Socioeconomic, Political, and Demographic Overview
The situation in Cuba since 1989 has been characterized, above all, by a profound economic crisis that has affected virtually all spheres of national life. The severity of the crisis is evidenced by the fact that between 1989 and 1993 the countrys gross domestic product (GDP) fell 35% and exports declined by 75%. The two determining factors underlying the crisis are well known. One is the dissolution of the Soviet Union and the socialist bloc, and the other is the economic embargo the Government of the United States of America imposed on Cuba more than 30 years ago,.
In the face of this new situation, the Cuban Government has introduced a series of adjustments and restructuring measures aimed at halting the crisis and reviving the economy.
In 1994, the downward trend of the economy reversed and a modest growth in the GDP (0.7%) was reported. In 1995 the GDP increased by 2.5%, and in 1996 it grew significantly by 7.8%. That same year, per capita GDP went up 7.5%, and the minimum wage, the earnings of the population, and the distribution of income all improved. In addition to other positive indicators, it should be noted that the budget deficit fell to 2.4% of the GDP (compared with 33% in 1992 and 3.6% in 1995), total exports grew 33%, labor productivity increased 8.5%, investment went up 54%, personal consumption rose 4%, and collective and government consumption increased 4% and 2%, respectively. The value of the peso, which averaged 60 pesos per United States dollar in 1994 and 32.1 pesos in 1995, dropped to 19.2 pesos per dollar in 1996. Although the negative trend seems to have reversed and the economy appears to be growing, the country still faces difficulties as a result of unfavorable foreign borrowing terms, especially high short-term interest rates.
On the political front, noteworthy developments include efforts to extend the decentralization of the government (including decentralization of the National Health System) and the economic sectors; to promote and develop popular participation in decision-making and to strengthen the Parliament and its commissions, including health, sports, and the environment commissions, as the legislative organ of the State.
As of 30 June 1996, the estimated population was 11,005,866, and the population density was 99.3 inhabitants per km2. The birth rate has declined steadily, reaching a low of 12.7 in 1996, with a reduction of about 30% for the decade. Fertility rates have also decreased. The general fertility rate dropped from 66.1 per 1,000 women aged 1549 years in 1985 to 46.7 in 1996. At the same time, the group aged 60 and over continued to increase in absolute terms as well as proportionally and in 1996 made up 12.7% of the population. In 1992, persons under 15 years of age made up 22.4% of the population and in 1996, 22.0%. The general mortality rate was 7.0 per 1,000 inhabitants in 1992 and it reached 7.2 in 1996. Projected life expectancy at birth for the five-year period 19952000 is 75.48 for both sexes, 73.56 for males and 77.51 for females.
Whereas infectious and parasitic diseases were the main causes of death 30 years ago, today the vast majority of deaths are due to chronic and degenerative diseases and accidents.
From the political-administrative standpoint, the country is divided into 14 provinces and 1 municipality with special status (Isla de la Juventud). These areas have populations ranging from 0.5 to 1 millionexcept the city of Havana, which has slightly more than 2 million inhabitants, and Isla de la Juventud, which has 77,429 inhabitants. The urban population has increased from 69.0% in 1981 to 74.5% in 1995, according to intercensus estimates of the National Statistics Bureau of Cuba. The population under 15 in rural areas is proportionally larger than in urban areas (24.3% and 21.5%, respectively). The reverse is true of the populations aged 1559 years (64.2% and 65.4%, respectively) and 60 and over (11.5% and 13.2%, respectively).
Analysis of the mortality profile according to six major groups of causes and by urban and rural populations in 1996 reveals that adjusted mortality rates in urban, rural-urban, and rural areas were 649.1, 617.4, and 490.6 per 100,000 inhabitants, respectively, with a mortality ratio of 1.3 between the highest and lowest rates. In general, this pattern holds for all groups of causes, with the exception of conditions that originate in the perinatal period and violence, both of which account for more deaths in rural-urban areas. Provisional data from 1996 indicate that the mortality rates per 100,000 inhabitants associated with five major groups of causes are as follows: diseases of the circulatory system, 311.4; malignant neoplasms, 141.0; external causes, 79.3; infectious and parasitic diseases, 51.4; and all other causes, 136.4.
For a number of years, general mortality has been characterized by a marked predominance of causes associated with chronic noncommunicable diseases. Mortality from diabetes, for example, has risen steadily, increasing from 9.9 per 100,000 in 1970 to 11.1 in 1980 and 23.4 in 1996, with a larger proportion of deaths occurring among women.
SPECIFIC HEALTH PROBLEMS
Analysis by Population Group
Health of Children
Perinatal mortality has decreased significantly, from 14.2 per 1,000 live births in 1992 to 12.4 in 1996, a 13% decrease for the period.
