Cuban Medical Research

From Municipal Polyclinics to Family Doctor-and-Nurse Teams

José Díaz Novás, MD¹
José A. Fernández Sacasas, MD²

ABSTRACT: The establishment and development of primary care within the Cuban health care system has been accompanied by the political, social and economic changes that have taken place in Cuba since the 1959 revolution. The purpose of this study is to characterize the three main models of primary care that have been in place in Cuba since 1959: the municipal polyclinic model, the community medicine model (also called the community polyclinic model), and the Comprehensive General Medicine model (also known as the family doctor-and-nurse team model). In addition, we analyze each model's achievements and shortcomings, and specify the factors involved in transitioning from one model to the next, wtih today's model of family medicine considered the highest expression of healthcare delivery in the Cuban healthcare system. We also outline probable changes in the current model.

Introduction

Amidst the major social, political, and economic changes in Cuba since the 1959 revolution, numerous efforts have been undertaken to achieve long-term solutions to the Cuban population's historically poor and inadequate health status and quality of life. Healthcare services have been set up throughout the country, where preventive and curative attention is offered free-of-charge to the population. 1

Before the Cuban revolution, ambulatory healthcare facilities were limited in number and not universally accessible. Poor-quality curative medical care was delivered at first-aid stations, set up in a limited number of municipalities, as well as at hospital emergency rooms. These facilities were poorly equipped and did not meet the demands of the population. Medical insurance collectives provided medical care only for their associates, who comprised just 20% of the population. Higher-quality medical care, available only to the wealthy, was delivered through a private-practice model. 2

At that time, high morbidity and mortality rates for curable and preventable diseases reflected the precarious living and health conditions in which a large part of the Cuban population lived. The infant mortality rate was 60 per 1,000 live births (according to conservative estimates) and life expectancy was approximately 61years. 3,4

Once in power, the Cuban revolutionary government began efforts to improve living conditions for the average Cuban, and in this context increased public access to physicians in hospitals, first-aid stations and clinics, and created rural medical services aimed at expanding the reach of ambulatory care. 2

Municipal Polyclinics

In 1963, a new type of institution was created for ambulatory care: the integrated municipal polyclinic. 5-9 These clinics were defined as the Cuban health care system's basic unit, and were charged with directing all health activities aimed at persons or the environment within their jurisdiction. This included activities at workplaces, schools, childcare centers, and production and service units located in the municipality.

· These polyclinics were staffed with professional, technical, and auxiliary personnel.

· Healthcare activities carried out by these institutions were regulated and systematized, becoming the embryo of today's basic programs for community-based health care.

· A system of statistical information was created, to collect data on the municipal polyclinics' health activities. The data was used by health authorities to evaluate the effectiveness of the work at the polyclinic level.

· The work of municipal polyclinics was coordinated with other facilities at the various levels of medical attention (termed "regionalization" of healthcare delivery). This model's aim was to ensure access by every patient to the Cuban health care system's wide range of resources whenever necessary.

· Ample community participation in priority health activities was encouraged through community-based social organizations. These activities included vaccination campaigns, blood donations, and community clean-up drives, to name a few.

Upon creation, these municipal polyclinics were immediately faced with the struggle to reduce morbidity and mortality from communicable diseases-a major health problem in Cuba in the 1960s. When most of these diseases were eradicated or brought under control, various preventive-curative programs were put into place, leaving behind the period of predominantly curative medical care solely targeting illness and damage.

By 1970, the following programs were already being implemented, in an elementary form, in every municipal polyclinic in Cuba:

· Comprehensive attention to women.
· Comprehensive attention to children.
· Comprehensive attention to adults.
· Hygiene and epidemiological surveillance.
· Dental care.
· Post-graduate training programs for medical staff.

These programs coherently outlined the purposes of health care actions that were to be undertaken at the primary level of attention at the different stages of Cuba's health and social development.

The Three Stages of Primary Care in Cuba

In the early stages of establishing primary care in Cuba, healthcare activities were mainly aimed at: curing disease and looking after people who sought medical attention in healthcare facilities (subject-perceived morbidity); reducing mortality; treating disease; and lessening the effects of disabilities. Vaccination and environmental cleanups had a major medical and sanitary impact. This was the first stage of the emergence, extension and consolidation of primary care, during which the integrated municipal polyclinics were the basic units.

