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Healthcare Recidivism in Boaco

A Brief Overview of the Relationship between Public and Private Healthcare in Boaco, Nicaragua:

Results from the Field


Special Thanks:

Clinica Verde (Boaco, Nicaragua)

Kellogg Institute of International Studies (Notre Dame, IN, USA)


Daniel J Olivieri, PI University of Notre Dame, Notre Dame, IN

Please note that this research was approved by the IRB of the University of Notre Dame


Ann Mische, Professor of Sociology, University of Notre Dame

James McKenna, Professor of Anthropology, University of Notre Dame

Principal Investigator’s Note Follow 

Executive Summary

The purpose of project is to understand the relationship between ownership of healthcare in communities surrounding Boaco, Nicaragua and use that understanding to help Clinica Verde (1) provide more successful outreach and holistic care. In order to do this, the investigator’s time was split between working in the clinic (shadowing and volunteering) and also visiting rural communities surrounding the clinic for weekly community visits with clinic personnel. While not working at the clinic, the other half of time was spent working on a “Encuesta de Salud” (2) that attempted to understand any niches that existed in the surrounding community that Clinica Verde could expand on, and so that the clinic is able to obtain a more coherent understanding of the community around them and in Boaco.

The results demonstrate several niches that Clinica Verde might be able to focus on in the coming years. To start, one main takeaway of this research is that Clinica Verde underscores the importance of the diversity of sources from which we obtain public health information. There was no simple majority of sources that we receive information for diseases such as dengue, payment information, or private health services. While this at first might seem like an obstacle, this study suggests otherwise. By recognizing that there is no one perfect way to engage patients in promoting positive health­seeking behavior, a clinic can diversify (3)  the ways of which they communicate to their community members to make sure that they are effectively relaying information to their patients.

No one, I strongly feel, is an expert in design thinking or international development, and much effort should be spent in any research or development project on understanding that the most successful projects work with and not for communities.

Furthermore, here this research sharply underscores the importance of community­based care in research projects. More than obtaining IRB approval, our research aimed to transcend the barriers that prescribe many standardized research projects. Much effort was made to integrate within the community through baseball, through talking, through listening to locals.

No one, I strongly feel, is an expert in design thinking or international development, and much effort should be spent in any research or development project on understanding that the most successful projects work with and not for communities. Development, like the best football (or soccer) teams, are just that: communal; the most successful teams work in a respectful, synergistic desire to accomplish their goal. Accompaniment is just one tool in that toolbox that can be utilized to catalyze the delicate relationship of development practitioners and communities, and I believe that is absolutely essential to the dignity, respect, and outcome of inequality in developing countries. Although I am not an expert in development or accompaniment nor do we (my co-­researcher and I) hope to be. However, I do hope that this research can shine light on the importance of vision and focus on international development, especially in the medical sector.


Clinica Verde plays a unique role as the only provider of social­cost healthcare in the entire Boaco department4. Boaco, as does Nicaragua in general, provides universal healthcare

to all citizens and foreigners. However, the free public health care that exists in Boaco and in the surrounding communities is sharply contrasted by privatized healthcare clinics, many of which cost up to 300% more than public health services in Boaco. In helping Clinica Verde provide healthcare at a social cost, we are hoping to provide more tangible solutions to the void of effective, low­cost healthcare in the poorest developing country in Latin America.

As investigators, the goal was to be able to combine past research experience to implement a short term, two month project that could potentially help frame outreach strategies by Clinica Verde.

Materials and Methods

The ‘Encuesta de Salud’ (5) was implemented in three main barrios surrounding the location of the intern apartment in the city of Boaco. The following barrios of Herman Polmares, La Planta Alta, and San Miguel, were therefore chosen based upon convenience sampling since they surrounded the main location of our house and San Miguel is the biggest barrio in Boaco.

To choose participants, we flipped a coin at the start of a new street in the chosen barrio. From there, a dice would be thrown to decide which side of the street would be used in sampling.

