Pan American Journal Overview of

Transformations in the health system in and current strategies for its consolidation and sustainability*

Roberto Morales Ojeda,1 Pedro Mas Bermejo,2 Pastor Castell-Florit Serrate,3 Carmen Arocha Mariño,3 Nelly C. Valdivia Onega,4 Dalilis Druyet Castillo1 and José A. Menéndez Bravo1

Suggested citation (original manuscript) Morales Ojeda R, Mas Bermejo P, Castell-Florit Serrate P, Arocha Mariño C, Valdivia Onega NC, Druyet Castillo D, et al. Transformaciones en el sistema de salud en Cuba y estrategias actuales para su consolidación y sostenibilidad. Rev Panam Salud Publica. 2018;42:e25. https://doi.org/10.26633/RPSP.2018.25

ABSTRACT In Cuba, universal access and health coverage rest on three key principles: health as a human right, equity and solidarity. Although many of the Cuban health indicators are among the best in the Region of the Americas, in 2011 it was decided to reorganize health services, in line with the process of updating the Cuban economic and social model that occurred in all sectors. For this purpose, an action-research project was designed, including a situation diagnosis, imple- mentation of changes and evaluation of the results, in several stages. As a result, human resources were rationalized with a reduction of more than 150 000 posts not directly linked to care, management structures were reduced in 57 municipalities, 46 polyclinics were compacted, the Family and Nurse Program was optimized with 20 specialties for the community care, teaching was reorganized, and the international medical cooperation pro- grams were revisited. These changes have contributed to improving the sustainability of the National Health System and its performance: increase in the number of consultations at the primary level (19.3%) and oral care visits (56.6%), reduction in the number of visits to emer- gency rooms (16.1%), increase in the number of surgically treated (12.1%), increase in the number of research projects (300%) and increase in the number of medical students (55.7%), among others. In Cuba, transformations in health is an ongoing project.

Keywords Health systems; sustainability indicators; efficiency; Cuba.

The strategy for universal access to as a human right, equity and solidarity —without diminishing quality of and universal health cover- (1). Worldwide and in the Americas care— and reaching ever higher levels age rests on three key principles: health ­region, universal health is increasingly of efficiency­ are pressing problems, at the center of all policies, with discus- augmented by the aggravating factors * Non-official English translation from the original Spanish manuscript. In case of discrepancy, the sion focused on the paths that will best of climate change and population original version (Spanish) shall prevail. lead to its full realization. This is not, aging. 1 Ministerio de Salud Pública, , Cuba. however, the problem in Cuba, where As the opening article in the Pan Amer- 2 Instituto de Medicina Tropical Pedro Kourí, Havana, Cuba. Send correspondence to Pedro the State is responsible for a single ican Journal of Public Health’s special issue Mas Bermejo, [email protected] health system that provides coverage dedicated to , this over- 3 Escuela Nacional de Salud Pública, Havana, Cuba. and access without exclusions. Never- view aims to explain, describe and ana- 4 Dirección Provincial de Salud, Havana, Cuba. theless, sustainability of this system lyze the rationale for the transformations

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Rev Panam Salud Publica 42, 2018 1 Morales Ojeda et al. Transformations in the health system in Cuba