In the second stage, the fundamental objective was to discover unexpressed morbidity-that hidden portion of "the iceberg of disease" 10,11, which is larger than the visible part. Healthcare activities were directed at diagnosing unexpressed morbidity, caring for those who did not seek medical attention or those who visited the doctor looking only for relief of given symptoms, unaware that they suffered from a particular disorder. This second stage also included prioritizing healthy people who exhibited risk factors for certain diseases or disorders. Thus, the community-based model of primary care developed at this point included sectorialization, continuous medical attention and assessment of risk facorts, and the development of integrated health programs.

The third stage of primary care was characterized by a family and community-oriented approach to the health and disease process (the family doctor-and-nurse team model). The aim is to attain maximum public satisfaction with the services offered, and increase their participation in identifying and solving health problems in their community. This new model of the family doctor-and-nurse team is the highest expression of the Cuban healthcare system in general and, in particular, of the primary care subsystem.

How did the transition from one stage to the next take place?

In the early 1970s, the health situation of the Cuban population had already changed significantly. Mortality, and to a significant degree morbidity, were now concentrated in the adult population, rather than among children; and non-communicable chronic disorders had replaced communicable diseases as the main causes. An assessment of the municipal polyclinics 7,9,11 was in order, as well as an evaluation of their capacity to fulfill new objectives in the development of Cuba's health care system.

Among the principle limitations detected in the municipal polyclinic model were were:

1. Lack of integration of healthcare activities within the polyclinic. Health professionals and technicians working in the municipal polyclinics' health teams carried out isolated actions, with little or no interdisciplinary work.

2. Prevalence of curative over preventive actions in the work of physicians.

3. Inadequate doctor-patient-community relations in the work of physicians and dentists.

4. Inadequate solutions to health problems at the primary level. This dramatically increased the number of referrals to specialists in hospitals. Moreover, it led to a undue burden on hospital emergency care services.

5. Insufficient training of physicians to work at the primary care level, having received the bulk of their medical training in hospitals and not in polyclinics.

6. Little motivation of health professionals and technicians working at municipal polyclinics, due to scant possibilities for teaching and research activities at the primary care level.

7. Inadequate working relations with hospitals.

8. Little recognition of physicians working at the primary care level as compared with that given to those working at other levels.

9. Still limited use of the community's creative potential.

10. Low public satisfaction with primary care delivery services, as a result of all of the above.

Such deficiencies led to the establishment of community medicine as a new model of primary care. With the purpose eliminating the inadequacies found in the municipal polyclinic model, this community medicine model of primary care 6,12 was put into place, first in the Alamar teaching polyclinic (November, 1974) and later in the rest of the country.

The purpose of this community medicine model was to resolve the remaining deficiencies in primary care. The working principles of municipal polyclinics were enhanced and renewed, and basic health programs--some of which, such as attention to senior citizens, had never gotten past the planning stages--were finally implemented. 13

Better-quality medical care was provided, and expressed and unexpressed morbidity were both taken into consideration. The concept of social morbidity was also introduced.

Moreover, further achievements in the eradication and control of communicable diseases were consolidated and improved. And the first results were obtained in the control of non-communicable chronic disorders and associated risk factors.

Certain factors inherent in this model constitute fundamental transformations in community medicine as compared to the earlier stage of integrated municipal polyclinics. 6,7,9,14

1. Health care delivery by sectors.

2. Continuous care.

3. Continuous assessment and risk evaluation (dispensarización).

4. Participation of professors and residents in services offered at polyclinics.

5. Introduction of inter-consultations with specialists.

6. Development of teaching and research activities in polyclinics.

In spite of these improvements, the community medicine model of primary care fell short. Among this model's deficiencies were 2:

1. The development of this model was not consistent or harmonic. The quality of medical services in teaching polyclinics (less than 10% of polyclinics in the country) was higher than in non-teaching polyclinics. 15

2. The delivery of truly comprehensive health care to the population was not properly undertaken. A technical and biological approach to the health and disease process continued to prevail over adequate emphasis on psychosocial and environmental factors.

3. Promotion of healthy lifestyles was inadequate, and medical attention lacked sufficient family and community dimensions. Family attention was divided among three specialists, an impediment to a holistic approach to health care.

4. The "symptomatic" doctor's visits persisted, in which acute episodes of a chronic disorder were treated without searching for the relation between the patient's illness and the possible biological, psychological or social causes. Lacking was a comprehensive evaluation that would explain the patient's condition.

5. The physician's attitude was oftentimes passive, waiting for "the arrival of morbidity" instead of actively participating in the prevention, search for and elimination of health problems in the community following a careful assessment of the population's morbidity.

6. The quality of medical attention was sometimes inadequate, mainly due to an excessive number of patients served in non-teaching polyclinics. When dissatisfied with these service, patients went to hospital emergency rooms for faster attention. Delays in obtaining results of laboratory tests and x-rays in some polyclinics also contributed to the flow of patients to hospital emergency services.

