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ISSN 1527-3172
ISSN 1527-3172 Cuba's National Comprehensive Program for the Elderly
Osvaldo Prieto Ramos, MD
UBA HAS BECOME an example of a developing country with
a significant rate of population aging. Currently, 12% of the Cuban
population is over 60-a figure expected to reach 13.4% by the year 2000,
and 20.1% by 2025. Life expectancy is now 75 years. In relative
terms, the proportion of elderly in Cuba is higher than the 7% expected
in underdeveloped countries by the year 2000, and even higher than the
10% expected for the world by 2000 or the 14% by the year 2025.
The process of population aging in Cuba has mainly occurred
during the 20th century. At the beginning of the century,
there were 72,000 people over 60 in Cuba; but by 1950, this number had
jumped to 425,000. And in 1990, Cuba had over 1.2 million
older people. Consequently, the growth in this age group has been
estimated at 250,000 every 10 years to the year 2000; and thereafter of
400,000 every 10 years, to the year 2025.
From a demographic point of view, several factors contribute
to explaining this process. The annual rate of population growth
has remained very low in Cuba over the years, as compared with those of
the underdeveloped countries in general. The growth rate for the
population over 60 years of age (1.5 ) has remained relatively stable
and is double the rate for the general population.
Therefore, Cuba is one of the "oldest" countries in Latin
America. This phenomenon, the result of progressive social policies,
must now be tackled with the scarce economic resources available to a
developing country.
Cuba's advances in health care and social security services
for the general population have been significant. However, the increase
in population aging as well as the speed at which it has taken place have
resulted in the need for a complete change in the order of priorities
for Cuban health policies to deal effectively with this new development.
Unfortunately, this situation has emerged during Cuba's worst economic
crisis in the last 30 years.
In
shaping Cuban policies related to elderly care, we must take into account
the background described above, and recognize that Cuba need not be obliged
to simply adopt the traditional policy responses formulated by developed
countries, but rather fully consider the great economic and social differences
between our societies. In this context, full use should be made
of Cuba's favorable social and health-care infrastructures, as well as
of the potential represented by family and community participation in
developing the most humane and economic solutions to the problems of the
elderly. This must include promoting and facilitating active participation
by the elderly in the formulation and implementation of these solutions.
Vital to this process has been an integral approach, combining medical
and social concepts in a comprehensive national program for the elderly.
(For the complete Program, see Appendix 1.
)
This
program, in addition to promoting improved medical attention and services
for the elderly at all levels, establishes a parallel system of geriatric
attention at each level of health care, which complements and improves
on the Cuban system of geriatric care in general.
This program has been included in the
Program for Comprehensive Family Medicine-the main guide for family
doctors practicing at the community level in Cuba-pursues greater familiarization
with the individual and social needs of elderly people, and improved problem-solving
capabilities at the primary-care level. The program relies on three
main pillars:
These three coordinate activity at two
basic levels of community attention, and are supported by a third level
of secondary or hospital care (geriatric services) and other social institutions.
At the first level, emphasis is placed
on health promotion, prevention of disease and primary care for older
persons. The family doctor and nurse carry out a comprehensive assessment
of the social, psychological and biomedical conditions of the elderly
in their zone, by applying continuous assessment and risk evaluation
(CARE) on an annual basis and a personalized program of regular
check-ups and attention to specific conditions. This allows them
to evaluate the state of health of older people as individuals and as
a population, identifying the main risk factors and diseases which affect
morbidity, mortality and disability for people over 60.
The local Delegate, elected by the community
to sit in the Municipal Assembly, collaborates in prevention and solution
of social problems that can be dealt with at that level. Together the
family doctor, the family nurse and the Delegate promote the creation
of community senior citizens' clubs-autonomous organizations that offer
broad possibilities for social participation and carry out self-help and
mutual-assistance programs, contributing to active participation of the
elderly in solving their problems.
The second level treats patients with
biomedical, psychological or social problems that cannot be solved at
the first level, and whose cases require more profound study and more
complex management. The main structures at this second level of
attention are the so-called Gerontology Boards based at community polyclinics.
