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11/1/1992 - “Just” a Clue about the Cuban Primary Health Care DeliverySystem by Bacete Othwonh Bwogo

NoT FOR PUBLICATION WITHOUTWRITER SCONSENT BOB INSTITUTEOFCURRENTWORLDAFFAIRS Residencia victoria Giron Albergue No Calle No entre Cubanacan F1aya Zona Postal La Habana CUBA November Peter Bird Martin Institute Current World Affairs West Wheelock Sreet anover N H 03755 Dear Peter CLUEABOUTT CPRIMARYF_LTICDELISYSTEM When I first learnt about Cuban health system achievements I asked myself I chance I question anymore because right I seeing unfolding right front The emphasis primary health another story practice pursued interest vigor decades Pues entonces vamos polyclinic Lawton My first encountex health system began November From outset important mention different levels health exist tertiary highly specialized medical centers secondary hospitals primary mainly polyclinics The institutions respon1ble delivery primary health polyclinics I opportunity Dr Jose Rodriques Abrines director Polyclinic Lawton municipality octubre Havana graduate Havana medical school fifties first pioneers polyclinics experiment Cuba after revolution I asked focus primary Cuba Dr Redriues brief historical review health situation distribution health services Cuba before revolution necessary appreciating present organization health delivery system Before revolution thirds health services available small population Cubans lived cities towns country The majority people country Bacete Bwogo ICW fellow studying primary health delivery Crrba Costa Rica Kerala State India USA Since InstituteofCurrentWorld Affairs theCrane Rogers Foundation hasprovidedlong fellowships enable outstanding young adults outside United States write about international areas issues Endowed bythelateCharlesR Crane theInstituteisalsosupportedbycontributionsfromlike mindedindividualsand foundations BOB anything llttle access health Medical mainly oriented toward curative which provided through private health facilities institutions Most conmon Caas Seguros_ Th_s_ small clinics hospitals through Membership anyone could afford premuims bem_eficiaries people worked cities towns constm_nt ncome The majority Cubans mostly countryside depended their health other practxces cures provxeee Dy curaneeros traditional healers The causes morbidity mortalilty infectious parasitic diseases diarrhoea tuberculosis worms infestations The training medical doctors place medical school University Havana Now there medical schools polyclinics spread throughout cou_try A Pan American ealth Organization review Cuban health services highlight aspects access health Before Cuban revolution health services Cuba conformed social class The small wealthy class served purely private doctors hospitals The middle class sklled workers about population served largely resources mutual societies Mnorn casas seguros The large class rural peasants urban proletariat served crowded understaffed govermental hospitals clinics received Why focus health Well triumph revolution promise progide health coverage entire population extending health services parts country urban rural areas neglected before lacking essnta health services preventive curative Thus casas seguros coverted polyclinics health centers other countries These comprehensive health clinics provide preventive curative services They centres activities primary health Cuba Each polyclinic usually serve population about Through political decision revolutionary goverment passed aimed improving health conditions people living rural urban areas wanting imunediate health services Most peasants working agricultural farms The decision aimed increasing medical doctors already redundant cities A regulation enacted which rural service obligatory medical doctors after their graduationi medical school The period subject extension another years Many small rural hospitals constructed throughout country consequence policy BOB initiated The means achievino specific objective throughhelh education promotion healthdprevention dseases prenatal tenatal caredhospital deliver preset women InfL uoaLIiLx dxupd Lu I000 births compared births By coicle diseases malaria poliomyelitis ddiphtheria irradicated In period whole I000 although national objective rains improve fibre births A vigorous programme immunization followed Cuba All children vaccinated against communicable diseases tuberculosis hepatitis B tetanus diphtheria whooping cough measles mumps rubella meningitis polio However disease pattern general population Cuba changing Now average about years chronic diseases associated increasingly co_mmon Cancer heart diseases stroke among leading causes death elderly Furthermore health services structured effort health closer available accessible community Hence population divided geographic areas provincial municipal health areas Each health would usually population about would served polyclinic ambulatory The structuring services meant construction facilities provinces there provinces before revolution country Of course population density different province another population served polyclinic similar throughout country However could isolated areas Finally health areas subdivided health sectors population about people purpose assignments among health personnel Usally these personnel would medicos familia family doctors nurses Each family doctor serves population about people blocks Community participation primary family doctor assisted community through peoples committees organizations Poder Popular Peoples power Federacion Mujeres Cubanas Federation Cuban Women Committee Defence Revolution Brisada Sanitaria Sanitary Brigade Circulo Abuelos Elderly clubs The representativ these committees selected their communities The committees support family doctor providing general information about health situation community BOB Comprehens Inte_qrated Medicine Having sabllsed xLensive healh scrvicedpolyclinics concern press ality medical improvins place This debate resulted conception approach model primaryhealthcaredellve