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MR FEATURES Changes to Cuban Health Care Aim to Extend Equity
“You can’t quarrel with results,” goes the old saying. After all, at 5.8 per 1,000 live births, infant mortality in Cuba is the lowest in the region; its other indicators are in similar good shape, showing less internal disparities than even many developed countries; and its health and social policies have emerged from the test of fire of the 1990s, holding the line on health advances despite that decade’s economic free-fall. International health policy studies are beginning to take note of these results and the Cuban health system’s track record, from vaccine development and physician training to preventive medicine.[1,2] “Cuba applies the principles of the Alma Ata (1978) Declaration - Health for All with a primary care focus - more thoroughly than anywhere else,” notes a recent article in the Journal of Public Health Policy.[3] Yet, true to the historic ‘dynamic of dissatisfaction’ that has propelled Cuba’s health movement over the years, Cuban health professionals, authorities and government are shaking up the system again. The question is the same: how to improve the population’s health status? But it’s the search for answers that goes deeper, with big implications for 11 million Cubans at the center of what promises to be a profound functional reform. Catalysts for Change Since the 1960s, the Cuban government has taken responsibility for building a health care system based on principles of universal coverage and equitable access, with the emphasis on community-oriented preventive care. At the primary level, where international studies indicate up to 80% of health issues can be addressed, Cuban services have consistently been moved closer to the population - in the early years through doctors travelling to rural zones, and later, through the building of community-based polyclinics (see MR Feature Bringing Services Closer to Home in MEDICC Review Vol. VII, No. 5, 2005). In the 1980s, the system’s reach was further extended with the family doctor-and-nurse team, who live and work in the neighborhood they serve. Now providing care to 99.4% of the Cuban population, each is responsible for the health of 150-200 families - the family being the basic focus of a holistic concept of attention to individuals, families and the neighborhood.[4,5,6] Family doctors undertake preventive education, with the help of nurses and local activists; counsel, diagnose and treat patients in their offices; make house calls; and carry out continuous assessment of major health problems and risk factors. As a result, patients’ collective medical records yield an annual neighborhood health diagnosis. Anywhere from 20 to 40 of these doctor-nurse teams are clustered around the community polyclinic, the hub that now provides referral services in other fields, such as pediatrics, ob-gyn, geriatrics, psychiatry, etc., offering another dimension to comprehensive primary care. Secondary and tertiary facilities (including institutes dedicated to specific pathologies), complete the health care delivery model, offering more specialized care for complex health problems. Over the years, says Dr. Joaquín García, Vice Minister of Health for Medical Attention, “we were seeing disparities in health outcomes consistently reduced - both by improving social determinants of health and health services. The gap was closing and yielding more positive and equitable results.” So, for a time, the ‘one size fits all’ family doctor-polyclinic-hospital model seemed to fit the bill. But now, other changes are prompting deeper analysis, and suggest that once a certain plateau of positive outcomes is reached, equality in services does not assure further positive, equitable gains in either patient access or outcomes. Take just two variables in Cuba today: aging of the population and availability of transportation. As a result of increased life expectancy and decreased birth rates across the island, Cuba’s population is one of the fastest aging in Latin America, with 15.4% of its population over 60 years old.[7] Improvements in health status mean these seniors are not only living longer, but are also vulnerable to the chronic diseases that appear later in life. Simply put, there are more older people needing health services more often than younger people for prevention, treatment and rehabilitation. Enter the transportation crisis, especially in Havana (pop. 2.2 million), where the vast majority of residents without private vehicles depend on public buses that often leave them waiting for hours, passengers so crammed into SRO coaches that a local artist used Picasso’s Guernica as a billboard metaphor for the experience. So, having the cardiologist or physical rehabilitation services only available at hospital level might be enough for the 30-year-olds in a particular community, but may be too far away to be of real help to the growing vulnerable population of aging heart patients who most need them - thus generating inequity. The aim of the current analysis - which has resulted in a pilot program already under way in Havana’s municipalities - is to shape health services at the local level to prioritize the most pressing health problems in each place. Thus, the constellation of specialized services offered at one polyclinic may be different from another’s, and only resemble each other to the extent that the community health diagnosis in each place reveals a similar set of major health problems and risk factors. The purpose is to use the interplay of health indicators and levels of care as guides for action, moving the right amount and type of resources to where they can be used most rationally, and above all, are most accessible to the patients who need them.[8] All this requires better integration, harnessing the different capabilities at the secondary and tertiary, as well as the primary level, and putting them to work more closely together. “The main point, however,” says García, “is to improve people’s health, not to make changes in the system for better flow charts. The idea is to measure what we do more consistently against results we obtain in health status: not how many people visited the ophthalmologist, but rather how many people recovered their vision.” Suit the Patient In the new design being piloted first in Havana, the following approach is being applied:
The polyclinics have already become a major training scenario for physicians, nurses and other university-level health sciences careers, giving them a more robust academic role and more cross-generational professional depth on their staffs.
This is not yesterday’s paint-peeling polyclinic, its potential sapped by economic woes. As a result of Cuba’s modest economic recovery and policy decisions, over 440 polyclinics across the island were completely refurbished by 2004, adding new technology and new services - including ultrasound and other imaging, endoscopy, ophthalmology, a greater range of lab tests, natural and traditional medicine departments, physical therapy, plus information technologies.
There is no doubt that the current pilot program to re-orient care, the mammoth investment programs and the assignment abroad of over 25,000 of Cuba’s 70,000 physicians, bring some turbulence to the system, and with it, logical patient dissatisfaction. In addition, Dr. García notes that the historic gaps between primary, secondary and tertiary care that the new integrated design aims to close could still be felt by patients until the pilot becomes a fully functional model. But, says Dr. De Armas, in the Cerro Municipality, where it all began, the shift to “tailor-made” services has already taken place. “In Cerro, we’ve used the health diagnosis to determine a number of new specialized services now offered at our four polyclinics, corresponding to the health picture in each of their surrounding communities. For example, as we looked at figures for smokers in the municipality, we discovered that it wasn’t enough to have a psychiatrist on board - but that we had to refine that service, and offer a special ‘smokers’ clinic’ at least one day a week. In one community, we also decided that the growing problem of obesity merited a multidisciplinary service at the polyclinic for referrals from family doctors in that area. Depending on the human resources on hand, the staff comes from the polyclinic itself or is seconded from local hospitals. We now have 28 specialists and 33 services offered at Cerro’s polyclinics.” Figure 1 offers a snapshot of how some of these 33 services are distributed. Figure 1: Sample of Actions for Selected Communities, Cerro Municipality, Havana
Source: Y. de Armas, “Integración Policlínico-Hospital, Municipio Cerro, Ciudad Habana,” Feb., 2005. PowerPoint presentation. While it is still too early to measure impact on health outcomes, preliminary indicators show that patients are increasingly relying on the polyclinic rather than the hospital for the diagnostic, therapeutic and emergency services newly available at this primary care level.[9] Pitfalls for the new design? “They are many,” Dr. García told MEDICC Review. “First we have to remember that we are a country in the Third World. We still have challenges when it comes to hygiene and sanitation, to nutrition, and we have to keep in mind that the actions we take have to be feasible, and progressively applied depending on our economic possibilities. We have to keep our feet on the ground. And we have to make sure that the process doesn’t become bureaucratized - that would be suicide.” Notes and References
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