Overview Morales Ojeda et al. • Transformations in the health system in Cuba

carried out as part of the strategy for re- services, and efficient use of resources is a The health system responded by de- organizing and consolidating the Cuban prerequisite for guaranteeing the system’s veloping and implementing an improve- health system toward making it sustain- sustainability and alignment with univer- ment and transformation plan aimed at able. With this baseline information, the sal health (14–16). reorganizing, downsizing, and regional- reader will be better prepared to delve Over the past 58 years, despite mate- izing health services in order to consoli- into the accompanying articles covering rial constraints, the SNS has achieved date their functions and increase the several intersecting topics: health prob- international renown for continually efficacy and efficiency of plans and pro- lems, their conditioning factors, and the upgrading its health services and sys- grams. It also sought to raise the system’s health system’s response through di- tems, leading to steady improvements capacity to meet foreseeable challenges verse programs and strategies; economic in Cuba’s main health indicators. Cuba related to population aging and other factors affecting public health in Cuba ranks at the top of several key health health contingencies, such as those that and its sustainability; research and the indicators in the region (17, 18) (­Table 1) might derive from climate change and its use of new information technologies to and presents relevant outcomes in oth- impacts (19, 21). improve the quality and efficiency of er sensitive population health indica- In 2011, Cuba began updating its eco- public health practice in Cuba; among tors, such as birth and mortality rates nomic and social model in all sectors others. (Table 2). (22). The Ministry of Public Health in- At the beginning of the 21st Century, cluded updating as part of its systematic GENERAL CONSIDERATIONS the SNS was engaged in a process of con- processes of supervision and control, AND BACKGROUND solidation and renovation. During the conducting a critical evaluation that first decade, a broad social program was brought to light a set of difficulties relat- A key dilemma faced by public health implemented (19) that renovated and ed to health service operations in need of globally is summarized by the following modernized health services through the transformation. It also identified the question: should the State take responsi- introduction of modern technologies at need to devise a new strategy and take bility for health services, privatize them, all levels of care, including primary care. steps toward reorganizing services in ac- or apply mixed or intermediate ap- Addressing the National Assembly in cordance with the country’s economic, proaches? This quandary became partic- late 2009, Cuban President Raúl Castro social and health context (19, 23). ularly pressing during the 1990s with the stated that, “Without affecting the quali- application of policies encouraged ty of health care provided to all citizens THE TRANSFORMATION largely by the World Bank and the Inter- at no cost, and even improving it, expen- PROJECT national Monetary Fund, which pro- ditures can be substantially reduced” moted reforms to remodel health systems (20). This urgent appeal from the highest As a result of the grave economic crisis and reduce State participation (2). More level of government was a clear call for suffered by Cuba in the 1990s with the recently, this question has been the sub- efficiency without undermining excel- loss of its traditional markets due to po- ject of continuous debate from diverse lence in service delivery. litical changes in Eastern Europe and standpoints reflecting a broad spectrum of political tendencies and economic ap- TABLE 1. Cuba’s ranking in relation to countries in the Americas region, selected proaches (2–6). indicators, 2015 From a regionalization and politi- cal-administrative organization perspec- Americas region countries Cuba (regional Indicator Cuba tive, two trends characterize Latin (minimum; maximum) ranking)a American health systems: concentration (years) 79.1 63.5; 82.2 5 of public and collective services within a Under-5 mortality (per 1 000 live births) 5.5 4.9; 69.0 2 single system, on one hand; and transfer Maternal mortality (per 10 000 live births) 39.0 7; 359 10 of responsibilities to autonomous subna- Health professionals (per 10 000 population) 157.8 7.5; 157.8 1 tional units, on the other. The oldest ex- a Ranked from best to worst, according to polarity of the indicator amples of unified health systems are in Source: Created by the authors based on reference 17. Chile, Costa Rica and Brazil, in that or- der. Currently, Argentina and are moving in a similar direction (7–12). TABLE 2. Birth and mortality rate indicators in the world, Latin America and the The Cuban health system is organized , and Cuba, 2016 by levels of care and provides universal coverage through medical and epidemio- Indicator World Latin America and the Caribbean Cuba logical care to the population, irrespective Birth of skin color, religious belief, geographical Crude (per 1 000 population) 19 17 10.4 location, or economic, social or political Total fertility (children per woman) 2.5 2.1 1.6 status (13). Health promotion and Mortality prevention are top priorities. The Nation- Crude (per 100 000 population) 8 6 8.8 al Health System (Sistema Nacional de Sa- Under-5 (per 1 000 live births) 43 18 5.5 lud, SNS) operates on the premise that Infant (per 1 000 live births) 32 15 4.3 improving population health indicators, Neonatal (per 1 000 live births) 19 9 2.4 quality of medical care, satisfaction with Source: Created by the authors based on references 17 and 18.

