The public health sector in Nicaragua has entered the sixth month of a strike that has left the vast majority of Nicaraguans without any access to health care.
Background
Doctors in Nicaragua currently earn an average of $144 per month, 40% less than their counterparts in other Central American nations. To protest this situation, the 3,000 member strong Médicos Pro Salario doctors’ union initiated a strike in the nation’s 32 public hospitals and 150 health centers on November 14, 2005, demanding a 140% pay increase. Initially the doctors continued to treat emergency cases, but in an effort to step up the pressure on the government, the Médicos Pro Salario union has periodically closed emergency rooms in public hospitals. Even when the emergency rooms have been open, service has been extremely spotty, as many hospitals and health centers remain occupied by striking workers and closed to the public.
On January 30th, the 20,000 health care workers (including nurses, medical orderlies, administrative personnel, laboratory specialists, and custodians) represented by the FetSalud union joined the strike, demanding a 48% pay increase and more money to buy medicines for public hospitals. Médicos Pro Salario and FetSalud later decreased their pay raise demands to 30%. Both unions also indicated a willingness to accept a pay raise that was not immediate, but rather implemented incrementally over a three-month period. The 2006 Nicaraguan government budget does include a 13.75% increase in spending on health workers’ salaries, but the workers demand a 30% pay increase in addition to this already-budgeted salary augmentation.
FetSalud Strike Ends
On April 6, one of the two striking unions, FetSalud signed a 16 point accord with the Nicaraguan Ministry of Estates and Public Credit, bringing the more than two-month-long health worker strike to a close. These accords only allow for a 16.25% pay increase, instead of the 30% demanded by FetSalud throughout the strike. This pay raise will cost the Nicaraguan government C$153.4 million (US$8.84 million). The accords also promise that the government will provide C$50 million (US$2.9 million) to create a revolving fund for a health worker home financing program, as well as C$15 million (US$865,000) for uniforms and safety equipment. The government has also agreed to supply C$30 million (US$1.73 million) to replenish the medicine supply in public hospitals.
Mounting Tension
While FetSalud workers agreed to lower their pay increase demands, the 3,000 strong Médicos Pro Salario doctors’ union, on strike since November of 2005, persists in its demand for a 30% pay raise in addition to the 13.75% increase approved by the government in January. However, the Nicaraguan government asserts that it cannot raise the doctors’ salaries by more than 16.25%. Israel Kontorovsky, the Vice-Minister of Health, states, "There will not be a higher salary increase for anyone. It is very difficult because the President said that what he signed with FetSalud is all that the government can give."
The protests have intensified to the point of desperation, with daily demonstrations around health centers, government offices, international financial institutions, and principle roads. Striking health workers have taken over and destroyed MINSA and other government offices, as well as public hospitals and health centers, resulting in violent evictions by the police. The doctors have vowed not to permit the hospital entrance of non-union doctors contracted by the Ministry of Health (MINSA) to make up for the personnel deficit and have declared that they no longer recognize the Minister of Health, Margarita Gurdián Lopez. Doctors have vowed to begin a hunger strike at the Nicaraguan Red Cross if the situation is not resolved by Monday, April 24. Tensions have also arisen between FetSalud workers and doctors from Médicos Pro Salario, as FetSalud workers have refused entrance to protesting doctors who have arrived from outside Managua to participate in the hospital takeovers.
The IMF and "Megasalarios"
Throughout the strike, government officials have insisted that due to International Monetary Fund (IMF) budget restrictions, it is impossible to authorize a further wage increase. Loan packages granted to Nicaragua by the IMF are contingent on the maintenance of a budget that meets IMF requirements, which include a ban on public sector wage increases, supposedly in an attempt to avoid inflation. The overall objective of IMF economic programs, which include budget austerity, privatization, and the reduction of trade barriers, is allegedly economic growth, which will theoretically allow Nicaragua and other countries to pay of their debts with the IMF. While the IMF-approved budget passed by the Nicaraguan government for 2006 assigns C$3,545.9 million (US$204.37 million) to finance the internal debt and C$1,377 million (US$79.36 million) to pay the external debt, it will not allow for more than a 9% increase in public sector wages and forbids any increases in social spending above year 2000 levels. Nicaragua currently spends $68 per capita annually on social programs, representing the lowest social spending level in Latin America.
