Cuban Medical Literature
Origins of Primary Health Care in Cuba

ABSTRACT:Examples of what can be called primary care can be found throughout several centuries of health care in Cuba. However, it was not until the 1960’s that a nationwide movement emerged to create and develop a subsystem of the National Health System with a clearly defined structure and functions, as well as specific resources to guarantee its own sustainability. This subsystem reached its maturity with remarkable efficiency and efficacy in the last decade of the 20th Century. This paper refers to the origin, principles and relevant moments in the development of this subsystem in the last 40 years, as well as to its present status and prospects.

Keywords : PRIMARY HEALTH CARE/history; PHYSICIANS, FAMILY/history; PREVENTIVE MEDICINE; SOCIAL MEDICINE; COMMUNITY MEDICINE

ANTECEDENTS

Although no exact circumstances or replica exists, history shows us antecedents in terms of [primary health care] ideas and concepts. The oldest record of Primary Health Care in Cuba can be found in a weekly rotation of physicians for the indigent poor in Havana.

This was in 1825, and is described by medical historian Gregorio Delgado Garcia: “This model consisted in appointing two specialists per week: a doctor and a surgeon, who rotated to include all of the specialists in the city. They offered free medical care to all the sick and injured people among the indigent poor. They administered treatment in their patients’ own houses, sending them to charity hospitals when necessary. They also acted as forensic doctors, inspected hygienic conditions in public places, and were responsible for food hygiene in the city's markets." (1)

This rotation was rigorously observed, and included all doctors and surgeons in the city. Important figures were on call in this system, namely Tomás Romay, an outstanding figure in Cuban medicine at the time, and Nicolás J. Gutiérrez, first president of the Academy of Medical, Physical and Natural Sciences.

It should be noted that these doctors offered a state (municipal) service that was free to all of the population, but mainly oriented to the poorest. This service was compulsory for all doctors, who had many functions in addition to curative care. The model was kept until 1873, when the weekly doctors were replaced by municipal doctors who were first appointed in 1871.

Until some 90 years later, government-run Primary Health Care was relegated to medicine for the poor offered in places called first-aid houses or dispensaries, which were few, under equipped and understaffed. Their main function was to give first aid to the injured, with limitations regarding the quality of actions performed.

Hygienic and epidemiological surveillance depended on the Local Health Offices. There was one of these in every municipality, where corruption was common, ignoring the legal dispositions regulating public health and control of communicable diseases.

Aside from the exceptions that can be found in the above mentioned system, my most favorable evaluation in terms of Primary Health Care goes to the nurse-doctors (commonly called practitioners and mainly empirical but very competent, and most often men), and others, who worked in hospitals and doctor’s offices in the sugar mills.

Since the country’s main agroindustry was sugar, workers’ health in the mills received a level of attention not found in other social strata. My experience with hospitals for sugar workers substantiates this view: I found a very good level of professional care being offered in sugar mills, such as that in Banes, (now known as the Nicaragua Sugar Mill and previously as Boston); in Preston (known as Guatemala today); in Tacajo (now Fernando de Díos); and in Piña (Ciro Redondo today). It appears further study of this Primary Health Care subsystem and its history is needed, where I would expect to find good examples of solidarity between the health-care personnel and the mill workers.

Seeds of the Movement

But it is my goal to tackle the origins of the Primary Health Care movement in Cuba. To deal with a movement, with the meaning we attach to this word in the current socio-historical context, I should first explain that we can only speak of a movement since the 1960’s [with the onset of the revolutionary and socialist period] and the consequent political, economic and social transformations. In February 1959, the Department of Technical, Material and Cultural Assistance to the Farmers of the Rebel Army is created, including among its functions health care for the peasant farmer population. (2)