Low birthweight, after declining steadily until 1989, when the rate was 7.3%, began to climb again, reaching 9.0% in 1993. The national program for the prevention and control of low birthweight was subsequently revised and updated, and by 1996 the level had dropped back to 7.3%.
Infant mortality in 1992 represented 2.1% of total mortality in all age groups; in 1996, this proportion dropped to 1.4%. The five leading causes of death in children less than 1 year old accounted for 83% of all infant deaths in 1996.
Infant mortality continues to fall: from a rate of 10.2 per 1,000 live births in 1992, it decreased to 7.9 in 1996.
Mortality from all causes in the group aged 14 years remained stable at 0.6 to 0.7 per 1,000 people in this age group during the last five-year period. The five leading causes of death in this age group are, first, accidents, with a rate of 1.9 per 10,000 inhabitants in 1996; second and third are malignant neoplasms and congenital abnormalities, with rates of 0.6 and 0.8, respectively. Pneumonia was the fourth leading cause in 1996, and Meningitis ranked as fifth cause of death.
The crude death rate for all causes in the group aged 5-14 years, remained at 0.4 per 1,000 children in this age group in 1987, and it dropped to 0.3 in 1996. Accidents were the leading cause of death with rates of 14.7 in 1992, 17.0 in 1994, and 14.8 in 1996. Accidents were the leading cause of death in the 5-14 age group, accounting for 38.8% of all deaths in this group, more than in 1992, when the number was 34.5%.
Health of Adolescents and Adults
Accidents remain the leading cause of death for individuals up to 49 years of age, with a rate of 38.9 per 100,000 in the group aged 1549 years in 1996, slightly higher than the value of 37.9 reported in 1992, and they are one of the principal health problems of adolescents and young adults. Other important problems in these two groups are the high incidence of sexually transmitted diseases (STDs) and the increase in viral hepatitis type A, the incidence of which increased from 161.2 per 100,000 in 1992 to 217.0 in 1996.
The crude death rate for all causes in the group aged 1549 years was 1.7 per 1,000 in 1996. Accidents were the leading cause of death in 1996, and they accounted for 20.4% of all deaths in this age group. As in 1992, malignant neoplasms ranked second, with a rate of 28.8 deaths per 100,000 inhabitants. Heart disease ranked third (20.4 per 100,000); suicides and self-inflicted injuries (18.2) and homicide (10.2) ranked fourth and fifth.
Health of Women
The number of women employed in the public sector increased from 669,100 in 1975 to 1,429,900 in 1990, when 40% of all workers were women. Health care for women and children and the work of the Maternal and Child Health Program are considered top public health priorities.
The average number of prenatal medical visits per woman increased from 17.2 in 1992 to 23.6 in 1996.
The rate of induced abortion decreased from 70.0 per 100 deliveries in 1992 to 59.4 in 1996. The prevalence of contraceptive use is estimated at 79%. Maternal deaths due to complications of pregnancy, childbirth, and the puerperium decreased from 3.3 per 10,000 live births in 1992 to 2.4 in 1996.
Mortality from all causes among women aged 5064 was 8.4 per 1,000 women in 1996. The five leading causes of death were malignant neoplasms (236.8 per 100,000), heart disease (222.3), cerebrovascular disease (79.2), accidents (42.2), and diabetes mellitus (38.9).
Health of the Elderly
In 1996, 84.7% of all deaths occurred among persons aged 50 and over. The over-60 age group accounted for 76.3% of all deaths, and the group aged 65 and over accounted for 68.9%.
Mortality from all causes in the group aged 65 and over was 54.9 per 1,000 in 1996. The five leading causes of death were heart disease, with a rate of 1,803.9 per 100,000; malignant neoplasms (968.0); cerebrovascular disease (631.3); influenza and pneumonia (378.6); and diseases of the arteries, arterioles, and capillaries (330.2).
Morbidity from communicable diseases in older adults decreased in 1996 compared with the previous year, as did morbidity from acute diarrheal diseases, which fell 6%. On the other hand, medical consultations for acute respiratory infections increased to a rate of 28,212.7 per 100,000 inhabitants. The incidence of tuberculosis in 1996 was also lower than in 1995.
Certain occupational risks decreased because of paralysis of the work force in some sectors, which led to a reduction in accidents, especially fatal accidents, however, other risks increased as a result of job changes, reintegration of workers into the work force, and redefinition of duties in factories and other workplaces. There are two principal occupational disorders linked to urban and industrial environmentshearing loss from excess noise and skin diseases.
Occupational accidents have shown a downward trend. Between 1992 and 1995, the incidence declined from 8.2 to 5.3 per 1,000 workers. During 1995, there were 20,805 disabling injuries, 33,000 fewer than in 1992, and the number of fatal accidents decreased to 72. Of the deaths that occurred, 70 % were males, and the largest proportion occurred in the 2140 age group.
