cuban public health projections for...

GAVI HSS Application Form 2007

ANNEX 1

CUBAN PUBLIC HEALTH PROJECTIONS FOR 2015

Ministry of Public Health

Havana, February 2006

“Year of the Cuban Energy Revolution”

Design and editing: D.I. Yasmila Valdés Muratte

Editorial Ciencias Médicas, 2006

Editorial Ciencias Médicas

Centro Nacional de Información de Ciencias Médicas,

Calle I No. 202, esquina a Línea, Piso 11,

El Vedado, Plaza, Ciudad de La Habana, Cuba.

Telephones: (53 7) 55 3375 and (53 7) 832 5338

Email: [email protected]

© ISBN 959-212-185-9


Contents Forward 4 Introduction 6 Scenarios 6 Objectives 9 General Directives 10 Environmental Factors Associated with Health Problems 13 Behavioural Factors 13 Behavioural Directives 13 Chronic Noncommunicable Diseases and Other Health Impairments 14 Chronic Noncommunicable Diseases and Other Health Impairments - Directives 14 Oral Diseases 15 Oral Diseases - Directives 17 Communicable, Emerging, and Re-emerging Diseases 17 Communicable, Emerging, and Re-emerging Diseases - Directives 22 Disability 24 Disability – Directives 25 Special Environments 25 Special Environments - Directives 27 Special Groups 27 Special Groups - Directives 29 Areas of Key Results to be Implemented 30 Implementation, Control, and Evaluation Strategies 31


FOREWORD The progress made in Cuban public health is a testament to the achieved socioeconomic

development and the high degree of priority accorded by the Revolution and our people to human health and well-being.

In the nearly 50 years since the Revolution, the health status of the Cuban population has witnessed marked improvements, comparable to those of countries with a high degree of socioeconomic development. The just and equitable distribution of the Cuban health system has helped to mitigate the disparities between regions and human groups that are the legacy of capitalistic societies.

Cuba has fostered the development of impressive human capital of the highest scientific and technical calibre, following a comprehensive approach to the practice of medicine that puts society and people first, while underscoring the important values of solidarity and selfless dedication to the field of health.

The Cuban health system is comprised of an extensive network of high-tech, responsive services, providing high levels of coverage and access for our people: a role model, at international level, for national health systems.

Drawing on these cumulative strengths, our country is moving forward into a new era of political, economic, and social development.

The “Battle of Ideas”, the economic take-off currently under way, new trade relations, and the fight against corruption and crime have facilitated the development of new Revolution-inspired programs, which in addition to buttressing the political and ideological foundations of our society, provide our people with significant economic and social goods, including health and quality-of-life benefits.

We in the Cuban National Health System, from our corps of managers to out rank-and-file health workers, are aware of this new commitment acquired on behalf of the Revolution and the Cuban people. Consequently, it is our duty to refine the public health development strategy so that it may contribute to achieving the beautiful purposes pursued by the Revolution.

The cumulative body of experiences, the current health conditions, the level of human capital, the degree of development of the health system, and the country’s political, economic, and social scenarios provide us with objective, scientific bases for the design of a long-term strategy that will weigh all the components and determinants of the health status of the population in a comprehensive manner, with an emphasis on risks.

While the strategy emphasizes environmental and behavioural factors, these cannot be addressed by health actions alone. Consequently, it is the responsibility of the health sector to identify and associate such factors with health status with a view treating them through an inter sector approach.

The strategy considers the main health problems that impact and threaten us both internationally and domestically, as well as care for special population groups, such as mothers and children-which still faces considerable obstacles-and older adults, given the rapid aging of the population and the challenges this poses to the economy, society, and the public health system in particular.

These public health objectives for 2015 constitute a valuable strategic and programmatic road map that we must follow closely over the next 10 years, inasmuch as they not only identify the objectives and goals to be achieved, but also specify organizational and operation needs, based on health system priorities.


Our General Directives incorporate the principal lines of work, mandated from highest policy levels of the health sector, which will guide us in achieving the proposed goals and require the active collaboration of health authorities and workers with all the Cuban people.

Our goals and specific directives are the culmination of collaborative efforts by experienced scientists and technical personnel working in different areas, specialties, and disciplines of the health sciences. As is always the case with goals of any type, we will face obstacles and challenges, but we can ultimately meet them provided we work together with science, intelligence, and creativity.

These projections will lay the foundations for the design of the National Health System Objectives, as well as plans and programs, both administrative and technical, to ensure their fulfilment at all levels.

The implementation, control, and evaluation of the National Health System Objectives will involve technical and administrative exercises, and our actions in this regard will be based on a comprehensive approach, science, and research, thus constituting another new challenge of these projections.