If the dice landed on the numbers of 1­3, we would only sample the left hand side of the street, and if the dice landed on 4­6, we would only sample the right hand side of the street that day. Next, we would roll another dice and divide the resulting number by two in order to determine the exact house we would go to next. If the number was odd, we would round down to increase sampling size. The second roll of the dice was rolled after each interview, on the same side of the street. (6)

For example, if a two was rolled on the first dice, then the left hand side of a street would be used for the duration of the sampling period. Then, another dice would be rolled. If this dice resulted in the number six, we would go to the third home (six divided by two equals three). This procedure was utilized for each of the days that the encuestas were utilized.

Once a house was approached, the preamble was utilized to explain who we were, what we were doing, and what we were going to do. This preamble was modeled using the IRB approved document7. No personal identifying information, medical or otherwise, was divulged in the process of the interviews. No names, dates of birth, or physical descriptions were noted.

Individuals were, however, coded by their year of birth, biological sex, and level of education. It is also important to note that no protected groups were sampled during the duration of this investigation.

On top of the over 45 surveys conducted in the field, the individual observations that were obtained from shadowing physicians, working with doctors, staff, and other volunteers of Clinica Verde are included later in this report. Verbal consent was obtained to include recommendations in the report, and no personal identification has been transcribed from these experiences.


A. Significance

Since several basic demographic information could be extracted without divulging personal identifying information, the results are able to be corroborated with the latest Boacan Census to determine if our randomized population is representative of the entire Boaco community. Please see resulting Demographics below to corroborate our claim that the population was representative of the population of Boaco. For the sake of length, the transcriptions of the individual interviews have not been added to this report. However, the interpretation of those results is included throughout the paper and in the following “recommendations” section.

 B. Demographics

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Conclusions and Recommendations

A. Religion

One of the tangential goals of the study aimed to evaluate if there was a relationship between the Church and public health. Or, at the very least, the study hoped to examine if a relationship did not exist, the possibility of elaborating on that relationship in the future. The results of the study suggested that there was little to no relationship between the church and public health. More specifically, the Church did not play any role in the public health education of the community. However, it should be noted that although the Church did not play a significant role in the public health education of the community (0% of all respondents answered “religious actors” as sources of public health information), that does not mean that the church cannot play a role in the public health education of the community. Furthermore, several interview participants and physicians at Clinica Verde were intrigued by the option to engage religious actors within the healthcare sector.

The idea to integrate religious actors within the healthcare sector came from the (1) realization that the church plays a significant role in the community of Boaco, being, in many cases, the focal point of the community, and (2) that an overwhelming majority of interview participants and individuals living in Boaco and Nicaragua are Evangelical or From our sample size, which was representative of the Boacan population, around 72.5% of all participants were Catholic and 17.5% were Evangelic, the remaining did not identify with a particular religion. If a clinic were able to utilize religious actors to spread public health information, then, I believe that they could spread their information to other non­religiously affiliated community members through word­of­mouth. This is based on the statistic that of the 20% of all participants who stated that they received health information from the “Diario,” 18 of those 20

participants mentioned some form of social spread of information in their daily activities. In other words, they were able to learn and obtain health information from other community members, whether that’d be family or friends (25%), or from health brigades, neighborhood organizations, or doctors who worked down the street (35%).

To implement a health partnership with the local churches, one can look towards what we already do at Clinica Verde. Mari, who helps organize all of the weekly rural community visits of Dr. Leal and the nurses, might be able to reach out to the churches and community members who help coordinate the visits and see if we can offer charlas after mass for five minutes or so if community members decide to stay. This may furthermore be possible given the involvement of Mari already in one particular church in Boaco.

B. Design Thinking

Not only did the study help illuminate systemic problems within the public health sector in Boaco, it also demonstrated the importance of design in order to gain trust in a community. To start, the clinic that I mainly worked in utilized bright, eco­friendly color schemes to engage patients with their care when they walked into the clinic. This, which sharply contrasted the bland colors of the local Puesto de Salud and Casa de Ancianos, demonstrated the welcoming mantra of the clinic while also promoting its eco­friendly L.E.E.D. certified design (9).

The staff is entirely Nicaraguan, born and bred in Boaco, and is able to, as one doctor told me “combine service and medicine.” They believe in Clinica Verde, because Clinica Verde believes in them. And if that’s not the definition of trust, I don’t know what is.

When talking about recidivism, or the rate of preventable readmission to a health entity (public or private), the question shifts from services to effectiveness. In other words, is the clinic providing the care that it needs to be able to support the community. Healthcare systems are essentially teams that are only as good as their weakest link.