Analysis by Type of Disease
Cholera and Other Intestinal Diseases. The incidence of intestinal infectious diseases has increased in recent years. Between 1989 and 1996, morbidity from hepatitis A increased from 24.5 to 189.0 per 100,000 inhabitants. In 1996, 90.9 medical visits per 1,000 inhabitants were reported for acute diarrheal disease. Morbidity from typhoid fever increased during the period 19891996, rising from 0.5 to 0.7 per 100,000 inhabitants at the national level. Mortality from acute diarrheal diseases, some of which are of infectious origin, increased from 4.2 per 100,000 in 1992 to 5.0 in 1996, accounting for 0.7% of all deaths that year.
Vaccine-Preventable Diseases. Five cases of tetanus were reported in 1992 and four were reported in 1996. The effectiveness of the Cuban immunization system is reflected in the elimination of three diseases (poliomyelitis, diphtheria, and measles) as well as in the suppression of two serious diseases (tuberculous meningitis and neonatal tetanus) and the disappearance of two serious complications (mumps meningitis and congenital rubella syndrome). Fifteen cases of measles were reported in 1992, but none has been reported since 1994. No cases of rubella or mumps were reported in 1996. The level of immunization coverage for all vaccine-preventable diseases is satisfactory: more than 95% at the national level.
Acute Respiratory Infections. Respiratory infections, especially acute, short-lived infections, are by far the leading causes of morbidity in Cuba. About 60% of these visits are for children under the age of 15, and 41.7 % of these are children between 1 and 4 years of age. In 1996, the total number of medical visits for this cause totaled approximately 5 million. In the past three years, the number of affected infants and preschoolers has increased, as has the number of affected persons over the age of 60.
Tuberculosis. By 1990 the incidence of tuberculosis had fallen to 5.1 per 100,000 inhabitants. However, in recent years the number of cases has risen to 12.0, 14.2, and 13.3 per 100,000 in 1994, 1995, and 1996, respectively. The largest concentration of cases is found in the group aged 65 and over and the pulmonary form of the disease is most common, with a total rate for this age group of 38.9 per 100,000 in 199635.0 for the pulmonary form and 3.9 for extrapulmonary tuberculosis. In 1994 the activities of the Tuberculosis Prevention and Control Program were stepped up, and at present improvements in detection have reported a slight decrease in incidence.
Leprosy. The prevalence of leprosy has declined steadily since 1989, and by 1993 it had fallen to a level of less than 1 per 10,000 inhabitants. During 1994, the prevalence was 0.7 and in 1995 it dropped to 0.62 per 10,000 inhabitants. In 1996, the rate was 0.57, and the ratio of new cases detected to those who have completed treatment appeared to have stabilized.
Vector-Borne Diseases. No indigenous cases of malaria were reported in the period 19921996. With regard to dengue, no indigenous transmission occurred between October 1981 and December 1996. Since January 1997, dengue cases have been reported in the countrys easternmost region, in the municipality of Santiago de Cuba. A total of 2,946 cases were confirmed by serological tests; of these 205 were hemorrhagic dengue. Twelve deaths occurred, all in adults. Serotype 2, genotype Jamaica, was identified as the infectious agent in the outbreak. Transmission occurred with infestation indices of less than 2%.
Zoonoses. The incidence of leptospirosis peaked in 1994 (25.8 per 100,000 inhabitants), an epidemic year, after which the incidence declined markedly. The actions undertaken, which were aimed, above all, at protecting the groups at highest risk, included vaccination and chemoprophylaxis, environmental sanitation, and improving the quality of diagnosis as well as efforts to eliminate the rodent vectors. By 1996 the incidence had been reduced to 12.9 per 100,000 inhabitants. The prevention and control activities are ongoing.
After a 10-year period during which no human cases of rabies were reported, the disease reappeared in 1988. Between that year and 1995, six fatal cases of rabies occurred in humans. No cases were reported in 1996.
AIDS and Other STDs. Between 1986, when the seroepidemiological detection program was launched, and the end of 1996, 1,468 HIV-positive individuals were detected; of these, 534 developed AIDS and 381 died. More males than females are infected, and most of the infected males (65%) are homosexual/ bisexual. The incidence is highest in the group aged 1519 years, followed by the 2024 age group. The majority of HIV-infected individuals acquired the infection in Cuba; only slightly more than 15% became infected abroad. The Cuban strategy for addressing this problem includes conducting studies of the groups at highest risk, carrying out epidemiological investigation of 100% of cases, performing analyses of hospital admission records (as well as outpatient care records since 1993), and implementing a comprehensive program of health education for the general population.
Reports of sexually transmitted diseases are on the increase especially in the case of syphilis and gonorrhea, the rates for which in 1996 were 143.7 and 368.7, respectively, per 100,000 inhabitants. Work is currently under way to upgrade the prevention and control program.
