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Challenges for Cuba's Family Doctor-and-Nurse Program
By Gail Reed

The family doctor-and-nurse model, first introduced in Cuba in 1984, charges each team with promoting and caring for the health of approximately 150 families assigned to them. It takes medical care into the neighborhood, by locating the family doctor's office literally "just down the block".

The program represents a giant step forward in comprehensive, integrated care in at least five directions:

1) Public health practice is integrated with clinical practice: family doctors regularly assess the health situation of their communities in epidemiological terms, using this information to help them ferret out health problems and the individuals that might be at risk. This is also the basis for the preventive approach to community-based health care practiced in Cuba. At the same time, the same physicians' clinical approach to their patients takes into consideration extensive individual clinical histories, kept from birth and enriched over time, so as to effectively tailor treatment to each person.

2) Care is a continuous proposition. One of the key tools applied by Cuban family doctors is the Continuous Assessment and Risk Evaluation (CARE) of their patient population. In Spanish, this is called "dispensarización", or literally being able to account for all the patients in their care. In practice, this means that once an initial evaluation of the health situation is carried out, and at-risk populations defined, each hyptertensive patient, each diabetic, each expectant mother, and so on, will all receive prioritized and differentiated treatment, in accordance with nationally prescribed procedures and programs. CARE is carried out as its name implies: on a continuous basis, so that new problems don't go very long before they are diagnosed.

The family doctor program is designed to provide continuous care in another sense: follow-through and follow-up on patients who have been treated at other levels of the health system. For example, a family doctor will follow his/her patient's progress in the hospital, and provide special care once the patient is discharged.

3) Individuals are dealt with in the context of family and community. This single component of the program allows a clearer understanding of patients' lives, the influences acting upon them, and the burdens they carry. It also promotes active involvement by families in the promotion of the health of their individual members, and active involvement of the community in the health of the families within it and the environment without.

4) Patients are treated holistically as bio-psychosocial beings. The Cuban family medicine program advocates and practices with this orientation in mind, actively opposing the strictly "biologist" framework in which patients become "cases" and the forest is often lost for the trees.

5) Services are institutionally integrated, both horizontally and vertically. Each family doctor is a member of a team, composed of family medicine residents, other family doctors in the same community, and primary-care pediatricians, ob-gyns', psychologists and medical professors. Together, they review the handling of patient care, paying special attention to troublesome diagnoses, difficult social cases, and the demands of rehabilitation. At the hub of this team is the community polyclinic, where family doctors and the team can refer such patients.

In addition, physicians at the secondary level are mandated to work with the family doctor when one of his/her patients requires hospitalization, in order to have a more comprehensive understanding of the patient's condition.

Just a few years after the family medicine program was implemented across Cuba, it was faced with a test of fire: in two short years from 1991 to 1993, Cuba's trade was cut by 85%, due to the collapse of socialist European trading partners and the tighter US economic embargo on the island. Transportation ground to a halt; blackouts lasted as long as 16 hours a day; hospitals cried out for everything from sophisticated antibiotics to aspirins. The country was literally on the brink of disaster.

Throughout the worst years, and until recovery began to be felt after 1996, Cuba's primary care model was largely credited with the near-miraculous feat of keeping the country's basic health indicators stable, and moving swiftly when they began to waffle. In some cases, indicators actually improved.

Infant Mortality in Cuba

Low Birth-Weight in Cuba 1975-1999

The magnitude of this accomplishment behind them, Cuban health authorities, with the guidance of the National Group of Experts on Primary Care and benefited by the experience and judgment of over 29,000 family physicians in the field, have begun an extensive review of the family medicine program to improve it.

Number of Family Physicians by Place of Assignment in Cuba 1999

The current process is a continuation of earlier assessments which, in 1995-96, reaffirmed the family doctor-and-nurse program as the the point of departure for the national health system's strategic development, and for the development of all corollary health programs. A decision was made to "reorient the entire health system towards primary care, and towards the pillar of primary care, the family doctor and nurse team", prioritizing investments at the primary care level that would allow more health problems to be successfully resolved there; and secondly, mobilizing more community involvement in health through the Healthy Communities Movement and the Municipal, Provincial and National Health Councils.

While the current re-assessment is far from completed, some challenges for the program are evident:

1) As stated in 1996, there is a need to resolve more health problems at the primary level, by providing the means (technical and otherwise) to do so. In the last few years, the recognition of this necessity has resulted in the creation of beefed-up emergency services at specially designated family doctor offices and polyclinics-even making beds available for overnight observation if necessary. This has already had the effect of increasing outpatient visits (family doctor and polyclinic) in relation to visits to emergency rooms (hospitals).

Medical Visits Per Inhabitant by Type Selected Years in Cuba

2) Promote more community involvement, responsibility and leadership in health issues and problems. Generate stronger participation in the Healthy Communities Movement.

3) By implication, increase the influence of the primary-care, holistic approach on the rest of the health system and in the other fields of medicine.

4) Improve working relationships between the primary and secondary-level health professionals to improve continuity of care.

5) Debureaucratize the family doctor's practice, consolidating record-keeping and reporting.

6) Increase research opportunities at the primary level, key to continuous analysis of the model and the health situation.

7) Increase the use of computer sciences at the primary level, and increase access to bibliography through this and other means. The greatest single complaint of family doctors today is a lack of current medical literature.

8) Evaluate the role of the family nurse in the team, reassess family nurse training in this light. As a result of a national analysis over the past few years, the role and training of nurses at all levels of the health system are expected to be strengthened during the coming period.

9) Reassess the curriculum for family physicians, especially in light of their increasing social role in the community they serve. (It should be noted that the Cuban family physician carries out a three-year residency in Comprehensive General Medicine/family medicine) .

10) Increase the range of opportunities for post-graduate training opportunities. The creation of the Primary Attention Department at the newly restructured National School of Public Health, which is merging with the National Post-Graduate Medical Training Center, is expected to make considerable progress in this direction.

Cuba's family medicine model has already proven its ability to ensure health and health care under the most adverse of economic and social circumstances: now the challenge is to make the model more workable, generate greater public satisfaction, and to train health professionals with the resources to become tops in their field and ever more responsive to their communities.