Preventive Health Model for the North Atlantic Autonomous Region of Nicaragua

Dr. Robert Holmberg

I. History, Goals and Key Achievements – Bilwaskarma Clinic


In 1930 the Moravian Church established a renowned hospital and nursing school in Bilwaskarma.  During the civil war of the 80s both the hospital and nursing school were destroyed.  In the beginning of the 90s the communities near Bilwaskarma started to look for ways to recover their health system.  In 1996 Bilwaskarma community members, the Nicaraguan Ministry of Health (MINSA), the Moravian Church of Nicaragua and of the US and various volunteers built a clinic with 12 beds.  This clinic has a physician and nurses that attend close to 300 patients per month.

Currently, the Bilwaskarma Clinic offers numerous services including periodic surgeries, outpatient services, internment, birthing, and community visits.  The clinic is administered by Dr. Patricia Ballesteros.  The clinic is supported by the Moravian Churches in Nicaragua and the US, Partners in Health of Maine, and the Strachan Foundation.

Key Achievements

The Bilwaskarma Clinic attends 300 patients on average per month or a total of 3600 patients per year.  In addition, the clinic has trained close to 70 community members, 14 health promoters, and 10 nurses aides in preventive health education.  In 2008 community members and health promoters also received training in the CBIO methodology.  These members participated in the community mapping and census of the 10 villages participating in the project.

II. Project Description

Preventive Health Model for the RAAN is a community-based preventive health care project that will enable rural communities in northeastern Nicaragua with little access to health care to identify the most significant causes of morbidity and mortality in their communities and implement appropriate health interventions.  The project uses a methodology developed by Curamericas called the Census-Based Impact Oriented Methodology or CBIO.  This methodology is currently being implemented by the Bilwaskarma Clinic in 10 communities of the Municipality of Waspam near the Coco River, namely, Saupuka, Bilwaskarma, Klar, Sakling, Uhry, Batchilaya, Tuskrusirpy, Tuskrutara, Wasla, and Koom.  The project is implemented by the Bilwaskarma Clinic and Health Unlimited of Nicaragua.

Project Goal

Reduce morbidity and mortality of rural communities in the municipalities of Waspa

The activities to reach each one of these objectives are the following:

Objective 1:  10 rural communities of the municipality of Waspam identify health priorities in their communities and target appropriate interventions.


HU staff offers Bilwaskarma staff monthly training and coaching

Bilwaskarma Clinic staff offer training to health promoters from the 10 participating villages.

Health promoters monitor health practices in their communities.

Health promoters offer presentations on health topics in their communities.

Health promoters prepare monthly reports on community illnesses and deaths

Bilwaskarma Clinic staff make monthly visits to the communities

Objective 2:  One community of the municipality Francia Sirpy and one of Santa Marta implement a community census and train health promoters to identify health risks.


Bilwaskarma Clinic staff offers training to health promoters from Francia Sirpy and Santa Marta in the CBIO methodology.

Bilwaskarma Clinic conduct monitoring visits and assists health promoters in the census and community mapping of Francia Sirpy and Santa Marta.

Objective 3:  Bilwaskarma Clinic staff develops a regional plan with the local and regional health committees to extend the CBIO methodology to other municipalities


Bilwaskarma staff coordinates meetings with local and regional MINSA commissions to develop an implementation plan of the CBIO methodology on a regional level.

Bilwaskarma staff offer updates to MINSA local and regional commissions on CBIO implementation in Waspam, Francia Sirpy and Santa Marta

Needs and Challenges this Project Addresses

Preventive Health Model for the RAAN addresses the lack and difficult access to adequate health care that many rural communities face.  The average life expectancy in Nicaragua is the lowest in the region with infant mortality rate at 30 per 1,000.  Malnutrition among children is 40% and maternal mortality is about 230 deaths per 100,000.  These indicators are even worse in the RAAN.