Infectious Neurological Syndromes. The incidence of meningococcal disease has continued to decline since the initiation of vaccination in the country in 1986. The rate in 1989 was 3.8 per 100,000 inhabitants, but by 1996 it had dropped to 0.5 per 100,000. Other bacterial meningoencephalitides are associated with endemic levels of morbidity. As for viral meningoencephalitides, an epidemic increase began in 1995 and extended into the first months of 1996. Three types of enterovirus were identified in the samples studied: Coxsackie A9, Echo 30, and Coxsackie B5.
Noncommunicable Diseases and Other Health-Related Problems
In the past 20 years, the relative importance of noncommunicable diseases and injuries due to violence has increased and these two groups of causes now account for the largest proportion of deaths in all age groups. Three causes account for the largest proportion of years of potential life lost (YPLL) in the groups between 1 and 64 years of age: accidents, malignant neoplasms, and heart disease, with rates of 10.3, 7.3, and 5.5, respectively, per 1,000 inhabitants.
Cardiovascular Diseases. Cardiovascular diseases are the leading cause of death in Cuba, with a crude death rate of 205.9 per 100,000 inhabitants in 1996. Although this number is higher than in 1989 (189.3 per 100,000 inhabitants), the trend, based on age-adjusted rates, is downward. Males are at greatest risk of dying from heart disease; in 1996 the rate among males was 222.2 per 100,000 inhabitants, compared with 189.4 for females.
Cerebrovascular disease has been the third leading cause of death for several years. In 1996, the crude death rate from this cause was 72.7 per 100,000 inhabitants. Nevertheless, standardized rates indicate a downward trend. In 1996 the male/female ratio was 0.9. Most of these deaths (79.5%) occur in the age group over 65.
The prevalence of high blood pressure (30.6%) is high but similar to that of other countries; one in three Cubans aged 15 or over suffers from hypertension. A national survey of risk factors in 1995 detected 12% new hypertensives. Of all the hypertensive patients interviewed, only 45.2% were being monitored regularly.
Malignant Tumors. For the past 26 years, malignant neoplasms have been the second leading cause of death in all age groups. The crude death rate from this cause increased from 128.8 per 100,000 inhabitants in 1990 to 137.3 per 100,000 in 1996; however, the adjusted rates for the same years went down from 116.6 to 111.0 per 100,000 inhabitants. The number of deaths from malignant tumors varies according to sex; the rates per 100,000 are 156.1 for males and 118.3 for females. The highest rates occur in the groups aged 5064 and 65 and over.
The incidence of all forms of cancer, including both crude and adjusted rates, decreased during the three-year period between 1992 and 1994. The adjusted rate fell from 176.8 per 100,000 inhabitants in 1992 to 159.2 in 1994. The incidence by sex declined more markedly in females (from 164.7 per 100,000 in 1992 to 142.2 in 1994) than in males (from 189.8 to 177.9 per 100,000 during the same period).
For the period 19851993, the five most frequent cancer sites were the lung, prostate, skin, bladder, and colon for males and the breast, skin, cervix, lung, and colon for females.
In 1996, as part of the Early Cervical Cancer Treatment Program, 1,023.913 women aged 20 and over were screened, yielding a screening rate of 26.0%. Of the positive cases, 88% were detected at stage 0 and 11% were detected at stage 1. The mortality rate increased from 6.2 per 100,000 in 1995 to 6.8 per 100,000 in 1996. The incidence during the period 19911993 was 4.9 per 100,000 inhabitants, similar to the previous three-year period. The program has not produced the expected results.
The preventive activities assessed in the national risk factor survey of 1995 (Pap smear, breast examination and self-examination, among others) reflect a moderate level of performance. Among the women over the age of 30 surveyed, 26.6% had performed a breast self-examination in the preceding 12 months, and 53.5% had performed a self-examination on at least one occasion.
Chronic Obstructive Pulmonary Disease and Bronchial Asthma. These disorders are among the leading causes of death in all age groups. They occur in both sexes similarly and are most frequent among persons over the age of 55. In 1995 the crude death rate from these causes for both sexes was 22.4 per 100,000 inhabitants, higher than in 1989 (16.7). Mortality from bronchial asthma has shown a rising trend. In 1996 the crude death rate from asthma was 5.3 per 100,000 inhabitants, higher than the rate of 4.4 registered in 1989 and similar to the rate of 5.5 recorded in 1995. More females than males die from asthma, and this excess female mortality has become more marked in the past three years. In 1996 the death rate among males was 4.4 per 100,000, and among females it was 6.1. A plan aimed at reversing this trend is currently being implemented as part of the new program for the treatment and control of asthma.
