Implementation of Strategies Relevant to

National Health Care and Specific Centers in the

Emerging World:

Implementation of Strategies Relevant to

National Health Care and Specific Centers in the

Emerging World: The View of Central American and Caribbean CountriesThe View of Central American and Caribbean Countries

Raúl Herrera-Valdés, MD, PhDInstitute of NephrologyHavana – Cuba

Raúl Herrera-Valdés, MD, PhDInstitute of NephrologyHavana – Cuba

Context of the Americas

Health inequalities reflect

socio-economic structural inequalities

Health inequalities reflect

socio-economic structural inequalities

Values

Equity – Excellence – Respect – Integrity

Mission:

Promote equity in health, combat disease, and improve quality of life and life expectancy in the region.

34 countries

Population: 76 million

Poverty: + 40%

Countryside: 45%

34 countries

Population: 76 million

Poverty: + 40%

Countryside: 45%

Wealthiest 20%

INCOME

Poorest 20%

16 times

Central American and Caribbean Countries

Segregation

Marginalization

Stress

Extreme living conditions

Education

Information

Health Services

DiseasePoverty

+

-

-

-

+

Illiteracy

Central America5%- 36%

Central America5%- 36%

Latin Caribbean:4%- 51%Latin Caribbean:4%- 51%

Non- Latin Caribbean:2%- 19%Non- Latin Caribbean:2%- 19%

Infant mortality rate: > 30 x 1,000 l.b. Life expectancy: < 70 years

Infectious diseases Tendency Aging

Non-Comm. Chr. Diseases

Communicable Diseases Non- Communicable

Morbidity – Mortality Morbidity – Mortality

Health Picture

Near-poor population: Obesity epidemic

Diabetes: 6% - 8%

Hypertension: 8% - 30%

IncreasingPrevalence

Ethnic Composition / Socio-economic

conditions

Ethnic Composition / Socio-economic

conditions

Health Picture: Risk factors for Renal Disease

Incidence Prevalence

289

6356 50

32 205

0

50

100

150

200

250

300

Pu

ert

o R

ico

Co

sta

Ric

a

Cu

ba

Pan

amá

R. D

om

inic

ana

Sal

vad

or

Ho

nd

ura

s

Gu

ate

mal

a

Nic

arag

ua

Reg. L.A. de Diálisis y Trasplante.2001

Patients/MH

País

830

103 8960 42 38 30 23

0

100

200

300

400

500

600

700

800

900

Pu

ert

o R

ico

Pan

amá

Cu

ba

R. D

om

inic

ana

Sal

vad

or

C. R

ica

Ho

nd

ura

s

Gu

ate

mal

a

Nic

arag

ua

Patients/MH

País

Incidence & Prevalence of ESRD in RRT

Situation

Not enough professionals trained to meet health care needs.

Existing resources are inequitably distributed, concentrated mainly

in the big cities.

Low salaries.

Internal and external migration.

Imbalance in the composition of healthcare workforce.

Minimal development of information resources.

Oriented towards curative care rather than prevention.

Human Resources

Central America6.2 to 15 per 10,000 inh.

Central America6.2 to 15 per 10,000 inh.

Nephrologists:

• < 20 p.m.p in vast majority of countries

• None in several non-Latin Caribbean nations

Nephrologists:

• < 20 p.m.p in vast majority of countries

• None in several non-Latin Caribbean nations

Physicians

Non-Latin Caribbean1.5 to 21.5 per 10,000 inh.

Non-Latin Caribbean1.5 to 21.5 per 10,000 inh.

Latin Caribbean2.5 to 58.2 per 10,000 inh.

Latin Caribbean2.5 to 58.2 per 10,000 inh.

Central

America

Latin

Caribbean

Non–Latin

Caribbean

Hospitals per 100 000 inhab. 1.5 2.1 3.0

Hospital beds per 1 000 inhab. 1.4 2.8 3.6

Out-patient facilities per 10 000 inhab. 2.5 5.4 1.6

Health Care Infrastructure

No preventive strategies in place for chronic renal insufficiency

No institution which acts as a regional reference center

No preventive strategies in place for chronic renal insufficiency

No institution which acts as a regional reference center

In the Central American and Caribbean context, Cuba

shares many of the economic limitations of other

countries, and at the same time, has advanced along the

route of equity described by PAHO as critical to

improving health in the region, as one of the countries

with the least social disparity.