Dr. José Ramón Balaguer Cabrera

Minister of Public Health


INTRODUCTION

The changes in the health status of the Cuban population are attributable to the high priority accorded to health by the Revolution and its social efforts, including the qualitative transformation of living standards for its citizens.

Despite the toll taken on the infrastructure and resources of the National Health System throughout the years of the Special Period, attributable to the collapse of the Soviet Union and the intensification of anti-Cuban actions through the criminal blockade of the United States, the efforts of its workers and society allowed the country to continue its course improvement regarding the leading health indicators, maintaining them at level with developed countries.

Thanks to current socioeconomic development conditions and the extension and expansion of international cooperation, the country’s socioeconomic structures are being strengthened and enhanced, particularly in the areas of education, culture, and the National Health System. The programs of the Revolution are having a significant impact with respect to the rehabilitation and construction of new health care centres, the installation of modern equipment, the enhancement of scientific training for health sector professionals and technical personnel, and the search for excellence in health care services.

These conditions make it possible for us to set new goals for increasing Cuban life expectancy at birth, with better health and quality of life based on the most important consideration: the human being.

Accordingly, it becomes crucial to develop projections and goals that identify health system priorities and necessary actions, with a view to targeting efforts in an organized manner and tapping the vast scientific, technological, and human potential at its disposal.

Given the scope of this task and the complexity of health system interventions, the participation of grassroots organizations is essential, such as the Federation of Cuban Women (FMC), the Committees for the Defence of the Revolution (CDR), the National Association of Small Farmers (ANAP), the Federation of University Students (FEU), the Federation of High School Students (FEEM), the José Martí Young Pioneers’ Organization (OPJM), and the Union of Cuban Workers (CTC), but especially the National Union of Health Workers, under the direction of the Communist Party of Cuba at all levels. SCENARIOS Below are the projected scenarios for the Cuban health system between 2006 and 2015.

Demographics Fertility and births rates will remain low and even decrease further, while mortality should continue to rise among the highest age groups of the population. Geriatric mortality, which is still very low in the country, will likely increase in the upcoming years. Due to a combined effect of the variables-fertility, mortality, and migrations-population growth will slow down and eventually result in a negative rate in the upcoming years, as is the case in most developed areas of the world.


This population pyramid (stationary model), coupled with the high life expectancy of the Cuban population, will result in one of the fastest and most profound aging processes in the American Hemisphere and, indeed, the world.

Socioeconomic The Battle of Ideas, initiated during the struggle for the return of Elián González, was founded on the main socio-political scenario, while at the same time serving as a catalyst for important processes.

In the event that the current conditions facilitating the present socioeconomic scenario continue, or should these improve, the country will continue on a path of economic and social recovery, reflecting the sustained growth of the country’s gross domestic product and its equitable distribution among the different sectors of society, which will, in turn, favour improvement in the population’s quality of life.

The agreements signed with China open important perspectives and create favourable conditions for the development of our economy. The agreements signed with Venezuela represent a significant step toward economic integration and the development of new possibilities.

This economic recovery will impact the annual health budget, both in terms of domestic and freely convertible currency. The system will include a group of credits to revitalize areas previously affected by the economic situation and will continue to pursue the timely development of mechanisms for the mobilization of internal and external resources. In this way, we can recover capacity lost during the years of Special Period, and at the same time, increase coverage and access to needed services to a progressively aging population. Moreover, we can improve the sustainability of these health programs which have high costs due to their technological implications and the growing demand for care as life is prolonged.

The recurring threats of the imperialism (i.e., economic, trade, and financial blockade, as well as the possibility of military aggression), the unstable international situation (especially the volatile market for oil and other products), and climate aberrations and other natural disasters that are occurring with greater frequency and intensity, are examples of external factors that can cause variations in these scenarios.

The military and economic invulnerability of the Revolution will guarantee its continuity. Against this backdrop, the struggle against the subjective factors denounced by Fidel on 17 November 2005 and the recently initiated Energy Revolution will guarantee the availability of new sources of financing for social development.

Health Undeniably, the aging of the population will be the predominant scenario. Consequently, chronic noncommunicable diseases and other health problems will prevail and significantly affect the structure of morbidity and mortality.

This future scenario will demand health prevention and promotion approaches, and the development of services and technologies with greater response capability, which will certainly increase the costs of care. As the population ages, handicap and disability rates will also increase.


The epidemiological environment, both at the national and international levels, will remain a threat, and even as infectious diseases are no longer a public health issue, surveillance activities and preparations to address emerging and re-emerging diseases will continue to be a priority, given the significant increase in the exchange of Cubans working in countries with exotic diseases and the arrival and settlement of foreigners from such countries.

The causality of nosocomial infections in hospitals and polyclinics will change: Gram-negative and other antibiotic-resistant bacteria will act as the causative agents alongside viruses and fungi.

