Where Are the Doctors? Nicaragua Among Countries With the Fewest Medical Personnel

Nicaragua ranks among the three countries in the Americas with the lowest number of medical personnel—including doctors, nurses, and midwives—available to meet the healthcare needs of its population. According to the World Health Organization’s (WHO) standard benchmark, at least 44.5 health workers are needed per 10,000 people. Nicaragua barely reaches half that target. What factors contribute to this low average, which results in fewer consultations or poor-quality care—despite the government’s promise of free healthcare?

Rubén, a doctor in southern Nicaragua, says that firings, summons and threats, surveillance, the shutdown of medical organizations, and lack of hiring are part of the daily reality for doctors in the country.

“It is a reality that anyone who goes to a health center or hospital in Nicaragua can see — there are not enough of us to attend to patients, and that is evident,” he stresses.

This has been the case “for years,” says the doctor, who has worked for the Ministry of Health (MINSA) for over a decade. But he believes that since 2018, “hostility and pressure have intensified.”

“There have been many dismissals of staff who protested or helped demonstrators seen as opposition supporters, and many others have resigned out of exhaustion. The reality is that we’re always understaffed, even if we manage to get things done,” he says.

Nicaragua Stagnant in Health Worker Hiring

At the end of April 2025, the Pan American Health Organization (PAHO) published a report titled “The Health Workforce in the Americas: Data and Regional Indicators.” The study examines data from 39 countries and territories that make up PAHO, focusing on eight key health occupations: medicine, nursing, midwifery, dentistry, pharmacy, physiotherapy, psychology, and community health work.

Researchers analyzed the most recent data available for each country between 2017 and 2021 and warned that “without immediate intervention,” the Americas could face a shortage of between 600,000 and 2 million healthcare workers by 2030.

“Health workers are the backbone of our health systems. Without them, it’s simply not possible to talk about access or universal coverage,” said PAHO Director Jarbas Barbosa when presenting the study.

“This report gives us concrete data to guide investment in training, retention, and decent working conditions—ensuring that healthcare reaches everyone,” Barbosa added.

But Nicaragua’s situation has not changed since the period covered in the study—at least not in the public sector. Between January 2015 and March 2025, the average number of health workers in the country rose by only 2,021 people, according to official figures from the Central Bank of Nicaragua (BCN), analyzed by CONFIDENCIAL.

In 2015, the average annual number of public-sector health workers was 18,446. By the first quarter of 2025, that figure had only grown to 20,467.

The analysis of official statistics also shows that although the number of health workers has increased since 2015, there were years—such as 2020 and 2023—when the annual average actually dropped compared to the previous year. The downward trend returned in the first quarter of 2025.

Health sector with much room for improvement

Only two countries rank below Nicaragua in the average number of healthcare workers: Honduras and Haiti.

The study reports that the regional average in the Americas is 66.57 health workers per 10,000 people, but researchers point out significant disparities across the region.

On one end of the spectrum, countries like Cuba, the United States, and Canada nearly quadruple the WHO benchmark. On the other, Bolivia, St. Kitts and Nevis, Jamaica, Belize, Guatemala, Venezuela, Saint Lucia, Colombia, the Dominican Republic, Peru, and Suriname round out the list of countries with the lowest number of medical personnel.

The PAHO report warns that without strategic investments in training, regulation, working conditions, and equitable distribution of healthcare workers, it will be impossible to build health systems that are “truly universal, equitable, and resilient.”

“The challenge isn’t just having more healthcare professionals,” PAHO Director Jarbas Barbosa stressed, “but making sure they are where they’re needed most and have the right skills to meet the population’s needs.”

The report notes that the COVID-19 pandemic exposed major global weaknesses in the healthcare sector, including staffing shortages, difficulty retaining personnel, unequal distribution, and insufficient investment in training—issues that hinder the development of resilient health systems capable of responding to emergencies.

The pandemic also revealed a widespread “lack of data for proper health workforce planning” in many countries in the region.

For instance, the report points out that in Nicaragua, Dominica, the Bahamas, the Dominican Republic, Grenada, Bolivia, Colombia, Costa Rica, Cuba, Ecuador, El Salvador, and Guatemala, there is no data available on midwifery personnel.

Healthcare Workers in Nicaragua: “We’re Under Surveillance”.

Byron has worked at the Ministry of Health (MINSA) for over two decades and says he’s considered quitting several times. “I don’t do it because I don’t have any other job options—and I’d leave with practically nothing now that they’ve cut back severance pay for public employees,” he says.

In November 2023, the Nicaraguan government passed a law drastically reducing severance packages for public sector workers who resign. Under the new law, only employees with at least three consecutive years of service are eligible—unlike the previous law, which granted compensation starting from the first year. Now, those with 3 to 10 years of service receive only one month’s salary; 10 to 15 years: two months; 15 to 20 years: three months; and only those with more than 20 years get five months’ salary.

Byron also explains that since 2018 and especially after the COVID-19 pandemic, healthcare workers in Nicaragua have had to keep quiet about public administration and working conditions. “We keep our mouths shut so we don’t say a single word of criticism against the government,” he explains.

“I’ve seen many colleagues get fired—just for making a minor complaint, for pointing out a lack of medicine, or even because they were suspected of talking to independent journalists,” he adds.