What then, does it say that some healthcare systems fail to provide their patients with the successful tools to not only get healthy, but to stay healthy?

Clinica Verde aims to overcome and transcend the normally stoic healthcare sector by giving their patients the tools to succeed and obtain true biopsychosocial care.

Pregnant? There’s a class for that.

Teen? We have a program to teach you, develop you, and guide you. All led by one of the nicest nurses you’ll ever meet.

Live far away? We’ll come to you. And not just often praised community health workers, but doctors, nurses, and optometrists.

Sick? Of course, we can help you there too.

The so­-called wicked problems (10) that Clinica Verde aims to solve (problems that are only exacerbated by a lack of holistic care within a healthcare sector), are able to be solved by innovation, outsiders, and a whole of lot insiders. In development, there needs to be better oversight with the role that foreigners play in the international sector, and this need cannot be more apparent within healthcare. Clinica Verde, however, might have some of the answers. For example, Clinica Verde can leverage the U.S.­Nicaraguan connections throughout the United States to challenge the status­ quo of the relationship between the public and private healthcare sectors in Boaco. The connections between entities in the United States can bring more ideas, fundraising, and inspiration to the table for the team at Clinica Verde in Nicaragua.

At the same time, Clinica Verde embraces the modern model of aid in a renewed focus on accompaniment not only with the patient, but with the staff on the ground in Nicaragua. The staff is entirely Nicaraguan, born and bred in Boaco, and is able to, as one doctor told me “combine service and medicine.” They believe in Clinica Verde, because Clinica Verde believes in them. And if that’s not the definition of trust, I don’t know what is.

Just as accompaniment can help define trust, vision can set the tone of trust. In this case, the leadership of Clinica Verde has collaborated to address healthcare that Boaco sorely lacked. In the process, they demonstrated that the tried-­and­-true current model of aid ­delivery might not be the best or, at the very least, the most efficient; finally, the results of this study suggest that design thinking and integration within the community of Boaco had a lot to do with that.

Furthermore, the overall design of the clinic (physical and structural in programs) was more strongly represented in the respect that the clinic received, unprompted, throughout the interviews. This is important to note since of the interview participants who mentioned Clinica Verde, all 19 responses were coded by the researchers as having a “positive” or “extremely positive” tone. Their feelings toward the clinic were often gained through word of mouth and community engagement by the clinic, furthermore underscoring the importance of community accompaniment and integration in international development, health sector or otherwise.


C. Niches for Development, Systematic Problems

The final recommendation is of continued integration within the community in order to continually understand and redefine what public health means in Boaco. From weekly outreach visits to rural communities surrounding Boaco to cost­-sharing for medicine on a case­-by­-case basis, charlas to consejerias, Clinica Verde’s holistic moxie not only upholds the right to health, but it demonstrates the importance of trust, not money, buildings, or awards, as an effective solution to sometimes ineffective public healthcare.

Clinica Verde serves a powerful role in the community. When we look at the world today, it is easy to see the problems of aid, development, and inequality. It’s hard to think that organizations can be very effective when they are constantly fighting against the current. Development is not clear­cut. Clinica Verde’s solution, however, starts and ends with the community at the core of its design. And if I’ve learned one thing through my experiences in Nicaragua, it’s that when the community is at the center of design, you have a very good chance to be successful. When the community’s not, you might as well not even try. Easier said than done, but also completely worth it. Development, like life, is meant to be a challenge, backs bourne against the current, swimming upstream as so­called development practitioners utilize accompaniment in a postmodern context to work with, and not for, communities worldwide, eliminating inequality in the process.

By framing patients as people and not numbers, the clinic aims to provide Boaco with a more refined approach to care. One day, hopefully, holistic healthcare will be tried­-and­-true, the bread and butter of public health care, but until then, clinics like Clinica Verde provide a reprieve from sometimes corrosive systems of care that merely provide biological care without holistically “treating” the patient. Does Clinica Verde have all of the answers? Can they help every patient in Boaco and its surrounding departments? Probably not. (At least not right now, they might tell you) What Clinica Verde does have is trust.

And as I’ve learned here in Boaco, that might be all that they need.