Although Cuban strategies for controlling HIV/AIDS have met with success, the increased survival rate of infected cases becomes a risk factor by increasing the number of potentially infectious subjects. Compounding this situation are international reports of anti-retroviral drug resistance. All this will bring about a gradual increase in the prevalence of the disease, and will influence the dynamics of health services, both in terms of HIV-specific treatments and of those for treatment of other common ailments affecting these patients.

The strategy for strengthening primary health care and technology transfers for this level of care, in addition to harmonizing the objectives and functions of family medicine, will consolidate the polyclinic as the regulatory institution of the National Health System, will differentiate its functions form those of the hospital, and will integrate the efforts of both institutions towards solutions for the health problems of the population.

Thus, the immediate consequence of this phenomenon is that the outpatient health care subsystem will emerge with greater clarity and the relationship between it and the hospital will be replaced with integration, taking into consideration that what distinguishes the two categories is that, conceptually speaking, their interrelationship assumes defined areas of responsibility, whereas integration leads to a community of objectives geared toward the positive transformation of the health status of the population of a given territory.

Attention to the community and the environment rather than just the isolated care of the individual patient, comprehensiveness, its base in the needs of the population, popular participation, access and care administered by multidisciplinary teams, characteristics currently attributed to primary health care, will be common to the entire National Health Care system.

The application of new concepts in the formation of human capital and the transfer of teaching scenarios to the polyclinic, together with growing enrolments—in keeping with the universalization of teaching—will, within a short period of time, supplement the minimal workforce workers, as well as solve the current crisis of the aging of the workforce that is negatively affecting some specialty areas, and in addition facilitate the addition of other such areas that will be needed.

Medical technology will be modernized with the introduction of innovative, complex equipment in order to meet new quality, efficacy, and safety standards for patients. In addition, the computerization of all of these processes will be introduced, thus allowing greater efficiency in performance.

The introduction of new molecules and formulations for medications as a consequence of the modernization and the expansion of the drug industry and the contributions of scientific research centres, will improve treatment results, reduce hospitalizations, and facilitate the development of complex outpatient treatments


Health research should emphasize the specific needs of the community served by each polyclinic, hospital, and faculty and be geared toward solving the main determinants of the most prevalent or serious diseases, as well as strengthen the System of Scientific and Technological Innovation in the provinces, with a view to transferring the “good science” of the national institutes to provincial or municipal centres able to generate scientific results of greater applicability.

International collaboration, due to growing demand for the quality of our health services and hour human capital, in close coordination with out policy of solidarity with the poorest countries, extending to their most remote outreaches, predicts an increase in the number of workers to serve on various types of international missions. Moreover, we must provide, in Cuba, for the education of our students as well as those from other countries, and at the same time we will train, in collaboration with others, significant human resources in those nations. All this implies a greater dynamic in terms of the quantity and quality of training of these resources and their utilization in different countries.


OBJECTIVES General Improve the health status of the Cuban population by the year 2015.

Specific Implement, through an adequate inter sector approach, actions that have a favourable impact on the environment, and with this, greater protection of the health of the population;

Carry out effective work aimed at reducing and controlling the most important risk factors affecting the health of the population;

Reduce mortality and morbidity due to noncommunicable diseases and other health conditions constituting the leading causes of disease and death among the Cuban population;

Maintain and improve the health status attained with regard to infectious and parasitic diseases, and emphasize those that have not yet been resolved with the application of immuno-biologicals, as well as exotic diseases which may be introduced into the country

Consolidate and improve the levels of maternal and child health attained;

Carry out actions that make it possible to successfully address the care needs that the aging Cuban population demands.

DIRECTIVES The directives listed below indicate the main methods of action that the organization will focus on in order to meet the planned targets.

Said directives include guidelines that define and guide priority directions of the System during the period. For this it is required that, at the territory level, units and services must be transformed into concrete actions that assure their fulfilment.

The general directives form a set aimed at strengthening and perfecting the overall System to provide it with the necessary capacity and organization in order to adopt the new challenges set forth in these projections.

The specific directives are those that identify actions with a direct impact on the causes of disease, injury, and death targeted for reduction.


GENERAL DIRECTIVES

1. The Programs of the Revolution integrate concepts, projections, strategies, and specific actions designed to improve our social system. With particular regard to the health system, they will help improve the health and well-being of the population, increase life expectancy with greater quality, introduce technologies and innovative forms of care, improve services and their structural and comfort conditions, make services more accessible to the population, and increase user satisfaction. These projections will contribute to the success of such programs and, in turn, serve as a guarantee to reach the proposed targets.

2. The Ministry of Public Health and all its agencies are considered direct participants in the “Battle of Ideas.” This means that its management style of its authorities must be based on the principles of: dedication, integration, comprehensiveness, cohesion, demand, immediacy, enthusiasm, initiative, preparation for the fulfilment of tasks, follow-through on what we do, and direct control of each task (Know every aspect of your work).

