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Introduction

The Republic of Cuba is an archipelago of 1,600 islands, islets, and keys covering a total area of 109,886 km2. It is divided into 15 provinces and the special municipality of Isla de la Juventud (1). The capital is Havana, with 2,135,498 inhabitants (1). Cuba is a socialist state organized as a unitary democratic republic, and its official language is Spanish. Access to all health and education services is universal, and free for the country's citizens. Citizens also have the right to a job and access to the country's solid social security and assistance system (2).

Cuba continues the ongoing process of updating its economy. This process, which began two decades ago, aims to protect social gains and to continue economic development with efficiency and rational resource use. The per capita gross domestic product (GDP) at constant 1997 prices rose 583 pesos between 2006 and 2010 despite the world economic crisis, financial difficulties, increasing prices of raw materials as well as of food and fuels, adverse natural factors, and the United States Government's continuing blockade of the island (1, 3). Specialized services (health and education), pharmaceutical products, tourism, nickel, and exports from agroindustrial and fishing activities are the principal sources of income. Between 2006 and 2009, unemployment declined from 1.9% to 1.7% (2% for women, 1.5% for men) (1).

Life expectancy at birth is high (77.97 years), while the incidence of and mortality associated with communicable diseases is low, and the infant mortality rate very low (4.5 per 1,000 live births). Fifteen infectious diseases have been eliminated, and eight others are not health problems, since their incidence rates are under 0.1 per 100,000 population.

The National Health System has a complete integrated network of services based on primary care and the family physician and nurse model. It is oriented toward health promotion as well as disease prevention, cure, and recovery at all care levels. The capacity of its academic institutions is ample in terms of training human resources (4).

As of 31 December 2010, Cuba had 11,241,161 inhabitants, with a male:female ratio of 1,003:1,000. The aging of the population and stagnant population growth are the two main demographic challenges. The population pyramid reflects the rapidity of the population's aging: 17.6% of the population is 60 or over, fertility rates are low, and life expectancy at birth is high. Women live on average 4.02 years longer than men (Figure 1). Over the five–year period of 2006–2010, the number of births averaged 120,829 per year, the birth rate was 10.8 per 1,000 population, the fertility rate among women of childbearing age was 43.4 live births per 1,000 women, and the total fertility rate was 1.70, with a zero population growth rate (1).

Figure 1

The crude death rate in 2010 was 8.1 per 1,000 population, 11% higher than in 2006, while the age–adjusted rate remained stable, which confirms the role that population aging plays in the crude death rates. The highest rates were reported in the west and center of the country, in the provinces of Havana and Villa Clara (10.1 and 9.2 deaths per 1,000 population, respectively), which are also home to the oldest population. Male mortality exceeds female mortality, especially in the under–75 population, as reflected in the years of potential life lost-75.6 for men and 48.9 for women. The leading causes of death are chronic, noncommunicable diseases, accidents, and intentional self–harm (Table 1) (5, 6). Years of potential life lost, considering all causes, totaled 63 per 1,000 population in the 2006–2010 period. Malignant neoplasms, heart disease, and accidents were the leading causes of mortality (Figure 2).

Figure 2

Table 1

Health Determinants and Inequalities

The State is making efforts to improve Cubans' quality of life and welfare by reducing inequality and ensuring full and universal access to health programs and actions. Vulnerable groups, the sick, and those who are disabled or socioeconomically disadvantaged receive special protections and benefits. Food at very low State–subsidized prices provides half the nutritional needs of the population. Education through the ninth grade and access to higher learning are guaranteed in all of the provinces. Improved water sources are available to 92% of the population, and the percentage of that water that is treated rose from 96.8% to 98.8% between 2006 and 2009. Overall, the dwellings of 96% of the population have sanitary facilities (7). Mass media are broadly accessed by the population, and electrification indices are high (95.9% in 2006 and 97.3% in 2009).

In the provinces, municipalities, people's councils, and electoral districts (which make up the structure of the State and government), inequalities are identified, even down to the personal level, and differentiated strategies are implemented for each area, community, family, and individual.

The Environment and Human Security

The Constitution of the Republic of Cuba makes the protection of nature a duty of all persons, both natural and juridical. Legislation has created a series of institutions, including the National Environmental Protection System and the Ministry of Science, Technology, and Environment, with full authority in this area.

Cuba has promoted and signed the agreements and documents coming out of summits and meetings on the environment, and the country mandates the protection of water, the atmosphere, soil, flora, fauna, and all of nature's potential (7). The country is addressing the effects of climate change with comprehensive programs and technological research and services, in which there are 17 institutions participating. Mitigation of and adaptation to climate change are addressed from the perspective of an island state. Although the environmental situation is favorable, problems such as soil degradation, reduction of forest coverage, pollution, loss of biodiversity, and lack of water have been identified (1).

