsequent technical support and maintenance for two years.
Today the support period has passed and both the equipment
and facility have fallen into disrepair.
-- The Japanese government was reportedly committed to
provide MINSA with 37 ground ambulances and one water
ambulance during 2008. A date of arrival has not been
provided, and a written plan for disbursement was not
provided, although some facilities were verbally promised to
receive one or more of these ambulances.
-- In Boaco, the Japanese have agreed to build a $20 million
hospital. Construction has not started and a date has not
been set.
-- In an effort to improve care at regional referral centers
and hospitals, relationships (to exchange information on
research and treatment protocols) have developed with experts
and specialty centers in several countries, including the
United States, Italy, and Spain. Some of these relationships
yield free donations that amount to archaic equipment that is
essentially dumped into Nicaraguan facilities, to be used
only for few months or years before becoming inoperable and
pushed into a corner of the facility.
A visit to a private hospital in Managua vividly brought the
contrast between the public and private health systems into
focus. The private hospital was approximately three and a
half to four years old and in immaculate shape. There was a
real effort to maintain the physical facility not noted in
the public centers that were visited. The private hospital
had a state-of-the-art power plant to protect the entire
facility from the inadequacies and power fluctuations of the
national power grid. Other observations included:
-- All equipment was modern state-of-the-art and had been
purchased new.
-- Staff was trained and capable of maintaining the
biomedical equipment as well as the physical infrastructure.
This included a well-developed preventative maintenance plan.
-- Hospital management has a plan, which includes short, mid
and long-range goals tied to identified funding sources.
-- Management had initiated and as focused on the process for
certification by the International Joint Commission for the
Accreditation of Healthcare Organizations, an expensive,
labor-intensive and time-consuming process. It signals
leadership's commitment to ensuring top-quality patient care.
CONCLUSIONS
-----------
The public health system in Nicaragua is in extremis despite
the heroic efforts of an under-funded and overworked medical
staff. There are numerous requirements for assistance and it
will take years to improve health care provision in
Nicaragua. Current efforts to maintain the current physical
infrastructure of most facilities is a losing battle.
Eventually replacing all the public facilities should be
considered for the long term and a funding plan to carry this
out should be identified.
Personnel must be trained to maintain and repair biomedical
equipment. In conjunction, steps must be taken to improve
the national power grid and/or at least to protect hospital
equipment from the fluctuation and surges in power.
Providing new and advanced equipment would be futile under
the current environment, as it would be rendered useless
within one to two years. Any equipment provided would need
to be donated in conjunction with a technical support plan to
include training for personnel who will remain responsible
for future maintenance, and surge protection with each piece
of equipment.
Something that is not considered in MINSA requests for
assistance is the increase in cost associated with the
installation and utilization of advanced technology.
According to United States studies regarding medical
equipment installation, when a new MRI is installed, a one
unit increase in use leads to a corresponding increase in
expense to national health care at a rate of $32,900 per one
million beneficiaries per month or $395,000 per year (Baker
L., et al, Health Affairs, November 5, 2003). Given the
current financial state of the public health system in
Nicaragua this would be an added burden for which they have
neither budgeted nor have the means to support.
MINSA should consider developing a long-term strategic
planning process to help identify short-term, mid-term and
long-term goals. They also need to identify budget
requirements and shortfalls so they can be addressed by the
government. If this process is already in effect, it was not
clearly evident nor were MINSA officials able to adequately
articulate it. The expertise to initiate and implement this
process does exist in Nicaragua as evidenced by what the
private sector is currently doing.
There is no way to rapidly overcome years of neglect caused
by underfunding, lack of training, and a poor public
infrastructure.