Accidents. Accidents remain the fourth leading cause of death for all ages and the leading cause in the group aged 149 years as well as the primary cause of premature death as measured by YPLL (10.0 per 100,000 people aged 164 years). Mortality from accidents has shown a slight rising trend, based on adjusted rates. The largest proportion of accidental deaths are due to motor vehicle traffic accidents, with a rate of 19.7 per 10,000 inhabitants in 1996.
Diabetes Mellitus. Diabetes mellitus was the seventh leading cause of death for all ages in 1996, with a rate of 23.4 per 100,000 inhabitants. It causes more deaths among females than males (31.4 per 100,000 inhabitants in 1996 compared with 15.5 per 100,000 for males). There are also differences among urban and rural populations, with adjusted rates of 22.2 and 13.4, respectively, per 100,000 inhabitants. Based on the records of family physicians, it is estimated that the prevalence of the disease in 1996 was 19.3 per 1,000 inhabitants.
Suicide. Deaths from suicide and self-inflicted injuries decreased from 21.1 per 100,000 inhabitants in 1992 to 18.2 in 1996. During the period 19811996, suicide was greater among males in all but one age group; in the group aged 1019, the rate was greater among females.
Epidemic Neuropathy. An outbreak of epidemic neuropathy has been ongoing since 1992. The epidemic began in the western region and spread to the rest of the country in early 1993. From 1994 to 1996 the disease showed an endemic pattern, and by the end of 1996 a cumulative total of 54,640 cases had been reported, yielding a case rate of 496.5 per 100,000 inhabitants. Of the reported cases, 41.3% were the optic form of the disease. The epidemiological pattern by age, sex, and severity of the various clinical forms has not varied. The clinical optic form is most frequent among males in the group aged 4564 years, and the peripheral form predominates in females aged 2544. In a follow-up analysis of all cases reported since 1992, 47,994 patients were evaluated (88.4% of the total) and 39,754 were given a clinical discharge (82.8%); 8,729 were found to have sequelae (18.8% of all patients evaluated). The patients with sequelae to the peripheral form have been included in the Community Rehabilitation Program, and those with sequelae to the optic form (impaired vision) are receiving rehabilitation services in three specially equipped centers. Doctors continue to treat the disease with A, E, and B-complex vitamins, and a national campaign is under way to promote two vitamin supplements.
Oral Health. In 1996 there were more than 17 million visits to the dentist in Cuba, which makes the rate 1.6 visits per person. Of these visits, more than 85% were for general dentistry services provided in the framework of primary health care. During the year, 3,361,122 persons were examined; 51.7% of them were under the age of 15 years. Of all those examined, 28.4% were found to have good oral health. Of those under 15 years of age, 31.8% had good oral health. The preventive program continues to be carried out at the national level, and during the year 24,103,414 fluoride rinse treatments were administered to children aged 514 years and 1,324,971 topical fluoride treatments were given to children under the age of 4 years. Oral cancer was detected in 1,922 of the patients examined.
Natural Disasters. The most recent natural disaster was Hurricane Lili, which struck Cuba on 17 October 1996 and caused severe economic damage to housing and agriculture. Nevertheless, thanks to the populations preparedness and the preventive evacuation of some 200,000 people, no human lives were lost. To enhance the countrys capacity for disaster management, a disaster medicine center was established in June 1996.
Behavioral Disorders. In 1995, the National Institute of Hygiene, Epidemiology, and Microbiology, in collaboration with the National Statistics Bureau, conducted the first national survey of risk factors and preventive activities for noncommunicable diseases. The study population consisted of urban dwellers (75% of the Cuban population) over the age of 15.
Systematic efforts to prevent and control tobacco use, which have been under way since 1985, have succeeded in halting the rising trend of tobacco use and reducing its prevalence. During the five-year period 19901995, tobacco use decreased. The current prevalence of tobacco use is 36%. The percentage of males aged 15 and over who smoke regularly is 48.1%, and that of females is 26.3%.
Frequency of consumption and quantity consumed were the criteria used to evaluate consumption of alcoholic beverages. The results can be considered acceptable in terms of the population as a whole, given that 55% of those surveyed reported not having consumed any alcoholic beverage in the preceding 12 months or having done so fewer than five times. Men aged 2029 and 4059 are the groups at highest risk.
Nutritional Diseases. The nutritional situation, evaluated on the basis of body mass index, compared favorably with that in 1982 and is related to apparent levels of consumption per capita in the period 19921995, according to data from the National Statistics Bureau. However, a larger proportion of people with chronic energy deficiency and underweight was noted in those aged 2059 years and, to an even greater extent, in those over the age of 60, although the levels vary from region to region within the country. Overweight and obesity are more frequent among women and tend to increase with age.
