Strengthening the Family and Community Health Care Model in Nicaragua

Challenge

As in most resource-limited settings, the health of the population depends on equity and efficiency and on overcoming access gaps in the provision of healthcare services. In 2010, Nicaragua was one of the poorest countries in Latin America and the Caribbean. Between 2005 and 2010, the country experienced a slight reduction in maternal and infant mortality, with better control of transmissible diseases and improved immunization coverage. However, the health system continued to respond poorly to other health challenges, including the spread of H1N1 and dengue and the rise in non-communicable diseases, creating a double burden of disease. Through the introduction of health reform in the early 2000s, Nicaragua created a new Community and Family Health Model focused on universal access to basic health and nutrition services; health promotion and prevention; access to health services for vulnerable populations of indigenous residents, women, children, and the elderly; and community participation.

Approach

The Improving Community and Health Care Services Project (and its additional financing) was designed to support the Community and Family Health Model, and it aligned with Nicaragua’s 2009–11 National Human Development Plan (NHDP) and the World Bank’s 2008–12 and 2013–17 Country Partnership Strategies (CPS). The project’s interventions included introduction of the results-based financing mechanism in 66 municipalities; establishment of social contracts for well-being between administrative levels; results-based budgets at the hospital level; development and implementation of the National Strategy for Sexual and Reproductive Health; strengthened knowledge and skills bases for health workers; improved Ministry of Health (MOH) operational capacity at the central, regional, and local levels, including rehabilitation of health centers; maintenance and repair of medical equipment; and activation of a public health emergencies component. The project also effectively supported several policy goals articulated in the NHDP and CPS, including reducing maternal and child mortality and progressing toward the Sustainable Development Goals. It narrowed gaps in health service coverage and quality for vulnerable groups, and it implemented strategies for the better use of existing financial funds and health infrastructure. 

Results

 Project financing helped to support these crucial outcomes in the following ways:   

·         The percentage of first-time consultations increased by 29 percent over the project timeframe and by 31 percent and 26 percent under the additional financing of the project 2009 and 2016, respectively.

·         The percentage of follow-up healthcare consultations increased by 52 percent between 2009 and 2016 (under the additional financing) from 22 percent to 74 percent, respectively.

·         Adolescent pregnancies decreased by 2.0 percent between 2009 and 2016 (from 27.5 percent to 24.5 percent, respectively).

·         Between 2009 and 2016, 85 percent of municipal health networks achieved at least 7 of 10 performance goals.

·         Institutional deliveries rose by 22.6 percent in the targeted municipal health networks (MHN) between 2009 and 2016 (from 72 percent to 93 percent) and by 18.2 percent with the additional financing expanded to other municipalities.

·         The number of postpartum women receiving postnatal care within 10 days of delivery in the targeted MHNs increased 50.8 percent (from 32 percent to 65 percent, respectively), with a 56.2 percent increase among postpartum women receiving postnatal care under the additional financing (from 32 percent to 73 percent, respectively). 

·         Pentavalent vaccines were administered to 100 percent of the children younger than one year in the targeted MHN over the project timeframe (from 88 percent in 2009 to 100 percent in 2016). 

·         Medical and nonmedical equipment required to reestablish operating capacity were replaced in 12 hospitals and 32 MHN between 2009 and 2015, and an additional 4 hospitals and 2 MHN completed the process through the project’s additional financing.

·         Two mobile regional maintenance centers for medical and nonmedical equipment were established between 2009 and 2016. 

Bank Group Contribution

The Bank, through the International Development Association, provided approximately US$30.85 million in a blend of credit and grant terms. Additionally, trust fund grants, totaling approximately US$630,000, were contributed to the project to support interventions. These grants include: (i) “Strengthening the Management of the National Immunization System,” designed to ensure equitable access to quality vaccines, with special attention to the target population; (ii) “Strengthening Nicaragua's Vital Statistics System,” aimed at strengthening Nicaragua’s existing National Vital Statistics System by creating a national strategic plan and developing a reliable database, consisting of information on births and deaths in the country, made accessible to all Nicaraguan government institutions working on the production of statistics; (iii) “Strengthening the Institutional Capacity of the Nicaraguan Ministry of Health,” designed to provide a knowledge exchange with Argentina to provide a frame of reference for the implementation of the National Cervical Cancer Program; (iv) “South-South Exchange Strengthening the Management of Health Technologies (Medical Equipment) in the Public Health System,” aimed at improving the managerial function in the maintenance of health technology, including repairing and restoring medical equipment;  and (v) “Nicaragua Scaling Up Nutrition,” designed to produce videos providing parents with information on how to recognize when a child is malnourished, thus empowering them to demand quality services for prevention.

Partners

The project counted on the participation of local health leaders, health promoters, traditional healers, youth clubs, senior citizen councils, and others to help identify community health needs and ways to work in partnership at the community and municipal levels. The Ministry of Health developed strong linkages with other ministries and government institutions, including the Ministry of Family, Youth and Children (MIFAN) and the Ministry of Education (MINED), during the implementation of several programs. The project’s support in implementing the Adolescent Health Strategy led to strategic partnerships with institutional stakeholders in the territories, such as Promotoría Solidaria, MINED, MIFAN, municipalities, and the national police, and it helped Nicaragua to leverage strong collaboration on healthcare-related issues with the United Nations Population Fund and the Pan-American Health Organization.   

Moving Forward

The project contributed to the successful implementation of the Community and Family Health Model, introducing municipalities to the modality of a results-based financing approach to help them improve the quality of their services and health outcomes. However, good quality of healthcare remains a challenge in the absence of systematic reviews of health results, maximized efficiency, and attention to culturally sensitive services. The project closed with adequate staff to continue performing the new activities and tasks introduced during project implementation. In addition, the project results framework and its indicators continue to be included in MOH and SILAIS strategic planning after the project closed.

Beneficiaries

The project beneficiaries include the 6 million inhabitants of the 153 municipalities of Nicaragua. The first project component, “Capitation Payment,” has directly benefited three million inhabitants from the eleven Local Systems of Integrated Health Care involved in this component, consistent with the existing free healthcare model, with a particular emphasis on the rural populations of 66 municipalities and in the indigenous territories of Alto Wangki and Bokay. In addition, the project also benefited health professionals by increasing their skills and capacities to better perform their tasks.