RECOMMENDATIONS CONCERNING THE NICARAGUAN REQUEST FOR
ASSISTANCE
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
-
The Government of Nicaragua provided a comprehensive list of
needed equipment. Given the current state of the public
health system, there are many possible assistance packages
that could be configured. Action should be taken in a phased
approach to avoid a massive overload to an already fragile
system. Taking into account the current problems with
infrastructure, staffing, level of training and numerous
shortages of equipment, the following three recommendations
are submitted for consideration as a preliminary phase (POST
NOTE: cost estimates for each course of action appear in
Appendix 1 at bottom. END POST NOTE.):
COURSE OF ACTION ONE:
---------------------
Rebuild and outfit the emergency room, neonatal and pediatric
intensive care units and the laboratory at the children's
hospital in Managua. This would include monitors,
ventilators, beds, heating units and diagnostic test
equipment as well as technical assistance and training in use
and maintenance.
PROS:
This would help improve patient outcomes in an area where
mortality is high. This hospital is a national referral
hospital; the impact of these improvements will be beneficial
across the country.
CONS:
This only addresses a small part of the needs required by the
public health system. The staff may not currently have the
expertise to utilize and maintain the equipment. MINSA will
need to be willing to provide personnel for the required
training and implement a term of service requirement to keep
newly trained employees from seeking employment elsewhere.
Since the national power grid is unstable, it could damage
new equipment. Therefore, any new equipment must include
surge protection in the package. A contract for maintenance
and repair should be negotiated as part of any purchases.
COURSE OF ACTION TWO:
---------------------
Purchase numerous ventilators, monitors and diagnostic test
equipment for distribution to hospitals throughout the public
health system.
PROS:
From a medical standpoint, this will enable medical staff to
improve the quality of care in critical care units and
emergency departments across the country.
CONS:
The number per facility is greatly reduced and overall impact
may be less than narrowing the focus. Again, the requirement
for training, maintenance and surge protection exists and
must be included in the planning process. A contract for
maintenance and repair should be negotiated as part of any
purchases.
COURSE OF ACTION THREE:
-----------------------
Build a complete health center in Managua with state of the
art equipment to include physical therapy and occupational
therapy capabilities.
PROS:
this will provide an important step forward in improving
preventative medicine and primary care for entire families in
the affected service area.
CONS:
This course of action directly affects a smaller portion of
the population. As with the other two courses of action
training, maintenance and surge protection are required. A
contract for maintenance and repair should be negotiated as
part of any purchases.
COMMENTS:
This course of action may also be considered in addition to
outfitting the requested epidemiological laboratories. While
not directly used in patient care, it does help improve
overall health and monitoring in Nicaragua.
NOTE:
For courses of action that require construction, it is
recommend that staff from the Health Facility Planning Agency
(HFPA) be tasked to assist the Nicaraguan Government in
planning and construction of any and all medical facilities
constructed with U.S. dollars. HFPA is located in Washington
D.C. and is a subordinate organization to the U.S. Army
Medical Research and Material Command, within the U.S. Army
Medical Command.
APPENDIX: COURSE OF ACTION ROUGH COST ESTIMATES
- - - - - - - - - - - - - - - - - - - - - - - -
Based on MINSA and Hospital Director Requests and Equipment
Cost Estimates. (Some estimates were obtained from the
internet)
NOTE:
Construction costs could not be added in to any estimates as
they will fluctuate based on design and space. They are
estimated to be approximately USD 800 per square foot.
COURSE OF ACTION ONE
--------------------
The cost estimate below is a rough estimate and lists
equipment only. Construction estimates depend on the design
and size of the renovations. Discussions with MINSA
representatives indicate construction costs to be
approximately USD 800 per square foot.
As some equipment costs were unable to be identified on-line,
all cost numbers are estimates. These costs can change based
on what configurations are purchased. Some of the monitoring
equipment will also be needed for the emergency room even
though it was not initially requested by the hospital during
their presentation. Even though not all the prices are
known, the total cost of equipment should be around one
million dollars. If a fixed x-ray machine should be needed
along with the supporting equipment, costs should not exceed
1.5 million dollars. Renovation of the hospital area under
consideration should be able to be completed with the rest of
the discussed dollar amount. Each piece of equipment should
be connected to a UPS battery system, which should be
purchased.
Neonatal ICU Items Cost Number Total
------------------
Cost of Construction 800 (Per sq. foot est.)