All sectors of the State and society, including the health sector, participate in protecting and improving the environment through comprehensive programs that deal with water; with protecting and caring for sea, soil, forested areas, and air quality; with noise and liquid and solid wastes (biological wastes in particular); and with health surveillance. In Cuba, human security takes the form of equal opportunity for all citizens, the full enjoyment of their rights, and the development of their potential, provided the country's sovereignty and territorial integrity are respected.

The country has a Road Safety Code (Law 109) and a program for accident control and prevention designed to reduce risks and accidents, along with their effects on health, the society, and the economy. The number of accidents increased from 9,710 in 2006 to 10,371 in 2009, but the number of injured remained unchanged (7,475 in 2006 and 7,477 in 2009). In addition, deaths from traffic accidents even diminished, from 1,103 in 2006 to 981 in 2010, with the risk of death dropping from 9.8 to 8.7 per 100,000 population (5).

The mortality rate from intentional self–harm rose in the period, from 12.2 per 100,000 population in 2006 to 13.7 per 100,000 in 2010, while the mortality rate due to assault declined from 5.1 to 4.5 per 100,000 population (5). Both of these types of mortality are more frequent in men than in women. Intentional self–harm is the more prevalent of the two causes among older people and rural inhabitants, while assault is the more common of the two among young adults.

There is an international health control program that conducts strict epidemiological surveillance of diseases that may be introduced into the country, and that conducts focus control activities for every event that represents a health hazard.

Health Conditions and Trends

HEALTH PROBLEMS OF SPECIFIC POPULATION GROUPS

Maternal and Reproductive Health

Women constitute one half of the Cuban population. They are the object of special and differentiated care for each stage of the life cycle, and they are provided with specialized services to preserve and improve their health. The average age of the female population is 38.8 years (8), 1.4 years more than the average age of the male population. Between 2006 and 2010, the female population of childbearing age decreased 2%, while the population of women over 60 increased 9%. Life expectancy at birth for women is 80.02 years.

Between 2006 and 2010, the total fertility rate increased from 36.9 to 43.4 live births per 1,000 women of childbearing age, increasing for all age groups, particularly those under 20 and those 30 and older. Fertility is greatest in the 20–24 age group, followed by the 25–29 group. There is a discernible shift in the fertility rate to higher ages within the childbearing period, although high fertility among adolescents persists (55.4 per 1,000 women in the 15–19 age group). Couples control fertility through contraception (78% of the coverage) and by interrupting unwanted pregnancies. Mortality among women of childbearing age (15 to 49 years) is 9 per 10,000 women, and accounts for only 7% of total female mortality. The average total maternal mortality rate for the 2006–2010 period was 42.9 per 100,000 live births, with a direct rate of 29.4 per 100,000 and an indirect rate of 13.5 per 100,000.

Children (under 5 years old)

Infant mortality, showing a sustained downward trend, declined 18% during the 2006–2010 period, at the expense of the neonatal component, and without significant differences among the provinces. Perinatal disorders, congenital malformations, influenza and pneumonia, accidents, and sepsis accounted for 82% of deaths in this age group (Table 2). The incidence of low birthweight was 5.4%. Mortality among children under 5 declined from 7.1 per 1,000 live births to 5.7 per 1,000, with a 99.4% survival rate.

Table 2

Schoolchildren (5–9 years old) and Adolescents (10–19 years old)

Cuba has a school health program with 18 objectives, and 77% of the program's activity is for health promotion and disease prevention. Health and education sector personnel conduct 61% of the program's activities. Health services are provided by physicians, nurses, and, in many cases, stomatologists, for children under 5 in kindergartens, for children in primary schools with enrollments of over 600 students, and in boarding schools and special education institutions.

Risk factors, morbidity, and mortality have been reduced in the school–age population, and work to promote healthy habits and behavior is conducted at the community level under an integrated, intersectoral, interdisciplinary approach. Mortality in the 5–9 age group is 0.2 per 1,000 population of that age. The three leading causes of death were accidents, malignant neoplasms, and congenital malformations.