2 Rev Panam Salud Publica 42, 2018 Morales Ojeda et al. • Transformations in the health system in Cuba Overview tightening of the economic, trade and fi- with polyclinics), maternity homes (cen- creation of the operational bases for nancial embargo imposed on Cuba by ters providing care for pregnant women modifying the distribution of organiza- the since the early 1960s facing some type of risk or who live in re- tional structures and for rationalizing in- (24), Cuba’s healthcare facilities deterio- mote locations), oral health centers and stitutional resources and increasing rated physically and shortages of sup- services, and institutions providing care efficiency in service provision without plies worsened. To a certain degree, the for elderly or disabled persons. diminishing quality of care in meeting quality of health service management For each indicator, the frequency or the population’s needs. Subsequently, a also deteriorated as demand for hospital periodicity of collection was defined timeline was created for the enactment, services increased. A survey conducted (one time only, monthly, quarterly, implementation and evaluation of the re- by the National Hygiene, Epidemiology twice-annually or annually), as were sults of the transformation. Three stages and Microbiology Institute during this flow or levels of circulation (institutional, were defined, each with specific pur- period evidenced people’s dissatisfac- local or national) and sources (continu- poses and actions, as described below tion with the health services (25). ous statistics, surveys, interviews and (21). The entire process was led by teams In 1997, Suárez (26) demonstrated the monitoring actions or audits). The com- of professionals selected for their experi- magnitude of the challenges Cuba needed ponents, description and simple algo- ence and specific skills in health service to overcome to withstand the effects of the rithm for calculating each indicator were management and administration, in reg- economic crisis and maintain the achieve- also specified. Depending on their char- ular consultation with the entities in- ments and high quality of health services acteristics, indicators could be structural volved and the community, aiming in a country with free, universal access (need for PHC clinics and demand for toward appropriate decision making. and coverage, and a population accus- human resources), process (general indi- First stage. Carried out in 2011–2012, tomed to making extensive use of such cators of resources and productivity), actions in this stage were aimed at rede- services, from primary health care (PHC) outcome (coverage and availability of fining strictly necessary staffing needs in to specializations equipped with cutting services) or satisfaction of the population human resources, streamlining manage- edge technologies. with services received. ment structures, determining need for In response to the difficulties identified For purposes of the evaluation, the fol- Family Doctor and Nurse Program of- and the subsequent need to reorganize Cu- lowing definitions of three of the key fices, applying a new structure in small ba’s health services in alignment with na- concepts in the transformation process municipalities with a single health area, tional policies and changes in the economic were applied (28): reorganizing teaching processes and re- model initiated in 2011 (22), an action re- arranging international medical coopera- • Reorganization: Process by which the search project was designed. This project tion programs. distribution of organizational struc- was led by an expert group of specialists This stage of the transformation pro- tures for health service delivery is with more than five years experience as cess determined that municipal health de- modified, as well as corresponding heads of health services and academic cre- partments and polyclinics had a similar resources, in order to meet the health dentials as professors and researchers in structure, regardless of their level of com- demands of the population in accor- the field of health systems and services. plexity. Cases of duplicate functions were dance with changing circumstances, The project had two components: assess- identified, as teams and working groups and individual and collective goals. ment and evaluation; followed by enact- had been created to provide specialized • Downsizing: Process by which two or ment, implementation and concurrent care for specific . This meant that more departments or services of the evaluation of outcomes. Throughout the patients were seen outside their clinics, same specialty or activity are merged process, the expert group’s main role was causing a breakdown in the concept of re- or unified in order to guarantee opti- to analyze and collectively discuss the in- sponsibility and continuity of care. This mal functioning through the most ra- formation, and provide technical assis- organizational model of care affected ful- tional use of time and available tance to the Ministry of Public Health. fillment of a foundational objective of the human and material resources. Family Doctor and Nurse Program: to • Regionalization: Process by which the Assessment and evaluation turn the polyclinic and its affiliated clinics services provided by health institu- into sites for patient care, teaching and re- tions are made available and orga- The first phase, devoted to assessment search by means of a process of consulta- nized in an accessible and equitable and evaluation, was based on the applica- tions with specialists who would transfer manner in order to guarantee the cov- tion of a set of 147 indicators that measure technology to the family doctor. erage required by the population, sup- structure, process and outcomes, and sat- During this stage of the transforma- ported by the referral/counter-referral isfaction with the health services provid- tion process, health actions that had been system that allows the family doctor ed. Results were entered into an ad hoc “verticalized” returned to the clinics, the to be in charge of their patient’s rout- health information system by category number of clinics was increased, and the ing through the system until the pa- (27). Institutions included in the assess- foundation of the system—the doctors tient’s health needs are resolved. ment and evaluation phase were hospi- and nurses providing care to families— tals, polyclinics (health facilities serving was expanded. This guaranteed cover- the population of several neighborhoods; Enactment, implementation and age to the population and reinforced the these polyclinics are linked to hospitals), evaluation of outcomes principle that the primary level of care is Family Doctor and Nurse Program offices the point of entry into the system. (located in every neighborhood to serve The principal outcome of the assess- Second stage. Evaluation of first stage the surrounding population; affiliated ment and evaluation component was the outcomes laid the foundation for a