Thew uodelbeceknoastho Medicina General Inesral Or comDrehensive integrated medicine The objectives progr nclude promotion healthdprevention diseases curative services adults pediatrics Iderly preset women dalso psvcho soclo conom isues coity The polyclnic centre newprima activities epeCalzed departmtm stlished exple obstetrics aecolo pediatrics psychiatry internal medicine physiotherapy nvestgatve departments diagnostic loratores X AI departments headed specialists They responsible training family doctor specialist comprehensive integrated medicine The place family doctor community The doctor works consultorio clinic This usually story building The ground floor serves clinic This where consults patients The second floor house doctor All family doctors assisted their nurses Living community expected family doctor become acquinted health problems community Some family doctors I interviewed working neighbourhoods years They relate community Every patient doctor personal clinic together files other members their families Besides their consultorio family doctor looks after health elderly Circulo Abuelos Elderly Club The clubs really health institutions rather social groups various activities including physical exercise There exercise specialst attached every Circulo Abuelos All aspects clubs business managed elderly themselves I Dr Jose Diaz Novas professor comprehensive integrated medicine Polyclinic Lawton about training programme family doctors specialize Medicina General Integral The person wanting specialize Medicina ntegral would normally graduate faculty medicine having pursued medical studies years He comnunity After graduation spend working Inity Then another years residency polyclinic where receive regular ition assessment their progress specialists various departments BOB Medicina integral geared toward learning about health society whole ciriculum consist studying determinants health example education housing nurti vnment ocfal organization health education about styles effects smoking alcohol ingeson pysical exeruise health While general effort directed improving health situation actSvltles fsmily doctor This accessed through priodic s19weys patient satisfaction either interviewing consumers health their complaints through peoples committees The family doctor periodically assessed apptitude teaching professors polyclinic place consultorio This accomplished through revision clinical records patients professors occassional supervision Family doctors required present cases discussion seminar sessions polyclinics Usually family doctors conducting research projects which present theses completion three years training Specialst status confered successfull candidates three years rsidency It candidate continue practicing family doctor switch other specialities desired cases majority choose remain A consultoro family doctor I visited consultorio Dr Leonardo Cuesta Mejas It short walking distance polyclinic Lawton The clinic consist doctor consultation waiting patients physical examination There refrigerator keeping vaccines autoclave sterlization instruments special examinations Also there weighing scales adults child The general environment clinic quite The nurse insde doctor consultation And beside helping keeping records patients general order clinic responsible vaccination monitoring growth children visiting various health activities According doctor patients elderly usually presenting chronic health conditions example blood pressure heart vascular problems diabetes mellitus psychiatric problems elderly In youner patients parasitic nfection giardia amoeba oxyuris thread common Z opportunity operated abdominal cancer years He permanent colostomy fixed abdomen since operation I asked feeling He quite visiting doctor today different B OB reason According doctor patient condition diagnosed early before spread other parts hence operatlve survival It recognised secondary quite expensive And efforts directed early diagnosis diseases their treatment achieve follow treated cases In family doctor links secondary hospitals levels health systems complement other nfact family doctors refer patients directly hospitals specialzed special investigation services obtained polyc A healthy married woman routine check She weeks pregnant In Cuba nearly pregnant women their doctor after gestation All tested presence fetoprotein weeks pregns_ncy The early detection congenital malformations anencepahiy bifida Early termination pregnancy carried positive fetoprotein This particular young woman negative scheduled ultrasonography other tests sickle naemia hospital following I asked sickle anaemia tested The answer sickle anaemia medical condition commonly occurSng Cubans mixed parentage black white mandatory Also pregnant women tested human immtulodeficeincy virus A normal healthy brought mother routine check She weighed llkgs length All healthy babies doctor every months When brought clinic anytime without appointment All vaccination cards checked doctor ensure received appropriate vaccinations I asked Dr Leonardo whether there other providers health community After revolution medical services extended throughout country access health improved Also health facilities population increased Medical provided charge Cubans In traditional healers either herbalists spiritual healers resort people access medical could afford private hospital Of course traditional healing still exist communities today demand their services declined quite remarkably years since people access medical clear provided traditional healers discouraged regulated extent medical sector The through health education campaigns social workers CO IKIUII ebout their hcalth increased And result increased awareness BOB people choose medical attent_on available health facilities polyclinics family doctors hospitals Spiritual healing practiced splzitual healers Babala_w They derive their spiritual powers beliefs Yoruba tradition which quite stron Cuban Culture I origin Yoruba tradition Cuba traceable coast Africa Green Herbal medicine medicina verde known domain