The report evaluates the evolution of Cuban health care systems. The main goal is to evaluate the sustainability of Cuban model in view of the ageing population, increased chronic disease, ever-increase cost and technology and the demand on the entire healthcare system. Cuba is considered the best candidate for the study because it has distinct health care system that is dynamic and evolving. For example, beginning in the 1980s, a group of Cuban health professionals began to introduce the economy’s tools in the country to calculate how much was invested in relation to various conditions, as well as the day / patient cost in certain services and institutions. hospital. Currently, new notions have been acquired in this sub-section of knowledge and its scope of application has been expanded, whose greater effectiveness is exercised in the prevention of diseases. Health demands grow steadily and with it their supply (supplies for the restoration of health); but since resources are relatively scarce to respond to these requests, their rational use is imposed. In the guidelines of the economic and social policy of the Party and the Revolution approved in 2011 and ratified in 2016, emphasizes the need to achieve maximum efficiency in the use of resources and human capital in health, since Only in this way will it be possible to achieve greater coverage, quality and sustainability of the services in that sector. The report is divided into three main sections. The first section will cover the guiding principles of value-based healthcare reform. The second section will focus on the key findings. The key findings will be based on a number of health care economic elements. Key elements of health care economics that will be at the heart of the report include market concentration, elasticity of the supply chain, elasticity of demand, the need for volume, population demographics, risk transfer, regulatory authority and executing the health reform framework. Using comparative approach, the report will attempt to relate the nature of health care system at different years. At the end of the report a number recommendations on what Cuba can do in order to ensure that its health care system is effective would be highlighted.
The guiding principles of value-based healthcare reform is based on the right to health as a core value, equity and solidarity (Carberry, Landman, Xie & Feeley 2015). The right to health is recognized in the constitution of 19 countries in the region and guides the development of strategies, plans, and health and social protection policies. However, the differences shown by the limited disaggregated information (by characteristics of population groups) on access and health outcomes reveal notable differences in the realization of this right for all people. Hence, the search for equity is a consubstantial value to the right to health. Solidarity is considered as a guiding value of social protection. This value, according to Matthey (2010) represents the intentional effort of society so that people in conditions of greater vulnerability improve their situation through the redistribution of wealth from the most favored. This implies that the healthy are in solidarity with the sick, the young, with the elderly, and the rich with the poor. This solidarity is concretized through the establishment of financing mechanisms that distribute risk and prevent impoverishment due to unexpected health expenditures. In fact, the value-based healthcare reform emerged due to 2 fundamental issues. The first issue is the need to contain costs. When health economy was created in United states, one of the concerns was rising cost. By then, rapid growth of costs was beginning to be experienced at the expense of advances in medical technology and specialization in health services, so that expenditures in the Sector were increasing at an accelerated rate and it was necessary to look for methods that would lead to greater efficiency in their employment (Matthey 2010). In this regard, in a periodical publication on applied economics studies cited: “The budgetary pressure suffered by healthcare systems is greater than ever, with less money and more patients to treat (due to factors such as the aging of the population, the high prices of new technology, the higher expectations of patients and others), health systems need products that are profitable (Porter & Teisberg, 2007). This tendency persists and is consubstantial with the increase in health demands, motivated by the production of various social transitions (demographic, epidemiological, ecological, political, economic and educational), which imply the prolongation of life expectancy, the care of the terminally ill, the increase in chronic diseases and the care they require, as well as the incorporation of novel technological advances in the field, whose conjunction is considered the main cause of the rising costs of health care (Porter, 2010).
The other principle is equity problems. The aim for adopting value-based healthcare reform is to seek greater coverage of health services, since financial resources were limited in relation to ever-increasing health requirements. Health economics has been developed in many countries as a means to respond to their different health systems; hence the statement that “… the prospective evolution of this discipline will continue to create useful tools in terms of being applied to improve the quality of health care and equity in the access of its citizens (Porter and Kaplan, 2015). In Cuba, with the exception of some previous works, the take-off of the health economy dates back to 1980, when a group of professionals from the sector, mostly doctors, began to apply economic techniques and procedures to determine the costs generated by certain conditions, which could be defined as the disease’s economy, since it allowed estimating the amount by type of disease, by consultation, by day / patient and by other indicators. However, since the true economy of health seeks efficiency in the use of resources from the health-disease process, this makes the primary level of attention an essential aspect for the achievement of that objective. Borowy (2011) revealed that since its inception, the Cuban Revolution focused its interest on preventive medicine, although continuing to deal with the serious health problems that exist as a result of the poor health system that prevailed before 1959, among which were communicable diseases such as polio, smallpox, tetanus. and others; all eradicated in the nation. These precautionary actions have saved a lot of resources by reducing the number of sick or infected people and allocating them to the application of other programs, raising the quality of services or expanding health coverage (Antoni 2014). In the country, free access to health care has been endorsed as a right of all inhabitants, which has made it somehow a public good, since people demand and consume it without taking into account their costs. , so this market is then inefficient; however, the free health services are for