Pan American Journal Special report of

Science and technological innovation in health in : results in selected problems*

Nereida Rojo Pérez,1 Carmen Valenti Pérez,1 Nelcy Martínez Trujillo,1 Ileana Morales Suárez,2 Eric Martínez Torres,3 Ileana Fleitas Estévez,4 Miriam Portuondo Sao,2 Yisel Torres Rojo2 and V. Gustavo Sierra González5

Suggested citation (original manuscript) Rojo Pérez N, Valenti Pérez C, Martínez Trujillo N, Morales Suárez I, Martínez Torres E, Fleitas Estévez I, et al. Ciencia e innovación tecnológica en la salud en Cuba: resultados en problemas seleccionados. Rev Panam Salud Publica. 2018;42:e32. https://doi.org/10.26633/RPSP.2018.32

ABSTRACT In Cuba, health research is based on the priorities of national scientific policy, derived from the health status of the population. The objective of this article is to describe the characteristics of the Science and Technological Innovation System and how the results of its research benefit the health of population groups. To this end, research related to the generation of products and technologies, diabetes, dengue and disability was selected. This system follows a methodology outlined by the Ministry of Science, Technology and the Environment, and has 37 research entities. It is organized into pro­grams and projects that support basic and applied research using a multidisciplinary and intersectoral approach; these programs and projects are funded mostly by the State and are organized as a closed-loop system, i.e., the same entity is responsible for the entire process, from research to marketing, including market studies and post-marketing­ monitoring. The selected research projects demonstrate the alignment between research, gener- alization of results, and their effect in improving the population’s health and universal access to . Results were obtained in diagnostic methods, pre­ventive and therapeutic vac- cines, warning signs for the prognosis and treatment of dengue, prevention of congenital mal- formations, and policies and programs that have benefited people with disabilities and their families. The State’s commitment to developing and funding scientific research, taking inter- sectoral action, identifying research priorities, and providing systematic training and attention to human resources have been key factors in meeting the system’s objectives.

Keywords National science, technology and innovation policy; health sciences, technology and innovation management; biomedical research; health programs and plans; research design; Cuba

* Non-official English translation from the original The Science and Technological In- productive and service activities (1). Spanish manuscript. In case of discrepancy, the original version (Spanish) shall prevail. novation System in Cuba is overseen Consequently, the number of research 1 Escuela Nacional de Salud Pública, , by the Ministry of Science, Technolo- programs and structures was re- Cuba. Send correspondence to Nereida Rojo gy and the Environment (CITMA), in duced, and they were renamed and Pérez, [email protected] 2 Ministerio de Salud Pública, Havana, Cuba. accordance with Resolution No. classified according to their mission 3 Instituto de Medicina Tropical Pedro Kouri, 44/2012, which resulted in the reor- as follows (2): Havana, Cuba. ganization of scientific activity based 4 Representative of the Pan American Health • Research centers, when their main ac- on a policy aimed at achieving greater Organization in Havana, Cuba. tivity is scientific research and 5 BioCubaFarma, Dirección de Política Científica, efficiency and closer ties with Havana, Cuba. innovation;

