Spotlight
20 Years of Family Medicine in Cuba

By Clarivel Presno Labrador, MD, MPH * and Felix Sansó Soberat, MD **

On January 4, 1984, a pilot program began in the health area of the Lawton Polyclinic in Havana, known as the Family Doctor and Nurse Plan. Involving 10 physicians and an equal number of nurses, the aim was to test in practice ideas put forward over the last few years by the country’s leadership concerning the need to transform the model of primary health care services. (1)

Family doctor, nurse and med students in the Lawton community today.

Fusing the clinical, epidemiological and social approach to health problems of individuals, their families and community, (2) the family medicine model that emerged from the Lawton Polyclinic was eventually extended nationally, propelled by the creation of a new medical specialty, developed at the Plaza de la Revolución Polyclinic in Havana: Comprehensive General Medicine . (3) At this writing, 32,291 family doctors and a similar number of nurses provide national coverage under the program for 99.2% of the Cuban population. (4)

With the creation of the National Health System and by the early 1980s, Cuban public health services (See Origins of Primary Health Care in Cuba this issue) had already noted important achievements, but development itself revealed new demands and arenas for more profound action, due to:

• The splintering of medical care among various specialists, as the different medical fields developed but did not offer comprehensive care for families. And the biological-technical approach continued to dominate, overshadowing the psychosocial and ecological elements of health. Real health promotion and individual lifestyle changes were not being achieved. More attention was focused on the “damage” or the “illness” than on the person and their health, and pro-active care was not developed.

• The need for medical care that was more relevant to demographic changes (an aging population) and to the epidemiological picture in the country (dominated by chronic non-communicable diseases).

• The growing international recognition of the need to develop primary health care as a strategy for achieving the goals of “health for all” by the year 2000 projected at the Alma Ata conference of 1978. (5)

• The political will to develop a new kind of medical care.

This model - also referred to as the “Physician for 120 Families,” “Family Doctor” or “Community Doctor” model - is based on the duo of physician and nurse working together to form a Basic Health Team (BHT), which provides comprehensive medical attention and consistent health assessments of a defined population in a neighborhood, usually between 700 and 800 people. The family is the core unit for care, but attention is also focused on the individual and the community, including the physical environment.

Two instruments are fundamental to the work of the teams: the neighborhood health diagnosis, designed to identify, analyze and find solutions for health problems, with active community participation; and CARE (continuous assessment and risk evaluation), a method aimed at organizing and developing comprehensive medical care.

The team also relies on the Basic Work Group, each one composed of an internist, pediatrician, ob-gyn, psychologist, biostatistician, nursing coordinator and social worker. This group becomes a referral unit in the community itself, carrying out support, supervisory and assessment functions for a group of family doctor-and-nurse offices, and providing the basis for academic training of residents in Comprehensive General Medicine (see Medical Education: Training Cuba’s Family Doctors this issue).

GOALS

The general objective of the new family medicine program has been to: (6)

Improve the population’s health status through comprehensive actions for individuals, families, the community and the environment, carried out in the context of close ties with the community itself.

Specific objectives:

• Promote health through positive changes in the population’s knowledge, sanitary habits and lifestyles.
  
  
• Prevent the appearance of diseases and damage to the population’s health.
  
  
• Guarantee early diagnosis, ambulatory services and hospitalization; and timely, continuous and comprehensive medical care in the community.
  
  
• Develop community-based rehabilitation for physically or psychologically disabled persons.
  
  
• Achieve positive changes in environmental cleanup in the neighborhood, as well as in the sanitary conditions of family homes in the area under her/his responsibility.
  
  
• Achieve positive changes in social integration of the community and families.
  
  
• Develop research studies that respond to the health needs of the population.

To attain these ambitious goals for the work of family doctors and nurses, strategic changes were required in the organizational structure of ambulatory care and in the organization of services and health programs, using the family as a basis. This was to be achieved without neglecting special comprehensive actions corresponding to women, children, adolescents, adults and the elderly. This new kind of health professional - the family doctor and nurse - reclaimed the notion of medical care for persons as bio-psycho-social beings, recognizing the influence of environment on health.

Medical and nursing care from then on was offered in a neighborhood office or in the person’s home. Patients can be accompanied by their family doctor or nurse to a lab test or when hospitalized, or visited during hospitalization, where the family doctor confers directly with the attending physician.

Our work as family physicians leads us to conclude that education of today’s children and adolescents is key to achieving healthy communities, raising their consciousness around health concerns as a way to minimize health risks in the future. Our experience also teaches us that even among the elderly, primary and secondary preventive actions can make a difference. The final aim must be to promote change towards more healthy lifestyles, one of the central strategies at the primary care level.

