Nicaragua

The Health in the Americas+¹ country profiles are based on the interagency indicators available as of the dates referenced. The sources are referenced in this table. In some cases, the values of the indicators may differ from the most recent data available in the country.

Environmental and social determinants of health

In 2000 the total population of Nicaragua was 5 123 222 inhabitants; by 2023 this figure had risen to 7 046 310, representing a 37.5% increase. Regarding the country’s demographic profile, in 2023 people over 65 years of age accounted for 5.4% of the total population, an increase of 2.2 percentage points compared to the year 2000. In 2023, there were 102.9 women per 100 men and 18.5 older people (65 years or older) per 100 children under 15 years of age, as can be seen in the country’s population pyramids, distributed by age group and sex (Figure 1). Considering the population between 15 and 64 years of age to be potentially active (i.e., potential participants in the labor force), this group represented 65.2% of the total population of the country in 2023 (4 594 767 people). When we add these figures to the potentially passive population (2 068 160 under 15 years of age and 383 384 over 65 years of age), the result is a dependency ratio of 53.4 potentially passive people per 100 potentially active people. This ratio was 77.5 in 2000.

Life expectancy at birth in 2023 was 74.8 years, lower than the average for the Region of the Americas and 7.6 years higher that in 2000.

Figure 1. Population pyramids of Nicaragua, years 2000 and 2023

The unemployment rate in 2022 was 5.6%. Disaggregated by sex, the rate was 5.7% for women and 5.5% for men.  The literacy rate was 82.6% in 2015. In men, this figure was 82.4%, and in women, 82.8%. In addition, 24.9% of the population was below the national poverty line in 2016, a decrease from 45.8% in 2001. In 2019, 3.4% of the population was living in poverty, defined as the percentage of the population with an income of less than US$ 1.90 per day; this is above the regional average of 3%. 

During the period 2000-2021, the country improved its score on the Human Development Index, with an increase of 17.8% (from a score of 0.566 to a score of 0.667); during the same period, the index rose 13.5% internationally and 9.4% in Latin America (Figure 2).

Figure 2. Human Development Index in the Region of the Americas, 2021

In 2020, public expenditure on health accounted for 5.34% of gross domestic product (GDP) (Figure 3) and 18.42% of total public expenditure, while out-of-pocket spending on health accounted for 32.27% of total health expenditure.

Figure 3. Domestic general government health expenditure as percentage of gross domestic product, 2020

Digital coverage

In 2021, 57.1% of the population had an internet connection, representing a considerable increase from 2000, when 1.0% of the population had an internet connection.

Health situation

Maternal and child health

Between 2001 and 2019, infant mortality in Nicaragua decreased from 30 to 12.7 deaths per 1000 live births, a decrease of 57.7% (Figure 4). The percentage of low-weight births (less than 2500 g) decreased from 8.2% to 7.8% between 2001 and 2019, while exclusive breastfeeding in the child population up to 6 months of age was 31.1% in 2001 and 30.67% in 2006 (latest available data).

Regarding the immunization strategy, measles vaccination coverage was 100% in 2022, the same percentage as in 2000.

The maternal mortality ratio for 2020 was estimated at 77.9 deaths per 100 000 live births, a reduction of 53.9% from the estimated value for 2000 (Figure 5). In relation to fertility, it is estimated that in 2023 women had an average of 2.3 children throughout their reproductive lives. In the specific case of adolescent fertility, there was a 27.6% decrease, from 113.9 live births per 1000 women aged 15 to 19 years in 2000 to 82.5 in 2023. In 2019, 97.4% of births were attended by skilled birth personnel. These data are not in line with the country's reports, which state a maternal mortality ratio of 73.3 for 2000 (93 maternal deaths) and 31.4 for 2021 (37 maternal deaths), a reduction of 57% for the period 2000–2021. 

In relation to fertility, it is estimated that in 2022 women had an average of 2.3 children throughout their reproductive lives. In the specific case of adolescent fertility, there was a 26.3% decrease, from 113.9 live births per 1000 women aged 15 to 19 years in 2000 to 84.0 in 2022. Between 2008 and 2020 the percentage of pregnant people who had four or more consultations for antenatal care increased from 61% to 95.4%. In 2020, 96.8% of births were attended by skilled birth personnel.