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• Science and technology service cen- In the 2013 World Health Report, the science and set research priorities for ters, in charge of service delivery, Director-General of the World Health Or- 2012–2016 in five national programs, specialized production and research; ganization (WHO) stated, “All countries based on changes in the population’s • Development and innovation units, must be producers as well as consumers health status, availability of resources organized as enterprises,6 budgeted of research. (7). and the need to optimize them (Table 2), units (funded by the State) or other Cuba has systematically worked to- explained as follows (11): types of organization, all of which are ward that goal. The Science and Techno- Program 1: Health determinants, mandated to develop or innovate in logical Innovation System for Health risks and prevention in vulner- order to add value to the goods, ser- (SCITS) is singular and all-inclusive, and able groups. Emergence of new econom- vices and processes they offer. guided by two principles: the interdepen- ic actors and income disparities between dence of education, services and research; different social groups—along with a de- Research and development activities and the integration of scientific advances mographic situation marked by low fer- are organized on the basis of programs into social practice (8). This approach en- tility and birth rates, population aging and projects (basic research unit), and are ables the study of health problems and and migration—have imposed a new so- classified as follows (1): needs at the three levels of care (primary, cial/health context on the National • Projects associated with science, tech- secondary and tertiary) with alternative Health System (SNS), in which certain nology and innovation programs de- solutions in accordance with a sectoral, social groups may be affected. signed to study problems of national intersectoral, multidisciplinary perspec- Program 2: Organization, efficiency interest, supervised by CITMA re- tive and adherence to local culture (9). and quality in health systems and ser- gardless of sector; programs group SCITS’ present development is due to vices. Given the constraints imposed on together interrelated projects to fulfill the government’s commitment and pri- Cuba’s access to markets under favor- State priorities; management units in ority attention given to research, innova- able conditions (12) and the global eco- the health sector are responsible for tion and development of products and nomic crisis, the SNS has been obliged to health-related programs services to meet the population’s health prioritize and optimize organizational, • Projects not associated with pro- needs. Consequently, conditions, re- quality and efficiency processes in order grams, aimed at resolving national sources and human capital formation are to maintain the sustainability of current priorities that do not require imple- guaranteed so that actions developed in services, based on their design and mentation of a program SCITS programs and projects contribute realities. • Institutional projects, which conduct to efficiency, equity and the well-being of Program 3: Natural and traditional research on priorities identified by the population (10). medicine. The program attempts to pre- non-entrepreneurial entities for solv- The purpose of this article is to de- serve culture in health care through inte- ing concrete problems scribe the features of SCITS in Cuba and gration of traditional and modern natural • Entrepreneurial projects, which aim present research results that illustrate its medicine techniques. to solve priority problems specific to positive effect on the population’s health. Program 4: Cancer. Cancer is the sec- enterprises or business groups ond-leading cause of death in Cuba. This CUBA’S SCIENCE AND group of causes approximately Approximately 26% of all Cuban scien- TECHNOLOGICAL 18 and 19 years of potential life lost in tific institutions are dedicated to health-re- INNOVATION SYSTEM IN women and men, respectively (13). Re- lated research, development and HEALTH search focuses on improving prevention, innovation, and are part of the Ministry of diagnosis, comprehensive care and Public Health (MINSAP), the Biotechnol- SCITS comprises 37 science and tech- rehabilitation. ogy and Pharmaceutical Industry Group nological innovation institutions: 16 re- Program 5: Aging, longevity and (BioCubaFarma), universities and other search centers, 3 science and technology health. Individuals aged ≥60 years ac- sectors (4). MINSAP sets the sector’s pri- service centers, and 18 development count for 19% of the population, and the orities in accordance with the country’s and innovation units administered by indicator is trending upward (13), signi- economic and social policy guidelines (5). MINSAP with methodological over- fying a greater burden on social and The State provides funding to carry sight by CITMA. Scientific societies con- health services; research should contrib- out research, innovation and develop- tribute to its functioning as do other ute to attainment of healthy aging. ment programs and projects at all levels. organizations involved with technologi- By the end of 2016, more than 2 000 re- In 2016, 35.4% of the total national sci- cal innovation for import substitution search projects were underway, mostly ence and technology budget was allocat- (e.g., the National Association for Inno- in primary and secondary health care in- ed to science and technology in the vation and Rationalization, the Youth stitutions; 401 of the studies in the five health sector (6). Other funding sources Technical Brigades, and the Science and national programs were more closely include businesses, bank loans, interna- Technical Forum). This system employs linked to the tertiary level and to institu- tional agencies, nongovernmental orga- more than 20 000 workers in different tions in Havana, the country’s capital. nizations, donations and cooperative occupational categories (Table 1). In ad- The results helped identify new research agreements with other countries (1). dition to research, these centers offer priorities for 2017, such as premature 6 A state enterprise is an entity with it own legal undergraduate and graduate courses, mortality and accidents; the need for fur- status, created to produce goods and services and provide specialized services to the ther research in basic sciences and state- through efficient administration of financial, -ma public. In line with CITMA’s policy, of-the-art medicine (robotics, computer terial and human resources. It is considered a fun- damental link in the economy. MINSAP analyzed the situation of science, nanotechnology); evaluation of

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TABLE 1. Science and technological innovation institutions in the health sector by type and mission. Cuba, 2016a