He says medical personnel are constantly being cycled through: “They fire people, hire new ones, and then fire again—but the overall numbers stay more or less the same.”

For Byron, switching to the private sector isn’t a viable option either. “It’s not growing much, and those who quit usually end up doing something completely different,” he says.

“Low wages and enforced political loyalty.”

Ana Quirós, a public health specialist who was exiled from Nicaragua in 2018 for participating in the April Rebellion protests, has continued her work in Costa Rica, focusing on the Nicaraguan migrant and exile community. She says that in Nicaragua, hiring practices and the current medical workforce are shaped by “low wages and enforced political loyalty.”

“Health professionals are subjected to arbitrary decisions—from being forced to participate in rallies they have no interest in, to being ordered to stop treating patients based on their political leanings,” explains Quirós.

Public employees have denounced that they consider themselves “hostages” of the regime of Daniel Ortega and Rosario Murillo, which has radicalized political surveillance and party control against state workers.

Some of the pressures health workers face include being forced to participate in marches, mandatory financial contributions to the ruling party, coerced and monitored voting in elections, self-censorship, political indoctrination, and even restrictions on leaving the country.

Quirós believes that Nicaragua’s public health system suffers from “a serious problem of political-party dependence,” which has led to many professionals being “fired, sidelined, or punished for speaking their minds—or forced into silence on a regular basis.”

The Exodus of Health Workers

According to Ana Quirós, Nicaragua has never reached the number of healthcare workers recommended by the WHO, for several reasons: on one hand, the country’s training programs aren’t sufficient to meet demand; on the other, there’s no effective hiring policy.

The public health specialist warns that this has led to a “brain drain” in the health sector—especially in nursing, which she describes as “a key pillar of the healthcare system.”

“Nurses have a lot of opportunities to find work abroad,” she explains. “Even if it’s not directly in healthcare, they can often find jobs caring for children, the elderly, or people with disabilities—roles that are in high demand in many countries.”

Rubén, who has worked as a doctor in several cities across Nicaragua, admits that the availability of medical staff depends heavily on location.

“There are places where doctors and medicines are scarce, and the care available is extremely basic,” he says.

“There’s a big gap between the concentration of health personnel in Managua and major cities versus rural areas. Many people have to travel long distances to get specialized care,” Rubén adds.

The core problem, Quirós says, is that the country isn’t training enough new professionals—and the situation has worsened due to “the dismissal of a large number of medical school instructors,” which means no major improvements can be expected in the coming years.

Rubén also points out that the shutdown of medical organizations that used to “support the ongoing training and professional development of specialists” is a serious issue that, in his view, “hasn’t been treated as the problem it is.”

A data analysis by CONFIDENCIAL, based on the cancellation of legal status for NGOs, estimates that around 218 health-related organizations have been shut down between 2018 and early 2025.

Fired for Thinking Differently

In Nicaragua, it’s estimated that at least 686 doctors were dismissed by the Ministry of Health (Minsa), primarily for protesting in 2018 and for speaking out scientifically or protesting the government’s poor handling of the COVID-19 health crisis.

The Nicaraguan Medical Unit, made up of dismissed doctors, warned that many were fired for providing medical care to those injured during the 2018 civil protests, which were violently repressed by police and paramilitary forces sent by the dictatorship.

The Ministry of Health has also been singled out by national and international human rights bodies as an actor in “serious human rights violations” by limiting medical care to victims of state repression during the 2018 protests. This failure resulted in the deaths of many demonstrators due to lack of medical attention. One of the most well-known cases was the death of teenager Álvaro Conrado in April 2018.

As a result of this wave of repression, hundreds of doctors went into exile, while others unsuccessfully sought to be reinstated.

The Inter-American Commission on Human Rights (IACHR) documented that between April and September 2018, at least 300 doctors were fired from public hospitals in Managua, León, Masaya, and Estelí.

Two years later, in 2020, when the pandemic hit, Minsa fired staff from several hospitals—including Manolo Morales, Bertha Calderón, and Antonio Lenin Fonseca—without justification.

Among those dismissed were medical specialists who had decades of experience in the public sector and who, during the pandemic, gave interviews or signed public statements demanding personal protective equipment.

Many dismissed public workers have reported that, years later, they still have not received their severance payments following resignation or unexplained dismissal.

Death of Medical Personnel Due to Negligence

Just four days before the Ministry of Health (Minsa) reported the first case of COVID-19 in March 2020, the dictatorship forced public workers to participate in the “Love in Times of COVID-19” march, putting their health at risk while the rest of the world was starting quarantines to prevent the virus’s spread. The regime also prohibited preventive measures such as wearing masks or face shields, arguing that these could cause panic among the population.

Due to the regime’s negligent attitude, Nicaragua became one of the countries in the Americas with the highest number of medical personnel deaths from COVID-19, with over 200 fatalities, revealed in a report by CONFIDENCIAL.

Nicaragua was one of the countries that did not follow the WHO’s recommendation to vaccinate frontline health workers within the first 100 days of 2021. Vaccination for this sector started later and was not initially widespread.

Private practitioners working in clinics or private offices who treated patients with COVID-19 symptoms were also not prioritized.

Throughout the pandemic, healthcare workers reported not receiving adequate protective equipment and being overworked. Many were dismissed or threatened for raising concerns. Today, no one dares to complain about the difficult conditions under which they continue to work.