Although the RAAN has sought to decentralize health care by forming local, municipal, and regional commissions to deal with health policy, local participation still needs to be emphasized.  This project provides a viable model for strengthening local participation.

Opportunities, Assets, and Strengths of the Project

The CBIO methodology is being implemented successfully in the 10 communities near the Bilwaskarma Clinic.  In 2008 health promoters, with the assistance of Bilwaskarma Clinic and supervision of Health Unlimited staff, successfully carried out a community census in each one of the communities and identified the priorities for 2009.  This year health promoters will receive training in XXX, YYYY and ZZZZ.  In addition, health authorities in Waspam have expressed interest in the CBIO methodology applied in the 10 communities near the Bilwaskarma Clinic.  This openness to learning about the CBIO methodology is an important asset in getting the model replicated in other municipalities and in the region.  Con el uso de esta metodologia hemos logrado establecer lazos con las comunidades, hemos logrado obtener datos sensales reales, hemos logrado disminuir la mortalidad infantile por enfermedades communes de la infancia y sobre todo hemos logrado encontrar que ademas de nuestros grupos de riesgos que principalmente son el binomio madre hijo, que han aumentado el numero de embarazos en pre adolecentes (ninas entre 11 y 15 anos) y que ademas tenemos problemas de drogadiccion y alcohol en adolecentes, por lo que estos seran considerados como nuevos grupos de riesgos en nuestro territorio. Using this methodology we have established links with the communities, we have secured actual (real) census data, we have managed to reduce infant mortality from common childhood diseases.  We also found that in addition to our risk groups, primarily the mother-child binomial (pairing?), the number of pregnancies in pre-adolescents (girls aged 11 to 15 years) have increased and we have problems with drugs and alcohol in teenagers.  Consequently, these will be considered as new risk groups in our territory.

The Bilwaskarma Clinic has received funding from the Strachan Foundation and from Partners in Health of Maine.  The former is a family foundation that operates out of Costa Rica and offers funding to NGOs working on education and health in Central America.  Partners in Health of Maine is an NGO operated by a group of physicians from Maine.  In addition to supporting the Bilwaskarma Clinic, Partners in Health operates several health programs in Puerto Cabezas and brings a group of surgeons each year to provide surgery for community membe

II. Project Management and Staffing

a) Project Staff and Volunteers

Bilwaskarma Clinic Staff

Patricia Ballesteros, MD is a graduate from UNAN Medical School in Managua.  She has 18 years of primary care attention, 8 years of experience as an administrator, and 5 years of experience in pediatric secondary attention.  She currently works as Director of the Bilwaskarma Clinic and Program Manager for Partners in Health of Maine.  Dr. Ballesteros? responsibilities include staff supervision, management of all monies, and communication with donors.  Dr. Ballesteros lives in Puerto Cabezas.

Frecia Thomson, MD is a graduate from UNAN Medical School in Managua.  She has three years of experience as a physician.  She is the local project coordinator, responsible for training of health promoters and project monitoring together with Clara Muller.

Clara Muller is a registered nurse.  Her work has focused on infant and maternal health care, obstetric emergencies, epidemiological monitoring, and evaluation of water and sanitation projects.  She is a midwife trainer as well.  Clara has been responsible for training community members, health promoters and health auxiliaries.

Nursing staff:  Each community has either a nurse or nurse?s aide for a total of 9 staff members [1] covered by the Ministry of Health (MINSA).  These staff members are the first reference point for community members.  They receive training and work together with the volunteer health leaders.

Volunteers:  The project has 14 health leaders that work as volunteers.  They are an essential part of the project and serve as a liaison with each community health committee that in turn has 5 to 7 volunteer members.  The health leaders have been trained in a variety of topics including:  preventable infancy illnesses, vaccines, community health, hygiene, traditional medicine, water and sanitation, epidemiology, malnutrition, birthing, community organization, leadership, HIVAIDS, prescription of basic medications, and CBIO methodology.

