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To address some of the problems about health and the links between health and society in today’s Cuba, the journal Temas invited a group of specialists who devoted October’s Ultimo Jueves panel to the topic «Primary health care: updating the model?»
“It is not the first time that we cover this subject. For example, in 2006, we dedicated an issue of the journal to health and society, including a long interview with Dr. Francisco Rojas, a member of the journal’s editorial board and close collaborator… We want to dedicate today’s session especially to him,» Temas director and usual Ultimo Jueves panel moderator Rafael Hernández remarked. “Temas is a journal of Social Sciences and cultural studies, but we understand that medical health care and science are part of it.»
Silvia Martínez, an authority on Public Health topics and professor emeritus of the National School of Public Health; Dr. Karen Valdés, specialist in Comprehensive General and Internal Medicine; José Acosta, second degree specialist in Public Health and chair of the Department of Bioethics of the University of Havana; Jesús Menéndez, a specialist in Gerontology and Geriatrics and holder of a Master’s Degree in Public Health and Aging who has been a regular contributor to Temas; and Reynaldo Taladrid, in his capacity as user of primary health care, made up the panel that for just over two hours shared their concerns, experiences and views about the past, present and potential of primary health care in the country.
In the first round of interventions, one of the most interesting answers to the question, «How would you describe Primary Health Care in Cuba to an alien, that is, to someone who has not experienced it or can’t explain what it is about?», was that of Professor Silvia Martínez, who stressed the need to explain very clearly «to the Cuban population, to ordinary people, to the authorities, to all kinds of persons, the meaning of primary health care.”
As part of her explanation, she highlighted the importance of the document known as the «Declaration of Alma Ata»—signed in 1978 and usually presented as being exclusively related to medicine and to the doctor-patient relationship—the development of primary health care systems in the world. “You see,” she said, “I believe it is a political, economic and cultural document by no means related only to health care.”
She summarized in a few sentences her opinion about what Primary Health Care (PHC) is about: «PHC is a philosophy, a strategy and a new level of medical care; that is very clear. Why a philosophy? Because if you expect to provide primary care and yet you are not very clear about the concept of health, seen not as the opposite of disease, you are not providing any PHC care, nor have you understood its meaning. If the system is not adjusted to PHC, you are not providing any; if the system is not modified and reorganized, you are not providing PHC. And the third and most complicated aspect, the community has to be there, together with the medical team members.”
On her end, Dr. Karen Valdés spoke from her own experience as a specialist in Comprehensive General Medicine. She said that a typical feature of PHC in Cuba is its universal character, since there are family doctor clinics from one end of the country to the other. Although it is oriented toward the community by its very concept, «in practice, PHC is more focused on individual problems than it is on an overall vision of the community». Besides, somehow anticipating the second question for the panel, she pointed out that nowadays the Cuban PHC model «is not very flexible, rather less and less flexible and more and more distant from the reality of life in Cuba, as its intentions and desired parameters and indicators are not a reflection of what happens on a daily basis».
To these views, Professor José Acosta mentioned what he considers as the main pillars of the PHC concept: universality as its chief feature. «As few others in the world, Cuba’s PHC reaches more than 90% of the population». As an example of its effectiveness, he mentioned its relevant role during the confrontation with the COVID-19 pandemic: «In the present economic situation, if there had not been a health care system in Cuba like the one we have, the outcome would have been quite different». A noticeable detail, however: despite the fact that preventive medicine is also one of PHC’s cornerstones, this is still a major unresolved matter, as it places more emphasis on disease prevention than on health promotion. In Professor Acosta’s opinion, this is essential for PHC to achieve its full potential. He also defined the persons of the family doctor and nurse as pivotal to the health support networks and their cross-sectional character. «(…) if the physician works, the social networks and their cross-sectional impact will work too».
As another characteristic of PHC, Jesús Menéndez mentioned the international cooperation that Cuba has developed for decades, with results in the application of the concept of PHC that has been extended to other countries, specifically in the so-called Third World.
In the midst of the criticism, catharsis and limitations that may affect the performance of the family doctor and nurse system, Menéndez urged to keep in mind that “the health care system is a reflection of the situation of the country».
These opinions led the panel to answer the second question, related to the identification of the current problems facing PHC.
Menéndez himself answered that one: «The health care service is like a two-year-old child for whom you buy some clothes that fit him perfectly, but then the child outgrows those garments». He agreed with Reynaldo Taladrid in that the issue of motivation, or rather the lack thereof, is one major problem these days. «No one wants to be a family doctor, which has to do with a public image that has emerged in people’s mind about how capable of solving people’s health problems you can be.»
Other issues that he underlined are related to the same problems that the country is coping with, namely the economic woes and the migration of health workers.
José Acosta, on the other hand, pointed out the deviations from the original idea as another problem. «When Fidel conceived this plan, he saw it as a guardian of health care, and more efforts are devoted to cure diseases than to promote health». He also added that the medical staff turns to PHC very rarely, if at all, which also undermines the model.
Karen agreed with the comments by several panelists about the bureaucratization of the system, but called their attention to the fact that it is not only about the amount of paperwork that doctor’s clinics must deal with every day, but also «the number of chiefs and deputy chiefs in each municipal sector versus the fewer and fewer number of those who provide health care. Of course, this overburdens the medical staff, which became noticeable during the pandemic…»
Another observation she made had to do with the centralization of the concept, direction and implementation of health programs. “Those programs come from the Ministry of Health, just like that, in a vertical manner, and this gives the health system very little margin for possible initiative and management activity”. Little attention is paid to territorial differences and to the various needs that may arise in each municipality.
Based on the remarks of the panelists and her own teaching experience, Professor Silvia Martínez stated that, “this country suffers from an appalling medical-centrism, and then we say that the system is built on primary care and this model, in turn, on an entity, an axis that sets it in motion. Namely, a professional practitioner of comprehensive general medicine, albeit others are also involved». However, that professional wonders about what is missing, about the institutional commitment of other sectors, about what is communicated to the population and about the culture of health that people in Cuba must have. The lack of consistent answers to these questions is also an expression of the problems facing the system, not PHC, which by definition is not a living entity or an organization but a process. It is for politicians, social actors, representatives of other sectors, health care professionals, etc. to answer and solve these questions… This defies understanding».
When the time came to give the floor to the public, there were many and diverse comments. Standing out among them, for example, was a remark by Professor Benito Pérez Masa, who referred to the history of PHC’s accomplishments in Cuba to state that, «we managed to establish a model of worldwide renown, except that we failed to realize it». What happened, he explained, is that the model was the object of many modifications and no corrections. It is necessary to work in the system in order to understand the day-to-day complexities of primary care and make consistent decisions, he added. «I was director of a polyclinic and I learned from the staff there what it is like to be a family doctor».
Carlos García Pleyán emphasized that the Cuban health care system is under very strong internal and external pressures, whereas others in the audience were of the opinion that it is necessary to update and improve the ways to develop our PHC strategy. Why not begin to reduce the role of doctors in hospital management, for example, asked Reinaldo Taladrid to introduce the topic of the outsourcing of services within the health care system, an issue that prompted controversy between the audience and some of the panelists.
Traductor: Jesus Bran