The nutritional status of children aged under 1 and 14 years, based on the weight-for-height indicator, has remained stable and is similar to that found in previous years. In 1996, 1.8% of children under the age of 1 year were below the third percentile. In the group aged 14, the proportion was 0.8%.
Iron deficiency anemia is the most common nutritional problem in Cuba. It affects more than 40% of women in the third trimester of pregnancy, around 50% of infants between 6 and 11 months of age, between 40% and 50% of children aged 13 years, and between 25% and 30% of women of childbearing age.
Vitamin A intake, as measured by analysis of data on apparent consumption and nutritional surveillance, is also low. There are no national studies on serum levels of this nutrient, but work is under way to enrich foods with vitamin A as a preventive measure. Intake of vitamin B continues to fall below recommended levels.
RESPONSE OF THE HEALTH SYSTEM
National Health Plans and Policies
In 1991, the Ministry of Public Health drafted a document entitled Objetivos, propósitos y directrices para incrementar la salud de la población cubana 19922000 ["Objectives, Aims, and Guidelines for Improving the Health of the Cuban Population 19922000"], which defines health goals and objectives to be achieved by the year 2000. In 1996 five strategies and four priority programs were identified. The strategies include reorientation of the health system toward primary care and the family doctor and nurse program, which is considered the pillar of the system; revitalization of hospital care; revitalization of high-technology programs and research institutions; development of a program on natural and traditional medicine and remedies; and care with an emphasis on system objectives, such as dentistry, optical services, and health transport. The priority programs are those on maternal and child health, chronic noncommunicable diseases, communicable diseases, and care of the elderly.
The Ministry of Public Health has developed a strategy for responding to existing, emerging, and reemerging problems.
The process of decentralization and the creation of a new structure of government that allows for more grassroots involvement (through the popular councils) has encouraged active participation of the social sectors in health management at the local level. In 1995, health councils were established at the national, provincial, municipal, and popular council levels. These health councils are made up of representatives of the various social sectors and civic organizations and are headed by a government representative at each level. They have facilitated intersectoral collaboration and have increased the capacity for social participation in the identification and solution of health problems in the community. The country, as part of the "health initiative" process aimed at mobilizing national and international resources to support reform and modernization of the sector, has developed a master investment plan that sets out the basic problems, outlines strategies and actions for addressing those problems, and recommends a series of investment projects for resolving or mitigating them.
Organization of the Health Sector
The National Health System
In Cuba the State assumes full responsibility for the health care of its citizens. In 1983 the Parliament adopted the Public Health Law, which lays out the general activities to be carried out by the State to protect the health of Cuban citizens. The law establishes the organization of the sector and the services to be provided by the State.
Despite the development attained by the sector in recent years, the Public Health Law needs to adapt to new factors and determinants, which have modified the public health environment, both internally and externally. Since 1995, the Health Commission of the Cuban Parliament, in conjunction with the Ministry of Public Health, has been in the process of revising the existing legislation.
Organization of the National Health System
The National Health System is organized at three levels (national, provincial, and municipal), which mirror the countrys administrative structure. The National Assembly (Parliament) and the provincial and municipal assemblies have permanent working commissions. In addition, the National Health Commission also deals with issues relating to sports and the environment and advises the leadership of the National Assembly and Council of State in these areas
The national level is represented by the Ministry of Public Health, which serves as the lead agency and fulfills methodological, regulatory, coordination, and control functions.
The provincial level is represented by the provincial public health offices, which are under the direct financial and administrative authority of the provincial administrative councils. At the municipal level are the municipal public health offices, which come under the financial and administrative responsibility of the municipal administrative councils.
Organization of Health Regulatory Activities
Since 1993, the country has been working to develop an integrated surveillance system. Health trend analysis units have been created from the national to the municipal level. The function of these units is to integrate all monitoring and surveillance information in the context of each program, department, service, or strategy of the health system. At the same time, they conduct rapid assessments and epidemiological investigations in relation to the principal health problems, undertake a quarterly analysis of the health situation at each level, and follow trends and make forecasts for the short and medium terms. During the past year, an evaluation component has been added.
The Regulatory Bureau for Health Protection, created in 1996, is the highest official health regulatory institution in the country. Its mission is to ensure, together with other agencies, fulfillment of the specific objectives, functions, and faculties approved in the legislation on monitoring and surveillance of all products that may affect human health; regulate and monitor the approval, execution, and evaluation of biomedical research projects or any other type of research involving human subjects; and evaluate, register, regulate, and control domestic and imported drugs, medical equipment, disposable materials, and other health care products.
The National Drugs Program was established in 1991 with a view to ensuring more rational use of drugs and improving the quality of medical care. In 1994, the program was reformulated and measures were implemented to require a medical prescription for most drugs (with some exceptions); to regulate prescriptions written by doctors according to their medical specialties; to assign patients to drug distribution units in their area of residence; to strengthen the work of the pharmacotherapeutic committees; and to maintain the regulations on distribution of consumer products intended for long-term or lifelong use.