Figure 4. Infant mortality per 1000 live births, 1995–2020

Figure 5. Maternal mortality per 100 000 live births, 2000–2020

Communicable diseases

In 2021, there were 27 new cases of tuberculosis per 100 000 population in Nicaragua. In 2019, the overall tuberculosis mortality rate (age-adjusted and per 100 000 population) was 2.2 (1.5 in women and 3.0 in men).

In 2021, the estimated human immunodeficiency virus (HIV) infection incidence rate (new diagnoses) was 13.7 per 100 000 population. The age-adjusted mortality rate for HIV was 2.4 per 100 000 population in 2019. It should be noted that during the 2000-2019 period this indicator decreased by 27.2%.

There were no reported cases of human rabies in the country in 2020.

Noncommunicable diseases and risk factors

In Nicaragua, the prevalence of overweight and obesity among people aged 15 and older was 58.2% in 2016.

In 2015, the reported prevalence of arterial hypertension (high blood pressure) among people aged 18 years or older was 20.8%, a decrease of 2.5 percentage points compared to 2000 (23.3%). The prevalence of diabetes mellitus, which stood at 7.9% in 2000, increased to 10.1% in 2014.

Mortality

In 2019, the adjusted rate of potentially preventable premature mortality in Nicaragua was 272.4 deaths per 100 000 population, a decrease of 11.7% compared to the rate of 308.6 in 2000. This meant that, in 2019, the rate in the country was 20.2% higher than the average rate reported for the Region of the Americas as a whole. Among potentially preventable premature deaths, the rate for preventable causes was 129.9 per 100 000 population in 2019, which is 5.3% lower than the regional average rate; and the rate for treatable causes was 142.5 per 100 000 population, above the regional average of 89.6.

The overall age-adjusted mortality rate was 6.5 per 1000 population in 2019, a decrease of 5.8% compared to 2000 (6.9 deaths per 1000 population).

When deaths are categorized into three main groups, it is observed that, in 2019, the age-adjusted mortality rate from communicable diseases was 51.1 per 100 000 population (59.7 per 100 000 in men and 44.1 per 100 000 in women), while the age-adjusted mortality rate from noncommunicable diseases was 547.6 per 100 000 population (670.5 per 100 000 in men and 453.2 per 100 000 in women). The rate of age-adjusted mortality from external causes was 48.8 per 100 000 population (81.7 per 100 000 in men and 19.5 per 100 000 in women), including road traffic accidents (18.7 per 100 000 population), homicides (9.5 per 100 000 population) and suicides (4.7 per 100 000 population). In 2000, the percentage distribution of causes was 64.4% for noncommunicable diseases, 24.0% for communicable diseases, and 11.4% for external causes; in 2019, the percentages were 81.6%, 9.5%, and 8.9%, respectively (Figure 6).

Figure 6. Proportional mortality in Nicaragua, 2000 and 2019

Cancer mortality

Regarding cancer mortality from tumors, in 2019, the adjusted mortality rate from prostate cancer was 20.6 per 100 000 men; lung cancer, 8.1 per 100 000; and colorectal cancer, 6.9 per 100 000. In women, these values were 10.1 deaths per 100 000 for breast cancer; 4.3 per 100 000 for lung cancer; and 6.4 per 100 000 for colorectal cancer.

The health situation and the COVID-19 pandemic

In 2020, Nicaragua ranked 44th in the Region of the Americas in terms of the number of deaths from COVID-19, and 51st in 2021, with a cumulative 30 deaths per million population over the two years (Figure 6). 

As of 31 December 2021, at least one dose of COVID-19 vaccine had been given to 84.6% of the country's population. As of 2 July 2022 (latest available data), 82.1% of the population had completed the vaccination schedule. The vaccination campaign began on 20 March 2021, and nine types of COVID-19 vaccine have been used to date.