Family Medicine during the Economic Crisis

In the 1990s, these transformations were threatened by the profound economic crisis unleashed in Cuba with the disappearance of socialist Europe - the Soviet Union in particular - and the tightening of the US embargo against the island. The consequences were far-reaching and debilitating, especially in the first years. In the health sector, as hard currency became more scarce, government earmarked larger Cuban peso budgets for health care, in an effort to maintain basic services and indicators.

Yet, the limitations were evident:

• Scarce funds were available to complete construction of the full number of family doctors’ offices throughout the country. Yet, the government maintained its commitment to train more family doctors, and to leave none unemployed. The temporary solution was to convert other places into offices - apartments, small houses, etc. - and sometimes more than one physician worked in the same less-than-ideal office space.

• Shortages of all kinds affected the work of family doctors and nurses - furnishings, the necessary forms for managing patients, etc.

• At the polyclinics and hospitals, where patients were referred, x-ray film was at a premium and reserved for the most needy cases; parts were lacking for key equipment requiring repair; and clinical laboratories were running out of reagents. Only a few polyclinics retained physical rehabilitation services, with distance and transportation problems an obstacle for patients to use these facilities at the hospital level. In short, the capability of primary care to solve health problems at this level was considerably hampered.

• Therapeutic alternatives became very limited, as scarcities of medications began to take their toll, reaching one half the number of medications normally available in the country. At the same time, the number of doctors prescribing increased.

• New medical literature was reduced to a minimum, as the health system was forced to adopt more urgent priorities,; the scientific development of family doctors suffered as a result.

• Family doctors and nurses, living in the communities they served, witnessed daily the harsh effects of the economic crisis on their patients, sharing their difficulties and the effects on their health. This produced a profound psychological impact on the professionals themselves.

Experts credit the continued government priority afforded to health care during the worst years of the crisis, and the presence of family doctors and nurses in Cuban communities, as fundamental reasons why the majority of basic health indicators did not take the plunge with the economy.

The New Millennium

As the modest economic recovery has continued from the late 1990s, so, too the health system has recovered, and its commitment to family medicine reflected, among other actions, in a program called “Revolution” - or “revolution within the revolution.” The program, initiated in 2002 by the Cuban government and Ministry of Public Health, is aimed at increasing accessibility to health services by bringing them still closer to the population as a whole, and improving the all-around quality of medical care.

This comprehensive program includes repair and remodeling of health institutions (from family doctors’ offices, to polyclinics, hospitals and institutes); expansion and modernization of services (ambulatory at primary care level, hospital and emergency services; teaching facilities); and training of management and technical personnel to assume responsibility for these units.

Eye exams at the Plaza Polyclinic, Havana

Services once only available at hospital level are now installed in community polyclinics: ultrasound (diagnostic and therapeutic), areas for comprehensive rehabilitation, endoscopy, billiar drainage, etc. Other services only available at a handful of polyclinics have been extended to polyclinics across the country: optometry, dentistry, natural and traditional medicine, and libraries with computerized services able to access Infomed (Cuba’s Intranet and Internet provider for the health system). In addition, more optical services are now available for the production and fitting of glasses.

The program in its entirety serves to considerably strengthen the primary level of health care services, and the family doctor and nurse team in particular, by providing them with vital and scientifically proven technologies to increase the practical reach and capabilities of family medicine. This promises an unquestionable leap in the quality of care, and as a result in public satisfaction, as well as considerable savings in time and resources.

Final Considerations

During the creative, and yet difficult, first years of Cuban family medicine, the implementation of the family doctor-and-nurse model throughout the country has had particular social impact, which can be summarized as follows: (4)

• High degree of public satisfaction for services received.
  
  
• Significant contribution to reductions in infant mortality (down to 6.3 X 1,000 live births in 2003) and under-five mortality (at 8.0 X 1,000 live births in 2003).
  
  
• Continuous assessment and risk evaluation (CARE) of over 96% of the population.
  
  
• Decrease in hospital out-patient visits (21.7% in 1980 down to 13.2% in 2000), as well as in hospital emergency room visits. Increase in primary care visits (73.2% to 86.2% during the same years).
  
  
• Continued decrease in hospitalizations (from 15.1 X 100 inh. in 1984 to 10.8 X 100 inh. in 2003).
  
  
• Decreases in length of hospital stays, as well as hospital beds occupied (the latter from 78.5% in 1990 to 69.4% in 2003).
  
  
• Early enrollment for 95% of pregnant women in prenatal care programs.
  
  
• Institutional (hospital) births now at 99.9%.
  
  
• Immunity levels over 95.5% in children, protected against 13 vaccine-preventable diseases.
  
  
• Elimination of a group of preventable diseases from the Cuban health picture: Meningoencephalitis TB in 1997, Congenital Rubella Syndrome and Post-paradotis meningoencephalitis in 1989.
  