3. This strategy is based on and contributes to the true integration of the National Health System, both in the areas and agencies of the Ministry of Public Health, and in the territories, units, and services it comprises. The strategy views man, the family, and the community as the object and centre of the System, which will integrate all efforts and actions to ensure their better health and well-being.

4. International solidarity, which is the principle and inherent value embraced by health workers and our system, will contribute to the political-ideological and scientific-technical training in the sector, and will promote creative and innovative forms of organization and performance in the programs, services, and institutions it comprises. The training of Latin American physicians and those from other countries, the “Operation Miracle” program, and Brigadier Henry Reeve are revered exponents of this principle.

5. The inter sector approach, a critical component for improving the health and well-being of the population, will be an essential strategy for meeting these goals. The role of the National Commission of Health and Quality of Life will be strengthened, as will the role of the health sector regarding said Committee and in the contribution of elements that facilitate the adoption of decisions in support of such elements.

6. The struggle for excellence in health care services will make decisive contributions in meeting these objectives and their targets. It will be a comprehensive process designed to institute qualitative improvements in the quality of medical care, and the satisfaction of patients, family members, and workers.

7. Improve the performance and behaviour of health workers by stepping up motivation to do everything better, further strengthen their solid values, seek their commitment to these goals, with a view to becoming selflessly devoted to their fulfilment, and encourage them to identify with the requirements of a team ethic [Colectivo Moral] in a unit of the National Health System in order to achieve and maintain this condition.

8. The long-term perspective of these goals requires the sustainability of systems and the actions carried out, which will be sufficiently flexible and dynamic in order to permit timely and pertinent adjustments with regard to planned results.

9. These projections will require adaptations in the health system organization and management in order to strengthen local initiatives and ensure rigorous administrative and technical discipline of the sector. Strengthening of the regulatory framework of the system will be essential.

10. The country’s scientific and technological development, promoted by scientific think tanks, research institutes, hospitals, polyclinics, and other institutions, comprise a significant contribution to this strategy; the timely and expeditious introduction and dissemination of its results will be decisive with in terms of the scope of these projections.


11. The considerable resources made available to the health services and programs, together with the important planned results, require organization, performance and efficient control of the part of our institutions, departments, and services. The economic and financial approaches will complement the clinical, epidemiological, and administrative analyses of these projections.

12. The quality of technical inputs, interpersonal relations, and the environment will continue to be a basic objective of our system. The programs developed at the institutional and services levels will ensure ongoing systems of quality assurance and improvement. The processes of unit accreditation and categorization will also contribute to the development of the health system.

13. The development achieved by our health system, and especially by the human capital of its personnel, facilitates clinical, epidemiological, and administrative management of a very high scientific calibre, based on research and the use of the most current and refined techniques.

14. Enhance and improve the quality of the information system, as it is crucial for analysis and decision-making at the different areas and levels of our work, placing emphasis on correct preparation of clinical histories and death certificates.

15. Health situation analysis and the opinions and suggestions of the public regarding service performance are invaluable elements in decision-making. Every phenomenon has its causes, and it is a fundamental part of the work of system managers is to investigate and analyze in detail, in order to ensure the scientific direction of the health system.

16. Human capital constitutes the greatest strength of the health system and we rely on it to meet these goals. The formation, preparation, and ongoing improvement of human capital, especially with regard to master’s and doctorate programs, will fulfil the needs of the Programs of the Revolution and the purposes stated here.

17. Due to the high degree of responsibility entrusted to the specialized areas of medicine in terms of caring for the sick and at-risk population and complementing and ensuring the continuity of comprehensive general care, these areas will be the object of a development program to help these professionals become the best in the world and to meet these goals in terms of greater quality and sustainability.

18. Comprehensive general medicine is the health system’s basic area of specialization. Focusing on clinical, epidemiological, and environmental aspects through promotion, prevention, treatment, and rehabilitation approaches/actions, its possibilities of addressing the health-disease process in man, the family, and the community have been demonstrated by its results in more than twenty years of service under the most diverse scenarios and conditions, both in Cuba and abroad.

19. The interdisciplinary approach, as a means of organizing work in health, will make it possible to address the complex problems of health and disease in a more holistic manner, including issues of quality and efficiency, using the most innovative technologies, and obtaining better results for our people.

20. The clinical method, the maximum expression of scientific thought and practice in patient care, will be developed and enriched by our physicians in their daily practice of medicine, with the requisite dedication and responsibility.

