December 7th, 2014 | By Eric Peterson

The Tula Foundation's Past Work in Nicaragua

The Tula Foundation got started in Central America in 2003 working with the Centre for Nursing Studies (CNS) in St. John’s Newfoundland on a project entitled “Promoting Primary Health Care in Central America”. Although we have ended up focusing on Guatemala, in the first five years of the project we also supported a significant amount of work in Nicaragua.

The main work of the Tula Foundation was based in Bluefields on the Caribbean coast. At the request of the Ministry of Health we worked with POLISAL (the Politechnic Institute of Health) and the Bluefields School of Nursing at two field locations: Kukra Hill and Laguna de Perlas.

The following excerpt from Lonely Planet gives the flavor of this area.

"At last, you’ve arrived in the real Caribbean. Here are dirt roads and palm trees, reggae music, and an English-speaking Creole community that fishes the local waters for shrimp, fish and lobster, and still refers to Spanish-speaking Nicaraguans as ‘the Spaniards.’ You can feel the stress roll off your shoulders as soon as you get off the boat from Bluefields. And the best part is that this town still sees just a few dozen tourists a month – which means you may well be the only foreigner buzzing through the mangroves and jungle that surround Pearl Lagoon (the bay), a timeless expanse of black water home to more than a dozen ethnic fishing villages."

And it's also the southern end of the "Mosquito Coast", the domain of the indigenous Miskito people. This Creole/Miskito cultural mix makes it very distinct from the rest of Nicaragua.

Transport to the teaching sites was via canoe.

I attach the Final Report  of the work in Nicaragua, which was written by Wanda Wadman of CNS.

The Executive Summary follows here:

“The objective of the “Promoting Primary Health Care in Central America” project was to support the achievement of the millennium development goals (MDGs) in health in Central America by promoting primary health care nursing to improve access to health care in under-served rural communities of Nicaragua and Guatemala and to strengthen the policy dialogue on the role of primary health care nursing within health system reform programs. This report describes the project results for Nicaragua only.

“In collaboration with the Nicaraguan Ministry of Health (MINSA) and the Universidad Politécnica de Nicaragua (UPOLI), a carefully planned set of activities consistent with the project goals and objectives as outlined in the Logical Framework Analysis were implemented to improve access to primary health care nursing services in rural and remote communities of Nicaragua; and contribute to a Health Human Resources (HHR) regulatory environment which recognizes the role of primary health care nursing.

“The project achieved the expected results by accomplishing the following:

• increasing the number of health care workers available in vulnerable communities in rural and remote areas of Nicaragua;
• improving access to primary health care nursing services;
• improving the knowledge of community health nurses and other frontline health care workers;
• contributing to the development of a HHR regulatory environment which recognizes the role of primary health care nursing.

“These factors increased the possibility of Nicaragua improving the health indicators in relation to the MDGs.

“The beneficiaries of this project include the following:

• the newly trained health care workers, as well as those health care workers who received continuing education to better prepare them for their role in rural communities;
• the communities that received improved health care services;
• the population of men, women and children in rural and remote areas that have improved access to primary health care services.

“The project has directly contributed to improved access to primary health care nursing services for more than 373,577 people in more than 494 rural and remote communities in the departments of Madriz, Nueva Segovia, Estelí, and the Región Autónoma Atlántico Sur (RAAS). In Nicaragua, approximately 51.3% of the population are female and approximately 37.5% are children under the age of 15. Given that women and children generally tend to access health care services when needed and available, it is estimated that more than 119,778 women and 140,090 children (boys and girls) were positively impacted by this project and now have improved access to primary health care nursing services.

“Education and training, both entry level education and continuing education, was completed for 542 men and women in rural and remote areas of Nicaragua.

• 61 new graduate auxiliary nurses were prepared by distance education in the departments of Madriz, Nueva Segovia and the RAAS;
• 21 Community Health Leaders were trained in the municipalities of Las Sabanas, Macuelizo and Mozonte in the Departments of Madriz and Nueva Segovia;
• 30 professional nurses completed the “Community Health Diploma“ course in the departments of Madriz, Nueva Segovia, and Estelí;
• 312 nursing graduates received continuing education to prepare them for their role in rural communities by participating in the “Programa de Atención al Servicio Social de Enfermería” (PASSE).
• 118 others participated in workshops and conferences.

“The original intent of this project was the education and training of auxiliary nursing personnel. However, in the early stages in Nicaragua, there was limited support for this approach from government. In addition, there was opposition from the Nicaraguan Nursing Association. With the support of Canadian International Development Agency (CIDA) and through negotiation with the rural communities involved, 21 “community Health Leaders” were educated. As the project progressed, the Nicaraguan government supported the education of auxiliary nurses.

“The real challenge to extending primary health care coverage to rural areas was ensuring that, once trained, these primary health care workers would stay in their communities and provide health care services where they were needed most. This project was based on the belief that the education and training could be given quickly and effectively by utilizing distance learning methodology. The primary health care nurses were taught in their own communities or nearby districts. Following graduation, the graduates work and provide health care services in their rural home communities.