the citizen, not for society, represented by the State (Porter and Lee, 2015). Likewise, the resources (financial or otherwise) dedicated to this relevant activity implicitly have an opportunity cost, because to fully carry it out, it is necessary to stop investing in other tasks or commitments. On the other hand, to meet the demands of health in terms of diagnosis, treatment and rehabilitation of patients requires the use of increasingly expensive health technology, which entails that the expenses for this concept increase considerably every day (Porter and Lee, 2015). In Cuba there is the same situation, so that the fact of having made great advances in public health with scarce resources, makes the efficiency in the Sector continue to be imperative; However, to speak about health efficiency does not mean in any way to diminish the necessary means to provide the required assistance, but to eliminate superfluous expenses, the amount of which could be destined to the development of other sanitary actions, aimed at improving coverage or increasing quality from service. However, to provide a more precise idea about this problem, some figures concerning the execution of health expenditures from 2009 to 2013 in the country, whose amount was 4 899 800 560 million pesos on average in the five-year period, suffice. per capita average per inhabitant of 432.39 pesos. The figure below summarizes the health expenditures in Cuba
Market concentration
Since the conception of the new system, primary health care has been registered as the first priority in terms of reform and as the main strategy for the development of the system. It was the creation of the rural social medical service and the consequent extension of coverage, by taking a significant number of physicians first to the rural areas that were previously lacking in service, followed by nurses and dentists one year later. For this extension did not resort to paramedics, such as the so-called feltcher, widely used in Eastern Europe, or midwives (midwives). It was an early decision to achieve full coverage of the needs of primary care with doctors, despite the acute shortage of them that caused a migratory movement, stimulated from the outside by political forces hostile to the country and its political program (Verissimo, & Currie, 2013). In the city, the transformation of existing expressions of primary care up to 1960 began: the relief homes, for the care of certain emergencies, the children’s clinics (program parallel to those of the Ministry of Health) and the health units, defined to carry out epidemiological control and hygiene of the physical environment. These institutions were integrated into a health center that we call a polyclinic. These evolved and were the object of reform actions, such as those that gave rise to the successive denominations of integral polyclinics (by strengthening their promotive and preventive actions) and community polyclinics (by giving greater force to the care of families and the close coordination of the programs with the communities) (Verissimo, & Currie, 2013).
An elastic supply chain is the ability of a supply chain to maintain a continuous supply and quickly return to normal supply when it partially fails. Cuban health care supply chain is elastic. This is attributable to the fact that it is maintained by the national government. The Cuban government and state through its Law 41, approved in July of 1983, guarantees Health to the entire population, having as premise that “health is a right of all individuals and a responsibility of the state”, being the Ministry of Public Health (MINSAP) responsible for executing it in its network of services organized in a Health System, which has the characteristics of being unique, integral and regionalized (Sweig, 2009). To fulfill this mission, the country has made great efforts guaranteeing the required budget (Keck & Reed 2012). Expenditure per inhabitant and the percentage of Gross Domestic Product dedicated to Health have increased systematically, in 1998 it represented 5.5% while in Latin America it was only 2.5 and despite the limitations imposed by the blockade, the national health system has continued to improve its health indicators, comparable today even with developed countries. The Cuban health care system guarantees access to comprehensive health services that are provided in ambulatory and hospital units (Keck & Reed 2012). The primary level must provide solutions for approximately 80% of the population’s health problems and offer health promotion and protection actions. Although these activities can be carried out in any unit of the SNS, they are mainly provided in polyclinics and family doctor’s offices. These units correspond, essentially, with units of municipal subordination (Kadetz & Delgado, 2010).
Elastic demand means that when the price of goods or services subject to change, the market for the product or service demand has also undergone significant changes in the situation. In Cuba, since the price and cost is managed by central government, the elasticity of demand is low. Schneider, Kallis & Martinez-Alier (2010) observed that the National Health System of Cuba has a set of institutions that have the obligation to guarantee free and equal access to all health programs and services and provide coverage to 100% of the population (William 2015). Such access is not determined by the level of income, occupation in the economy or membership of a public or private insurance system
In recent decades, the health indicators of the Cuban population have shown a gradual and constant improvement, up to current levels. In the first years of the nineties this progress was interrupted by the economic crisis that affected the country, the most serious in its history, accentuated by the economic blockade imposed by the Government of the United States of America and the disappearance of the group of countries of centrally directed economy, with which we supported almost all of our economic relations (Verissimo, & Currie, 2013). From this situation we have recovered to a great extent (Ullman, 2008). The high level of institutionalization of the sector, the wide degree of coverage of the services, the rates reached in preventive care, the qualification of the health personnel, the mysticism in its delivery to the daily work and the national collective effort, have made it possible for important health indicators Cuba remains among the countries with the best situation among those of the Third World and, even, that can compare its results with those of the highest level of economic and technological development (Verissimo, & Currie, 2013). The demographic transition has been accompanied by the consequent epidemiological transition, which is characterized by a predominance of chronic noncommunicable diseases as causes of morbidity and mortality. Heart disease, malignant tumors and cerebrovascular disease have been the three leading causes of death in recent decades in the general population, accounting for 64% of all deaths in 2009 (Eusebio 2011).