21. Epidemiology and its development, as a concept and tool, is needed to meet these goals.

22. The community, more than just the object and beneficiary of the health programs and services, is in fact the system’s raison d’être. Its participation in the detection and prioritization of health problems, in intervention activities, and in the control and evaluation of results embodies the guarantee that public health responds to the interests and needs of our people and society.

23. The polyclinic is the regulatory institution of the system. Its infrastructure, services, technologies, and specialized human resources enable it to perform the most complex and important health care functions, human resources education, and research, hence its responsibility for the comprehensive health of the community and University Polyclinic role.


24. The hospital, as a high-level scientific and technical institution with heightened response capacity, charged with recovering and rehabilitating the health of the population, will have the means to develop and integrate with the primary health care services in order to achieve greater efficiency, quality, and user satisfaction in the implementation of this strategy.

25. The research institutes and national reference centres, charged with the scientific and technical responsibility for implementing, executing, monitoring, and evaluating these goals with respect to their specific programs, will prepare a plan of research in accordance with these functions and responsibilities. They will develop the Health Systems and Services Research Program “Ramal” (Branch) and increase the quantitative and qualitative level of research.

26. Guaranteeing logistical support is fundamental and critical to the scope and sustainability of these goals. The pertinent systems will be enhanced to ensure such support is systematic, timely, effective, and efficient. The nature of the services will determine the logistics, bringing resources closer to the units.

27. Compliance with Ministry of Finance and Prices Resolution No. 297 of 2003 contributes to the enhancement and strengthening of ideological, technical, organizational, and control mechanisms aimed at curbing illegal activities, corruption, and crime.


SYSTEM PRIORITY AREAS

I. Environmental Factors Associated with Health Problems Water 76% of the Cuban population receives wastewater by water supply systems. Below the national average 7 provinces are. In the entire year 2004, the provinces reported 207 156 drinking water leaks, that together with the intermittency of the service, the dumpings of liquid residuals and the networks in poor condition, continue to constitute a danger for the communicable disease spread of hydric vehiculación. The situation of the supply of the water continued to be more critical in the northern area of the eastern provinces and Camagüey as a result of the drought. Although 95% of the population has some service of sanitarily acceptable water supply of this 75% it only receives by house connection and 15% by easy access (up to 200 m of housing), 5% remaining by public services of pipes. The networks, for the most part, have ages higher than the 60 years, which induces the existence of permanent leaks. That fact, united to the problems of the sources, which influence the intermittency of the service of water supply, they constitute a danger of contamination of the networks. Purpose 1: Increase to 95% the coverage of population served by water supply systems with house connection or easy access. Goal:

Baseline 2010 2015 90% 93% 95%

Source: PNA 2003 and Bulletin GEAAL October 2005, both of the INRH. Indicator: Percentage of population served by systems of water supply system. Purpose 2: Increase to 100% the water disinfection.

Goal: Baseline 2010 2015 98% 99% 100%

Source: PNA 2003 and Bulletin GEAAL October 2005, both of the INRH. Indicator: Percentage of treated water. Sanitation - 49% of the population has sewerage service with deterioration in the network, permanent

leaks, and intermittency of the water supply, which constitutes a danger of contamination to the systems of water and evident risks to the population. 94% of the population has some service of collection and disposal final of wastewater sanitarily acceptable but of this 38% it only receives by sewerage system and 55% remaining by means of latrines and fossae, which affects negatively the environment, in view of the fact that the deterioration in the networks with permanent leaks run them inadequately. United to the foregoing they influence the deterioration of the environment that surrounds man low percent of treatment that the wastewater that only 36% and the problems hit receives that still persist in the systems of treatment existing.

- The country counts with 1 030 spillways, of them 380 of Special Period. 20% does not have authorized sanitary microlocalization. 37% does not have periodic conditioning, which turns them into centers productive of vectors and bad odors, where 17% have activities of subtraction of waste, figure that added to the ones that do not have near, nor controller, turns them into an illegal source of procurement of products, that without control, pass a part of the population.


- The exposure to air pollutants and to the noise today constitute two large risk factors that since the year 2000 are being increased, affecting the environment and to the population. The environmental and sound pollution is related to the increase and aggravation of some diseases as acute respiratory infections, crisis of bronchial asthma, lung cancer, stress, among others. By the network of monitoring of the CITMA from 2000 to 2004 there has occurred an increase in the air pollutant concentrations as well as the increase of the levels of environmental noise in the country, which it has carried with it complaints of the population.

Purpose 3: Increase to 70% the current coverage of the evacuation of the liquid residuals by sewerage systems. Goal:

Baseline 2010 2015 38% 54% 70%

Source: PNA 2003 and Bulletin GEAAL October 2005, both of the INRH; PIHA 2004 of the UNSA. Indicator: Percentage of population served by sewerage systems.