7. Hospital emergency services were perceived as providing solutions to all health problems "in a matter of hours."

8. The interrelation between the work of polyclinics and hospitals was still insufficient.

9. Material resources were insufficient in polyclinics.

The Family Doctor-and-Nurse Teams

In the 1980s, in order to improve the quality of healthcare delivery, President Fidel Castro Ruz 16 proposed the creation of a new type of medical specialty in Cuba: the family doctor. Family doctors would be charged with primary care at the neighborhood level, with offices esconsed in the community being served. A pilot project to test the proposal was undertaken in the Havana's Lawton polyclinic in 1984. As a result of the success of the project, the family doctor model was extended to the rest of the country.

Family doctors are now the cornerstone of the Cuban health system. They receive training in general medicine, and then pursue a residency in Comprehensive General Medicine based at a municipal polyclinic, which includes rotations in hospitals in the last year. Specialists in Comprehensive General Medicine are eligible for any of the academic or scientific categories awarded to medical professionals in Cuba.

The family doctor model incorporates and develops all the positive elements of the community medicine model, and at the same time contributes new initiatives to primary care, helping to overcome previous limitations.

Following are some of the possibilities introduced by the family doctor-and-nurse model of primary care:

1. Consideration of the family as the basic unit of attention. The influence of family problems on the health of individuals, and vice versa, is taken into consideration. Families are encouraged to participate in prevention, curative, and rehabilitation therapies.

2. A closer relationship between family doctors and their patients, which encourages patients to participate more fully in healthcare activities. Greater community participation in decision-making processes in the healthcare system.

3. Enhanced possibilities for prevention and control of social morbidity and environmental problems.

4. Greater accessibility to healthcare services. Family doctors live in the community they serve and are available to their patients 24 hours a day. Their work load and focus is determined by the needs of their population, not by schedules.

5. Better continuity in attention to patients, which was difficult to maintain in earlier models. Such continuity has a family and interdisciplinary dimension, which includes all family members, regardless of their age or health problem. Family doctors never loose contact with their patients, even if they have been admitted to an intensive care unit.

6. Better knowledge of their patients and family members, enabling family doctors to make early diagnoses and carry out comprehensive assessments of the community's health needs.

7. Continuous assessment and risk evaluation extended to the whole population.

8. Greater emphasis on health promotion and disease prevention.

9. Participation of family doctors in patients' the rehabilitation, an aspect undeveloped in previous models.

10. Introduction of at-home treatment, based on the family doctor's judgment, the patient's condition and the family members' possibilities to care for the patient at home.

11. Greater possibilities for family doctors to detect and understand the causes leading to their patients' acute crises, hospitalizations and even death, enabling that physician to bring his or her experience to bear to prevent future complications and deaths whenever possible.

12. Use of more qualitative indices over quantitative ones. The work of family doctors is measured by their achievements. In previous models, quantitative indices were used more than qualitative ones.

13. Better possibilities for family doctors to evaluate their patients not only from their symptoms or from isolated episodes of their disorders, but also from a thorough analysis of the possible causes of their disorders. Upon analyzing disorders, family doctors focus on the essence of problems, not just on the particular phenomenon at hand.

14. Development of active mechanisms for the early detection and treatment of health problems. Family doctors review their patients' histories to detect risk factors and undiagnosed disorders, instead of waiting passively for their appearance.

15. Better interrelation between the work of polyclinics and hospitals. Family doctors have night duty at hospitals, visit their hospitalized patients, and exchange opinions with the hospital staff caring for their patients. They can also participate in discussions of their patients and make treatment suggestions.

16. The family doctor coordinates care for their patients, regardless of their health problem or the level of medical attention to which they have been referred.

17. Introduction of inter-consultations by patients with specialists at the family doctor's office. This results in higher quality medical care and prevents patients from having to wait for an appointment to see a specialist at a hospital. In some cases, these inter-consultations are carried out in the patient's house.

18. Less delay in lab tests and x-ray results.

19. The number of patients served by each family doctor (600-700 people) allows the doctor to carry out all the necessary health care actions without being overburdened.

20. Incorporation of highly qualified human resources into primary care delivery services, who are responsible for the training of family doctors.

21. Increased opportunities for teaching and research activities in the community. This was used as a model for the creation of a new curriculum in medical schools 17,18 aimed at providing students with a more harmonious training, between basic science subjects, the hospital and the community.