Care for adolescents (ages 10–19) is a priority in the country's health programs. Mortality in this age group fell from 0.4 to 0.2 per 1,000 persons in that group, and accounts for 0.5% of overall mortality. The leading causes of death for adolescents declined in the 2006–2010 period: accidents from 11.9 to 7.7 per 100,000 members of the age group, and malignant tumors from 5.2 to 4.6. However, intentional self–harm increased (from 1.8 to 2.9 per 100,000) (Table 3). The national survey on accidents in the under–20 population explored morbidity and resulting sequelae (9), and found that 63.2% of accident victims were under 10 years old, with boys the predominant victims (66.1%). Falls, wounds from sharp objects, and traffic accidents were the most frequent types of accident; 57.3% of the total number occurred in the home, and 41.7% between 4:00 p.m. and 8:00 p.m. The most frequent anatomical site of accidental injury was the head (41.5%). Nearly half of all the injuries were superficial wounds and trauma, with fractures ranking second (9).

Table 3

Adults (20–59 years old)

The adult population is 6,553,377, and is 50% female. There are health programs differentiated by sex, age group, job activity, and reproductive function. The leading causes of death among adults are malignant neoplasms, heart disease, and accidents. On average, adults receive one medical checkup annually, and more in the case of adults with special risks, disabilities, or illnesses. Persons in this age group who are workers or students receive their health services benefits in the workplace or place of study.

The Elderly (60 years old and older)

Persons who are 60 or over make up 17.6% of the population. Differentiated activities for their protection and benefit are conducted. Social, sports, cultural, educational, and health institutions are involved, generating and disseminating new knowledge and practices needed by this population group. With the shift of mortality toward the more advanced ages, 80% of mortality is now concentrated in this age group, with the three leading causes of death being heart disease, malignant neoplasms, and cerebrovascular diseases. Influenza and pneumonia, dementia, Alzheimer's disease, and accidents also play an important role. Male mortality exceeds female mortality for all the causes except dementia.

The health care system for this population group is based on the community–based volunteer group movement known as the Grandparents Circle (Círculo de Abuelos), which in 2008 had 830,486 members and a program of comprehensive care that served 132,936 single older adults, and provided social services in the home to 15,174 elderly. Family doctors provide comprehensive home care as well as institutional care, with the support of multidisciplinary geriatric care teams, one for each polyclinic (488). In 2010, there were 234 community–based old people's homes and 155 nursing homes. Of the general hospitals, 34 provide specialized geriatrics services (10). In 2010, there were 281 geriatrics specialists and over 900 physicians with diplomas in the specialty.

The Family

The Constitution of the Republic of Cuba and the country's Family Code set forth the rights and duties of the family as they affect health, protect parenthood and marriage, and affect the mutual responsibilities of parents and children (2, 11). The health teams at primary care facilities are run by the family physician and nurse program, along with specialists from the basic working group and from the polyclinic. The health team's functions include promotion, prevention, recovery, and rehabilitation at the family level through comprehensive and specific activities in the home, at the primary care facilities, and through community guidance groups, with social institutions participating.

The family–based approach to health care begins with a family health history and a study of its members, structure, living conditions, functioning, risks, and the problems it faces, then moving to diagnosis and the preparation of a comprehensive, interdisciplinary, intersectoral plan of action with family participation (12).

In 2006, the development of the country's Genetics Program made possible the prenatal diagnosis of 42 hemoglobinopathies, 1,117 fetal malformations, and 127 chromosomal abnormalities, including 54 cases of Down syndrome (13).

Workers

Cuba's workplaces are classified according to numbers of workers and occupational risks. The bodies to which the country's legislation gives the responsibility for occupational health and safety inspect all workplaces to assess compliance with standards and procedures for the prevention and control of risks, accidents, and illness in workers.

There are 43 medical offices specializing in the diagnosis of occupational illnesses. They are regulated by the Ministry of Public Health and the Ministry of Labor and Social Security. The most reported occupational diseases are: chronic nodular laryngitis among workers in the vocal professions, hearing loss in the metalworking industry, dermatosis in petrochemical industry workers, and chemical poisoning in the agricultural sector. While occupational injuries have declined, the highest incidence levels are still found in the sugar agribusiness and in construction. Preventive medical examinations are mandatory, both before hiring and periodically thereafter. There are regulations for protection in cases of occupational injuries and illness (14).

Other Groups

The Disabled

The State's socioeconomic policies and programs include regulations and intersectoral activities in the areas of health, education, sports, culture, employment, and social security, with a view to protecting and providing opportunities for people with differing capacities. Persons with disabilities have the right to freely join formal groups that have socially organized leadership and are recognized by the State (15). There are organizations and networks of social services that help to improve the well–being and quality of life of individuals with disabilities (16).

