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.
More:
http://www.medicc.org/publications/medicc_review/II/primary/sloframe.html
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Bulletin of the World Health Organization
Cuba’s primary health care revolution: 30 years on
With the community-based polyclinic as its centrepiece, the country’s primary health care system has produced enviable results as it continues to adapt to new challenges. Gail Reed reports from Havana.
“We fought for the Declaration of Alma-Ata before it was official,” says Dr Cristina Luna, “and its message has guided and challenged us ever since.” At 43, Luna is Cuba’s national director of ambulatory care, and on her shoulders rests the country’s entire primary health care system, by many standards one of the world’s most effective and unique.
Cuban health authorities give large credit for the country’s impressive health indicators to the preventive, primary-care emphasis pursued for the last four decades. These indicators – which are close or equal to those in developed countries – speak for themselves. For example, in 2004, there were seven deaths for every 1000 children aged less than five years – a decrease from 46 such deaths 40 years earlier, according to WHO. Meanwhile Cubans have one of the world’s highest life expectancies of 77 years.
The centrepiece of this system is the community-based polyclinic, each of the 498 nationwide serving a catchment area of between 30 000 and 60 000 people. The polyclinics act also as the organizational hub for 20 to 40 neighbourhood-based family doctor-and-nurse offices, and as accredited research and teaching centres for medical, nursing and allied health sciences students. “These are the backbone of Cuba’s health system,” Luna says.
“But today we’re not just challenged to provide universal care at all levels, but also better quality care, better organized and integrated services. People expect much more of us now than when we were introducing the Rural Medical Service.”
More:
http://www.who.int/bulletin/volumes/86/5/08-030508/en/index.html
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From Municipal Polyclinics to Family Doctor-and-Nurse Teams
José Díaz Novás, MD1
José A. Fernández Sacasas, MD2
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
More:
http://www.medicc.org/publications/medicc_review/II/primary/poly.html
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