Type Total Institutionb Mission Research centers 16 National Angiology and Vascular Surgery Institute Basic and applied research related to National Institute of Endocrinology and Metabolic Diseases burden of mortality, morbidity, risks and National Hygiene, Epidemiology and Microbiology Institute damage to health, according to specialty National Occupational Health Institute Cardiology and Cardiovascular Surgery Institute Gastroenterology Institute Hematology and Immunology Institute Pedro Kourí Tropical Medicine Institute Dr. Abelardo Buch López Nephrology Institute Dr. José Rafael Estrada GonzáIez and Institute National Oncology and Radiobiology Institute National Minimal Access Surgery Center National Medical Genetics Center International Neurological Restoration Center Research Center on Aging, Longevity & Health Carlos J. Finlay Center for Research and Rehabilitation of Hereditary Ataxias Science and technology 3 National Clinical Trials Coordinating Center (CENCEC) Surveillance and control of clinical trials services centers National Medical Sciences Information Center Research to strengthen the Scientific and Center for State Control of Medicines and Medical Devices (CECMED) Technical Information System and in the field of health information sciences National regulatory agency Development and 18 Ernesto Heart Center (Villa Clara) Research on health and technology innovation units William Soler Children’s Heart Center systems and services Center for the Development of Social Sciences and Humanities Immunology and Biologics Center Atherosclerosis Research and Reference Center Toxicology and Biomedicine Center () National School of Public Health Hermanos Ameijeiras Clinical-Surgical Teaching Hospital Juan Bruno Zayas Clinical-Surgical Hospital (Santiago de Cuba) Dr. Gustavo Aldereguia Lima University General Hospital () Juan Manuel Marquez University Pediatric Hospital William Soler University Pediatric Hospital Dr. Antonio Luaces Iraola University Hospital (Ciego de Ávila) Ramón Pando Ferrer Ophthalmology Institute Central Pharmacology Laboratory Cerebrospinal Fluid Laboratory Biomedical Research Unit of Villa Clara Experimental Toxicology Unit (Villa Clara) a Human resources according to occupational category: 20 171 health professionals. b Place: Havana (other location in parentheses). Source: Created by the authors based on records from the Ministry of Public Health’s National Science and Technology Office. health technologies; and accreditation of research ethics committees (1, 2). At the employs 21 000 workers. It is also part of quality in health institutions.7 national level, the Center for State Con- SCITS. Its objective is to ensure that the The health research process in Cuba trol of Medicines, Equipment and Medi- SNS has the essential medicines (biotech- follows universal tenets: starting with a cal Devices (CECMED) is responsible for nology and generic), products, raw ma- problem—and taking into account the ensuring safety and compliance with terials, , reagents, diagnostic socioeconomic environment, health con- ethical regulations in individuals and tools and equipment it needs, in addition ditions, societal principles and values—a communities. to its own lines of research (17, 18) scientific idea is identified; the problem Product- and service-related projects (Table 3). and method are defined; the project is (medicines, technologies and programs) BioCubaFarma is self-financed and designed and carried out; and the results are conceived as closed-loop processes. conceives scientific research not only as a are evaluated for subsequent introduc- BioCubaFarma was created in 2012 producer of knowledge but also as a tion and generalization in social practice (15, 16) as a senior management organi- source of material and financial resourc- until the intervention concludes with zation under the Council of Ministers, es for recouping investments without ne- new questions (14) (Figure 1). which integrates the research-develop- glecting its social commitment to public The ethical conduct and methodologi- ment-production centers for biotechnol- health. cal rigor of the research are the responsi- ogy, the pharmaceutical industry and The Cuban population’s access to high bility of the researchers, principal high-tech medical equipment. With 32 quality medical care is made possible by investigators and institutional directors, companies, 70 production facilities, 10 the integration of research centers with advised by scientific councils and research centers, 11 research and devel- science and technology services delivery opment units, and one science and tech- centers, development and innovation 7 Morales I. Science Day inaugural speech, Havana, 15 January 2017. nology services center, BioCubaFarma units, universities and health care

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TABLE 2. National science, technology and innovation programs in health. Cuba, 2012–2016