Health Unlimited Staff

Florence Levy, MD, MPH is the Country Director for Health Unlimited in Nicaragua.  Dr. Levy has extensive experience working with the Ministry of Health, international agencies, and international NGOs within the health sector, holding managerial positions.  She has a strong personal interest in woman and youth sexual and reproductive health rights.  She holds an MPH from the London School of Hygiene and Tropical Medicine (1995) and an MD from the UNAN School of Medicine (1991) in Managua.

Ivannia Lopes, MD, MPH, MS is the Safe Motherhood Program Coordinator for Health Unlimited (HU).  This program seeks to decrease child and mother morbidity and mortality in the RAAN.  She is also the technical advisor for the Bilwaskarma Clinic medical team.  Dr. Lopes is a physician with degrees in anthropology (Universidad de URACCAN, 2007) and a Master?s in Public Health (Universidad de, CIES-UNAN Managua 2005).  Dr. Lopes has been working for HU for 8 years. She has extensive experience training community health workers and in program management.  Dr. Lopes will offer training to Bilwaskarma Clinic staff and help to monitor the project.

b) Level and nature of the involvement of key project partners, local residents, and the community at large

Key project partners include the following:

Nicaraguan Ministry of Health (MINSA)

MINSA has played a fundamental role in the project.  Since the beginning of the Bilwaskarma Clinic, it has covered the salaries of the clinic physician and nurse as well as medications.  The clinic also has a strong relationship with the MINSA hospital in Waspam and refers cases to them that need greater attention than what the clinic is capable of offering.

Moravian Church of the US and Nicaragua

The Bilwaskarma Clinic is property of the Moravian Church of Nicaragua.  Although the Moravian Church has not been actively involved in the operation of the clinic, its legal status depends on the church.  In addition, the Moravian Church of the US offers funding for the clinic?s administration.

Partners in Health of Maine (PIHM)

PIHM has maintained an active role with the Bilwaskarma Clinic, sending medical brigades at least once a year to perform surgeries and offering funding.  In addition, members of this NGO have offered technical support throughout the clinic?s existence.  One of its most active members, Dr. Peter Haupert, was a surgeon at the Bilwaskarma Clinic at the height of its operations before the civil wars of the 80s destroyed the clinic and nursing school.

The Strachan Foundation

The Strachan Foundation is a family foundation that operates out of Costa Rica and has offered financial and technical support to the Bilwaskarma Clinic over the last 5 years.

The Bilwaskarma Clinic fills an important need for the surrounding communities.  It was at the behest of community members that the clinic was rebuilt after the war.  The clinic?s outreach program continues to be an important tool for community members to reduce morbidity and mortality in their communities.

c) Future plans for sustaining this effort and building a funding base.

Partners in Health of Maine and the Moravian Church in the US are the primary donors of the Bilwaskarma Clinic and together maintain the basic functioning of the clinic.  The Strachan Foundation?s financial commitment to the Bilwaskarma Clinic ends in 2009.

Dr. Ballesteros is looking for additional funds from other US foundations including the Glaise Foundation, the Kellogg Foundation, the Haus Foundation, the Brush Foundation, the Kings Foundation, and Mattel Foundation.  The Bilwaskarma Clinic will be sending concept papers to these foundations in 2009 to continue to strengthen its outreach program.

IV.  Monitoring and Evaluation Plan

Criteria for Success

Bilwaskarma staff in consultation with health promoters and community members have set as a priority attending to children under 5 years of age and pregnant women.  This priority is reflected in the short term and long-term project indicators below.

Short Term Outcome Indicators

1. Community members are aware of basic hygiene practices in order to prevent illness in their children.

2. Community members recognize early symptoms of diarrhea and respiratory infections and take children to the clinic before cases become critical.