Quantitatively, this did not offer sufficient services to meet the needs of the whole population. In January 1960, Law 723 was passed, creating the Rural Social Medical Service (RSMS), which offered new medical graduates a contract with an attractive salary, especially for the times and for recent graduates. The contract required a six-month minimum commitment, after which government medical posts would be available to participants. Although serving in the RSMS was voluntary, 318 of the 330 new graduates signed up. In the following years, 386 participated, while 347, plus 46 dentists were involved in the third period, once Law 919 for Rural Dental Service was passed. In 1973, 1,265 professionals were registered in this service for a two-year period. By then, 100% of the graduates joined this service, as it had become a tradition since 1965 to renounce private practice in the graduates’ oath. (3, 4)

From the very start, the primary health care functions of the RSMS assigned to a hospital or doctor’s office (called Rural Medical Post) were directed to medical care, epidemiological surveillance, vaccination, health inspection, health education, and forensic procedures. Notice the early intention to integrate services.

Rural Medical Service was the first program to have an impact in relation to Primary Health Care and public health in general. The reasons this was made a priority can be found in the long abandonment (in terms of health care and other services) endured by the rural population through the years of our colonial and republican history; the clear awareness of this situation by the Revolution’s leaders due to their close interaction with farmers [during their fight in the mountains against Batista]; [their] political commitment to the farmers who had themselves been fighters in the Rebel Army; and the fact that these health (and educational) services would be a perfect complement for the Agrarian Reform, which was the central policy in the Revolution's early years and the engine for economic development. (5)

Simultaneous with the implementation of the RSMS, Health Units were set up in the small towns that were the seats of each municipality. They carried out Primary Health Care tasks: ambulatory care to patients in the programs for tuberculosis, leprosy, venereal diseases, pregnancy, children’s acute diarrheas, and malnutrition in children. They conducted vaccination drives, administered waste disposal services, and carried out health inspections. These units integrated some vertical programs which existed since the previous administration, such as those for Leprosy, Cutaneous Diseases and Syphilis Prophylaxis (LCDSP) and Tuberculosis control. All of these Health Units later took up all Primary Health Care functions in the urban areas of their municipalities, managing the First-Aid Houses that still existed and also the Children’s Dispensaries of the National Children’s Dispensaries Organization (NCDO), which had been dissolved and integrated into the Ministry of Public Health. This confirms the fact that the idea of service integration was applied from very early times.

In those early years, the Primary Health Care movement, closely coordinating its work with health services and prompted by health education activities, generated the appearance of community initiatives for health. These initiatives were first expressed in the Rural Health Posts, then in the Volunteer Collaborators of the National Service to Eradicate Malaria (NSAP), and later in the Health Coordinators of the Committees for the Defense of the Revolution and the Health Brigades of the Cuban Women’s Federation. Social workers from the Ministry of Welfare in each rural area supported Primary Health Care services for as long as this ministry existed.

Another type of Primary Health Care Unit was created in 1962: the maternity homes, which made a useful contribution to the results of the maternal-child program.

In 1964, the Comprehensive Polyclinic was created, an institution that was to become the core of Primary Health Care in the years ahead. There were already some units described as polyclinics, but their scope was limited to doctor’s visits with outpatients. These new polyclinics were put to the test by having to minister to a population of 45,000 inhabitants over a 9 km² area. Furthermore, innovations were introduced in the polyclinics including keeping family records as an expression of the proposed comprehensive family care policy; making population groups; implementing damage or disease oriented programs (tuberculosis, venereal diseases, infant mortality, acute diarrheic diseases); encouraging community participation; and carrying out immunization programs and health education. Doctor’s offices services were also strengthened. (6)

The proposition was made to generalize the Comprehensive Polyclinic experiment on the basis of the results attained at the Aleyda Fernández Chardiet Polyclinic under the leadership of Dr. Roberto Fernández Elias. Polyclinics were defined as: (5)

• Medical institutions which develop activities for the promotion, protection and recovery of health for the population of a geographically determined area, by means of services covering the whole family.

• Institutions whose main goal is to dynamically offer basic health services, spreading over their communities by means of their field personnel, within certain geographic limits which are called health areas.