Program (year of creation) Management unit Main lines of research 1. Determinants of health, National Hygiene, Epidemiology • Maternal-child health risks and disease and Microbiology Institute • Demography (birth rate and aging) prevention in vulnerable • Non-communicable diseases groups (2012) • Communicable diseases • Environment, family and community • Food and nutrition safety • Self-inflicted injury • Mental health 2. Organization, efficiency National School of Public Health • Health management and its components: equity; access; efficiency; efficacy; social, community and and quality in health intersectoral participation systems and services • Improving risk management in regulatory functions (2012) • quality and safety • Application of information and communication technologies • Satisfaction of health personnel 3. Natural and traditional Medical • Safety, effect and quality of natural and in chronic non-communicable diseases medicine (2015) and primary health care • Clinical trials of these modalities approved by the National Health System • Use of herbal medicines and other approved forms of natural and traditional medicine • Sustainability and feasibility studies of technologies • Evaluation, registry and control of natural products, equipment and procedures used in natural and traditional medicine 4. Cancer (2016) National Oncology and • New tumor markers and diagnostic and treatment products Radiobiology Institute • Immunology and immunotherapy • Clinical trials with new products or new combinations for treatment • Cervical cancer incidence and mortality in women of childbearing age • Cancer prevention and health education, self-care and warning signs with interventions, from an early age • Evaluation of health technologies in the areas of surgery, radiation therapy, nuclear medicine and medical imaging 5. Aging, longevity and Center for Research on Aging • Biomarkers of normal and pathological aging health (2016) • Evaluation of physical performance, management of fragility and geriatric syndromes • Diseases associated with aging: risk factors, causes, disease burden, effect, costs, prompt detection, diagnosis and treatment • Disability, dependence, and friendly settings • Treatment and care for older adults, relatives and caregivers Source: Created by the authors based on reference 11. institutions. Medicines, services and dissertations directed; scientific honors increasing the number of publications high-tech products are also accessible to and degrees awarded; and registration and patents (22). population groups requiring them, with- of patents, copyrights and introduction Other challenges include access to out tangible costs and with a positive ef- of results (19). funding and proper use of funds, techno- fect on their health. At the end of 2016, MINSAP had 3 logical obsolescence, facilities mainte- 214 researchers classified as senior re- nance, researcher instability and aging, Developing human capital searchers (8.5%), associate researchers as well as the dismissive stance toward (21.7%), adjunct researchers (57.6%), research and innovation taken by some Scientific activity calls for highly and researcher candidates (12.2%). decision makers (7, 22). qualified personnel committed to solv- During that year, 224 posts became va- ing health problems (10). Training for cant (due to migration, death or retire- EFFECTS OF RESEARCH ON THE research begins in undergraduate edu- ment); the analysis shows the lowest POPULATION’S HEALTH cation, is strengthened through work percentages of researchers in the se- experience, and reaches the height of nior researcher and candidate groups To illustrate the influence of Cuban current knowledge and specialization in (20). SCITS research on health, several re- graduate education (in Cuba or abroad) Extending research to all health units search-and-development examples have up to the doctorate level (10, 19). has posed the challenge of a new “litera- been selected for their demonstrated Professional researchers are classified cy” process (21) for appropriate use of contribution to the study and control of through a system that combines years of scientific mechanisms and tools, given priority health problems. These exam- experience, professional level and out- the need to address difficulties common ples combine basic and applied research comes with annual evaluations that to all SCITS in the Americas, for exam- from biomedical, social and other science show advances or setbacks in indicators ple: developing research competencies, perspectives (Table 4). measured individually and institution- achieving conscious and responsible par- One example is the generation of ally, such as participation in scientific ticipation of affected communities and health products (medicines, reagents, projects and events; publications; other sectors, and validating results by etc.) and technologies (equipment and

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FIGURE 1. Health research process in Cuba, 2016

National priorities set • Population’s health status New goals and priorities • Search for more efficient solutions

• Projects associated with national programs Research and • Projects not associated with national programs y innovation • Institutional projects • Improved health status project • Entrepreneurial projects • More equity and quality of care • More user and provider satisfaction • More human development

• Scientific councils • Research ethics committees • Regulatory body: CECMED Execution

Presentation of scientific - technical results reached State budget • External funders • Collaborations and donations • Health care institutions • Community participation • Medical universities • Intersectorality • BioCubaFarma • New knowledge • Other OACEs • New or improved products • New or improved health services • New or improved procedures Generalization and introduction of results • New or improved technologies in social practice

Note: CECMED: Center for State Control of Medicines and Medical Devices; BioCubaFarma: Biotechnology and Pharmaceutical Industry Group; OACE: Central State Administration Agency. Source: Created by the authors.

TABLE 3. BioCubaFarma products supplied to the National Health System. Cuba, in the general population and in specific 2016 groups, such as pregnant women, blood donors, and human immunodeficiency Product Total virus (HIV) carriers (10). By September Medicines (biotechnology and generic) 499 2014, more than 48 million SUMA tests Reagents 64 had been administered to control trans- Diagnostic tools 135 mission of HIV, B and C, den- Equipment 76 gue, Chagas disease and Hansen disease Products for oral health use 24 (leprosy). More than 34 million tests had Raw materials for medical care 12 been administered to blood donors to Raw materials for traditional natural and chemical dispensary medicines 53 control transmission of HIV and hepati- Total 863 tis B and C (23). Source: Created by the authors based on references 17 and 18 In the framework of the National Ma- ternal-Child Health Program, more than 4 million pregnant women had been test- systems), which are essential to lowering services, and have led to changes in med- ed by 2014. Prenatal detection of congen- mortality from diseases in Cuba, primar- ical practice, social policies, and specific ital defects through measuring alpha ily the four leading causes of death: heart educational and health care programs for fetoprotein in maternal blood has given disease (217.7 deaths per 100 000 popula- vulnerable groups. pregnant women and their partners the tion), malignant tumors (216.3 per 100 option to receive additional tests, genetic 000 population), cerebrovascular diseas- Generating health products and counseling, or selective and informed es (84.2 per 100 000 population) and dia- technologies termination of pregnancy, since these betes mellitus (20.0 per 100 000 techniques can confirm severe congenital population) (13). The first outcome of this type of re- fetal defects (24). More than 7 million In addition, research on dengue and search was the Ultramicroanalytical Sys- pregnant women and their partners have diabetes, and the biopsychosocial study tem (SUMA), which enables mass been tested to control for vertical trans- of disability, span health systems and screening for several infectious diseases mission of HIV, syphilis and hepatitis B.

