01 Special report 02 03 04 05 06 Equity and the Cuban National Health System's 07 * 08 response to COVID-19 09 10 11 1 2 3 Pedro Mas Bermejo, Lizet Sánchez Valdés, Lorenzo Somarriba López, 12 Nelly Cristina Valdivia Onega,4 María Josefina Vidal Ledo,5 Ileana Alfonso Sánchez,6 13 14 7 8 8 Armando Seuc Jo, Yudivian Almeida Cruz, and Roberto Morales Ojeda 15 16 17 18 Suggested citation Mas Bermejo P, Sánchez Valdés L, Somarriba López L, Valdivia Onega NC, Vidal Ledo MJ, Alfonso Sánchez I, et 19 al. Equity and the Cuban National Health System's response to COVID-19. Rev Panam Salud Publica. 2021;45:e80. 20 https://doi.org/10.26633/RPSP.2021.80 21 22 23 24 ABSTRACT Cuba’s National Health System has managed to guarantee an effective and equitable response to COVID-19. 25 Universal and free health coverage, based on primary care, follows the principle of equity and the greatest 26 resources are allocated to areas of the lowest socioeconomic stratum (where higher risk is concentrated), 27 followed by those of medium and high strata, in that order. This allowed for similar mortality rates in the three 28 strata, and Cuban national mortality rate was one of the lowest in the Region of the Americas. Before the first 29 case was identified in Cuba, a Plan for Coronavirus Prevention and Control was elaborated with multisectoral 30 participation, and when the first case was confirmed the Temporary National Working Group to Fight COVID-19 31 was created as an advisory body of the government. The actions to face the pandemic began with preventive 32 measures in the community, continued in the isolation centers and ended again in the community with actions 33 of surveillance and follow up of recovered patients. Following the principle of territoriality, molecular diagnosis 34 laboratories were created in the provinces that did not have one. Free medical care and treatment; the prepa- 35 ration of a single national intersectoral government plan; the use of particular strategies for research, diagnosis 36 and case tracing; and the implementation of a universal protocol for disease prevention and treatment of con- 37 firmed cases made it possible to control the disease with a health equity perspective. 38 39 Keywords Coronavirus infections; health equity; universal health coverage; primary health care; Cuba. 40 41 42 43 44 Equity is a complex concept with a long history. The word administered with justice; and discrimination is avoided in the 45 has had various definitions, ultimately going back to the Latin delivery of care (2, 3). 46 aequitas, referring to justice (1). Today, achieving equity in As of 1 October 2020, the COVID-19 pandemic caused by 47 health means that people are able to develop their maximum the SARS CoV-2 coronavirus had caused more than 34 million 48 health potential regardless of their social status or other circum- confirmed cases and 1 million deaths, corresponding to an esti- 49 stances determined by social factors. More specifically, it means mated case-fatality rate (number of deaths in the cumulative 50 that resources are allocated according to need; processes are total of positive cases) of 2.98%. The countries in the Region 51 52 53 * Official English translation from the original Spanish manuscript made by the 2 Ministry of Public Health, Havana, Cuba. Pan American Health Organization. In case of discrepancy, the original ver- 3 La Pradera International Health Center, Havana, Cuba. 54 sion shall prevail. Access to original manuscript: https://doi.org/10.26633/ 4 National School of Public Health, Havana, Cuba. 55 RPSP.2020.138 5 National Medical Sciences Information Center, Havana, Cuba. 56 1 Pedro Kouri Institute of Tropical Medicine, Havana, Cuba. * Pedro Mas 6 National Institute of Hygiene, Epidemiology, and Microbiology, Havana, Bermejo, [email protected] Cuba. 57 Molecular Immunology Center, Havana, Cuba. 7 Council of Ministers, Havana, Cuba. 58 59 This is an open access article distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs 3.0 IGO License, which permits use, distribution, and reproduction in any medium, provided the 60 original work is properly cited. No modifications or commercial use of this article are permitted. In any reproduction of this article there should not be any suggestion that PAHO or this article endorse any specific organization or products. The use of the PAHO logo is not permitted. This notice should be preserved along with the article’s original URL. Open access logo and text by PLoS, under the Creative Commons Attribution-Share Alike 3.0 N61 Unported license. Rev Panam Salud Publica 45, 2021 | www.paho.org/journal | https://doi.org/10.26633/RPSP.2021.80 1 Special report Mas Bermejo et al. • Cuba’s response to COVID-19 of the Americas had reported more than 16 million confirmed Another strength of the SNS is its programmatic approach, cases and more than 560 000 deaths, for a case-fatality rate of which makes it possible to spell out the steps for leading patients 3.33%. This onslaught has severely tested the capacity of health through the service network within each region. The staff of 479 systems throughout the world (4). 