In the Central American and Caribbean context, Cuba

shares many of the economic limitations of other

countries, and at the same time, has advanced along the

route of equity described by PAHO as critical to

improving health in the region, as one of the countries

with the least social disparity.

The health system is universal, public, and free-of-

charge, with full coverage of the population.

Cuba’s resource-scarce environment, coupled with

public health principles, has reinforced a

commitment to primary health care and prevention

as the centerpiece of the system.

Cuba’s National Health System

Total population 11.251 million

Percent urban population 75.4%

Literacy rate 96.2%

Average educational level 9th grade

Infant mortality rate ( x 1000 live births) 6.5

Life expentancy 76.15

Physicians per 10,000 population 59.6

Total number of family physicians 31,059

Population served by family physicians 99.2%

Hospital beds ( x1000 population) 5.0

Health Care Situation in Cuba. Basic Indicators 2002

International Cooperation in Health (2003)

Cuban health professionals

serving abroad:14,691 in 64

countries

Cuban health professionals

serving abroad:14,691 in 64

countries

International medical students in Cuba:

9,023 from 83 countries

International medical students in Cuba:

9,023 from 83 countries

TRANSPLANTATION

PRIMARY

PREVENTION

SECONDARY

PREVENTION

TERTIARY

PREVENTION

HEALTHY

POPULATION AND

RISK GROUPS

HEALTHY

POPULATION AND

RISK GROUPS

CHRONIC RENAL

INSUFFICIENCY

CHRONIC RENAL

DISEASES

CHRONIC RENAL

INSUFFICIENCY

CHRONIC RENAL

DISEASES

ESRDESRD

CLINICAL

NEPHROLOGY

PRIMARY

CARE: FAMILY

DOCTORS

DIALYSIS

Cuban’s National Chronic Renal Disease Program:

TRANSPLANTATION CENTERS: 9

TISSUE TYPING LABORATORIES: 5

ORGAN PROCUREMENT CENTERS: 33NEPHROLOGISTS: 385

Adult: 214

Pediatric: 66

Residents: 105

100% Free Health Care

PHYSICIANS: 67,000

FAMILY DOCTORS: 31,000

NATIONAL COORDINATING CENTER

NEPHROLOGY SERVICES: 34

OPENING: 13

Cuban’s National Chronic Renal Disease Program:Organization and Resources

National Chronic Renal Disease Program: Basic Indicators

HD Incidence

0

200

400

600

800

1000

1200

2001 2002 2003

97.1

1088

CRF patients

CRI Patients in follow-up *

HD Prevalence Trasplants Incidence

0

0,2

0,40,6

0,8

1

1993

1994

1995

1996

1997

1998

1999

2000

2001

2002

2003

YEAR

RA

TE

PM

P

0

20

40

60

80

100

120

140

1982

1983

1984

1985

1986

1987

1988

1989

1990

1991

1992

1993

1994

1995

1996

1997

1997

1999

2000

2001

2002

2003

RA

TE

PM

P

YEAR

YEAR

RA

TE

PM

P

0

4

8

12

16

20

24

1982

1983

1984

1985

1986

1987

1988

1989

1990

1991

1992

1993

1994

1995

1996

1997

1998

1999

2000

2001

2002

2003 YEA

R

RA

TE

PM

P

880

13419.5

Transplantation

PATIENT AND GRAFT SURVIVAL MORBIDITY SEPSIS REJECTION

Dialysis

MORTALITY MORBIDITY

Ca-P METABOLISM CONTROL SEPSIS HEART DISEASE ANEMIA NUTRITION ADEQUATE DIALYSIS

ESRD

CRI

CRD

EARLY REPLACEMENT THERAPY VASCULAR ACCESS HB VACCINATION SYSTEMIC DETERIORATION CONTROL OF PROGRESSION RISK FACTORS ACTIVE FOLLOW-UP CAUSAL TREATMENT EARLY DETECTION ACTIVE SCREENING ADEQUATE TREATMENT EARLY DIAGNOSIS

