In the rural areas of Nicaragua almost all health care is provided by the Ministry of Health (MINSA). Each Department (province) is divided into municipalities,a governmental unit that includes both the rural and urban areas within its borders. roughly the equivalent of 'county'. In each Municipality there is a Health Center in the principal town, which receives financial and other support from the Departmental MINSA. In the smaller communities of the municipality there are smaller Health Posts, operated and supported by the Health Center. The Health Centers and Posts offer free primary care, primarily out-patient but with some hospital beds and surgical facilities in the Health Centers.
El Cuá Health Center, 2000
But in rural areas primary care is limited in its efficacy; first, by the limited resources available to MINSA. Secondly the population is disperse, with limited means of transportation and communication so that many patients cannot reach the Health Centers and Posts.
For these reasons preventive medicine is a large part of the work of the Health Centers; instead of the people coming to the Center, the Center goes to the people. The major elements of the preventive medicine practiced are;
Clean water Sanitation Vaccination Pre- and post-natal care Mosquito-borne and other endemic disease Health Education
The vaccination campaigns and Health Education are the work of all at the Health Centers and Posts. The other functions are the more specialized work of "Health Promoters".
Hygiene Promoters; Water & Sanitation
TASCA has worked primarily with the promoters responsible for maintaining clean water supplies and sanitation, the Hygiene Promoters. Their work is both important and difficult.
Carrying vaccines to the people, Cuá-Bocay, 2007
They work with each community in the municipality, forming and training Water Committees which are responsible for the operation and maintenance of their water systems, which are usually wells or spring-fed systems. With the Committees they educate the people of the community on the importance of clean water and good sanitation practices to health. On a regular basis they visit the communities, traveling by dirt-bike if they are lucky enough to have one or by whatever means available, sometimes on foot, or by boat on the Atlantic coast. At each visit they test several water samples for fecal contamination using primarily the Simple Field Test.
If the tests show contamination they return if possible to find and implement solutions. The response is usually to first chlorinate the system, using solid calcium hypochlorite, and then to find the source of the contamination. This can be a broken pipe or a cracked spring box or well apron which has allowed contaminated surface water to enter. Recommendations are made to the community to treat water for drinking, by boiling or chlorination, until repairs are completed.
The work does not always go as well as described, usually due to a lack of transportation or adequate training. The promoter must be well versed in many aspects of public health. as well as matters mechanical, hydraulic, microbiological and political. It is sad and ironic that no formal training is available for this important work.
Similar promoters are employed by many of the municipal authorities (alcaldía) and work in coordination with MINSA. These promoters were trained and supervised by ENACAL/DAR until its recent disbandment.
Hygiene Promoter in the field, El Cuá, 2006
Training session for Hygiene Promoters, Matagalpa, 2000