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Overview Morales Ojeda et al. • Transformations in the health system in Cuba

second stage of deeper transformations ­resources and analytical tools designed positions in the first and second (2013–2014), in which the same goals for the three stages of the project. ­stages of the transformation. Most of were maintained and new actions were It should be noted that the entire pro- those were administrative positions included, based on the experience ac- cess of health sector transformation has and jobs not involved in providing quired. New actions included promoting been characterized by the enactment of services to patients. In Cuba, there is development of workers’ job skills, as comprehensive intersectoral actions at all not now, nor will there ever be, a sur- well as their ethical and social competen- levels—local, intermediate (provincial or plus of Doctors, dentists, nurses and cies, using the most advanced medical regional) and national—, which has served health technicians, according to pro- science and technology. In addition, or- to advance consolidation of the presence jected coverage of domestic services ganization of different services and lev- of priority health issues in all national and and international commitments. els of care, and their integration, was sectoral policies adopted in Cuba (28). • Management structures were strengthened, and the family medicine streamlined in 57 municipalities, model was consolidated. Other important project milestones and 46 polyclinics serving popula- Third stage. In this stage (2015–2016), linked to the transformations tions of fewer than 5000 inhabitants actions were carried out to preserve the were downsized through redistribu- foundational concepts of the Family Doc- Major milestones of the transforma- tion in nearby health areas, so cover- tor and Nurse Program and the quality of tion project aimed at improving sustain- age was not affected. The basic services in polyclinics. The goal was to sat- ability of the system without affecting health team, integrated­ into Family isfy between 70% and 80% of the popula- the health budget include the following: Doctor and Nurse Program offices, tion’s health needs at the primary care was assigned a maximum popula- level; reorganize health promotion and • In the last decade, the State has main- tion size, which expands the team’s prevention, epidemiology and microbiolo- tained a high fiscal priority with per- performance and accountability for gy services, in accordance with the nation- centages that, in general, exceed 25% the health of the population under al and international situation; maintain the of the total expenditure of budgeted its care. This concept is reinforced principle of education at work during the activity (16). For example, in 2012- through activities related to elder teaching, service provision and research 2015, health spending remained be- care, genetic counseling and care of processes in Cuban medical schools; in- low 10.4% of the annual per capita specific population groups. It is crease the number of operational research Gross Domestic Product (Table 4). complemented, additionally, by the projects to optimize decision-making; in- • The number of health system work- participation of specialists in inter- crease the export of medical services; and ers was reduced by more than 150 000 nal medicine, obstetrics and diversify sources of income. Comparing some indicators of growth 5 and quality of service outcomes before TABLE 3. Cuban health system performance before and after application of and after application of the transforma- transformations, selected indicators tions, considerable improvement in the volume of the services provided was ob- Degree of Indicator Before (2010) After (2016) served, with an increase in the number of change (%) primary care (19.3%) and oral care Primary care visits (patients served) 64 907 659 77 449 154 19.3 (56.6%) consultations, and the number of Hospital emergency room visits (patients served) 21 788 808 18 286 319 -16.1 patients who underwent surgery (12.1%), Surgeries (patients served) 948 694 1 063 184 12.1 among others (Table 3), although this First-time caesarians (percentage of total patients served) 30.5 28.3 -7.2 cannot be solely attributed to the trans- Oral health consultations (patients served) 18 649 854 29 213 718 56.6 formations. Hospital emergency room Research projects 1 183 4 863 311.1 visits decreased by 16.1%, very possibly Medical school enrollment (number of undergraduate 32 848 51 152 55.7 due to a greater capacity for resolution at students in Medicine, Nursing and Health Technologies) the primary care level. Similarly, the pro- Source: Created by the authors based on reference 17. portion of first-time cesareans decreased slightly and surgical efficiency increased TABLE 4. Gross Domestic Product (GDP) per capita, and health and social welfare markedly. Notable increases were also spending. Cuba, 2011–2015 observed in the important areas of re- search and teaching. Year a Total health expenditure Future steps. The transformation proj- GDP per capita (in Cuban pesos) ect—with its components of assessment, Millions of Cuban pesosa Percentage of GDP (%) enactment, implementation and evalua- 2011 4 367.4 5 587 11.5 tion—has not concluded, since its 2012 4 498.0 4 568 9.1 ­outcomes are being used to monitor 2013 4 614.4 5 026 9.7 system performance through the use of 2014 4 649.2 5 405 10.4 5 In Cuba, the increase in polyclinic consultations is 2015 4 849.3 5 641 10.4 also an indicator of patient adherence to PHC as aExchange rate: CU$1.00 = US$1.00, at constant 1997 prices. the entry point into the system, resulting in fewer hospital emergency room visits, thereby enabling Source: Created by the authors based on reference 30. All primary data used to create this table come from the provision of higher quality hospital care. 1985–2015 statistical series, available on the Cuban National Statistics Bureau website http://www.one.cu/series2015.htm