Population´s

Epidemiological

Characterístics

CONTROL OF CAUSES AND RISK ACTORS IDENTIFICATION OF RISK FACTOR GROUPS POSITIVE LIFESTYLES HEALTH PROMOTION HEALTH EDUCATION

Tertiary

Prevention

Tertiary

Prevention

Secondary

Prevention

Secondary

Prevention

Primary

Prevention

Primary

Prevention

QUALITY

OF

LIFE

Prevention Program: Specific Objectives

47 Nephrology Services (Regions)

385 Nephrologists

444 Community Polyclinics ( Health Areas)

31 000 Family Physicians

99.2% Population

National CRD Program: Implementation of Prevention Strategies

1 Municipal Health Service

1 Nephrology Service

5 Nephrologists

3 Community Polyclinics-Health Areas

105 Family Physicians

81,000 Persons

Objective: Epidemiological follow-up for chronic renal diseases in total population by studying family units over time.

Isle of YouthIsle of Youth

National CRD Program: Epidemiological Laboratory

Total population

Phases of the project Actions Outcomes

Screening • Dipstick for proteinuria• Short questionnaire

CRD Diagnosisconfirmation.Etiology.

Case-control

study

Follow-up study

Intervention

Surveillance

Proteinuria (+)

Proteinuria (-)

CRD Cases

Total Cases

Cohort

Therapeutic intervention

Proteinuria (-)

Dipstick for microalbuminuria in risk groups

Microalbuminuria (+)

Longer questionnaire Laboratory test Physical exam

Laboratory test Physical exam

Intervention

Microalbuminuria (-)

Surveillance system

Control group

Sample

Cohort

Preventive actions

CRD Prevalence

• CRD Incidence• CRD etiological risk factors• CRD progression

Identify risk factors for CRD

• Risk reduction• CRD control

• Morbidity patterns• Mortality tendencies• Distribution dialysis and kidney transplant

Community epidemiological laboratory for study of chronic renal disease (CRD). Isle of Youth project. Cuba.

• Cuban School of Nephrology

• National Reference Center

• National Coordinating Center

Institute of Nephrology

National Chronic Renal Disease

Program

Raising the Level of Medical

Care

Training Specialized Human

Resources

Developing Scientific Research

• Prevention• Clinical Nephrology• Dialysis• Transplantation

• Management• Telenephrology• Epidemiological Laboratory

National CRD Program: National Coordinating Center

National Institute of Nephrology

National Network of Nephrology Services.

National Health System’s National Telematics Network (INFOMED)

Second Opinion Services.

Teleconferencing.

Distance learning.

Epidemiological control (PC).

o Selection of donor-recipient pairs.

o CRI and Dialysis.

o Statistics.

XML Web services

National CRD Program: Telenephrology Network

We place this modest Cuban experience at the

disposal of our Central American and Caribbean

colleagues and of nephrology societies

internationally, inviting them to share with us

their observations, reflections and expertise.

We place this modest Cuban experience at the

disposal of our Central American and Caribbean

colleagues and of nephrology societies

internationally, inviting them to share with us

their observations, reflections and expertise.

Conclusions

To prevent chronic renal disease in Central America and the Caribbean, we must:

• Reduce poverty• Increase equity• Improve nutrition• Advance education• Develop health services• Formulate prevention policies• Create reference institutions

To prevent chronic renal disease in Central America and the Caribbean, we must:

• Reduce poverty• Increase equity• Improve nutrition• Advance education• Develop health services• Formulate prevention policies• Create reference institutions

“These are dangerous times for the well-being of the world. In many regions, some of the most formidable enemies of health

are joining forces with the allies of poverty to impose a double burden of disease,

disability and premature death on many millions of people. It is time for us to close

ranks against this growing threat. “

“These are dangerous times for the well-being of the world. In many regions, some of the most formidable enemies of health

are joining forces with the allies of poverty to impose a double burden of disease,

disability and premature death on many millions of people. It is time for us to close

ranks against this growing threat. “

Gro Harlem Bruntland M.D.Director – General

World Health Organization

Gro Harlem Bruntland M.D.Director – General

World Health OrganizationThe World Health Report. WHO. 2002The World Health Report. WHO. 2002

Thank YouThank You