22. Development of the necessary material resources for primary care.

These are some of the possibilities offered by the family doctor-and-nurse team model that differentiates it from previous models of primary care.

The creation of this model represents a major social investment for the Cuban government, and is regarded as one of the achievements of the 1959 revolution. It has led to improved living conditions and health situation for the population, and to decreased morbidity, mortality, and disability rates.

Conclusions

The establishment and development of the primary care subsystem within the Cuban healthcare system has been the country's most formidable public health achievement. From its modest origins in integrated municipal polyclinics, many services and health actions were incorporated into primary care delivery. This original community polyclinic model of primary care evolved into a nationwide preventive and curative care delivery system with an epidemiological approach. Furthermore, it served as the foundation for the development of the theories and practical concepts of comprehensive general medicine, incorporating the social, biological, personal, environmental, individual and collective aspects of life into healthcare actions.

The community polyclinic model of medical care (also known as the community medicine model) served to crystallize plans for the insertion of graduate and postgraduate teaching and research activities into the work of municipal polyclinics.

Another important achievement was the development of comprehensive healthcare programs with ample public participation, which played an important role in the improvement of the population's health indicators..

The family doctor-and-nurse model of primary care is the highest expression of the organization of primary care and of the Cuban health system as a whole. It incorporates the positive contributions of preceding models and includes new concepts aimed at fuller satisfaction of present and future health needs of the Cuban population.

References

1. Valdivia Domínguez A. Intervención en la sesión plenaria del Primer Congreso del PCC. Rev Cubana Adm Salud April-June, 1976:119-121.

2. La atención ambulatoria. El policlínico y el médico de la familia en Higiene Social y Organización de la Salud Pública. Ciudad de La Habana, Ed. Pueblo y Educación, 1987:239-243.

3. Pérez Vizcaíno D. Mortalidad Infantil. Estudio de 10 años en el hospital "Pedro Borrás". Tesis de grado. Ciudad de La Habana, 1980.

4. MINSAP: Anuario Estadístico, 1987.

5. ______ : Programa de trabajo del médico y enfermera de la familia en el policlínico y el hospital. Ciudad de La Habana, 1988.

6. Colectivo de autores: Fundamentación para un nuevo enfoque de medicina en la comunidad. MINSAP, Ciudad de La Habana, 1976.

7. Fernández Sacasas J.A.; J. López Benítez: El profesor en la comunidad. Rev Cubana Adm Salud 1976;2:1

8. Rojas Ochoa F. El policlínico. Serie de Informes Técnicos 3, 1972.

9. Ordóñez Canceller C. : Organización de la atención médica en la comunidad. Rev Cubana Adm Salud April-June 1976;2:141-151.

10. Navarro V.: Planificación de la Salud en el desarrollo nacional. WHO, 1972, Sweden.

11. Last J.M.: "The Iceberg", Completing the clinical pictures in general practice. Lancet 1963;7,297:1-2.

12. Escalona Reguera, M.: "El policlínico" Presente y futuro. Medicina en la Comunidad. Serie Información de Ciencias Médicas 1975:23-33.

13. Fernández Sacasas J. ET AL.: Programa integral de salud para el adulto según el modelo de medicina en la comunidad. Rev Cubana Adm Salud July-December 1975;1:155-173.

14. Panel sobre el Policlínico en la comunidad, Segunda Jornada: "X Aniversario del Policlínico Docente Alamar". Policlínico Docente "Alamar". December 1984.

15. Primer activo sobre el programa de atención al adulto: Policlínico "Vantroi", September 20, 1980.

16. MINSAP (Higher Institute of Medical Sciences of Havana): Selección de discursos del Presidente Fidel Castro Ruz en el período de 1981 a 1984 sobre la formación de los médicos y la especialidad de Medicina General Integral. Edición Mimeografiada.

17. Ilizastegui Dupuy, F.: El desarrollo del nuevo plan de estudios de Medicina. Ciudad de La Habana, 1984 (folleto impreso).

18. MINSAP (Higher Institute of Medical Sciences of Havana) Características generales del plan de estudios para la formación del médico general básico. Ciudad de La Habana, 1986 (folleto impreso)

This article originally appeared in Spanish in the Revista Cubana de Medicina General Integral, vol. 5, No. 4, (pp. 556-564), October-December, 1989.

1 Second Degree Specialist in Internal Medicine. Assistant Physician. Deputy Director of the Alamar Teaching Polyclinic, Havana.

2 Second Degree Specialist in Internal Medicine. Full Professor of Medicine. Associate Dean for AcademicAffairs, Higher Institute of Medical Sciences of Havana.