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gynecology, pediatrics and a psy- process, 140758 health professionals development, prevention and care of chologist, who make up the basic provided services in 67 countries. emerging and reemerging diseases, clinic staff, along with community • Restructuring of the medical coopera- population aging, and the impact of the outreach in 20 specialties, 14 in poly- tion program produced an annual in- ­United States’ economic, commercial clinics and six in the municipality, come growth rate exceeding 200%, in and financial embargo against Cuba, whose frequency will depend on ter- addition to overall savings from more present a huge challenge to sustainabili- ritorial needs, based on health rational use of resources in service ty of the SNS. These challenges must be conditions. provision. This has made funds avail- confronted with the dedication of pro- • The Medical Cooperation Program able to guarantee the sustainability fessionals, technicians and workers; was restructured into three modali- and development of the SNS, acquisi- community ­integration; application of ties: in the first, Cuba covers expen- tion of supplies such as medicines and interwoven processes, innovations and ditures (20 countries); in the second, reagents, investment programs, insti- strategies in managing health systems expenditures are shared between tutional repair and maintenance, and and services; capitalization of human Cuba and the recipient country (17 introduction of medical technologies, resources; and greater use of informa- countries); and in the third, Cuba re- as well as computerization upgrades tion and knowledge management. ceives income (30 countries). In all in the health system and improved The greatest dividend of the transfor- cases, the principle of solidarity is training of health personnel in the use mation project transcends the outcomes emphasized, since Cuban profes- of advanced technologies. mentioned here, some of which stem di- sionals generally provide services in rectly from the transformations, while areas not covered by professionals in Despite new sources of financing others are trends already underway that the beneficiary countries, because from adjustments to the medical coop- coincide with the transformations. These they are remote, difficult to access or eration program and increased efficien- benefits materialized throughout the pose a health risk. Between 2011 and cy in health services, the costs of chronic process as valuable learning experiences 2016, during the transformation ­disease care, dynamism of technological (Table 5).