traditional healers alone practiced medical doctors regulate former given Plantas Medlclnaleg medicinal plants Dr Leonardo contains medicinal plants medical doctor prescribe patients treatment dfferent kinds illness Such prescrSptions obtained pharmacies other ordinary pharmae utical products Acupunure widely There special clinic octubre acupuncture According doctors I talked viewed necessary together available health resources maintain present health status country population whole during difficult times periodo esDecial special period This reference economic blockade Cuba which causing enormous difficulties country obtaining essential medicines medical equipment international markets abroad problems availability recent scientific literature Erom inquires appears there significant reversals major indicators health years infant mortality remainded fairly stable about births whole country C0mputers primary health Th computer department Polyclinic Lawton I talked department Dr Carlos Pe computers introduced polyclinic The objective programme obtain database information patients their families whole which served polyclinic easier family doctors access information patients without going through tedious routine looking files papers It saving The computer keeps medical records people living I direct opportunity seeing information gathered entered computer storage Two techncians women responsible Rut first information collected sources The sources nformatlon family dctors About S6 family doctors associated polyclinic Lawton Forty OB working reservists working polyclinic replacement family doctor required whatever reason insure continuity Da1y records patients forty consultoros family doctors polyclinic Information sorted patient personal history marital status occupation smoking smoking socio economic situation medical history previous illnesses treatments received results previous current laboratory tests presem_t treatments dlagns present medical condition For patient there nformat about their family living condition house hygiene sanitation number rooms space available members family Addresses patients entered computer By family doctors different identification numbers computer To access information particula patient ID doctor responsible known patient identificahion ntunber Information computer confidential produced health authorities doctors concerned Information required It Ss worth mentioning coding diseases unified World Health Organization The standardization codes hoped facilitate international comparisons health Thus according Dr Carlos Pelaez usefulness computers primary health obvious Besides providing access informtion about general health situation population computers could provide nformation health resources being utilzed identify which health areas consuming resources Also information obhained useful directing future planning health services according specific needs health question Moreover pooling together information country informative about health status different provinces regions country short state health nation whole could determined Hence national health planners Ministry Public Health benefit information computers directing national health polcy However computers introduced polyclinics throughout country hoped expansion occur include polyclnics future opportu allow Now computers donations organizations Others bought international markets about US dollars The computers polyclinic Lawton capacity storage health other polyclinics stored DOffs01 So I alklng about primary actvitie polyclinic Bu polyclinic system across whole country areas And there already operatins throusho country Besides there other hisher evels health which consume consideralble resources secondary trtiary hospitals specialized institutions I mentioned medical At point X believe services other words Is individual family unitM Well Ministry Publc Health It responible pport health services adminstration personnel salaries overseeins operation8 health facilities meets costs According Dr edriques about gross national product spend health olane T whnthnr services expensive sinco primary supposed affordable Ha health authorities aware expense xpanditure alone inevitable because national health strategy right after revolution promise Imfov health efvic Peoples productivity increase healthM Thi makes nvesmenf healfh worfhwhile_ I Dr Vlefor Fisueroa about accessibilty health services He doctors lometer where The obcctlve hoalth sector consolidation present health structures thelr mprovement The notional target 1970s cnstruc S00 polyclinics fhrouSbOuf country there It hoped Cuba achieve health objective Cuba Ministry Public Health polyclinic family doctor programme This viewed approach solving health problems country As narration above Cuban approach primary Alma Ata declaration Y Q which adopted World Iealth Organization WHO As defined WHO primary health PHC essential health based prctc gclentificallM socially universally accessible indivdzals famlles cmmunty through their participation BOB Ol community country afford reliance determination It forms integral bothofthecountrw she1thyem fwhch ntral unction focus overall social economic development ndlvlduals famly community It level first contact individuals family comuunity Ith MS closespooblotowhoropooplo IivcndworandconEtltu first clement continuln health process I above definition mindm primary health PH C given attention developins countries Some observers think halth aloha bring about halth promotion wider changes society required health total nutrition eqiJrmnf balng_ Tt J8 JnkeegtnS Oe reduction Infant mortality 1960s 1970s access dLtcatlo emplo iutzOvt U environmental sanitation In letter I shall about lnity partici O primary health We Peter I things always follow natural order seems first anythin always comes after story I guess until I information experience primary health dlivry right Cuba But X finallM I newsletter otmtiv interesting As I mentloned first Just I I You O shortly bfore Chzlstms Hasta proximo carta muchas racias Cordialmente Bacete Othwonh Bwogo M D