The Board is a multidisciplinary team consisting of a specialist in Comprehensive
General Medicine (family doctor), nurse, psychologist, and social worker,
all with special training in attention to the elderly. It is charged
with coordinating the implementation of the Program, carrying out a multidisciplinary
assessment of elderly patients with health problems, and providing them
with the specific social and health-care services they need. The
Board decides which patients need hospital care and attends those recently
discharged patients, coordinating their reinsertion into the community.
Furthermore, the Board coordinates social assistance services for those
elderly people who need them, promoting alternatives that reduce the need
for institutionalization. Finally, the Board brings specialized
attention to senior citizens in daytime hospital and care centers.
Senior Citizens' Daytime Medical Care
Facilities are mainly charged with the biomedical, psychological and social
rehabilitation of disabled elderly, assisting in the fullest possible
recovery of patients' functional capacities. The main innovation
of the Program is the placement of these centers in the community itself-which
contributes to better attendance and to a more efficient use of material
and human resources.
Senior Citizens' Daycare Centers provide
daytime attention for those incapable of caring for themselves in their
own homes and for whom no other alternative has proved effective. However,
a minimum degree of competence for daily activities is required.
Now, Senior Citizens' Cultural Centers
are being set up with the aid of People's Councils (the most grassroots
level of municipal government) and other local organizations, which will
be voluntary membership groups in each community. The leadership and rules
for each center will be decided by its membership. The Centers will
draw up programs of cultural, sports, recreational and other activities,
as a way to encourage their members to socialize and develop their capacities
for mutual assistance and self-help. These institutions may also
assist their members in reinserting themselves in the labor force on some
level, if they wish, to give them additional financial security.
The third "level" of the Program, charged
with providing health care at the secondary and/or tertiary levels, consists
of hospital-based Geriatric Services and Homes for the Elderly.
The purpose of hospital geriatric care
is to offer solutions to the health needs affecting the quality of life
of elderly people, which could not have been addressed at other levels.
When patients are discharged from hospital, they receive attention from
the community-based Gerontology Boards first, and then by family doctors
and nurses, to whom specific recommendations are sent from the hospital
Geriatric Service.
Homes for the Elderly are a crucial part
of this program. Their functioning should be reviewed periodically
to incorporate the latest scientific thinking in the field, and to assure
their full integration into the system of care for older people.
Cuba's National Comprehensive Program
for the Elderly is also aimed at diminishing the need for institutionalized
care, thus contributing to improvements in the attention and living conditions
of old people.
This Program takes into account the necessary
support given the Homes for the Elderly by the hospital-based Geriatric
Services, which will provide consulting services on medical attention,
teaching and research. References
1. Hernández Castellón, Raúl. El envejecimiento de
la población en Cuba. 2. Prieto Ramos, Osvaldo. Envejecimiento y Geriatría
en Cuba. Desarrollo y 3. San Martín, Hernán. Epidemiología de la vejez.
Madrid. 4. Vega García, Enrique. Seminario Taller Salud Integral
del Geronto. (Lectures). 5. Oficina Nacional de Estadística: Anuario Demográfico
de Cuba 1998. La Habana 6. Oficina Nacional de Estadística. Proyección de
la población de Cuba período 7. Alfonso Fraga, Juan C. "¿Nos estamos poniendo viejos?"
Revista Sexología y 8. Comité Estatal de Estadística, Oficina Nacional del
Censo. El envejecimiento 9. Comité de Trabajo y Seguridad Social. Monografía
sobre el envejecimiento de la 10. Colectivo de Autores, Cuba: Transición de la fecundidad
y conducta 11. CISS, La seguridad social en Cuba , serie monográfica
6, México, 1994 (basado 12. Prieto, O. Formación de recursos humanos en Cuba.
Conferencia en X Congreso 13. Prieto, O., Vega, E. Atención al anciano en Cuba.