The aging of the population is a remarkable fact that has been accentuated in the last decade. In 2000, 13% of the population turned 60 or more. Changes in morbidity and mortality profiles, increased immunological coverage, low infant mortality rates and, above all, low fertility have influenced this: in 1985 the fertility rate per 1,000 women of reproductive age it was 66.1 and in 2000 it was 47.3. 4 The crude reproduction rate has been below the replacement level during the past decade (0.72 children per woman in the middle of the mentioned period) (Verissimo, & Currie, 2013). Aging of the population is associated with the main burden of morbidity and mortality that affects the population. For three diseases, there are programs of dispensary care, as a result of the frequency of these and the need for adequate control to ensure a minimum of complications and a satisfactory quality of life. These and their respective prevalences, calculated on the number of patients dispensed, are diabetes mellitus (23.6 per 1000 inhabitants), arterial hypertension (155.6 per 1000 inhabitants) and bronchial asthma (77.1 per 1). 000 inhabitants) (Verissimo, & Currie, 2013).
In Cuba, the State regulates, finances and provides health services. These services operate under the principle that health is an inalienable social right, which defines the Cuban health system as a true National Health System (NHS). The Ministry of Public Health (MINSAP) is the governing body of the SNS and, therefore, responsible for directing, executing and controlling the application of State and Government policies in matters of public health, development of medical sciences and medical-pharmaceutical industry (Johnson 2012).
The Cuban health system has three administrative levels (national, provincial and municipal) and four levels of services (national, provincial, municipal and sector). The provincial and municipal health directorates are administratively subordinated to the provincial and municipal assemblies of the local government agencies, from which they receive the budget, supplies, labor force and maintenance. Each province forms local health systems in its municipalities (Johnson 2012).
Medical assistance is provided through a network of 219 hospitals, 13 research institutes, 498 polyclinics and a contingent of family doctors located in communities, work centers and educational centers. There are also 127 medical posts, 26 blood banks and three mineral-medicinal spas. Attention is also given in 158 stomatological clinics, 156 nursing homes, 338 maternity homes and 35 disabled homes for different situations and ages two (Johnson 2012).
The benefit focuses on primary health care (PHC) based on the model of the family doctor and nurse (MEF). To develop this approach, three elements were taken into account: the tendency towards super specialization of medical practice, changes in the pattern of morbidity and mortality with an increase in chronic noncommunicable diseases and the need to promote healthier lifestyles in the population (Johnson 2012). The MEF model guarantees greater accessibility to PHC services and has the general objective of improving the health status of the population. To achieve this objective, it applies an integral approach that ranges from promotion to rehabilitation, using as an essential instrument the analysis of health situations (Bonde, Bossen & Danholt, 2017).
The values ??of the main health indicators in Cuba are among the best in the region and even so, it is necessary to improve them to face the new epidemiological challenges. Far from serving them individually, it is proposed to continue improving the work of the polyclinic, as the basis of the system, so that a growing number of health problems find a solution at that level of care, as well as strengthen its role in relation to the prevention and promotion (Porter, 2009). It is also necessary to establish and improve programs (with a multisectoral and interdisciplinary approach) aimed at changing the lifestyles of the population, fundamentally those associated with chronic noncommunicable diseases, which constitute the greatest challenge for the sector at present (Porter and Lee, 2013).
Despite the fact that Cuba has one of the best health care models, a number of recommendations can be made. One of the recommendations is that Cuba ought to engage community in health issues so as to manage the ever-rising cost of health (Feinberg, 2011). The participation of the community in the activities of the health sector is diverse and is considered as fundamental in the management of certain programs. The engagement should include education and awareness of the population in relation to the causes and solutions of the main health problems that affect them (acute diarrhea, parasitism, care for pregnant women and newborns), and a very active promotion and participation in the campaigns and programs for voluntary blood donation, for example. The community should participate actively in carrying out collective sanitation, vaccination and promotion of early diagnosis of various diseases. The training of personnel for the development of certain health actions within the community is inserted in the basic social organization should be encouraged (Porter, Pabo & Lee 2013).
Another recommendation is that Cuba should improve the services to ensure that all issues are addressed. It should be note that there are still services that still do not meet the demand of the population (Porter and Lee, 2013). For example, optics do not meet the needs and there are still delays in the delivery of lenses. There are also dissatisfactions with some stomatological services due to the insufficient production of dental prostheses (Scutchfield, Mays & Lurie 2009).
The last recommendation is the need for innovation to address issues related to the aging and non-communicable diseases. Considering the demographic situation of the country, characterized by a marked population aging, Integral Care Teams for the Elderly were created. For this population a plan of action and differentiated attention has been directed with the purpose of covering their biological, psychological and social needs, and raising their quality of life. The program prioritizes the improvement of work in primary care, and promotes the circles of grandparents and other non-institutional alternatives with community participation (Porter and Kaplan, 2015). Cuba ought to create other services and innovations apart from the Integrated Care Teams for Elderly.
References
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