623 health workers, distributed across the three levels of care, Addressing this pandemic requires not only adequate hos- are interconnected through a referral and back-referral system. pital and laboratory infrastructure but also health systems that At the center is the family doctor, who follows each patient, have sufficient health personnel and equipment to trace con- receiving ongoing updates, as he or she goes through the net- firmed cases and at the same time treat the excessive number of work (13). patients. Meanwhile, as with other infectious diseases, inequi- Thus, the primary care system, based on community family ties are aggravating both the transmission of COVID-19 and the medicine clinics, is linked to the second level of care, which has severity with which it is assailing the poorest societies (5). Thus, 150 municipal hospitals that offer all the specialties, including the consequences of the disease are disproportionally affecting 110 hospital intensive care units. The third level of care consists vulnerable groups and those who suffer from discrimination. of 12 specialized research institutes that also provide care. All Faced with this reality, the Pan American Health Organization citizens have free access to all these health facilities, from pri- (PAHO) has appealed to the countries of the Region to focus on mary care to the highest degree of specialization at the third the equity perspective and the factors of gender, ethnic charac- level of care. Together, these institutions function as part of an teristics, and human rights in their responses to COVID-19 (6). overall process of regionalization of the services, both geograph- For Cuba, equity, social justice and the promotion of social ically and in terms of specialized care, thus representing a true and human development are basic pillars of social policy (7) expression of equity in terms of access and opportunities (13). enshrined in the Constitution of the Republic, which also Among other key processes, the Cuban family medicine emphasizes that public health is the right of all people and that model includes dispensation and ongoing oversight and anal- the State is responsible for guaranteeing free access to quality ysis of the health situation, which makes it possible to identify health care, protection, and rehabilitation services (8). individuals and families in vulnerable circumstances. In this In a recent process of updating the Cuban economic model, important way, the model defines the needs for resources to major changes in the health sector have involved redefining improve the health of the community. The family doctor and the functions and structures at all levels of care throughout the nurse, through their authority and their connections with local country (9, 10). This initiative has produced a service organi- government leaders and community organizations, have the zation that has proven to be capable of addressing disasters opportunity to modify behaviors and affect the perception of risk and extraordinary situations—in particular, the COVID-19 in the population under their care. At the same time, there are pandemic. also cultural and socioeconomic differences within the country As of 1 October 2020, Cuba had recorded a total of 5 670 con- that make for geographic variations in living conditions. In ear- firmed cases. Of this number, 5 078 of the patients had recovered, lier studies (14), Cuba’s 15 provinces and the Isla de la Juventud 518 were still hospitalized, and 122 people who tested positive Special Municipality were classified according to the following for SARS-CoV-2 had died, representing a case-fatality rate of three strata based on the Living Conditions Index: lower (<0.40), 2.15, one of the lowest in Latin America (4). intermediate (0.41–0.55), and high (>0.55). Specifically, the coun- The present study aims to show how the Cuban National try’s eastern provinces (Las Tunas, Holguín, Granma, Santiago Health System (known by its Spanish acronym, SNS) has been de Cuba, and Guantánamo) are in the low stratum, while some able to ensure an effective and equitable response to COVID-19. of the provinces in the western and central parts (Pinar del Río, Mayabeque, Matanzas, Villa Clara, and Sancti Spíritus) are in EQUITY IN THE PRIMARY CARE-BASED HEALTH the intermediate stratum, and the rest (Artemisa, La Habana, SYSTEM Cienfuegos, Ciego de Ávila, Camagüey, and the Isla de la Juven- tud Special Municipality) are in the high stratum. In the Cuban SNS, equity is taken as a premise for ensuring The SNS constantly works to develop its human resources that health care is efficient and meets the needs of society based and improve its services.