The health system has implemented a community–based network of comprehensive rehabilitation services using high technology and specialized human resources, while the education sector has a special education subsystem with over 400 centers for children and adolescents who have some type of disability. The job program facilitates their placement in normal work environments, and only in very serious cases is protected employment resorted to.

In 2003 in Cuba, 366,864 persons with disabilities were studied, with an incidence of 3.26 per 100 population. The province of Guantánamo had the highest rate (4.13), and Havana the lowest (2.13). The highest rates were in men and in persons 60 and older. The most common disabilities were cognitive ones, followed by physical–motor ones. The study was replicated in other countries of the Region (5, 17).

MORTALITY

The five leading causes of death are heart disease, malignant neoplasms, cerebrovascular disease, influenza and pneumonia, and accidents, which together account for 72% of all deaths.

Between 2006 and 2010, there was an increase in the crude death rates, except for influenza and pneumonia and for the diseases of the arteries, arterioles, and capillaries (Figure 3, Figure 4, and Figure 5). The greatest increases were associated with diabetes mellitus and cerebrovascular disease. Male mortality exceeded female mortality in the case of all causes except for the latter two diseases (18).

Figure 3
Figure 4
Figure 5

Chronic, noncommunicable diseases were responsible for 84% of deaths; communicable diseases, maternity–related causes, disorders originating in the perinatal period, and nutritional diseases for 8%; and accidents, intentional self–harm, and assaults for the remaining 8% (Table 4 and Table 5). In 2008, proportional mortality in the under–60 population was 21.8% for men and 16.7% for women (1).

Table 4


Table 5

MORBIDITY

Communicable Diseases

Vector–borne Diseases

The National Strategy for the Integrated Management of Dengue has utilized multisectoral activities, strengthened surveillance, vector control, and increased capacity and diagnostic quality in the country's laboratories. These actions have been decisive in reducing the levels of infestation of Aedes aegypti, and 86% of the country's municipalities are classified as negative or as being at low entomological risk. The year 2010 had the highest incidence of dengue in the Americas, and also had the greatest number of cases reported in Cuba, with 116 cases of imported dengue. Effective control of other vectors, such as those of the genus Anopheles, has helped interrupt the transmission of imported malaria.

Vaccine–preventable Diseases

The National Immunization Program provides protection against 13 diseases. Elimination has been achieved for five diseases (poliomyelitis, diphtheria, measles, whooping cough, and rubella), two severe clinical presentations (neonatal tetanus and tubercular meningitis in children under 1), and two severe complications (congenital rubella syndrome and meningoencephalitis following mumps). The incidence of tetanus is very low, falling from 3 reported cases in 2006 to only 1 in 2010. Hepatitis B was also reduced (34 cases in 2006, 11 in 2010), as was meningococcal meningoencephalitis (20 cases in 2006, 7 in 2010). In 2006, domestically produced pentavalent vaccine was incorporated in the official vaccination series for children under 2.

Zoonoses

No human rabies cases have been reported since 2009; the indicator of attacking animals that are under control is high; good medical care to individuals bitten is guaranteed; and treatment indices are satisfactory. Animal rabies basically affects dogs, cats, and mongooses. The number of cases of human leptospirosis has been reduced thanks to the control program implemented (557 cases were reported in 2006 and 167 in 2010). Men are the predominant population affected by the disease (5).

Neglected Diseases and Other Infections Related to Poverty

The incidence of leprosy continues to be stable, with an average of 240 cases annually and 2.2 new cases per 100,000 population, with slightly more cases in men than in women. Reports of leprosy in children are relatively few, and prevalence for the 2006–2010 period remained between 0.2 and 0.3 per 10,000 population. Surveillance and monitoring of contacts have been intensified, and the capacity to diagnose the disease has been enhanced.

HIV/AIDS and Other Sexually–transmitted Infections

At the close of 2010, the cumulative total number of cases of HIV infection stood at 12,217, and 83.2% of the infected individuals were alive. The group at greatest risk is men who have sex with men. They account for 72% of all cases diagnosed and for 89% of cases diagnosed among men. During the 2006–2010 period, the estimated prevalence of HIV in the population between the ages of 15 and 49 was 0.1%. It remained very low, and stable, among pregnant women (0.02%), blood donors (0.02%), and those treated for sexually transmitted infections (0.1%). The annual number of cases increased from 359 in 2006 to 617 in 2009, and then declined to 563 in 2010. The number of HIV tests conducted in the population increased, and life was prolonged for people receiving antiretroviral therapy. Table 6 shows some indicators of the progress made between 2006 and 2009 on HIV/AIDS and other sexually transmitted diseases.