A special effort has been made to revise the essential drugs list, as a result of which it has been possible to reduce the number of active principles to 343 distributed among 29 drug classes with 439 dosage forms. In addition, there are traditional and natural medicinal products. The official drug control center is responsible for ensuring that products meet international quality standards.
Health Services and Resources
Organization of Services for Care of the Population
Health Promotion. The health promotion strategy in Cuba stresses planning and execution of local projects, community organization, participation of all productive and nonproductive sectors, and the political will to support the development and implementation of health promotion activities.
The maximum expression of this strategy is the healthy communities movement, which seeks to pool local resources to promote health.
The Cienfuegos Comprehensive Health Promotion Project was implemented in 1989 with the participation of the government of the city of Cienfuegos. The national [health promotion] network, composed of 28 municipalities, was created in December 1994, and within two years it had expanded to include 51 municipalities. The project also has the support of PAHO.
Another important aspect of health promotion is mass communication.
Water Supply. Cubas hydraulic potential, although it is not uniform in density throughout the country, is sufficient to ensure the provision of water for household, agricultural, and industrial activities; 1,200 m3 of water per person per year is available for all uses. Of the total volume of water supplied to the population, 72% is of underground origin, and 28% is from surface sources; 68.3 % of the total population (7.5 million) receives water from aqueducts, 89.3% in urban areas and 10.7% in rural areas. The rest of the population is served by other means (tank trucks and others), especially in rural areas. Nevertheless, the quantity and quality of the water supply have deteriorated substantially. To correct this situation, various measures have been taken since 1994, including chlorination in about 50% of existing facilities and putting family doctors in charge of dispensing chlorine powder to families in the highest-risk areas. In 1997 water supply systems will be upgraded in 371 rural communities with a total of 119,838 inhabitants.
Sewerage Systems. Coverage of liquid waste disposal is 91% for the country as a whole, and 34.2% of the total population has sewerage services. All dwellings constructed in areas without seweragemost of which are concentrated in rural areashave individual collection and treatment systems, mainly latrines and septic tanks. The provincial water supply and sewerage authorities have adopted measures for the organization and optimization of resources, but the results obtained have been insufficient to solve the problem.
Solid Waste Disposal. The situation with respect to solid waste is similar to that of liquid waste. Collection and final disposal of solid waste has been affected by transport and fuel supply problems that began in 1992 and continue to the present. This situation has given rise to the appearance of microdumps, especially in cities. Other solutions have been sought but none of them has been sufficient.
Prevention and Control of Air Pollution. Air pollution is not a major problem in Cuba. In recent years, there has been an increase in the use of crude oil and petroleum products with a high sulfur content, which has increased the potential for pollution, with the associated health risks and ecological and economic damages. The national air pollution monitoring system, part of the surveillance system, has been seriously impaired by lack of resources. The national air pollution monitoring program is aimed primarily at identifying and controlling the problems of each source of pollution.
Food Safety. Cuba has been working to reduce the number and frequency of illnesses due to consumption of foods contaminated with germs that are harmful to health. Biological, chemical, and toxicological studies, as well as strengthening the technical components and the efficacy of official health inspections, were some of the objectives. In addition, the hazard analysis critical control point methodology was also adopted.
Food Aid Programs. In 1993, food intake in Cuba dropped 30% compared with 1989. The availability of foods fell below the level needed to meet the nutritional requirements of the basic market basket. In 1994 household food consumption increased by about 6%.
There are of three general types of national food safety programs: (1) programs aimed essentially at monitoring and assessing the food and nutritional status of the population and adopting preventive or curative health measures according to the situations at hand; (2) programs that seek to increase the production of foods, both quantitatively and qualitatively; and (3) social policy programs targeted to the entire population, addressing product availability, and especially the food and nutrition needs of vulnerable groups.
Organization and Operation of Personal Health Care Services
The National Health System comprises a network of institutions that are easily accessible and provide coverage to 100% of the population. In 1996 the system included 66,263 hospital beds (6.0 per 1,000 inhabitants) and 14,265 beds in social welfare institutions (1.3 beds per 1,000 inhabitants). Medical care is provided through a network made up of 281 hospitals, 11 research institutes, 442 polyclinics, and a contingent of family doctors practicing in workplaces and schools in the community. In addition, there are 164 health posts, 209 maternity homes, 26 blood banks, and 4 health spas. Oral health care is provided in 168 dental clinics. Social welfare services include 190 homes for the elderly and 27 homes for disabled persons of different ages and with various types of impairment. The family doctor and nurse program serves 97% of the Cuban population.