 Principal Investigator’s Note:

While this study aimed to tackle healthcare recidivism in Boaco, the research, interviews, and integration in the town and people of Boaco, demonstrated to us that the most important point of recidivism is understanding the community. For us, (and for the majority of individuals), that means that recidivism is best understood in the eyes of the community. Strategies such as participatory scenario planning, design thinking, and a renewed focus on community integration not only can hold great weight in development strategies, but uphold human dignity and respect when working in the delicate area of inequality and development.

Just as no study is perfect, we hope that this study can help Clinica Verde strengthen outreach programs by focusing on expanding community visits (something that also has been very successful with Partners In Health (CES, for their Spanish affiliates)) in rural communities in order to gain trust. The best development organizations don’t have all the answers. What they do have is tone. They set the vision for their team, their community, and then watch people respond. Good vision is not only contagious and infectious, but resonates with individuals who would otherwise have no reason to be connected.

I was told last year in Brazil11 that “people only see what they are prepared to see.” I often have thought that my experience in Nicaragua contradicts that; we live in a world that is much too complex for that. At the heart of every innovative design is a dream, a goal, a desire to make things better. That desire is crucial, and might be the most inspiring thing in education today.

We all want to make the world a better place. Once again, as I’ve learned in Brazil, Cuba, and Nicaragua, thankfully, people are resonant, and have enormous capacity. Yet, for some reason, some people matter less, and, as Dr. Paul Farmer (12) famously coined, that “is the root of all evil in the world”.

Just as Clinica Verde challenges the perception of development in Boaco, Nicaragua, they don’t have all the answers. Copying the Clinica Verde model and design and transplanting it to another Latin American country would be navie and futile. Development and inequality is too complex for any kind of “ten word answer”. Clinica Verde, does, however, represent a transcendent vision that can be transplanted to other countries and situations.

Vision, therefore, is the best tool to tackle recidivism.

The best thing about vision? You don’t have to go to college to learn it. It’s free, and it’s powerful. You can learn it from successful people, all over the world; like the one’s I worked with at a small clinic in the middle of rural Nicaragua­­a place called Clinica Verde.

 For more information on the Kellogg Institute for International Studies, or their numerous international programs that place Notre Dame undergraduates in developing countries, please go to or contact Mrs. Holly Rivers at

 Finally, any views in this study do not represent the views of the University of Notre Dame and all questions should be directed to Daniel J. Olivieri, PI, at

1 Clínica Verde is a global healthcare organization that designed and operates a prototype of a sustainably designed health hub in Nicaragua. They are located at

2 See attached (Health Survey or Census)

3 Much like how diversification of a financial portfolio safeguards risk, the diversification of outreach services can strengthen one’s voice to make sure that the community catalysts are provided with the information they need to spread information about the clinic.

4 ‘Departments’ in this case refer to the state of Boaco, as in Nicaragua the states or departments also have the same name as the largest town in that corresponding state

5 Ibid.

6 Interview techniques were developed with the assistance of Christopher Meyer at the Middlebury Institute of International Studies at Monterey.

7 IRB Approval received for this project and can be obtained through contacting the PI, Daniel Olivieri, at

8 For the sake of brevity of this report, only the demographic questions have been included in this report. The whole formatted survey/interview guide can be viewed in the appendix, and for more detailed information on the results of the study, please direct comments, questions, and concerns to Daniel J. Olivieri, PI, at

9 L.E.E.D Certification refers to Leadership in Energy and Environmental Design and is the “gold standard” of environmental design. Please see for more information on how buildings and architects can become L.E.E.D. certified.

10 Wicked problems refer to “a form of social or cultural problem that is difficult to solve because of incomplete, contradictory, and changing requirements”. For more information, please review strategies for tackling so­called “wicked problems” on the Harvard Business Review at­as­a­wicked­problem

11 “Analyzing the Effectiveness of the CHWs (Community Health Worker Program) in the Rocinha favela of Rio de Janeiro, Brazil” Experiencing the World Fellowship, Kellogg Institute for International Studies, University of Notre Dame.

12 Dr. Paul Farmer is the founder of Partners In Health, an organization that aims to tackle inequalities throughout the developing world by recognizing health as a human right. For more information on Dr. Farmer’s connection to the University of Notre Dame, please visit


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