Purpose 4: Increase to 70% the volume of treated sewer efficiently before its dumping to the environment. Goal:

Baseline 2010 2015 37% 53% 70%

Source: PNA 2003 and Bulletin GEAAL October 2005, both of the INRH; PIHA 2004 of the UNSA. Indicator: Percentage of volume of treated wastewater. Purpose 5: Achieve 100% of a correct management of the dangerous solid residuals. Goal:

Baseline 2010 2015 0 50% 100%

Source: ANNUAL REPORT OF THE PIHA and Statistical Yearbook of the MEP 2004. Indicator: Number of spillways with proper management of dangerous solid residuals. Purpose 6: Replace 100% of the spillways with sanitary landfill spillways. Goal:

Baseline 2010 2015 0 50% 100%

Source: ANNUAL REPORT OF THE PIHA and Statistical Yearbook of the MEP 2004. Indicator: Number of spillways with sanitary landfill. Purpose 7: Eliminate 100% of the microspillways from Special Period. Goal:

Baseline 2010 2015 339 60% 100%

Source: ANNUAL REPORT OF THE PIHA and Statistical Yearbook of the MEP 2004. Indicator: Number of spillways of Special Period. Purpose 8: Ensure that 100% of the new procurements of incinerators are ecological. Goal:

Baseline 2010 2015 1 100% to Maintain


Source: ANNUAL REPORT OF THE PIHA and Statistical Yearbook of the MEP 2004. Indicator: Number of ecological incinerators.

Purpose 9: Reduce in 30% the environmental pollution.

Goal:

Indicators Baseline 2010 2015 15% 30%

Concentrations of NO2 Concentrations of SO2 Concentrations of NO Concentrations of NOx Concentrations of NH3 Opacidad Apparent

3.3 mg/m3 0.8 mg/m3 2.9 mg/m3 6.2 mg/m3 5.6 mg/m3 60 %

2.8 0.68 2.47 5.27 4.76 51

2.3 0.56 2.03 4.34 3.92 42

Source: Environmental situation 2004. CITMA. Vectors The vectors live with the man since remote times and today are widely scattered throughout all the continents. It is the species of mosquito Aedes aegypti one of those most important for the man by its broad distribution, difficult control and permanent scourge to the health. The growing infestation of this species, in the countries with those which Cuba continues close relations, increases the possibility of introductions of this, in addition to the risk of emergence of disease outbreaks as Dengue. The efforts and purposes of the control strategies should win in perfection and head toward an integrated control that makes it possible for us to maintain the infestation indices by this species at levels that do not constitute health hazard. With regard to others types as the Anopheles, other culicides, intermediary hosts, rodents and triatóminos, also very harmful for the man and whose space in the transmission of diseases grows, it is important that the strategies of surveillance and struggle are designed for the control of these and thus to diminish the incidence of cases by the diseases that the same spread. Nationally Aedes aegypti has been dispersed per the country, basically in the provincial heads and in the City of Havana. The highest infestation indices by Aedes aegypti are reported in the capital and in the provincial heads of: Santiago of Cuba, Guantánamo, The TUNA and Camagüey. The country in the last cycle of 2005 had an index marry of 0,101. Aedes albopictus is limited to the western territory (Pinar del Río, Havana and City of Havana). In the specific case of the Anopheles there is found in the most rural areas. The presence of triatóminos has been reported in regions of the west and in the east, in its rural areas. Purpose 10: Maintain infestation indices by mosquito Aedes aegypti that do not constitute risk for the transmission of Dengue. Goal:

Baseline 2010 2015 0,101 Elimination Maintain to elimination Source: National Unit of Surveillance and Vector Control. Indicator: Index House. Purpose 11: Control the dispersion of Aedes albopictus through integrated strategies. Goal:

Baseline 2010 2015 0,103 Lower than 0.1 Lower than 0.1

Source: National Unit of Surveillance and Vector Control. Indicator: Index of deposits.


Purpose 12: Intensify the actions in order to maintain the indices of infestation by rodents lower than the 10%. Goal:

Baseline 2010 2015 24 Lower than 10% Lower than 10%

Source: National Unit of Surveillance and Vector Control. Indicator: Index of rodents. Purpose 13: Maintain low indices Anophelinos that do not constitute risk of malaria transmission. Goal: Baseline 2010 2015

Larval index 0.2 x m2 Lower than 20 larvae x m2

Lower than 15 larvae x m2

Index of bite 5% Lower than 5 bites man/hour

Lower than 5 bites man/hour

Source: National Unit of Surveillance and Vector Control. Environmental factors. Directives 1. Pay special attention, with an effective intersectoral approach and involvement of all the

responsible organisms, to the confrontation and solving of the complex problems that affect the quality of the water, the disposal, and treatment of the solid and liquid waste and the reduction of the environmental pollution.