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TABLE 4. Selected research projects and their effect on population groups’ health. Cuba, 2016

Health problem Research results Effect on population groups’ health Congenital defects, HIV and Development of the Ultramicroanalytical System • 4 098 860 alpha-fetoprotein tests; defects detected in 6.4%; hepatitis B infections during (SUMA) for prenatal screening, available in reduced to 2.1 per 100 000 live births; coverage: >98% of pregnant women in pregnancy hospitals, blood banks and research institutes country • Hepatitis B: 1 824 520 tests; 1.4% positive • HIV 1+2: 5 818 895 tests; 0.2% positive; in 2015 WHO declared elimination of vertical transmission of HIV and syphilis in Cuba Congenital diseases Development of SUMA technology for neonatal Congenital hypothyroidism (801 cases detected in 3 350 373 samples analyzed), screening, available in hospitals, blood banks and phenylketonuria (20 cases in 1 055 575 samples), suprarenal hyperplasia (45 in research institutes 780 771), biotinidase deficiency (5 in 759 935) and galactosemia (7 in 723 182) Transmission of HIV and Development of SUMA technology for certifying Blood donors: hepatitis B and C through blood donations and epidemiologic control, available • HIV 1+2: 12 798 394 tests; 0.7% positive transfusion; mass screening in hospitals, blood banks, and research institutes • Hepatitis B: 12 074 614 tests; 0.9% positive and epidemiologic control • Hepatitis C: 10 017 461 tests; 0.9% positive Epidemiologic control: • HIV 1+2: 35 514 618 tests; 0.6% positive • Hepatitis B: 9 365 416; 1.2% positive • Hepatitis C: 2 226 778 tests; 5.3% positive • Dengue (IgM): 980 104 tests; 32.7% positive • Chagas disease: 14 213 tests; 4.8% positive • Leprosy: 31 725 tests; 10.6% positive -preventable Heberpentax® combined pentavalent vaccine against Registered in 2010; simplified the National Immunization Program by reducing communicable diseases , , whooping cough, hepatitis B and the number of from 11 to 6. coverage >98.7% Haemophilus influenzaetype ba Meningococcal BC vaccinea Mass vaccination campaign in 1989. Included in the National Immunization Program since 1991. Incidence reduced from 14 per 100 000 population in the 1980s to <0.2 per 100 000 population in 2006 High mortality from acute Heberkinasa®, human recombinant streptokinase, Since its introduction in 1991, hospital mortality from acute myocardial myocardial infarction thrombolytic biopharmaceutical infarction reduced 50%–70%; the is available in primary health care centers with progressive care units High incidence of ischemic Policosanol (PPG®)a hypolipemizing pharmaceutical, Treatment of hypercholesterolemia (coronary risk factor); incorporated into the heart disease platelet aggregation inhibitor of natural origin CBM since 1991, available in pharmacies Neutropenia in with ior®-LeukoCIM, granulocyte colony-stimulating Incorporated into the CBM and available in hospitals since 2004; effective in hematological cancer, HIV/AIDS, biopharmaceutical recovery of absolute neutrophil count in patients with hematological cancer or secondary treatment with (adults and children) or HIV/AIDS; shorter hospital stay; lower risk of associated chemotherapy or radiation therapy infections; improved quality of life Mortality from non-small cell CIMAvax-EGF®, therapeutic vaccine Active immunotherapy; incorporated into CBM; increased survival and quality of life lung cancer Diabetic foot ulcers and Heberprot-P®, recombinant epidermal growth factor More than 20 000 diabetic patients treated in more than 85 health institutions amputations applied by intra-lesion injectiona (by 2014); establishment of the Comprehensive Care Program for Patients with Diabetic Foot Ulcers (includes use of the product) that coordinates actions at the primary and secondary care levels; incorporated into the CBM since 2007; amputations index reduced by 81.2% (12 000 amputations prevented) Diabetes and self-care National Diabetic Patient Education Program and its Lower medicine dosages in non-insulin-dependent patients; HbA levels reduced implementation from 12% to 7.6%; frequency of excess body weight reduced from 77% to 20% of cases; and average annual hospitalizations due to metabolic decompensation in diabetes type 1 reduced from 2–3 per person to <1 Dengue and hemorrhagic Identification of early warning signs of the disease Incorporated into the norms for therapeutic management in the guidelines of dengue Cuba, WHO and other countries of the Region; classification of cases: 96% sensitivity and 100% specificity Health and socioeconomic Description of the magnitude and scope of the Study of 366 864 persons with disabilities (prevalence: 3.26%); community status of persons with problem programs developed in genetics, rehabilitation and social work; technical, disabilities monetary and nutritional aid implemented; a law protecting mothers with affected children was passed and went into effect: since 2016, 7 462 mothers of individuals with severe disabilities have been protected a Cuban inventions awarded with Gold Medals by the World Intellectual Property Organization (WIPO). In the pentavalent vaccine only the Haemophilus influenzaetype b component (synthetic antigen) received the award (10). Note: CBM: essential medicines list; HbA: Glycosylated hemoglobin; WHO: World Health Organization; HIV: Human Immunodeficiency Virus Source: Created by the authors based on references 10, 17, 18, 23–38.