Bilirubin Meter 5,000 2 10,000
Infusion Pumps 600 6 3,600
Cephalic Box 10
Neonatal Transport Beds 6,000 1 6,000
Neonatal Beds 3,500 10 35,000
Stethoscopes 150 5 750
Gasometer 28,000 1 28,000
Glucometer 200 3 600
Suction 1,500 5 7,500
Neonatal Blood Pressure
Machines 800 5 4,000
Ventilators 42,000 5 210,000
Incubators 6,000 10 60,000
Swan Neck Lamps 300 3 900
Photo Therapy Lamps 2,000 6 12,000
Heating Lamps 2,450 6 14,700
Neonatal Laryngoscopes 2,000 5 10,000
Air Manometers 60 5 300
Oxygen Manometers 60 5 300
Cardiac Monitors 1,500 2 3,000
Vital Sign Monitors 1,600 2 3,200
PO2 and pco2 Monitors 500 2 1,000
Ultrasonic Nebulizers 200 3 600
Pulse Oximeters 240 3 720
Neonatal Scales 1,025 2 2,050
Medical Refrigerator 1,500 1 1,500
Subtotal 415,730
Pediatric ICU Items Cost Number Total
-------------------
Infusion Pumps 600 5 3,000
Neonatal Head Chamber unknown
Adult Head Chamber unknown
Pediatric Head Chamber unknown
Defibrillator 10,000 1 10,000
Adult Laryngoscope 2,000 2 4,000
Pediatric Laryngoscope 2,000 3 6,000
Cardiac Monitors 1,500 2 3,000
S/V Monitors
Pulse Oximeters 240 2 480
Blood Pressure Machines
Neonatal 800 1 800
Pediatric 800 2 1,600
Adult 800 2 1,600
Ventilators 42,000 5 210,000
Subtotal 240,491
X-ray Items
-----------
Mobil X-ray 30,000 1 30,000
Automatic Plate Reader 400 1 400
Plate Dryer 500 1 500
Ultrasound 150,000 1 15,000
Subtotal 45,900
Laboratory Items
----------------
Pipette Agitator 3,050 2 6,100
Tube Agitator 3,050 2 6,100
Bacteriological Autoclave 4,325 1 4,325
Electronic Scale 500 2 1,000
Warm Water Bath 1,184 2 2,368
Cell Counter 12,000 2 24,000
Drying Oven 2,500 1 2,500
Microscopes 1,352 3 4,056
Protein Refraction Meter 25,000 1 25,000
Spectrometer 3,152 1 3,152
Blood Plasma Freezer 2,000 1 2,000
Blood Refrigerator 1,000 1 1,000
Micro Centrifuge 2,500 1 2,500
Centrifuge 1,200 1 1,200
pH Meter 500 2 1,000
Thermometers 10 3 30
Subtotal 86,331
Equipment Estimate 788,452
Course of Action Two
--------------------
The table below is an estimate of costs for a possible
equipment purchase to disperse throughout the public health
hospitals under MINSA. This list is based on the most
critical diagnostic monitoring equipment as articulated by
health care providers at the hospitals. This is an example
only to demonstrate price but does provide for a large amount
of equipment for distribution. The equipment mix can change
as needed in consultation with MINSA.
Item Cost Number Total
-----
Ventilators 42,000 60 2,520,000
Vital Sign Monitors 1,600 60 96,000
Defibrillators 10,000 60 600,000
Cardiac Monitors 1,500 60 90,000
Infusion Pumps 600 200 120,000
Suction 1,500 100 150,000
Pulse Oximeters 240 200 48,000
Total 3,624,000
Course of Action Three
----------------------
The cost of this course of action depends on the design and
size of the health center and equipment. The current cost of
construction is estimated to be about $800 per square foot as
discussed with MINSA representatives. The total cost should
be within the discussed budget. Depending on final cost of
the health center, it may also be possible to outfit the five
epidemiological laboratories as requested by MINSA. The list
of equipment they priced and provided came to just under 1.6
million dollars.
END REPORT TEXT
TRIVELLI