In November 2008, Nicaragua Sugar Estates Ltd. (NSEL) and the Chichigalpa Association for Life (ASOCHIVIDA) agreed to participate in a dialogue process on chronic kidney disease (CKD), which was convened by the World Bank’s Compliance Advisor and Ombudsman (CAO) following a complaint filed by ASOCHIVIDA and other community members.

In accordance with the guidelines established in the Framework Agreement for Dialogue proposed by the CAO on November 20, 2008, to which NSEL and ASOCHIVIDA acceded, the dialogue aims to identify alternative solutions to the CKD issue. Since February 2009, seven dialogue tables have been held, in which the good will of NSEL and ASOCHIVIDA has prevailed to move towards concrete solutions on two fundamental topics:

(a) Identifying and addressing the causes of CKD

In the framework agreement, the parties agreed to jointly define the criteria and principles for conducting a study to identify the causes of CKD, the results of which would be transparent and trustworthy for everyone and would provide feasible solutions. As a result of the dialogue, it is expected that the parties will agree on the criteria and guiding principles of the study and will accept the results and alternative solutions to the problem.

Achievements thus far are as follows:

• Boston University was selected by both parties to conduct the study, as the institution that deserves the confidence of NSEL and ASOCHIVIDA. The selection process was carried out as follows:

(i) Following a first meeting in which ASOCHIVIDA and NSEL discussed the criteria and guiding principles for the study, the CAO drafted the Terms of Reference for selecting the scientific team, which were widely circulated in English and Spanish;

(ii) The CAO also agreed on a timetable with NSEL and ASOCHIVIDA and the deadline for submission of proposals was Friday 3 April 2009;

(iii) The CAO also drafted and shared with NSEL and ASOCHIVIDA a methodology proposal for qualifying the proposals based on these criteria and a scoring system;

(iv) The CAO invited 9 public agencies, 22 universities in the United States and Europe, and 5 private consulting firms to submit proposals for the study. It also published a notice on its website;

(v) The CAO received nine proposals on April 3, 2009, four from prestigious universities and five from private consulting firms. As of that date, the CAO began a process to review the proposals based on the criteria and scoring matrix that had been shared with the participants of the dialogue table.

(vi) The CAO held separate preparatory meetings with the participants to analyze the proposals and to reflect before a decision was made; and

(vii) Finally, during a dialogue session in April 2009, the dialogue participants selected a team from the Boston University School of Public Health (BUSPH) to conduct the study.
• In December 2009, BUSPH completed a preliminary study and proposed next steps for conducting a comprehensive study on the causes of CKD. To carry out this phase of the study in a serious and rigorous manner, the following activities were undertaken:

(i) The BUSPH reviewed all available literature and documentation on CKD in Nicaragua and in other parts of the world;

(ii) The BUSPH made a fact-finding trip to Nicaragua to interview people and organizations concerned with the problem of chronic renal failure.

(iii) The BUSPH team returned to Nicaragua to present to ASOCHIVIDA and NSEL their first findings and hypotheses on the problem of the IRC and to perform an initial proposal on how should undertake the comprehensive study. On this occasion, the BUSPH heard questions, criticism and reviews of both organizations.

(iv) The BUSPH team incorporated comments from ASOCHIVIDA and NSEL in their report and sent them to other experts in the United States and Nicaragua for a peer review. Experts emphasized the importance of this study and made recommendations which were taken into account by the BUSPH team.

(v) At the beginning of December, the CAO convened a new meeting in which Boston University presented the final report and made a proposal to conduct a comprehensive study.

(vi) At the end of January, a new meeting adopted the terms of reference so Boston University leads the activities under the first full year.

ASOCHIVIDA, NSEL, and CAO would like this process to move forward faster.

However, in order for a scientific study to be considered serious, it is necessary to complete all the steps that have been detailed. The CAO will be in charge of managing the funds and looking for other possible sources of funding.

(b) Options to support local communities where there is a prevalence of CKD.