As a result, Cuba was designated the first Research has also spawned domestic infection and typhoid fever have ceased to country in the world to eliminate moth- production of 8 of the 11 vaccines that be a health problem in Cuba, while mor- er-to-child transmission of HIV and con- make up the National Immunization Pro- bidity and mortality from hepatitis B have genital syphilis (25). Today, this program gram, which has achieved >98% coverage. been reduced by more than 98% (26). covers the care of more than 95% of preg- Diseases such as tetanus, meningococcal In addition to preventive vaccines, bio- nant women in the country (24). meningitis, Haemophilus influenzae type b technology provides other products to

6 Rev Panam Salud Publica 42, 2018 Rojo Pérez et al. • Science and technological innovation in health in Cuba Special report the SNS, such as biopharmaceuticals to compared with patients who received Entomological studies and operations treat non-communicable diseases (car- only individual counseling through tra- research on controlling the Aedes aegypti diovascular, cancer, diabetes, and oth- ditional medical checkups. In the former mosquito have identified and described ers). Another example is the group of group, concerns are listened to, skills are the vector’s main breeding sites and resis- technologies developed for screening, developed to manage different therapeu- tance mechanisms. BioCubaFarma and detection and early treatment of cervical tic demands, and efforts are made to de- other centers are also working to obtain a cancer, supplied to the SNS since 2010; in velop motivation and self-confidence for candidate vaccine against the disease. 2012­­–2014, 71.8% of women aged 25–64 confronting problems. Similar results Research on socioeconomic determi- years were tested, an advance compared were obtained when evaluating the evo- nants, and social and intersectoral partic- with 2009. However, this percentage re- lution of nephropathy and peripheral ipation, are also relevant, as well as mained below the 80% coverage recom- neuropathy (31). studies of public knowledge, attitudes mended by WHO to determine if these All this does not minimize the magni- and practices. Despite measures taken by interventions have influenced the reduc- tude of diabetes as a health problem. MINSAP and government support, at tion in mortality from cervical cancer Working in the community with patients the end of 2016 some municipalities still (39). and the general population to prevent di- had infestation indices8 above the maxi- BioCubaFarma’s products and tech- abetes must, therefore, continue, empha- mum level allowed for control of epi- nologies are part of the Essential Medi- sizing full compliance with medical, demics established in the National Aedes cines List (17) and other MINSAP health and hygienic treatment (32). Pro- aegypti Eradication Program (0.05), applications, thus significantly reducing moting the importance of personal re- which confirms the importance of socio- imports. sponsibility in health continues to be economic determinants for controlling fundamental (40). dengue. These investigations currently Educating people with diabetes include the study of other arboviruses Dengue research caused by the same vector (42). Research and interventions by the Na- tional Endocrinology Institute on the These studies reached their height in Biopsychosocial study of people knowledge, attitudes and practices of 1981 when Cuba suffered a lethal hemor- with disabilities people with diabetes have been an essen- rhagic dengue epidemic (41). Initial ef- tial pillar of the National Diabetes Care forts focused on the disease’s Persons with disabilities constitute and Patient Education Program since it epidemiology, on describing the clinical one of the most vulnerable sectors in any was implemented in 1981 (31). The re- evolution of children who died from se- society; their study and care are a chal- sults have helped prevent complications vere dengue, and on its warning signs, lenge in any country. In Cuba, the first and improve quality of life for diabetic defined as “a group of signs and symp- comprehensive study of people with dis- patients, who have not needed to resort toms indicating the imminent onset of abilities was designed and conducted in to new types of insulin or other technolo- shock from dengue” (36). These studies 2001–2003 (37). gies. Although Heberprot-P® has been received recognition from the Pan Amer- The study included 366 864 individu- introduced as an effective treatment for ican Health Organization (PAHO) and als with a disability (3.26% prevalence in diabetic foot ulcers (30), research also WHO as the guidelines for early detec- the surveyed population). The highest showed that patients obtain maximum tion of patients evolving toward severe rates were found in the provinces of benefit from the product only with strict dengue, who require a different type of Guantanamo (4.13%) and Santiago de adherence to the program’s therapeutic treatment (33–35). The prospective DEN- Cuba (3.79%). and hygienic norms. CO study (36), which included more The survey detected 140 489 people Studies found that patients’ in- than 1 700 confirmed cases, showed that (38.29%) with an intellectual disability, creased knowledge and skills related to the classification based on warning signs for a prevalence of 1.25%. Of those, 92 daily care (independent of age, educa- and initially used in Cuba had 96% sensi- 506 (25.2%) presented a physical-motor tion level, and type and duration of di- tivity and 100% specificity. As a result, it disability, for a prevalence of 0.82%; 46 abetes) were associated with a marked was incorporated into WHO policy doc- 455 (12.7%) had a visual disability (0.41% decline in average glycosylated hemo- uments and into guidelines in Cuba and prevalence); 36 869 (10.1%) mental dis- globin (HbA ) levels and reductions in other countries in the Region for compre- ability (0.33% prevalence); 23 620 (6.4%) 1 dosages of medicines, frequency of ex- hensive management of dengue auditory disorders (0.21% prevalence); cess body weight, and average number patients. 25 094 (6.8%) presented mixed disabili- of hospitalizations due to decompensa- The most important of these studies, ties (0.22% prevalence); and 1 831 (0.5%) tion (31, 32). led by the Pedro Kourí Tropical Medicine were diagnosed with chronic kidney fail- The presentation and development of Institute, include establishment of the ure (0.02% prevalence) (37). long-term complications in patients with comprehensive hypothesis about hemor- The following disability programs are recent onset of type-1 diabetes were also rhagic dengue (41), virologic studies to highlighted in the results of the study: studied. Frequency of diabetic retinopa- describe the viruses causing the epidem- • Community-based programs: genet- thy was found to be significantly lower ics and outbreaks of dengue in Cuba, and ics, rehabilitation and social work; in the group monitored with an interac- virulence markers and their association tive methodology based on constructive with severe dengue. These studies have 8 Indicates the degree of infestation by the vector in dialogue between the person providing also benefited other countries in the the area surveyed, expressed as the percentage of dwellings and other sites that tested positive with information and the one receiving it, Region. respect to the total number inspected (42).