  
• Increase in number of women examined and in programs for the early detection of cervical-uterine and breast cancer and colon-rectal, lung and skin cancer.
  
  
• Increase in number of men examined and in programs for the early detection of prostate, colon-rectal, lung and skin cancer.
  
  
• Decrease in low birth weight rate, from 7.9% in 1984 to 5.5% in 2003.
  
  
• Increase in rate of exclusive breast feeding through the baby’s fourth month.
  
  
• Sustained growth in the creation and functioning of “seniors’ clubs,” which now number 14,000 throughout the country.
  
  
• Increase in the creation and functioning of teen programs.
  
  
• Increase in the systematic practice of exercise as a health promotion tool, as well as for therapy and rehabilitation from illness.
  
  
• Progressive increase in the number of physical therapy gyms, as a higher level unit in polyclinic services, many staffed and directed by family doctors.
  
  
• Application and extension of new therapeutical tools, such as “green medicine,” acupuncture, acupressure and others.
  
  
• Positive results from activities related to family planning and sex education.
  
  
• Increased “home hospitalizations” (92,178 in the first semester of 1997), which has lessened the pressure on hospitals by keeping patients at home under the supervision of the family doctor if they do not require secondary or tertiary level care. Reduction in length of hospital stays, as well.
  
  
• Positive modifications in the sanitary habits of the population.
  
  
• Increased life expectancy to over 76 years.

As a final note, it is worth emphasizing that the development of the family doctor program has ushered in a new stage of more democratic health care, in which access is guaranteed, responsibility for health shared and cooperation promoted. This does not mean that Cuban family medicine is a complete and finished model - to conceive it that way would negate the dynamics and dialectics of its possibilities for improvement. But with comprehensive general medicine, the aim is to see fewer and fewer persons, families and communities with health problems; and more healthy persons, families, groups and communities, who are convinced that health is a need of individuals and communities.

In each new specialist of Comprehensive General Medicine, we find the result of her/his own efforts, those of professors, family members and the country as a whole. Thus, in the approach and activities of each family doctor, we also find the mark of these last 20 years, and in a very special way, of those first 10 doctors and nurses and their professors, who had faith in the project and demonstrated that the “generality” could indeed become a “specialty.”

REFERENCES

1. MINSAP. Pensamiento del Comandante en Jefe Fidel Castro Ruz como Doctrina de la Salud Pública Cubana. Proyección Estratégica del Sistema Nacional de Salud 1995-2000. Ciudad de La Habana, 1995 .
2. MINSAP. El Plan del Médico de la Familia en Cuba. UNICEF. UNFPA. OPS. OMS. MINSAP. 1991.
3. MINSAP. Dirección Nacional de Especialización y Grados Científicos. Programa de Especialización en Medicina General Integral. Editorial Ciencias Médicas. Primera versión. 1985.
4. MINSAP. Anuario Estadístico. 2003
5. Declaration of Alma-Ata , International Conference on Primary Health Care, Alma-Ata, USSR, 6-12 September, 1978
6. MINSAP. El Programa de Trabajo del Médico y la Enfermera de la Familia, el Policlínico y el Hospital . Ciudad de La Habana. Marzo, 1988.

ADDITIONAL BIBLIOGRAPHY

1. Álvarez Sintes, R and Díaz Alonso G: La Medicina Familiar en Cuba, Rev UDCA, Actualidad y Divulgación Científica, 3 (1) 2000.
   
2. Cardona Osorio, J: Una Interpretación Dialéctica de la Experiencia del Nuevo Médico de Familia en Cuba, Revista Facultad Nacional de Salud Pública, 11 (2): 96-113,1992.
   
3. Ministerio de Salud Pública: Objetivos, Propósitos y Directrices para Incrementar la Salud de la Población Cubana 1990-2000 , MINSAP, 1-19, 1992.
   
4. Ministerio de Salud Pública, Carpeta Metodológica 1999-2001, La Habana, Ed. ECIMED/MINSAP, 1999.
   
5. Piñón Vega, J, Guzmely Escalona, B, Vergara Fabián, E: El Subsistema del Médico y la Enfermera de la Familia, su Desarrollo en Cuba (1984-1993). Rev Cubana Med Gen Integral , 10 (1): 61-9, 1994.
6. Ministerio de Salud Pública: Carpeta Metodológica de Atención Primaria de Salud y Medicina Familiar, VII Reunión Metodológica del MINSAP, La Habana, 2001.

THE AUTHORS

* 2 nd Degree Specialist in Comprehensive General (Family) Medicine; President, Cuban Society of Family Medicine; Associate Professor, National School of Public Health.

** 2 nd Degree Specialist in Comprehensive General (Family) Medicine; Associate Professor, Higher Institute of Medical Sciences, Havana.