My Thoughts from My MGMA Sponsored Trip to Cuba – December 2011

by Joette Derricks, Derricks Consulting, LLC

“Access to health care for all, is a basic human right!” (Cuban Constitution)

While the United States struggles with how best to provide health care to their citizens, the Cuban government has made it a right in their Constitution. Joette Derricks, Derricks Consulting, recently returned from a week in Cuba to study how the Cuban government is able to structure a health care system that appears to be working well. The Cuban systemis not only free for all Cuban citizens,but also, is on par, or better, in terms of quality with the United States and other industrially nations -- at a fraction of the cost we incur in the USA.

The development of the Cuban system is based on three assumptions that were central to the Revolution:

1)health was the responsibility of the state,

2)health was a social as well as a biological issue, and

3)health was a national priority, requiring participation from all sectors of the government and civil society.[1]

Derricks along with a team of health care administrators sponsored by the Medical Group Management Association (MGMA) gained an appreciation of how the Cuban government has put into place an effective public health care system.

The base for the entire system is preventive care and the primary health care (PHC) model. While the Cuban government has achieved success in their current model, it was not their starting point. Shortly following the 1959 revolution, the government established municipal “polyclinics” which still function as multi-specialty clinics today. In the early 60s their emphasis was on health screenings, vector control, and other measures to bring infectious disease under control. The PHC model of the community family doctor was introduced in 1984.

Today the health care system is structured into two levels: Level 1 is the PHC and Level 2 is the secondary health care (hospitals).

Primary Health Care Level 1

  1. Family Doctor Unit
  2. Poly Clinics (includes dental care)
  3. Specialty Institutions
  4. Mothers Homes
  5. Grandparent Homes (not nursing home setting but senior day care homes)
  6. Community Mental Health Clinics

Secondary Health Care Level 2

  1. Inpatient Hospital
  2. Inpatient nursing home type care (minimal as the culture focuses on family members remaining in the home)

Unfortunately, with the limited time available to our group we did not have the opportunity to visit any secondary health care facilities. However, we did manage to visit most PHC Level 1 care units. We found the Medical Directors, Physicians, Nurses, and all we came into contact with to be welcoming and informative.

We learned that the “family doctor unit” is a single physician with a team of nurses, statisticians, and technical assistants that care for a set amount of the local population within their community. The average number of patients is approximately 1,000 patients per physician (compared to about 2,500 patients per PCP in the US). The physician in each unit has been trained to care for the entire group assigned to him. This includes home visits, specialty care after consulting with specialists in the polyclinic, office visits, acute illnesses, long term care in the home, and ultimately keeping his patient population out of the secondary level of care (hospitalization).

  • Polyclinics are larger more regional clinics that include multiple specialties, dental, rehab, diagnostic lab, radiology, urgent care, and 24 hour Emergency Services accessible by all in the community. Generally this is done by consultation request of the family unit doctor, but per the Cuban health officials, all may enter the polyclinic on their own if so desired. After consultation, the specialist will recommend treatment options to the family unit physician. The family doctor will then resume care, consulting with the specialist to meet the continued needs of the patient.
  • Specialty Institutions are also available if further specialty care is needed. For example, if a cardiac patient needed further testing done, such as a stress test, the patient would be referred to the Cardiovascular Institute for further care. Some testing due to limited resourceswithin the PHC[LindaB1] must be done at the Hospital itself. This varies from procedure to procedure and resource availability at the time of need.
  • Mother’s homes are maternity homes for at risk pregnant mothers or fetuses based on a limited number of criteria. The mothers can be admitted at any point during their gestation period. This would include: The need for bed-rest due to possible early labor or hypertensive, diabetic status, or nutritional deficiencies. Geographically location—99% of all babies are born in the hospital thus if the expecting mother is in a rural location she may reside at the Mother’s home late in her trimester.
  • We all thought that a Grandparent Home was the equivalent of the US nursing homes. They are actually Adult Day Care centers where the families can bring the elderly during the day while they work, etc. The senior adults are cared for and fed and have a chance to mingle with other senior adults from the community. Elderly care is promoted at the home as part of the Cuban culture. Families are encouraged to care for the grandparents with supervision of the family unit physician team. This team also includes social workers.
  • The Community Mental Health Centers care for mentally ill patients and support their families in centers located in the community. The Director stressed that optimally the whole family is involved in the patient’s care and in supporting their own needs as caretakers. Group sessions with patients and families are held daily at the Center. For example, mothers of children with ADD are able to network together and lean on each other for support. Each Center is staffed with Psychologists, Psychiatrists, Nurses, Technicians, and Social Workers.

We received a great deal of data regarding their quality indicator statistics and how they capture data throughout the entire health care system. We also received an open invitation to return again to learn more about their health care success and struggles along with the culture and people. It was a wonderful learning opportunity and one that all of us on the trip are happy to share with others. If you have any questions, or would like to learn more please feel free to contact me at .

1

[1]Primary Health Care in Cuba, The Other Revolution; Linda M. Whiteford and Laurence G. Branch, 2008, page 19.

[LindaB1]CK-Joette did I understand correctly? No, this should read within the specialty institutions