Hospital admissions have shown a downward trend in recent years. In 1996, admissions totaled 1,419,895 (12.9 per 100,000 inhabitants). In the same year, there were 77,499,250 medical visits (7.0 per person).
Family doctors, who number 28,350 and provide 97% of the national coverage, provided 74% of the outpatient consultations. Traditional and natural medicine services were expanded, as were outpatient surgical services.
The number of dental visits per person in 1996 (1.6) was higher than that reported in earlier years.
The National Disability Prevention, Treatment, and Rehabilitation Program seeks to reduce the frequency of disabilities or impairments through the creation of a grassroots rehabilitation structure. Within this structure, the family doctor and nurse are key figures, as the professionals who detect risks or incapacitating illnesses.
Mental health services are oriented not only toward the biomedical aspects of mental health, but also toward promotion of health, prevention of mental illness, and social rehabilitation.
The population of Cuba is one of the four oldest in Latin America and the Caribbean (12.7% of the population is 60 years old or more), and projections for the years 2000 and 2025 are that this proportion will increase to 14% and 21%, respectively. In 1996 the program on health care of the elderly was restructured.
In 1996, the country had 60,129 physiciansthat is, 54.6 per 10,000 inhabitants; 9,600 dentists (8.7 per 10,000 inhabitants); and 76,013 nursing personnel (69.1 per 10,000 inhabitants), 12,716 (16.7%) of whom were university-trained. The total number of mid-level technicians in 1996 was 192,781.
Inputs for Health
Total production of drugs remained at similar levels throughout the period, except in 1993, when it dropped considerably. Domestic consumption increased 13.2%. The production of biologicals and reagents increased substantially during the period. Drug marketing was oriented toward meeting the needs of the population and supporting the priority programs of the Ministry of Public Health.
National Health System Financing
Cubas health system is financed out of the state budget. The population receives free preventive, curative, and rehabilitation services, which range from primary care, routine medical attention, and dentistry to hospital care requiring the use of highly sophisticated medical technologies. In addition, all necessary diagnostic testing and drugs are provided free of charge to pregnant women and to persons receiving outpatient care in the context of certain programs.
Out-of-pocket expenditures for families include drugs prescribed for outpatient treatment, hearing aids, dental and orthopedic apparatuses, wheelchairs, crutches and similar articles, and eyeglasses. The prices for all these items are low and are subsidized by the State.
Despite the economic difficulties of recent years, spending on public health has increased steadily, which reflects the political will to maintain the successes achieved in this area. In 1994, health spending, which includes current health expenditures by all agencies in the country, totaled 1,061.1 million pesos, 17% higher than in 1989. This absolute increase was accompanied by a relative increase in public health spending as a proportion of GDP, total spending, and public spending. In 1994, health spending represented 7.8% of the GDP, 7.5% of total spending, and 14.6% of public spending.
In the period 19921996, there was a significant decrease in investment, which in 1994 represented only 3.1 % of total spending.
With regard to the structure of current spending, about 60 % is devoted to payment of wages.
In the early 1990s, 141.1 million pesos were being spent on drugs. By 1994, this number had declined to 123.8 million. However, the 1994 value does not take into account 60 million pesos spent on vitamin supplements supplied free of charge to the population to control the neuropathy epidemic that affected the country in the period 19921996. In 1995, spending on drugs began to increase again (135.3 million pesos).
The decisive factor for ensuring the sustainability of the National Health System is foreign currency financing for the sector.
In 1989 foreign currency spending by the health sector totaled US$ 227.3 million. By 1994 this figure had dropped to only US$ 90.1 million. In 1996, although it increased to US$ 126.5 million, this amount was insufficient to cover necessities. This severe reduction in foreign currency financing seriously affected supply.
For example, production of drugs by the domestic pharmaceutical industry dropped by more than one-third between 1990 and 1993. The reduced availability of foreign currency financing has also had an impact on the ability of the health sector to procure disposable medical supplies used in health care units and for diagnostic procedures, as well as in optical and dental services.
Cuba has received little foreign aid to maintain the vitality of its health system because its access to traditional sources of financing is seriously hindered by the United States of Americas blockade. The country has received humanitarian aid totaling around US $20 million annually.
External Technical Cooperation
With regard to multilateral cooperation, Cuba has entered into agreements with United Nations agencies specializing in health: PAHO/WHO, UNICEF, the United Nations Food and Agriculture Organization (FAO), the United Nations Population Fund (UNFPA), and the United Nations Development Fund (UNDP). Since 1989, this collaboration has played a very important role in that Cuba, in addition to obtaining the benefits of being a member country, has strengthened its relations with institutions of excellence and has been able to disseminate some of its own advances and technologies. In addition, Cuba has depended on the collaboration of Canada, Chile, Spain, France, Italy, Mexico, and Sweden for conducting research and human resources training projects as well as for health supplies.
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