3. Pregnant women go to the clinic for prenatal check ups and strive for a hospital delivery.

4. Que loss jovenes tengan mayor acceso a la informaci?n sobre educacion sexual y conocimiento de m?todos y formas de prevenci?n de enfermedads de trasmisi?n sexual y vih.  That the young people have greater access to information on sexual education and knowledge of methods and ways of preventing sexually transmitted diseases and HIV.

Short Term Process Indicators

1. Health promoters conduct home visits and verbal autopsies on a monthly basis.

2. Health promoters offer presentations on health topics once a month.

3. Bilwaskarma staff track health indicators on a regular basis.

Long Term Outcome Indicators

1. Reduction of morbidity and mortality in children under 5 years of age and pregnant women in the communities attended.[2]

2. Reduction of acute diarrheic illnesses in children under 5 years of age in the communities attended.

3. Reduction of acute respiratory illnesses in children under 5 years of age in the communities attended.

4. Difficult births are monitored and referred to Waspam Hospital.

5. Reducir el numero de embarazos en pre adeolecente en el area de Bilwaskarma. Reduce the number of pre adolescent pregnancies in the Bilwaskarma area.

6. Continuar con los procesos educativos haciendo mayor ?nfasis en las enfermedades de trasmisi?n sexual, principalmente hiv, para asi podrar lograr disminuir la incidencia, morbilidad y mortalidad  por hiv.  Continue the educational process placing greater emphasis on sexually transmitted diseases, especially HIV, in order to achieve the reduction in the incidence of and the morbidity and mortality from HIV.

7. Exterder los grupos de autocuidado de madres con hijos menores a las otras comunidades del territorio. Extend the self-help groups of mothers with young children to the other communities in the territory.

8. Implementar los grupos de autocuidado de j?venes a las otras comunidades.  Implement self-care groups of young people to other communities.

Evaluation Process methodology uses a planning and evaluation process that is designed to empower community health workers and provide information that can be acted upon thereby reducing morbidity and mortality in the targeted communities.  The CBIO methodology has three sets of measurement tools and three coverage strategies:

Measurement Tools


1. Census and baseline assessment.  Community members actively engage in a community mapping and census, providing basic demographic information and health status for each family.  Focus groups are used to develop a baseline for the community and understand community health priorities.

2. Health services and health status tracking system.  Staff members use family health folders to track health services.  Registers are also kept about particular age and sex groups, for example, children under five, malnourished children, pregnant women, etc.

3. Vital events and verbal autopsies.  Health promoters conduct verbal autopsies of preschool children and mothers that die during pregnancy, trying to find out possible cause of death.  Mortality data is then reviewed every three months.

Coverage strategies:

1. Home visits.  These visits are key in identifying illness and acting upon them before they become critical.  It is also a good way of interacting with people that may not normally seek the services of the clinic.  DESCRIBIR QUE HACE EL EQUIPO BILWAS DESCRIBE WHAT THE BILWAS TEAM DOES.

2. Group meetings.  Health education and health services are offered in a centralized community location.  This is a more efficient and cost-effective than home visits because health workers can reach a larger number of people at once.  DESCRIBIR QUE HACE EL EQUIPO BILWAS DESCRIBE WHAT THE BILWAS TEAM DOES.

3. Care groups.  Some CBIO groups have started using Care groups that rely on volunteers who carry health education messages and some services to each household with preschool children while bringing program service and vital events information back to project staff.  DESCRIBIR QUE HACE EL EQUIPO BILWAS DESCRIBE WHAT THE BILWAS TEAM DOES.

An annual assessment of health program outcomes and health priorities also allows staff to make changes to the intervention that is responsive to community needs.

[1] Bachilaya, one of the 10 communities participating in the project, is the only community that does not have its own nurse or nurse?s aide.

[2] Note:  It would be difficult to attribute morbidity and mortality reduction solely to the project.  There are other factors that could influence morbidity and mortality such as hurricanes, the impact of other projects in the area, and other external factors.  However, comparing morbidity and mortality from one year to another gives some general indication of the health status of the communities attended and how this is changing over time.