TABLE 5. Lessons learned during the Cuban health sector transformation process

Dimensions Difficulties Actions 1. Structure It was found that administrative structures did not provide Structures were adjusted based on fulfillment of the functions inherent to each greater links between health system managers and health position, personnel competencies and public health collaboration. services, nor with patients, and that capacity building was needed to identify and resolve problems at the primary care level. 2. Competencies of The decision-making capacity of administrative, scientific and Spaces for continuing education, training, and professional development were health administrators, health care sectors—essential to gaining a better appreciation of rehabilitated, contributing to increased professional and research competencies, professionals and the utility of research (especially operations research using among them: technicians action-research and evaluation methods) as a resource for SNS specialization in health administration development—had been reduced. other pre- and postgraduate teaching models for the technical and scientific qualification of health professionals 3. SNS efficiency Specific possibilities for increasing health system sustainability Professional competencies and performance were increased. in the work environment had not been directly identified, which The Efficiency Program was implemented. would require efficient processes and increased services, Use of technologies was rationalized through more consistent application of the technologies and professional skills. clinical-epidemiological approach, which improved the doctor-patient relationship and service quality. Health service and teaching site accreditation processes were instituted. 4. Primary level of The process of improving PHC was not continuous, and Comprehensive development of the Family Doctor and Nurse Program was health care guaranteeing the resolution and efficiency of more than 70% of increased as the key element of this process. primary care problems was required. This was reflected at all Advanced technologies were introduced that helped bring specialized services other levels of care. closer to PHC. A computerization strategy was initiated to sustain designated eHealth areas. 5. Secondary level of Problems with infrastructure and equipment in hospital services Medical technologies were introduced in secondary services in accordance with health care that required continuous improvement to increase their capacity the health situation. for resolution in controlling the principal causes of death and The referral and counter-referral system between primary and secondary care other health problems, complementing actions at the primary was improved. care level 6. Demographic The SNS was not fully prepared to confront: Attention to demographic changes related to preconception risks and care for and climate changes • low fertility and birth rates infertile couples was increased. in Cuba • population aging New aspects in elder care were included to improve quality of life through • impacts of climate change application of new and methods and models of care, according to the culture and needs of this population. Collaboration with other institutions on projects for confronting climate change and its consequences Note: SNS: ; PHC: primary health care. Source: Created by the authors.

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Overview Morales Ojeda et al. • Transformations in the health system in Cuba

CONCLUSIONS continues to develop, since everything of human capital must continue. The must contribute to the sustainability of capacity of systems that capture, pro- In accordance with the updating of the the SNS. As a result, efficiency in service cess, analyze and efficiently dissemi- Cuban economic model, transformation of provision has increased and professional nate information in order to monitor, the health sector has made it possible to re- performance has improved. evaluate and, eventually, measure the define functions and reclassify different After implementation of these trans- impact of these transformations, needs health system structures and units at all formations, it became clear that sustain- improvement. three levels of care, as well as adjust human ability of the SNS could be increased, resource staffing needs, all of which consti- while still taking into consideration the Acknowledgements. The authors tute an important organizational step. socioeconomic, cultural and environ- thank the Cuban Ministry of Public The proposals for reorganizing, re- mental factors that pose real challenges Health and representatives of the Pan gionalizing and downsizing services to development, such as the high rate of American Health Organization / World were applied nationwide once institu- population aging, low birth rate, and im- Health Organization (PAHO/WHO) for tions were certified. This led to contin- pact of climate change. their valuable contributions to the criti- ued improvement in Cuban population cal analysis and opinions expressed in health indicators, as health care activity RECOMMENDATIONS this article. expanded, from service provision to pro- motion and prevention, including treat- Health system transformations Conflicts of interest. None declared. ment and rehabilitation. The entire should be streamlined to respond to transformation process occurred simul- ­socio-demographic changes in Cuba. Disclaimer. Authors hold sole respon­ taneously and at lower cost. Its objectives The cost-cutting process must be main- sibility for the views expressed in the have been met with improved process tained in order to increase the system’s manuscript, which may not necessarily and outcome indicators and high quality sustainability, and the introduction and reflect the opinion or policy of the RPSP/ of care indexes that must be maintained. widespread use of technology sustain- PAJPH or the Pan American Health The system generates more income and ing eHealth, training and development ­Organization (PAHO).