2. Enhance the work of the programs for surveillance and control vector, prioritizing the actions against the mosquitoes trasmisores of Dengue and Malaria.

3. Develop and consolidate community participation strategies. Achieve the development of a real intersectoral approach that permits the confrontation of the problem of the vectors and their necessary sustainability.

4. Develop the laboratory network for entomological diagnosis in all the regions of the country. 5. Strengthen the integration of the vector control work into Primary Health Care. 6. Develop research of the vector capacity of some exotic species in our country. II. Behavioural Factors Smoking Smoking is the leading cause of avoidable death in the world. There is considered the major epidemic of the 20th century, representing a challenge for the World Public Health managing to diminish it. It is considered the risk factor that more affects the leading causes of morbidity and mortality from chronic noncommunicable diseases, which means that scientific evidence of the number of deaths attributable to this harmful habit has happened as one of the principal health problems, existing. The Second National Survey of Risk Factors and Non-communicable Diseases (II ENFR) found a prevalence of 32% in people of 17 years and more, the men smoked in general 10% more than the women; the global initiation in the group from 20 to 24 years is of 22% and 80% of the new smokers started before the 20 years. The average of beginning age it was 17.1 years. The men start before the females. Daily most frequent consumption was 6-10 cigarettes which it prevailed in the women. Only to 4 out of 10 smokers its physician recommended him quitting smoking in the last 12 months. A policy of effective smoking control constitutes the health intervention of greater impact on the health of the population.


Purpose 1: Reduce in 40% the prevalence of smokers in the populationCuban. Goal: Baseline 2010 2015 General 32% 20% 40% 32 25.6 19.2 Source: II National Survey of FR and NCD. Cuba, 2001. Indicator: Prevalence of smokers in population of 17 years and more.

Purpose 2: Reduce in 40% the prevalence in adolescents that hanconsumido cigarettes some time. Goal:

Baseline 2010 2015 25% 20% 40% 25 20 15

Source: World Survey on smoking in young people. Cuba, 2004. Indicator: Prevalence of adolescents who have consumed some time tobacco. Purpose 3: Reduce in 60% the prevalence of smokers in the health professionals. Goal:

Baseline 2010 2015 31% 20% 60% 31 24.8 12.4

Source: Provincial Survey on Smoking in physicians and nurses. City of Havana. Cuba, 2005. Indicator: Prevalence of smokers in health professionals. Purpose 4: Reduce in 12% passive smoking. Goal:

Baseline 2010 2015 88% 7% 12% 88 81.8 77.4

Source: World Survey on Smoking in young people. Cuba, 2004. Indicator: Prevalence in exposed persons to the environmental tobacco smoke. Purpose 5: Reduce up to 20% the global initiation in the group of 20 to 24años. Goal:

Baseline 2010 2015 22.2% 21% 20%

Source: II Survey of Risk Factors and NCD, Cuba 2001. Indicator: Percentage of global initiation in population of 20-24 years. Alcoholism The principal problems related to excessive consumption of alcoholic beverages are: at higher levels of consumption they correspond mortality and morbidity rates higher of cirrhosis of the liver, some types of cancer and fetal alcohol syndrome. It increases violence both physical and verbal, increase the traffic accidents, labor and domestic, also increase the high-risk behaviors social and for the health and is favored the commission of unlawful facts. There does not exist a safety limit of consumption of alcoholic beverages that can guarantee the absence of consecutive adverse effects to such ingestion, since each person and circumstances are only one. The percentage of deaths attributable to excessive consumption of alcoholic beverages equalizes or surpasses the ones related to the chronic abuse and contributes to the years of potential life lost, since majority-mind affects in young people. The per capita consumption reduction favors the reduction of the harm caused by alcohol consumption in a community, although the magnitude of such impact not only depends on


consumption per inhabitant, but also of the pattern of this consumption. At present, it is estimated that between 6% and 34% of admitted injured in emergency services, they have a positive blood alcohol and that around 25% of them positive diagnoses of abuse or dependency of the alcohol present tests. In the ones hospitalized by injuries, between 20 and 69% it suffers from some disorder by alcohol consumption, which converts to alcoholism in the chronic disease most prevalent in the patients with trauma. Purpose 6: Diminish in 20% the prevalence of consumption of bebidasalcohólicas in the Cuban population. Goal: Baseline 2010 2015 50% 10% 20% 50 45 40 Source: II National Survey of FR and NCD. Cuba, 2001. Indicator: Percentage of population over 15 years of age that consumes alcoholic beverages. Purpose 7: Diminish in 15% the alcoholic ydependencia prevalence of consumption detrimental. Goal:

Baseline 2010 2015 7.7% 7% 15% 7.7 7.2 6.5

Source: II National Survey of FR and NCD. Cuba, 2001. Indicator: Percentage of detrimental consumption and alcoholic dependency. Purpose 8: Prolong the age of sale of alcoholic beverages to 17 years. Goal:

