WASHINGTON — When Violeta Barrios de Chamorro defeated Sandinista President Daniel Ortega in Nicaragua's elections last February, many expected her administration to waste little time in revamping one of the most celebrated of Sandinista legacies--the country's health system. The new president's party platform had even called for abolishing it.
But Chamorro's new health minister says he has no intention of dismantling the system built after the ouster of dictator Anastasio Somoza in 1978. The system is based on the principle that health is a right of all 3.7 million Nicaraguans and the responsibility of the government to maintain.
The minister, Dr. Ernesto Salmeron, is a rotund 47-year-old pediatrician who has become perhaps the most controversial member of Chamorro's Cabinet because of his determination to preserve what is regarded as one of the most revolutionary Sandinista reforms.
"There is nothing to change in the health system except its efficiency," Salmeron declared in a recent interview.
Chamorro's support for Salmeron has angered the conservative elements of her coalition party, the National Opposition Union (UNO), as well as physicians who want to privatize the national health system. Her decision has also created special problems for the U.S. Agency for International Development (AID). For most of the '80s, the United States backed the Contra forces fighting the Sandinistas; during the elections, it embraced UNO's reform platform.
After having no presence in Nicaragua for the past eight years, the agency is now responsible for dispensing the $300 million in economic aid to Nicaragua that Congress appropriated after Chamorro's victory. According to Janet Ballentyne, mission director in Managua, $225 million has been spent on emergency economic recovery and repatriating the Contras and refugees, with about $11.6 million going to health. The remaining $75 million will be divided up among education, health, nutrition, agriculture and similar development enterprises.
For health care, the agency must now grapple with the politics of deciding what kind of health care to support and to which groups in Nicaragua to give the money. "The minister of health probably has the most difficult job in a country full of people with difficult jobs," Ballantyne said.
During its early years, the health system acquired an international reputation for its achievements in lowering the infant mortality rate, conducting vaccination programs and promoting prevention services. Assistance came from dozens of U.S.-based private agencies, which sent manpower, money and medical resources to Nicaragua. The aid helped prevent a total collapse of the system.
But after eight years of war and an economic blockade, Nicaragua's health system faces mounting epidemics, hospitals in disrepair, a scarcity of drugs and supplies, and a ruined economy.
Currently, the health ministry is drawing up a five-year plan, in which AID will participate, to prioritize the nation's health needs. A major fight is over whether primary health care--immunization, nutrition, sanitation and so on--or more complex and expensive hospital care--open-heart surgery and nuclear medicine--should receive top priority.
Many physicians, particularly the specialists whose skills require high-technology surroundings, are pressuring the government to devote a higher percentage of the health budget to upgrading hospitals and spending more on curative medicine. Salmeron flatly opposes spending money on exotic hospital care at the expense of primary care.
"As long as I remain minister of health, that will not happen," he said. "We have a people with a low cultural level, with no good housing, no water supplies and electrification. We must provide potable water, good housing, electrification and education on how to prevent disease. Then we can start with something better."
To date, nearly all the $11.6 million that AID has awarded for health has been allocated to private, voluntary organizations uninvolved in Nicaragua during the Sandinista reign. Only $100,000--for an immunization program--has gone to the ministry of health for primary care. Nearly $4 million has been given to private organizations for hospital services.
But Ballantyne predicted that when the five-year plan is ready, it will emphasize primary care. In that case, AID will support it with "a great deal of technical and financial expertise."
Ballantyne's promise assumes that Salmeron will be successful at carrying out his crusade for primary care. Whether he will last long enough to achieve his goal is uncertain. In the beginning, Salmeron recalled, he was concerned about his future; now, he feels secure.
Just before the February election, conservative medical leaders of UNO said they would replace the unified national health system with one similar to the shamefully inadequate system under Somoza, which favored the wealthy and middle class.