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C O N F I D E N T I A L SECTION 01 OF 09 MANAGUA 000344 
 
SIPDIS 
 
NOFORN 
SIPDIS 
 
DEPT FOR WHA/CEN AND WHA/FO - GSNIDLE 
DEPT ALSO FOR PM/WRA - RICHARD KIDD AND MARK ADAMS 
DEPT ALSO FOR INR/IAA - AEMERSON 
DEPT PLEASE PASS TO USAID/LAC 
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