The country’s economic and social advances made their contribution to solving health problems. These advances included doing away with corruption that siphoned off state-budgeted resources, (7) and passing a new social security law (Law 1100 of 1963), which defined social security as applicable to all workers in a non-contributing health system, that is, as the government's responsibility. (8,9) Other advances consisted in establishing free medical services starting June 1, 1960, (10) lowering medicine prices, and nationalizing private pharmaceutical laboratories. (11) In addition to this, the Agrarian Reform Law freed 85% of Cuban farmers from paying rent, raised their purchasing power, and created 208,000 additional jobs in agriculture. Telephone, electricity and housing rates were lowered between 30% and 50%. (13-15) Reductions were also achieved in the unemployment rate, achieving virtually complete employment. The percentage of unemployment in the economically active population waned from 12.5 in 1958, 11.8 in 1960, 9.0 in 1962, to 1.3 in 1970. (12)

Another unquestionable contribution to improving health indicators was the Literacy Campaign, which did away with illiteracy as a social phenomenon, and was followed by the Campaign for Sixth Grade. (7,12)

The comprehensive polyclinic became general practice in 1964. A revision was made 10 years later, finding that:

• The polyclinics remained integrated up to a certain extent, but their actions were carried out separately.
  
  
• Curative actions were predominant.
  
  
• There was no teamwork.
  
  
• The professional staff was rather unstable.
  
  
• Too many patients were referred to secondary care.
  
  
• A negative influence on Primary Health Care was exerted by the fact that medical training took place essentially at the hospital level.

This diagnosis brought about a new model for Primary Health Care, which was called community medicine, and its core institution, the Community Polyclinic. An experimental test was carried out at the Alamar Polyclinic, which is now named after the director who led the experiment, Dr. Mario Escalona Reguera. Innovations in the new model are described by Dr. Ana M. Más Hernández in her specialization thesis (Más Hernández AM. Primary Health Care in Cuba: Its Organization and Historical Evolution. Havana, School of Public Health. ISCM-H, 1998).

These units are expected to carry out actions to implement the Area’s Basic Programs, grouped together in a coherent manner to care for people and the environment. They are classified as:

I. Programs for the Care of Persons
      Children’s Comprehensive Care Program
      Women’s Comprehensive Care Program
      Adults’ Comprehensive Care Program
      Comprehensive Dental Care Program
      Epidemiological Control

II. Programs for the Care of the Environment
      Urban and Rural Hygiene
      Food Hygiene
      Medicine for the Workplace

III.   Service Optimization Program


IV.  Management Program


V.   Teaching and Research Program

Another innovation in this period was the introduction of the concept of the health team, and encouraging teamwork. According to the Community Polyclinic Program published by the Ministry of Public Health (Foundations to a New Approach to Community Medicine. Havana: undated):

“All polyclinic staff are part of the area’s health team. The primary team is formed by a small group of specialists who act together to tackle specific tasks, with very close contact among its members. Examples of these teams are the sanitation brigades or the pediatrician and the nurse’s aide. The former example would make a vertical primary team, as it is composed of individuals with the same profession or activity. The second example is a horizontal primary team, integrated by personnel with different categories or professions, thus being interdisciplinary…In the model proposed, these horizontal teams are composed of a doctor (internist, ob-gyn or pediatrician), and the nursing staff, each of which is responsible for one sector or a certain number of inhabitants.”

In addition, this model defines measures that are aimed at ensuring comprehensive teamwork in their own dynamics, coordinated by vertical teams, (the sanitation workers example), or carrying out actions that involve social workers. Guidelines are also given in the document for encouraging and coordinating the community’s active participation in protecting the public´s health, attaching particular importance to their role in health education. The document embodies the concepts defined as key elements in the Primary Health Care model of the Community Polyclinic: comprehensive by groups, regionalized, continuous, based on patient assessments for risk factors and disease, in teams and with active community participation.