Table 6

The incidence of syphilis and gonorrhea declined in the 2006–2010 period, from 18.7 per 100,000 population to 12.9 per 100,000 for syphilis, and from 53.1 per 100,000 to 37.5 per 100,000 for gonorrhea.

Tuberculosis

The incidence of tuberculosis was 6.4 per 100,000 population in 2006, but it fell to 5.9 in 2009 and then rose to 7.0 in 2010. Cases of tubercular meningoencephalitis have not been reported in children under 5 since 1997. Surveillance of vulnerable groups was maintained, and the association between tuberculosis and HIV/AIDS declined, from 60 cases in 2006 (8.1% of reported tuberculosis cases) to 36 in 2009 (6.2% of tuberculosis cases reported). The number of cases of multidrug–resistant tuberculosis is low, and the cure rate for these cases is above 85%.

Emerging Diseases

Surveillance of acute respiratory infections intensified in 2009 owing to the influenza A(H1N1) pandemic. Surveillance of severe acute respiratory infections and of influenza–like illnesses was put in place, along with detection of outbreaks. Diagnosis of the influenza virus and other respiratory viruses remained in force. In the first quarter of 2010, pandemic influenza A(H1N1) predominated, but October of that year marked the start of a period when the circulation of seasonal influenza virus A(H3N2) was more intense. The influenza vaccine is administered to vulnerable groups (14% of the population). During the epidemic, 300,100 doses of seasonal influenza vaccine and 1,222,460 doses of pandemic influenza vaccine were administered.

Chronic, Noncommunicable Diseases

Cardiovascular Diseases

Heart disease (Table 1) is the leading cause of death, with mortality at 211.8 per 100,000 population in 2010, 10% higher than in 2006. There are discernibly more cases proportionally among men and urban residents. The years of potential life lost figure was 11.5 per 1,000 population in 2010 (Figure 2). The 75–and–older population accounted for 59% of deaths from cardiovascular disease. Ischemic disease and hypertensive disease were responsible for 80% of the deaths from cardiac disorders, and 43% of deaths from ischemic cardiopathy were due to acute myocardial infarction, with a hospital case–fatality rate of 16%.

Malignant Neoplasms

Malignant neoplasms (Table 1) are the second greatest cause of death, and the leading factor responsible for years of potential life lost (Figure 2). Between 2006 and 2010, their incidence increased by 11% (from 175.9 to 197.5 per 100,000 population), accounting for 24% of all deaths. Malignant neoplasms were the leading cause of death in the 35–64 age group, with mortality higher in the male and urban populations. In people under 20, cancer was responsible for 0.6% of all deaths. The leading sites for cancer are the trachea, bronchia, and lungs for both sexes, followed by the prostate in men and breast in women, and thirdly, for both sexes, the intestines (rectum excepted). Male mortality from lung cancer is twice the female rate. For women age 25 and higher, the rate of those who had been examined in the National Program for Early Detection of Cervical Cancer was 196.8 per 1,000. Between 2006 and 2010, 6,615 cases were diagnosed, 82% in clinical stage 0. Mortality from cervical cancer declined by 9% between 2006 and 2010.

The highest cancer incidence rates in Cuba were in the provinces of Villa Clara, Camagüey, Matanzas, and Sancti Spíritus (5).

Diabetes

The prevalence of diabetes mellitus was estimated at 40.4 per 1,000 population in 2010, 18% more than in 2006, with women and urban dwellers being at greater risk. The crude death rate increased 21% between 2006 and 2010 (from 18.6 per 100,000 population to 23.5 per 100,000), with mortality higher in the female and urban populations.

Chronic Respiratory Diseases

Between 2006 and 2010, mortality from diseases of the lower respiratory tract increased 13%, with older adults, males, and the urban population figuring more prominently. Mortality due to bronchial asthma declined from 2.5 per 100,000 population in 2009 to 2.2 per 100,000 in 2010, although the prevalence of the disease remained at 92.2 per 1,000 population.

Cerebrovascular Diseases

Cerebrovascular diseases are the third leading cause of death (Table 1). They are responsible for 11% of all deaths, and they are among the leading causes of death for all age groups except those 1 to 4 years old. The rate increased from 74.2 per 100,000 population in 2006 to 86.9 per 100,000 in 2010. The incidence of cerebrovascular disease and the risk of dying from it are slightly greater for women and urban residents. The hospital case–fatality rate was 20%. Each province has specialized units, and clinical practice guides have been prepared for managing the disease. Hypertension, with a prevalence of 30.9% in the population over 15 years of age, is the principal modifiable risk factor for cardiovascular disease (5).