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TABLE 5. Lessons learned

Health research in Cuba and its application are a reality thanks to: • The political will of the State, which has provided funding, coordination and generation of synergies between health services, research centers, enterprises in different sectors and the disciplines, enabling a developing country to conduct research and introduce cutting-edge technologies to raise the health standards of its population. • Establishment of the Science and Technological Innovation System in Health (SCITS), since the State is committed to defining research and development priorities and to contributing contributes most of the resources. • SCITS’ dynamism in adapting its priorities, organization and functioning to changing social and health needs. • The systematic care and formation of human capital, dialogue with decision-makers, methodological rigor, and researchers’ ethics and social commitment needed in order for SCITS to meet its objectives.

• Establishment of 23 lines of research The results obtained are the product of introduced into health practice in the on factors associated with disability; a long and arduous process, involving form of policies, programs, products, • Legal recognition of the condition of political will, developing human capital, technologies, and high quality social and “caregiver mother,” who receives a building a national industry, creating the health care services. These advances full salary for caring for her disabled material and financial operating condi- have provided coverage for the popula- child at home; tions, and the need to resolve contradic- tion in need and have had a positive ef- • Technical and economic assistance, tions between epistemological positions fect on their health status. Even so, given and free meals, provided to persons and knowledge, or between managers their magnitude and complexity, these with disability. and researchers (Table 5). and other problems will continue to be objects of scientific study in the health In 2007–2010, the research was replicat- sciences ad infinitum. ed in Venezuela, Ecuador, Nicaragua, Bo- CONCLUSIONS livia, and St. Vincent and the Grenadines, Conflicts of interest. None declared. at the request of their governments (43). SCITS in Cuba is sustained by a na- Dr. V. Gustavo Sierra Gonzalez works for tional policy that promotes science at all BioCubaFarma. Final considerations levels of health care and that has solved priority health problems. It faces chal- Disclaimer. Authors hold sole respon- The research reviewed on each of the se- lenges common to other countries in the sibility for the views expressed in the lected topics are examples of how solu- region, such as access to funding, tech- manuscript, which may not necessarily tions emerge from overlaps between nological obsolescence and preservation reflect the opinion or policy of the RPSP/ different disciplines in the biomedical sci- of human capital, derived from con- PAJPH or the Pan American Health ences, and that “progress is made not only straints imposed on the economy and ­Organization (PAHO). by those who are most knowledgeable but changes in the socioeconomic context. by those who best combine their knowl- The research presented offers edge” (21). ­important contributions that have been