Despite several high-level meetings between the government and IMF officials since the strike began, the international lending institution has not given permission to raise public sector salaries. Juan Sebastián Chamorro, the Vice-Minister of Estates and Public Credit, states, "The salary increases for 2006 have reached the roof and so any salary augmentation would automatically imply the exit of the IMF’s economic and financial program with the Nicaraguan government." As a result, Oxfam International, along with the Coordinadora Civil, a national umbrella organization for more than 500 civil society organizations, launched an international campaign on April 17 to pressure the IMF to exercise more flexibility in its Nicaraguan economic policy and allow for more social spending in a country where over 80% of people survive on less than US$2 per day.
However, the IMF is not the only barrier to raising the wages of health workers. Gustavo Porras, the General Secretary of FetSalud, says that it is possible to raise the health workers’ salaries without jeopardizing Nicaragua’s relationship with the IMF: "The Deputies, Magistrates, and Ministers just have to be flexible and give up their megasalaries." While Nicaragua is the poorest country in Latin America and also has the lowest doctors’ salaries in Central America, the 695 top Nicaraguan government officials consume almost 1% of the country’s Gross Domestic Product (GDP), according to a recent World Bank study. Monthly salaries for these high officials average $3,500, complemented by free vehicles, gas, and insurance, among other benefits. Meanwhile, the average monthly minimum wage in Nicaragua is $75, which is not even sufficient to cover the cost of the $162 monthly basic food basket, according to recent data from the Nicaraguan Central Bank.
Effects of the Strike
The human costs of the medical strike are enormous. The Ministry of Health (MINSA) has tried to keep emergency rooms open throughout the strike, though service has been intermittent at best. Outpatient services were not reopened until this week, and entrance into many public hospitals remains impeded by the protests of striking doctors despite FetSalud’s decision to return to work. While the full extent of the health complications and deaths caused by the strike is difficult to measure, the statistics reported by MINSA are alarming. MINSA claims that at least 135,000 people have missed appointments and 22,250 people have missed scheduled surgeries. 28,000 mothers have been unable to receive prenatal care and 10,000 mothers have been unable to give birth in hospitals, resulting in a 10% increase in infant mortality and a 6% increase in maternal mortality. In mid-March, the Board of Hospitals concluded that at least 74 people had died as a result of the strike, but this is most likely a low estimate.
While private hospitals do remain open, their prices are completely inaccessible to the poor majority, who make up an estimated 80% of the population. Maribel López Martínez, a 14-year-old single mother, blames the strike for the death of her three-month-old baby from pneumonia: "My child died because the striking doctors would not help him. He died this morning." Similarly, Ivania Barahona says that doctors at the public hospital Roberto Calderón refused to treat her brother, Angel Andrés Lara Barahona, for cirrhosis on two different occasions, resulting in his eventual death. The medical strike also poses a great danger to AIDS patients, who have had trouble accessing the antiretroviral drugs that MINSA dispenses to them from hospital pharmacies. Doctors have also refused to attend cancer patients.
Medical Strike in Context
Despite the severe burden the medical strike has caused the people of Nicaragua, a February 9th La Prensa poll indicates that the public supports a salary increase for doctors. When asked what social program they would chose to spend 20 million córdobas ($1,176,471) monthly on, the second most common response (after child feeding stations) was a better salary for the striking doctors, reflecting the great disparity between the spending priorities of the government and those of the majority of the population. In fact, the medical strike is but one among many manifestations of the greater structural problems of poverty and inequality that exist in Nicaragua, where most people struggle to make ends meet while high government officials earn exorbitant salaries and international lending institutions pressure the government to limit social spending and give huge tax breaks to multinational corporations.
Sources: La Prensa, El Nuevo Diario, Hoy, Envío, World Bank, Nicaraguan Central Bank, MINSA Photo from El Nuevo Diario