Ed CITED, La Habana. Mayo, This article was originally presented in Spanish at the Gerontovida'99 Congress (Havana, September 1999). APPENDIX
1 General
Objectives
The main objective of the program is to improve the health
and quality of life of people over 60 through health promotion, disease
prevention, medical attention and rehabilitation programs carried out
by the national public health system in coordination with other related
government institutions and organizations. Older persons, their
families and the community, working together to find local solutions to
their problems, are among the most important protagonists in this effort.
Specific
Objectives
Create community-based gerontological attention that contributes to resolving
socioeconomic, psychological and biomedical needs of the elderly at the community
level.
Improve the quality of attention and quality
of life in social institutions, which permits greater fulfillment of senior
citizens' biosocial needs and demands.
Provide comprehensive medical attention to
the elderly in hospitals, based on the latest scientific advances in their
field.
This Program is applied throughout Cuba, and in all institutions
that care for people over 60.
Program
Design
The
program incorporates three interconnected levels of attention:
1. Attention in the community Activities
The work of the aforementioned levels of attention
has been designed as follows:
Institutional Attention is aimed at
addressing the needs of:
Attention in the community is aimed at carrying out
a multidisciplinary and multidimensional evaluation of the resident population
over 60. This provides an assessment of the health situation of the
elderly in this community, and allows for the developing of strategies for
dealing with the biosocial needs of this population.
Attention in hospitals is aimed at providing hospitalized
older people with specialized medical care.
Indicators related to structure, process and
impact will be used to evaluate program implementation.
Goals and General Indicators
for 1999
Develop
community-based care for the elderly in community polyclinics across the
country
1. Achieve 30% enrollment by people over 60 in senior
citizens clubs.
2. Create Senior Citizens' Daycare Centers in 60% of the
country's municipalities.
3. Create Senior Citizens' Cultural Centers in 80% of
the country's communities.
4. Ensure adequate functioning of the Gerontology Boards
in 100% of the nation's 5. To offer training courses for at least 50% of the
members of the country's 6. Increase by 30% assistance in the home to elderly live-alones. Improve
attention in Homes for the Elderly
1. Decrease the mortality rates from 1998 levels.
2. Carry out 100% of the multidimensional evaluations
planned.
3. Reduce the incidence of pressure sores to less than
0.8%.
4. Reduce the incidence of accidents from 1998 levels. Develop
medical attention to hospitalized older people in order to:
1. Ensure implementation of the Program for Attention
to the Elderly in 100% of 2. Extend geriatric services and wards in all clinical-surgical
and general medicine 3. Reduce mortality rates from 1998 levels, and lethality
due to acute respiratory 4. Extend Exhaustive Evaluation Services to 100% of the
hospitals with geriatric wards. Morbidity
1. Reduce morbidity rates from 1998 levels, due to tuberculosis,
suicide attempts and hip 2. Reduce morbidity rates from 1998 levels, due to diabetes
mellitus, cerebrovascular Mortality
1. Reduce mortality rates from 1998 levels, due to acute
respiratory disorders (ARD), This article originally appeared in Spanish in RESUMED, vol. 12, No. 2, (pp. 91-93), 1999.
Ciudad de La Habana. CEDEM, 1994. 105p.
perspectivas. Rev. Esp. Geriatr.
y Gerontol. 1992 ,27 (7). pp 425-429.
McGraw-Hill-Interamericana, 1990. 555p.
Lima. Instituto Peruano de Seguridad Social,
1993. 40p.
1999.
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Sociedad, 1(1-2). La Habana, abril-septiembre,
1995.
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Databases. 1994.
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Bello Horizonte. Brasil Sept-1994.
1994. 
Cuba's National Comprehensive Program for the Elderly
2. Institutional attention
3. Attention in hospitals
polyclinics.
Gerontological Boards.
clinical-surgical and general medicine hospitals with
over 100 beds
hospitals with over 100 beds
disorders (ARD), acute diarrheal disorders (ADD), hip
fracture, diabetes, stroke, and
chronic obstructive pulmonary disorders (COPD)
fracture in people over 60
disease, asthma and chronic obstructive pulmonary disorders
in people over 60
acute diarrheal disorders (ADD), tuberculosis, accidents,
suicide and hip fracture in
people over 60.