Orthopeadic Residency Collaboration

IGOT is working with Universidad National Autónoma de Nicaragua on the restructuring and unification of their orthopaedic residency program.

Nicaragua: A Brief History of the Current Health Care Situation

Nicaragua has followed a troublesome path in the area of healthcare for its 5.7 million inhabitants. In the Somoza years, before the Sandinista regime, the majority of the economically disadvantaged Nicaraguans had limited access to modern health care. In the 1980’s, the Sandinistas instituted policies that created a unified health system and created outreach clinics designed to bring primary and preventative care to the underserved. Vaccination and sanitation programs were instituted, community health volunteers were trained, and oral rehydration centers were established. New hospitals were built and medical school enrollment was increased. Nonetheless, civil strife took its toll on the system, resulting in war injuries and shortages of medicines and basic medical equipment.

In the years since the Sandinistas left power, there continues to be a lack of budgetary resources, resulting in limited access to health care by the majority of the population. Inequalities in Nicaraguan society are reflected in the current three-tier health care system in which the wealthy are treated in private hospitals or travel abroad for their care, select workers and members of the military are cared for in social security and military facilities, and the large majority of the population, around 90%, are treated in public facilities that are under-equipped, understaffed and poorly maintained.

Orthopaedic Volunteerism in Nicaragua

Several organizations, including Operation Rainbow and Orthopaedic Overseas, have sponsored orthopaedic missions to Nicaragua. Information gleaned from various participants in these missions, mainly in Managua and Leon, confirms the general statements above. Our experiences in Leon at the Hospital Escuela Oscar Danilo Rosales Arguello (HEODRA) in the summer of 2004 parallel those of UCSF residents who have worked in the Hospital Antonio Lenin Fonseca in Managua. Both of these facilities are teaching hospitals of the Universidad National Autónoma de Nicaragua (UNAN). Orthopaedic care in the large public teaching hospitals is rendered by part-time orthopaedists who must work in private clinics to make ends meet. In Leon there was a three year orthopaedic training program that included 3 residents per year. The residents in Leon were paid a paltry salary of about $200 a month to begin with, with salaries available for only one resident for the second and third years of training. Many residents quit due to lack of financial support. In Leon, there was only one third year resident in training in 2004. When we visited Leon and Managua in July of 2007, matters had improved. All residents in each year of training were receiving salaries, making it possible for all residents in each year to continue training. These doctors were eager to learn, and through access to the internet and through textbook CD’s, they were well aware of techniques and technology available in the rest of the world. Contact with practitioners in private clinics confirmed the disparity in resources available to them- the lack of equipment, drugs, supplies, implants, and radiographic studies, to name a few.

Future Challenges

A myriad challenges lie ahead for orthopaedic educators and department heads throughout Nicaragua. The largest hospitals are saddled with a high burden of trauma and have inadequate resources to deal with it. In public hospitals, treatment available for patients with chronic musculoskeletal conditions such as arthritis, infections and tumors is limited.

The orthopaedic training programs sorely need to increase from 3 to 4 years in duration. Training and curricula for orthopaedic residents should be standardized and improved. Consolidation of curricula and cooperation in the separate training programs in Managua would be desirable.

Role for IGOT

IGOT has a unique opportunity to collaborate with orthopaedic educators in Nicaragua. By providing volunteers with expertise in orthopaedic education, IGOT can add much needed teaching to the existing course of instruction. By supporting reforms in the structure and focus of residency curricula at a national level, programs will be able to produce better trained and more competent orthopaedic practitioners.