This care model was a quantitative and qualitative step forward in our population’s Primary Health Care, but after 15 years, certain limitations became evident: a deficit of qualified human resources for primary care; organizational dynamics hindering continuous and timely care for people; inoperable relationship with reference hospitals, especially in terms of cross- indexed information about patients; inadequate groupings of the population; lack of balance between hospital development and primary care in the polyclinic; increasing number of specialists for secondary care versus absence of definition as to what type of doctor should be offering primary care; and public dissatisfaction. These circumstances called for a new comprehensive assessment of the country’s Primary Health Care situation, which led to formulating a new model called Family Medicine, or the Family Doctor and Nurse.

In this article, I have synthesized what I have found to be most relevant historical precursors to the Primary Health Care Movement in Cuba, from the first quarter of the 19th Century, when the present model of Primary Health Care emerged. I should only add a reflection which I consider crucial for the present situation (2001): Primary Health Care is the very best field of action for the application of social sciences for research and solving public health problems. This is why I consider it essential to enhance professional knowledge and skills in these fields of our medical and technical personnel directly involved with Primary Health Care. I value highly the thinking of Virchow, Shemasko, Sigerist, Escalona, Ilizastigui, and above all of President Fidel Castro, who has recently and quite extensively dealt with the topic of social problems in present-day Cuba.

REFERENCES

1. Delgado, García G. Facultativo de Semana: Antecedente Histórico del Médico de la Familia. Cuadernos de Historia de la Salud Pública. No. 78. La Habana; 1993.
2. Cuba. Ley 100, 23 de Febrero de 1959. Gaceta Oficial de 26 de Febrero de 1959.
3. Cuba. Ley 723 de 22 de Enero de 1960. Gaceta Oficial de 1ro. de Febrero de 1960.
4. Cuba. Ley 919 de 1ro de Agosto de 1961. Gaceta Oficial de 3 de Agosto de 1961.
5. Rojas, Ochoa F. Acerca de la Historia de la Protección de la Salud de la Población. Instituto Superior de Ciencias Médicas de La Habana, 1988.
6. Hernández, Elías R. Administración de Salud Pública. La Habana: Ed. Ciencia y Técnica; 1971.
7. CEPAL. Cuba: Estilo de Desarrollo y Políticas Sociales. Siglo XXI. México; 1980.
8. Cuba. Ley 1100 de 27 de Marzo de 1963. Gaceta Oficial de 14 de Abril de 1963.
9. Comité Estatal de Trabajo y Seguridad Social. 24 Años de Revolución en la Seguridad Social Cubana. La Habana: CETSS; 1983.
10. Ministerio de Salud Pública. Decreto Ministerial No. 4 del 13 de Mayo de 1960. Gaceta Oficial del 30 de Mayo de 1960.
11. Ministerio de Comercio. Decreto Ministerial 709 del 20 de Marzo de 1959. Gaceta Oficial del 23 de Marzo de 1959.
12. Rodríguez, JL and Carriazo, Moreno G. Erradicación de la Pobreza en Cuba. La Habana: Ed. Ciencias Sociales. 1987.
13. Cuba. Ley 122 del 3 de Marzo de 1959. Gaceta Oficial del 4 de Marzo de 1959.
14. Cuba. Ley 135 de Marzo 10 de 1959. Gaceta Oficial del 11 de Marzo de 1959.
15. Cuba. Ley 502 del 19 de Agosto de 1959. Gaceta Oficial del 25 de Agosto de 1959.

THE AUTHOR

Francisco Rojas Ochoa, MD, 2nd Degree Specialist in Public Health, Professor, National School of Public Health; rojaso@infomed.sld.cu.

* Special Tribute to Adolfo and Rogelito, “practitioners” where I was born (Tacajo).

Excerpted from "Orígenes del Movimiento de Atención Primaria de Salud en Cuba" by Francisco Rojas Ochoa, Revista Cubana de Medicina General Integral, 2003: 19(1), 56-61.