Figure 7. Cumulative COVID-19 deaths in the Region of the Americas, to July 29th, 2023

Prospects

Measures to achieve universal health coverage

The public policies pursued by Nicaragua are aimed at achieving universal health coverage. Initiatives implemented with this aim include the following:

• Restoring the right to health and free health care.
• Implementing the Family and Community Health Model (MOSAFC), focused on health promotion and risk prevention.
• Free and universal access to comprehensive health services.
• Developing a national culture of prevention and protecting the health of Nicaraguans.
• Implementing a health-based approach in all public policies.
• Intercultural adaptation of MOSAFC in Nicaragua’s Caribbean Coast region.
• Sectorization of health care by Family and Community Health Teams and comprehensive intercultural health groups.
• Expanding the national laboratory network and developing the infrastructure of the health services network.
• Reducing gaps in training and in the distribution of human resources for health.

Challenges related to population health

Given that the public health system provides services to 80% of the country's population, its main challenge is to continue strengthening MOSAFC in the areas of individual, family, and community care, adopting an intercultural approach, and developing the health services networks.

The Government of Nicaragua has increased the public budget for health, and has encouraged coordination and cooperation among the various stakeholders in health, with the aim of strengthening:

• Development and management of human resources for health.
• Health system capacity to respond to endemics, outbreaks, epidemics, and pandemics.
• Development of the information and communication technology system of the Ministry of Health (MINSA).
• Management of medical supplies and rational use of medicines.
• Capacities of the National Health Regulation Authority.
• Planning, evaluation, and data management capacities at the local, national, and subregional levels.
• Development of the Nicaraguan Institute for Health Research.

COVID-19 pandemic response

The pandemic response plan, led by MINSA, continues several current initiatives, including:

• Implementation of a national strategy for quality in health care.
• Development of scientific/technical capacities for laboratory surveillance of emerging, re-emerging, and pandemic diseases caused by viruses, bacteria, fungi, and parasites.
• Strengthening the skills and competencies needed to implement predictive models for epidemiological, entomological, and virological surveillance.
• Implementing health intelligence rooms. 
• Strengthening national capacity to address immunopreventable diseases.
• Digital transformation of the health sector.

Measures to reduce inequalities in health

Public policy in this area involves addressing the social determinants of health, with a range of actions and initiatives, including:

• Developing road infrastructure to increase the flow of collective, selective, and private transportation, thereby facilitating access to health facilities.
• Expanding telephone connectivity throughout the country to facilitate communication in the community network for families, community, and health units.
• Reducing unmet basic needs such as access to safe drinking water, sanitation, electricity, and housing.
• Strengthening the care provided by Family and Community Health Teams and by comprehensive intercultural health groups in order to support health promotion, disease prevention, and basic health care in areas with the most exposed and vulnerable populations (territorial units with less than 5000 inhabitants in urban areas and less than 3000 inhabitants in rural areas).

The national strategy also provides for a series of measures targeting the health system, namely:

• Reorganizing the health services network. 
• Expanding the laboratory and imaging network.
• Periodic and systematic deployment of integral health brigades in remote and hard-to-reach areas.
• Establishing health fairs with mobile medical units, under the My Hospital in My Community initiative, with major participation by the community network, including families, communities, and different specialties in the field of health. 
• Transporting patients from the municipalities where they live to hospitals capable of handling more complex health problems. Ambulances have been provided for this purpose to all of the country’s municipalities and hospitals.
• Continuity of care, provided house by house by family and community health teams, aimed at serving priority groups such as households with young children, people with disabilities, and people with chronic diseases.

National strategy to address inequalities in health

Public policies, specifically the national strategy for reducing health inequalities, are directed primarily at:

• Free, quality health care.
• Free delivery of generic medicines. 
• Specialized clinical and surgical care.
• Cultural adaptation, and development of the intercultural health care model in the North and South Caribbean Coast regions.
• Recovery of ancestral traditional medicine and strengthening of natural medicine and alternative therapies.
• Integral development of human resources for health, based on the needs of the health sector. 

The sources of the interagency indicators used in this profile can be found in this table.

For the latest data on health indicators for the Region of the Americas, be sure to visit the PAHO Core Indicators portal.