Nutritional Diseases

According to the third national survey on risk factors and noncommunicable disorders, which was conducted in 2010, 48% of individuals had a body mass index (BMI) between 18.5 and 24.9. The prevalence of overweight was 30%, with no difference between the sexes, while 14% of the population was classified as obese, with this condition more prevalent among women. Iron is the most commonly deficient micronutrient. The deficiency fundamentally affects children under 2, women of childbearing age, and pregnant women in the eastern provinces. Some 50% of infants 6 to 11 months old, 30% of children 6 to 23 months old, 30% of women of childbearing age, and 24% of women in the third trimester of pregnancy are anemic. Strategies of food diversification and fortification, medicinal supplements, and nutritional social protection are in place for these groups (19).

Accidents and Violence

Mortality from accidents increased 12% overall between 2006 and 2010, but with some decrease at the end of the period. Accidental falls are responsible for 42% of deaths in this category; together with motor vehicle accidents, they are responsible for 64% of the total. Accidental drowning and submersion are the next greatest cause of mortality in this category.

Disasters

Between 2006 and 2010, Cuba experienced four hurricanes and droughts. The greatest damage was associated with hurricanes, with the combination of wind, rain, and flooding affecting practically the entire country, and causing losses of more than US$ 10,000 million. Over 4,400,000 people received protection, in addition to animals and buildings. The drought of 2009 and 2010 affected water resources and reserves, adversely impacting agricultural production and soil conservation. The country has a civil defense system that includes all the country's sectors, the society, and the population, and that involves coordinated actions to minimize risks, accidents, and epidemics, with a special focus on preventing the loss of human life. Cuba's ability to provide medical support in solidarity in disaster situations has been evident in numerous events in the Region of the Americas, as well as elsewhere in the world (20).

Mental Disorders

Mortality from dementia and Alzheimer's disease increased during the 2006–2010 period, from 22.3 deaths per 100,000 population to 33 per 100,000, with the greater share of the deaths in the female population (5). Among the mental disorders that generate the most demand for care are depression, anxiety, sleep disorders, delusional disorders, and behavioral problems (21).

Access to specialized mental health services begins in the family doctor's office and moves up by steps within a network of 55 community mental health centers, 31 psychiatric divisions based in hospitals, 9 health care centers for the chronic mentally ill, and 23 psychiatric hospitals.

Other Health Problems

Oral Health

Oral health is addressed by an oral disease prevention program that includes fluorine treatment and mouthwashes in residential facilities and other institutions that are a part of the educational system. The effectiveness of the program is evident in the fact that over 70% of children between the ages of 5 and 6 are healthy, there is a DMF index of 1.38 among 12–year–olds, and 91.2% of 18–year–olds still have all their teeth (5). Inhabitants undergo an average of two stomatology exams per year. There is a program for the treatment of oral cancer that begins at the primary care level. Mortality from cancer of the lip, oral cavity, and pharynx increased moderately, from 5.6 deaths per 100,000 population in 2006 to 5.9 per 100,000 in 2010, with the incidence predominantly in the male population (5).

Ocular Health

Cuba has ophthalmologic care services with modern technology and national coverage, and provides care for all ocular diseases. That is done as well in other countries that are in need, through the Operación Milagro (Operation Miracle) program. The country has 1,750 ophthalmologists (22). The average number of ophthalmologic operations carried out in the country annually in the 2006–2010 period was 98,008. A program of health services for people with low vision serves over 38,000 individuals with visual disabilities of one type or another (18% of whom are totally blind). The program guarantees specialized attention, rehabilitation, social inclusion, and differentiated special education for the affected individuals.

Risk and Protection Factors

Smoking

Cuban legislation controls the sale of cigarettes to minors, and prohibits smoking in enclosed public places as well as in health institutions and educational establishments (23). The price of cigarettes was increased, the advertising of cigarettes was prohibited, and the serious risks associated with the habit were publicized. The prevalence of smokers is 24%, and is greater among men (31%) than among women (16%). Daily smokers are 21% of the population, occasional smokers 3% (19).

Alcoholism

The percentage of the population who drank alcoholic beverages was 50.2% at the close of 2001, and had declined to 41.7% by 2010. The country's pattern of alcohol consumption is considered low, according to WHO classification. Consumption is greater among men and among residents of rural areas (19). There are governmental, social, and intersectoral strategies designed to reduce consumption, as well as specialized health care and deterrence services at all levels of the health system.

Physical Activity

The 2010 Global Physical Activity Questionnaire (GPAQ) (24) showed that 59.5% of the population engaged in some type of physical activity. According to national surveys conducted in the 1990s and the first decade of the 21st century, the percentage of the population that engages in periodic physical activity has not increased (25).