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RESUMEN En Cuba, el acceso y la cobertura universales de salud descansan sobre tres principios clave: la salud como derecho humano, la equidad y la solidaridad. Aunque muchos de Transformaciones en el los indicadores de salud cubanos están entre los mejores de la Región de las Américas, en el 2011 se decidió reorganizar los servicios de salud, a tono con el proceso de actu- sistema de salud en Cuba y alización del modelo económico y social cubano que transcurría en todos los sectores estrategias actuales para su del país. Para ello, se diseñó un proyecto de investigación-acción que abarcó el diag- consolidación y nóstico de la situación, la implementación de los cambios y la evaluación de los resul- tados, en varias etapas. Como resultado, se racionalizaron los recursos humanos con sostenibilidad una reducción de más de 150 000 plazas no vinculadas directamente a la atención del paciente, se aligeraron las estructuras de dirección en 57 municipios, se compactaron 46 policlínicos, se optimizó el Programa del Médico y la Enfermera de la Familia con la proyección comunitaria de 20 especialidades, se reorganizó la docencia y se reor- denaron los programas de cooperación médica internacional. Estos cambios han con- tribuido a mejorar la sostenibilidad del Sistema Nacional de Salud y su desempeño: aumento en el número de consultas en el nivel primario (19,3%) y estomatológicas (56,6%), reducción del número de consultas en cuerpo de guardia (16,1%), aumento del número de pacientes intervenidos quirúr- gicamente (12,1%), incremento del número de proyectos de investigación (300%) y crecimiento en el número de estudi- antes de Medicina (55,7%), entre otros. El proyecto de transformaciones en la salud emprendido en Cuba continúa.

Palabras clave Sistemas de salud; indicadores de sostenibilidad; eficiencia; Cuba.

Rev Panam Salud Publica 42, 2018 7 Morales Ojeda et al. Transformations in the health system in Cuba

Overview Morales Ojeda et al. • Transformations in the health system in Cuba

RESUMO Em Cuba, o acesso universal e a cobertura de saúde dependem de três princípios fun- damentais: a saúde como direito humano, equidade e solidariedade. Embora muitos Transformações no sistema dos indicadores de saúde cubanos estejam entre os melhores da Região das Americas, em 2011 foi decidido reorganizar os serviços de saúde, de acordo com o processo de de saúde em Cuba e atualização do modelo econômico e social cubano ocorrido em todos os setores do estratégias atuais para sua país. Para o efeito, foi elaborado um projeto de pesquisa-ação, que incluiu o diag- consolidação e nóstico da situação, a implementação das mudanças e a avaliação dos resultados, em várias etapas. Como resultado, os recursos humanos foram racionalizados com uma sustentabilidade redução de mais de 150 000 postos não diretamente ligados ao atendimento ao paci- ente, as estruturas de manejo foram reduzidas em 57 municípios, 46 policlínicas foram compactadas, o Programa Médico e Enfermeiro da Familia foi otimizado com a pro- jeção para a comunidade de 20 especialidades, o ensino foi reorganizado, e os pro- gramas internacionais de cooperação médica foram reordenados. Essas mudanças contribuíram para melhorar a sustentabilidade do Sistema Nacional de Saúde e seu desempenho: aumento do número de consultas no nível primário (19,3%) e odontolo- gia (56,6%), redução do número de consultas na emergência (16,1%), aumento do número de pacientes tratados cirurgicamente (12,1%), aumento do número de projetos de pesquisa (300%) e crescimento do número de estudantes de medicina (55,7%), entre outros. O projeto de transformação em saúde realizado em Cuba continua.

Palavras-chave Sistemas de saúde; indicadores de sustentabilidade; eficiência; Cuba.

8 Rev Panam Salud Publica 42, 2018