Like education, health care was among the top priorities of the Sandinista government. At the end of the Somoza era, most Nicaraguans had no access or only limited access to modern health care. Widespread malnutrition, inadequate water and sewerage systems, and sporadic application of basic public health measures produced a national health profile typical of impoverished populations. Enteritis and other diarrheal diseases were among the leading causes of death. Pneumonia, tetanus, and measles, largely among children less than five years old, accounted for more than 10 percent of all deaths. Malaria and tuberculosis were endemic.

By the beginning of 1991, twenty-eight persons had tested positive for the human immunodeficiency virus (HIV) that causes acquired immune deficiency syndrome (AIDS), and eight of those individuals had died. These figures were low in comparison with neighboring countries, but health officials regarded them as accurate because the government had conducted an aggressive search for HIV among prostitutes, blood donors, and tuberculosis patients in the late 1980s. The same officials cautioned against complacency toward AIDS. A large number of sexually transmitted diseases was reported in Managua and Bluefields, and if HIV were introduced into groups with multiple sex partners, AIDS cases would rise rapidly.

Nicaraguans depend on a three-tier health system that reflects the fundamental inequalities in Nicaraguan society. The upper class uses private health care, often going abroad for specialized treatment. A relatively privileged minority of salaried workers in government and industry are served by the Nicaraguan Social Security Institute. These workers and their families compose about 8 percent of the population, but the institute devoured 40 to 50 percent of the national health care budget. The remainder of the population, approaching 90 percent, is poorly served at public facilities that are typically mismanaged, inadequately staffed, and underequipped. Health care services are concentrated in the larger cities, and rural areas are largely unserved. In fact, the Ministry of Health, which has sole responsibility for rural health care, preventive health care, and small clinics, received only 16 percent of the health budget, most of which it spent in Managua.

In the early 1980s, the Sandinista government restructured and reoriented the entire health care system. Following a recommendation made by AID in 1976, authorities combined the medical functions of the Ministry of Health, the Nicaraguan Social Security Institute, and some twenty other quasi-autonomous health care agencies from the Somoza era into a unified health care system. Within a few years, spending on health care was substantially increased, access to services was broadened and equalized, and new emphasis was placed on primary and preventive medicine. During this period, the number of students annually entering medical school jumped from 100 to 500, five new hospitals were built (largely with foreign aid), and a national network of 363 primary care health clinics was created. With help from the United Natibf6 tions Children's Fund (UNICEF), 250 oral rehydration centers were established to treat severe childhood diarrhea, the leading cause of infant deaths, with a simple but effective solution of sugar and salts. The Ministry of Health trained thousands of community health volunteers (health brigadistas) and mobilized broad community participation in periodic vaccination and sanitation campaigns.

The expansion of access to health care was reflected in a doubling of the number of medical visits per inhabitant and a reduction from 64 percent to 38 percent in Managua's share of total medical visits between 1977 and 1982. These early years also saw a substantial drop in infant mortality and reductions in the incidence of transmittable diseases such as polio, pertussis, and measles.

In health as in education, some of the ground gained in the early 1980s was lost during the second half of the decade. Health care activities, including vaccination campaigns, had to be curtailed in regions experiencing armed conflict. The health care system was flooded with war victims. Among an increasingly impoverished population, children especially grew more vulnerable to disease. But the steep economic decline and tight budgetary restraints of the period resulted in severe shortages of medicines and basic medical supplies. In addition, deteriorating salaries drove many doctors out of public employment.

Despite the problems of the late 1980s, however, the Sandinista decade left behind an improved health care system. According to a 1991 AID assessment of Nicaraguan development needs, the Chamorro government inherited a health care system that emphasized preventive and primary care targeted the principal causes of infant, child, and maternal mortality provided broad coverage and elicited high levels of community participation. The AID report noted the effectiveness of the oral rehydration centers, the wide coverage of vaccination campaigns, and the key role of the health brigadistas, three programs maintained by the new government. The report concluded that the major problem of the health sector was lack of budgetary resources.

Data as of December 1993