Health Policies, The Health System, and Social Protection

HEALTH POLICIES

Cuba's social policy is designed to enhance the country's level of development and social welfare; to eliminate inequities among regions, areas, and populations; and to enforce the equal rights of all citizens to basic nutrition, health services, education, and income. The social policy also includes care for retirees and people requiring economic or social support, protection of sources of employment and workers, access to comfortable housing, preferably owned by the inhabitants, and evolution toward a society that is progressively more just and characterized by greater solidarity (26).

In terms of the caloric content of the diet, 60% of it is distributed through social channels: rationing with low prices, a network that provides food for low–income people, and free or very inexpensive food in health, educational, and other institutions. Free universal access to health services is guaranteed, including the most complex and costly medical treatments, as is education, including university and graduate study. Coverage by social security and social welfare is also guaranteed.

Cuba's conception of social policy is in the broadest sense, encompassing culture, sports, recreation, and rest, with equality of opportunity for population segments that have limited opportunities or are considered vulnerable. With the participation of its ministries, the Government implements national policy for health protection and promotion, for well–being, and for quality of life of its citizens, based on international agreements, charters, and conventions that the country has signed. The social policy strengthens the legal framework for, as well as the activities involved in, promotion, publicity, marketing, food production and access (both physical and economic), education and mass communications, environmental protection, and public safety, among other things.

THE HEALTH SYSTEM'S PERFORMANCE

The Ministry of Public Health is responsible for implementing health policies and regulations, and for managing health programs and services. The health system is structured at three territorial levels-national, provincial, and municipal-and at three levels of care based on a network of specialized, decentralized, and regionalized services beginning at the primary care level and covering the entire population. The primary health care model is based on family medicine and on general practitioners who are capable of promoting health, carrying out preventive and protective action, and providing diagnosis, treatment, recovery, and rehabilitation for the population for which they are responsible. They do this through a system of comprehensive health monitoring and care that is ongoing and sectorized, and that utilizes teams and involves community participation (27).

Health care is provided on a differentiated basis, according to the needs for each territory, community, population group, family, and individual, so as to guarantee equity and efficiency based on an assessment of the health situation in each area.

The Regulatory Bureau for the Protection of Public Health establishes and guarantees compliance with regulations regarding medical products and equipment. It also monitors practices and accredits and certifies the country's health units (28).

In 2010, a new process of change, reorganization, consolidation, and regionalization was undertaken in order to strengthen the sector and enhance the effectiveness, efficiency, and quality of services, as well as their sustainability. This process is organized around six objectives: (1) improving the population's state of health and its satisfaction with the services offered; (2) solidifying activities in the fields of hygiene, epidemiology, microbiology, and health surveillance; (3) strengthening strategies for the education and training of health professionals and technicians, as well as research by these individuals; (4) participating in international cooperation; (5) strengthening health regulatory functions; and (6) continuing the sector's institutional development (29).

HEALTH LEGISLATION

The Constitution of the Republic of Cuba establishes health care and protection as a duty of the State and a right of all citizens. The Public Health Act and its regulations establish legal provisions governing the sector's operation in correspondence and harmony with the development of the national health system. Other legal provisions contribute to health protection: the Environment Act, the Road Safety Act, the Social Security and Occupational Protection and Health Act, the Basic Health Provisions Decree, and the Decree on International Sanitary Control Provisions and Violations. There are provisions regulating the registration and control of drugs, food, cosmetics, toys, medical equipment, and other products.

HEALTH EXPENDITURES AND FINANCING

Total health spending as a percentage of the GDP increased from 7.7% in 2006 to 11.9% in 2010. Public spending on health as a percentage of total health spending rose from 92.2% in 2006 to 96.2% in 2010 (30).

The public health budget grew at an average annual rate of 9.5% in the years leading up to 2010. Between 2006 and 2010, spending increased 26%, and per capita health spending rose from 321.79 pesos to 439.47 pesos (5). Wages and salaries accounted for 192 million pesos, or 45.2% of total expenditure. Hospital institutions implement 42.3% of the budget, polyclinics 31.6%, stomatologic clinics 2.4%, and maternity homes 1.5%, reflecting a policy that emphasizes the importance of developing ambulatory and community–based health care.

INTERSECTORAL ACTION AND HEALTH

An intersectoral approach and social participation are essential components of Cuban society and of the country's health system, and are backed by political will and by a design that achieves complete participation in the production of health services. The intersectoral approach functions as the natural way of managing health activities, from the grassroots level up to the senior management levels of the Government and State (31).

