Cuba’s primary health care revolution: 30 years on

Abstract

We fought for the Declaration of Alma-Ata before it was official, says Dr Cristina Luna, 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 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. indicators--which are close or equal to those in developed countries--speak for themselves. For example, in 2004, there were seven deaths for every 100 000 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. The period Luna refers to was the early 1960s, when Cuban government policy first focused on reaching people--mainly in rural areas--with little or no access to medical services following the Cuban revolution during the 1950s. The government started by enlisting 750 physicians and medical students for a period of their professional lives to work in the mountains and coastal The aim of el servicio medico rural or the Rural Medical Service, according to its developers, was to provide disease prevention and to revitalize health services for those most in need, whether because they are poor, in precarious health or live far from urban centres. Multi-specialty polyclinics were established across Cuba in the 1970s, before the 1978 Declaration of Alma-Ata, and these were transformed with the addition of the family doctor-and-nurse programme in the mid-1980s, enhancing the health system's ability to deliver on prevention and community-health analysis, as well as clinical services. By the 1990s, the programme had posted family doctors and nurses throughout the country, and was attending to more than 95% of the population. We were conscious that prevention had to be a cornerstone of our system, Luna says, that people had to be understood in all their dimensions: biological, psychological and social [and] as individuals within families, and within their communities. [ILLUSTRATION OMITTED] Today, Cuba has about 33 000 family physicians. Specialization in family medicine is a requirement for more than 97% of medical graduates, who spend one internship year and two residency years in training after they receive their degrees. Later, they can apply for a residency in a second specialty. As a result, the ranks in these second specialties are being swelled by physicians who started their careers in family medicine. In 2008, Cuba's primary health care is again being transformed. Since 2002, 241 polyclinics have undergone extensive renovation, a process that continues today. The aim is to add services previously available only in hospitals. …