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RESUMEN En Cuba, la investigación para la salud se basa en las prioridades de la política cientí- fica nacional, derivadas del estado de salud de la población. El objetivo de este artículo es describir las caracte­rísticas del Sistema de Ciencia e Innovación Tecnológica en el Ciencia e innovación sector y cómo los resultados de sus investigaciones benefician la salud de los grupos poblacionales. Para ello se seleccionaron investigaciones­ relacionadas con la gener- tecnológica en la salud en ación de productos y tecnologías, la diabetes, el dengue y la discapacidad. Este sistema Cuba: resultados en sigue los preceptos metodológicos del Ministerio de Ciencia, Tecnología y Medio problemas seleccionados Ambiente y cuenta con 37 entidades de investigación. Se organiza en programas y pro­ yectos que favorecen la investigación básica y aplicada, con un enfoque multidiscipli- nario e inter­sectorial; estos son financiados mayormente por el Estado y organizados en ciclos cerrados o completos, es decir, una misma entidad se encarga de todo el proceso, desde la investigación hasta la comercialización, incluidos los estudios de mercados y la vigilancia poscomercialización. Las investigaciones seleccionadas evi- dencian la armonía entre la investigación, la generalización de los resultados y su efecto en mejorar la salud y el acceso universal de la población. Se lograron resultados en métodos de diagnóstico, vacunas preventivas y terapéuticas, signos de alarma para el pronóstico y tratamiento del dengue, prevención de malformaciones congénitas, y políticas y programas que han beneficiado a las personas con discapacidad y sus familiares. La voluntad del Estado para desarrollar y financiar la investigación cientí- fica, la acción intersectorial, la defini­ción de las prioridades de investigación, y la preparación y atención sistemática del capital humano han sido factores determi- nantes para el cumplimiento de los objetivos del sistema.

Palabras clave Política nacional de ciencia, tecnología e innovación; gestión de ciencia, tecnología e innovación en salud; investigación biomédica; planes y programas de salud; proyec- tos de investigación; Cuba.

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RESUMO Em Cuba, a pesquisa em saúde baseia-se nas prioridades da política científica nacio- nal, derivadas do estado de saúde da população. O objetivo deste artigo é descrever as características do Sistema de Ciência e Inovação Tecnológica e como os resultados de Ciência e inovação suas pesquisas beneficiam a saúde dos grupos populacionais. Para este fim, foram sele­cionadas pesquisas relacionadas à geração de produtos e tecnologias, diabetes, tecnológica em saúde em dengue e deficiência. Este sistema segue a metodologia do Ministério da Ciência, Cuba: resultados em Tecnologia e Meio Ambiente e possui 37 entidades de pesquisa. Está organizado em problemas selecionados programas e projetos que favorecem pesquisas básicas e aplicadas, com abordagem multidisciplinar e intersetorial; estes são financiados principalmente pelo Estado e organizados em ciclos fechados ou completos, ou seja, a mesma entidade é responsável por todo o processo, desde pesquisa até marketing, incluindo estudos de mercado e vigilância pós-comercialização. As pesquisas selecionadas mostram a harmonia entre a pesquisa, a generalização dos resultados e seus efeitos na melhoria da saúde e no acesso univer­sal à saúde na população. Resultados positivos foram obtidos em méto- dos de diagnós­tico, vacinas preventivas e terapêuticas, sinais de alerta para o prog- nóstico e trata­mento da dengue, prevenção de malformações congênitas e políticas e programas que beneficiaram pessoas com deficiência e suas famílias. A vontade do Estado de desenvolver­ e financiar pesquisas científicas, ações intersetoriais, a definição de prioridades de pesquisa e o treinamento e atenção sistemática do capital humano têm sido fatores determinantes para o cumprimento dos objetivos do sistema.

Palavras-chave Política nacional de ciência, tecnologia e inovação; gestão de ciência, tecnologia e inovação em saúde; pesquisa biomédica; planos e programas de saúde; projetos de pesquisa; Cuba.

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