Knowledge, Technology, Information, and Human Resource Management

RESEARCH AND KNOWLEDGE MANAGEMENT

The health science and technology system is composed of 47 scientific and technological innovation units, 19 categorized as research institutes and centers, 16 as scientific and technological service centers, and 12 as development units. Research in the sector is organized in scientific and technical programs and projects. The system has 2,095 researchers categorized as distinguished, 40,539 professors of medical sciences, 10 collaborating centers of the World Health Organization, 799 people with doctorates of science, and 1,006 students working for science degrees (5). Tied in closely with the health sector are the research, production, and development institutions of the so–called Science Pole, which produce a variety of medical technologies that are incorporated in the country's health care programs and services (28).

The country's use of scientific and technical information goes beyond its borders through the Virtual Health Library reference project (32), and that project's INFOMED information network, which includes over 19,000 scientific journal titles and more than 280 instructional and reference books. The country's scientific output is reflected in having 30 journals in the LILACS, SciELO, and MEDLINE bibliographic indexing systems. The sector has 50 medical portals and a Virtual Health Conventions Center to promote and manage scientific and academic events and activities.

INFORMATION TECHNOLOGY IN HEALTH

The National Health System is computerized, and is gradually integrating new information and communications technologies, strengthening connectivity between institutions with a patient–centered approach, and facilitating access to the information needed for clinical and management decisions. The results of the program for the computerization of health system information may be seen at the http://www.ris.sld.cu applications portal. The health system has more than 40,000 computers, 47% of which are for educational purposes, and 1,044 institutions have 24–hour connectivity.

HUMAN RESOURCES

The health system has 535,305 workers (69.5% women). There are 76,506 physicians (59% women), including 36,478 family doctors. There are 68.1 doctors per 10,000 population. There are 12,144 stomatologists (75% women), or 10.8 per 10,000 population. All physicians and stomatologists are certified specialists or residents. High–level technicians total 163,296, of whom 47,776 have nursing degrees (88% women).

Between 2006 and 2010, 91,225 health professionals received degrees, including 21,097 physicians, 2,888 stomatologists, 27,721 nurses, and 39,115 health technology graduates. Between 2005 and 2010, 8,594 physicians from developing countries and the United States received degrees (5). The institutions of the National Health System participate in the educational process. There are 13 universities of medical sciences, 25 medical schools, 4 stomatology schools, 4 nursing schools, and 4 health technology schools, in addition to the National School of Public Health, the Latin American Medical School, the National Center for Technical/Professional Continuing Training, 27 branches of educational institutions in the medical sciences, and 118 municipal branches of universities. Cuba contributes to human resources education in various countries, and maintains graduate education in medical specialties, which serves, among others, graduates of the Latin American Medicine School.

Health and International Cooperation

Cuba has a large program of international collaboration and assistance for health, both for normal situations and disasters, and contributes to human resources education and to the organization of health programs and services in several areas of the world, but especially the Region of the Americas. As of the end of 2010, 40,337 collaborators and 16,196 physicians provided health services in 68 countries through 132 projects, including projects for disaster situations, the Comprehensive Health Program, and ophthalmologic care (Operación Milagro). In Haiti, Cuba's medical collaboration began in 1998, and intensified with the presence of 1,081 collaborators in the wake of the January 2010 earthquake.

Synthesis and Prospects

The 2006–2010 period has seen improvements in the health situation of the Cuban population. The fundamental features are rapid aging of the population, low levels of fertility and population replacement, low mortality at early ages with a shift of mortality toward the oldest age groups, and high life expectancy.

Important communicable diseases have been eliminated or controlled and no longer constitute health problems, although environmental conditions and lifestyles persist that could favor their introduction and spread. Respiratory infections and acute diarrheal illnesses are the leading reasons for medical consultations.

Chronic, noncommunicable diseases and other health problems are the principal causes of morbidity, disability, and death. This is associated with the country's demographic structure and with lifestyles and living conditions, in particular tobacco and alcohol consumption, diet, accidents, and unprotected sex. Early and unwanted pregnancy, maternal mortality and morbidity, and mortality from cancer are the greatest problems facing the health sector.

The health system has comprehensive, high–technology programs, a harmonized and integrated network of quality services with sufficient and specialized human resources, access to scientific and technical information, and domestically produced medical equipment and products, both diagnostic and therapeutic. The challenge is to ensure the system's sustainability and efficiency by solidifying promotion, prevention, and surveillance activities, strengthening the network of decentralized, consolidated, and regionalized services, and increasing the sector's economic efficiency.

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