On the basis of good will and without entailing any legal obligation, the parties agreed to find ways to alleviate the situation of the families affected by CKD by involving local resources and state institutions.

Among the main achievements, NSEL committed to provide short-term assistance to alleviate the situation of families affected by CKD as follows:

• Provision of food supplies for a period of two years with an annual cost of US$ 300,000 for 1,153 households that are members of ASOCHIVIDA. This amount could be extended to US$ 500,000 per year for 1,800 households. Food supplies will be purchased at wholesale prices and NSEL can also deliver food supplies for that same amount of money through an intermediary organization. So far, four deliveries have been made. To make this possible, several activities were undertaken:

(i) ASOCHIVIDA was responsible for gathering all the necessary documents so that its members may receive this benefit. This task was carried out very efficiently and within a short period of time.

(ii) NSEL agreed with the American Nicaraguan Foundation (ANF) on the operating mechanisms that will be used to distribute food provisions;

(iii) ASOCHIVIDA turned over all the documents to the San Antonio Sugar Mill for approval and distributed the requisite food coupons quickly and efficiently; and

(iv) The dialogue table met to address the difficulties that emerged during the implementation of the food aid program in relation to several beneficiaries. Little by little, this benefit has reached 1,800 families.

• Provision of backpacks for 1,545 school children less than 18 years old. The delivery began in mid-January 2010 in two phases: in the first delivery, backpacks were distributed, and in a second delivery, notebooks and pencils.

• Health care assistance: NSEL committed to:

(i) Purchase and deliver an ultrasound machine for the Chichigalpa health center and to support the health center by hiring a radiologist to operate the ultrasound equipment.
This commitment has been already achieved and the health center has the equipment and radiologist. ASOCHIVIDA has asked to increase the frequency of care provided by the radiologist.

(ii) To complement the provision of medicines and reagents in the health center. This still needs to be discussed in further detail with MINSA and INSS representatives in order to ensure that the additional provision of medicines and reagents reaches the recipients. The CAO, ASOCHIVIDA and NSEL have held several meetings with the representatives of these institutions and work is underway to find a solution.

(iii) To provide two hemodialysis machines to the health center. This has not yet been completed and, to a large extent, will depend on the number of people who are willing to undergo this treatment. For this purpose, the CAO is trying to organize a series of workshops for ASOCHIVIDA members in relation to the disease and treatment options.
In addition, ASOCHIVIDA and NSEL are talking with MINSA (Minister of Health) and INSS (Social Security Institute) to improve health services that are provided to CKD patients in the area.

• Beyond this short-term assistance, NSEL has expressed its willingness to support families affected by CKD by giving them access to sources of income or employment that may be sustainable over time and that do not involve any indebtedness. NSEL is ready to begin providing this support through the San Antonio Foundation.

As an example of the projects that could be implemented, NSEL has suggested establishing a textile factory in Chichigalpa that could be owned by former workers with CKD and which would provide families with work uniforms. The CAO has accepted the request of NSEL and ASOCHIVIDA to include in the process an expert in new productive enterprises to advise ASOCHIVIDA in this process. To select this expert, the CAO carried out an open bid process and the finalists were interviewed by the Board of ASOCHIVIDA, which decided to hire Rogerio Cuadra. Mr. Cuadra’s work began on January 4 and is expected that by the end of March he will design, together with ASOCHIVIDA members, several projects to be funded by the San Antonio Foundation.

Finally, it is worth noting that this dialogue process has helped to gradually build a bridge of communication between ASOCHIVIDA and NSEL that is beginning to bear fruit in finding solutions to the CKD problem. It is important to note the efforts carried out by representatives of both organizations to engage in a productive and respectful dialogue. ASOCHIVIDA leaders have successfully reflected the most important needs of their members at the dialogue table and have reported back the results to the assembly. NSEL representatives have shown that the company is genuinely interested in finding out the causes of CKD and that it is willing to collaborate actively in order to alleviate the situation of the families. It is on this basis that the process is solidly moving forward.