“The vision of health care in Nicaragua places emphasis on Primary Health Care and Family and Community Medicine. The government of Nicaragua is promoting rural primary health care as outlined in the Nicaraguan Ministry of Health document, “Modelo de Atencion en Salud Familiar y Comunitaria” (MOSAFC). In addition, the Plan Nacional de Desarrollo Humano (2008-2012) establishes Family and Community Medicine as the new approach, with specific emphasis on meeting the health needs of the poor and extreme poor. A principle of the model is that it will be implemented with the participation of local organizations in the communities, will respond to regional differences and epidemiological profiles, and will promote decentralization of health management and administration.

“Within the policy development component, government has outlined the role of preventative, primary health care within national health care delivery strategies in their current health care model. The Nicaraguan Ministry of Health has supported the implementation of this project and has recognized the role of nursing in providing primary health care services to rural areas.

“This project was based on the belief that nursing personnel are able to deliver quality primary health care services in a cost-effective and equitable manner across a continuum of care while extending coverage to hard to reach populations in rural and remote areas.

“In the latter stages of this project, the government and education partners exercised ownership and took an active role in achieving project results and contributing to sustainability. MINSA and UPOLI worked together to develop the set of activities necessary to achieve project results. There are a number of additional factors, as follow, that are important to the sustainability of these results.

• Appropriate curricula designed to provide the knowledge needed for primary health care workers in rural communities;
• An effective teaching model using distance methodology that allowed students to be educated in their home communities, thus increasing the likelihood that they would stay and work in that area following graduation;
• Development of institutional capacity for nursing education with distance methodology at UPOLI and MINSA;
• Achievement of technical capacity at UPOLI which included the existence of technical assets, as well as the knowledge and ability to manage these technical components;
• Development of an ICT Strategy that is an institutional framework for adopting new and emergent distance ICT platforms into the future;
• Appropriate distribution of the physical assets of the project;
• The possibility of income generation through cross-subsidization and delivery of broad-based continuing education programs for other sectors capable of paying for programming; and,
• The existence of a common vision for health care in Nicaragua which places emphasis on primary health care and family and community medicine.

“The close collaboration between a university with the institutional and technical capacity to provide nursing education at a distance (UPOLI) and a government department and employer (MINSA) that supports the underlying vision and concepts of primary health care nursing will enhance the sustainability of project results.

“The rationale and justification for the project was clear, simple, and well defined. The need for cost-effective health care workers in rural areas was well documented. The implementation of programs to support the delivery of primary health care to underserviced remote areas continues to be a concept with significant validity in many developing countries. All graduates have remained in their home areas to work with their community, whether formally employed or otherwise.

“Support from local government is critical to project success. It is important to work in a collaborative framework which considers the uniqueness and specific needs of the partner country. It is critical that the CEA develop and maintain strong communication links with local government officials. In addition, the collaboration between the local government and the local education partner contributed directly to the achievement of the expected results.

“A mid-term evaluation was completed in February 2007 and provided guidance to strengthen the project. The mid-term evaluation recommendations were reviewed by CNS and CIDA to determine which were relevant in the current project context (See Appendix B). The project subsequently received an increase in time and funding which was essential to implement those recommendations, maximize results and ensure sustainability.

“The project ‘Promoting Primary Health Care in Central America’ has achieved the expected results as indicated in the LFA. Nursing is seen by stakeholders in Nicaragua as an important component of care within the primary health care delivery model.”

Tula Foundation

In those years the Tula Foundation acted as a flexible partner to complement to the CIDA-sponsored work of CNS. Two areas are highlighted in the project report:

• Taking the work into a new geographical region when the opportunity arose.
• Providing flexible funding for students and project personnel.

Here are two excerpts from the report:

“The CNS developed a partnership with the Tula Foundation, a Canadian philanthropic organization based in British Columbia (www.tula.org). This collaboration resulted in an innovative approach which gave financial flexibility to the project and allowed programming that was complementary to and supportive of the CIDA project activities. In Nicaragua, the Tula Foundation funded a large component of the project extension in the RAAS. In addition, the Tula Foundation, along with the CNS and PDCS, funded the ICT strategy assessment. This strategy provided the framework for decision making with respect to technologies.”

…

“Some students experienced financial difficulties, particularly due to the high costs of transportation to the teaching sites. Several strategies were implemented to deal with this situation. In subject areas where it was possible, there was some combining of teaching experiences to decrease the amount of travel required. Some clinical experiences were arranged at health posts located closer to the students’ home communities. In addition, the becas (scholarships) given to students were increased as necessary to help offset these costs. The mayors of the towns also supported the students with donated food and accommodations as needed during the course. It is very important that the situation of significant economic hardship for these students be considered. With the support of the Tula Foundation, the CEA was able to provide additional funding in these circumstances. In addition, the methodology chosen was effective in allowing the students continued opportunity for paid work. As the usual one-year program was delivered over a fifteen-month period, students were not required to be in school 5 days per week and, therefore, had some additional time for paid employment to support their families.”