摘要：The Cooperative for Assistance and Relief Everywhere (CARE) and Centers for Disease Control and Prevention (CDC) Health Initiative in Nicaragua is distinctive in its focus on developing a cadre of in-country trainers whose aim is to equip frontline public health managers with widely applicable tools and techniques to assist them in identifying and solving implementation problems. Since 1999, 137 trainees—37% more than originally planned—have demonstrated competence by completing and presenting applied management projects. Nineteen professors from the preventive medicine faculty at the Autonomous University of Nicaragua also have been trained. The country office now has a cadre of seasoned trainers who can meet the ongoing management training needs of CARE staff and their counterparts in the Ministry of Health and in other nongovernmental organizations. PUBLIC HEALTH INITIATIVES in developing countries often fail not because of a lack of scientific knowledge but because of a lack of managerial competence. 1 Most training programs follow categorical funding and have a narrow focus on a particular disease or problem. Emphasis usually is placed on prescriptive management procedures oriented toward technical protocols designed by external experts (e.g., family planning logistics, vaccine cold chain maintenance, treatment protocols, agricultural protocols, infrastructure models). A successful program should equip frontline managers with crosscutting skills in priority setting, planning, and problem solving. 2 Lack of management skills among the public workforce has been exacerbated in recent years by the global trend toward decentralization of services. 3, 4 In many countries, decentralization has occurred abruptly and without the benefit of planning for developing the management capacity of the local public workforce to assume their new roles and responsibilities. 3, 5 In Nicaragua, a Central American country with a population of approximately 5 million people, decentralization has led to about 150 municipios' (the smallest political/administrative units) becoming responsible for local health services. The Ministry of Health operates about 60% of the country's health facilities through its structure of local health systems (SILAIS). Under a 1995 agreement with SILAIS, CARE's health sector professionals provide training to staff members of local health services in a wide range of programmatic areas. CARE staff also assist SILAIS supervisors with joint supervisory visits to municipio health services. In 1999, CARE International and the Centers for Disease Control and Prevention's (CDC) Sustainable Management Development Program (SMDP) began to collaborate to strength-en management training capacity in Nicaragua by developing a cadre of in-country trainers in public health management.