Baseline 2010 2015 15 16 17

Source: Alcohol consumption in the population 15 years of age and older. Municipio 10 October. 1998. National Institute of Hygiene, Epidemiology, and Microbiology. MINSAP. Indicator: Average of age of beginning of consumption of alcoholic beverages Drug use The II National Survey of Risk Factors showed that 4.7% of the respondents answered that they indeed have knowledge concerning people who use drugs. 5.2% of men answered that indeed have knowledge and in the case of the women it was of 4.3%. 1.3% of the respondents it was among “themselves and I am not certain to use drugs”, in the event that there were given them to prove. The level of responses among “themselves and I am not certain”" behaved more or less the same in both sexes and was something greater between 15 and 29 years (1.8%). It is currently estimated that there exists a downward trend of consumption of illegal drugs and increase of the licit ones. Among the treated patients the datum of the relapse and repeated offense is not collected. Purpose 9: Increase in 10% the dispensing of consumers of drugs. Goal: Baseline 2010 2015

3.6 5% 10%

Source: Provincial GOSMA. Indicator: Rate of dispensarizados patients by consumption of drugs x 10 000 inhab. Purpose 10: Increase the proportion of dispensarizados patients by consumption of drugs incorporated to dishabituation treatment.


Goal: Baseline 2010 2015 85% 92% 97% Source: Provincial GOSMA. Indicator: Percentage of dispensarizados patients by consumption of drugs incorporated to dishabituation treatment. Diet and nutrition The risk factors in the diet of the population, related to bad eating habits, are several and some of long tradition: According to the II ENFR, 24% of the surveyed population does not have the habit to breakfast. 28% uses the lard in order to systematically cook. Daily 14.5% of the population only consumes vegetables and 14.4% consumes fruits. 12.1% of the population adds salt to the food on the table. 31% of the population takes vitamin and mineral supplements. In 2004 28% of the pregnant women in the third trimester of the pregnancy presented anemia by iron deficit. Malnutrition at the beginning of the pregnancy hits 16.4%, while the gain of deficient weight in the pregnancy is of 12.1%. 30% of the children from 6 to 12 months had anemia by iron deficit. Obesity and overweight as risk factors showed an increase between 1995 and 2001. In 2001, the women had overweight prevalence rates higher than men (47.0 and 37.6%) and much smaller levels in normopeso that the men (57.0 and 46.8%), which becomes a health problem of greater magnitude upon being combined with higher prevalence rates of sedentary lifestyle and Diabetes Mellitus, which increases its cardiovascular risk. Especially in the case of the children of 1-14 years a prevalence of overweights of 13% is observed. Purpose 11: Increase the proportion of adults who have a “healthy” bodyweight. Men to 65% and women to 56%. Goal: Baseline 2010 2015 Male 57% 61% 65% Female 46% 50% 56% Source: Data obtained of the II National Survey of FR and NCD. Cuba, 2001. Indicator: Proportion of adults with “healthy” bodyweight (BMI of 18.5 to 24.9.

Purpose 12: Diminish the proportion of obese adults. Men to 4% and women to 10%. Goal:

Baseline 2010 2015 Masculine 8% 6% 4% Feminine 15% 13% 10%

Source: Data obtained of the II National Survey of FR and NCD. Cuba, 2001. Indicator: Proportion of obese adults (IMC= 30). Purpose 13: Diminish to 3.5% the proportion of children less than 5años with growth retardation. Goal:

Baseline 2010 2015 5.7% 4.6% 3.5%

Source: Data obtained of the II National Survey of FR and NCD. Cuba, 2001. Indicator: Proportion of children under 5 with retardation in elcrecimiento. Purpose 14: Decline to 8% the proportion of pregnant women quetienen a gain of deficient weight during the gestation. Goal:

Baseline 2010 2015 16.9% 10% 8%


Source: Data obtained of the II National Survey of FR and NCD. Cuba, 2001. Indicator: Proportion of pregnant woman with gain of weight deficientedurante the gestation Purpose 15: Increase to 40% the proportion of people queconsumen at least two daily parts of fruits ˜ 200g. Goal:

Baseline 2010 2015 16% 25% 40%

Source: Data obtained of the II National Survey of FR and NCD. Cuba, 2001 Indicator: Proportion of people who consume at least two daily servings of fruits ˜ 200g. Purpose 16: Increase to 50% the proportion of people queconsumen at least three daily parts of vegetables ˜ 300g. Goal:

Baseline 2010 2015 17% 32% 50%

Source: Data obtained of the II National Survey of FR and NCD. Cuba, 2001. Indicator: Proportion of people who consume at least three daily servings of vegetables ˜ 300g. Purpose 17: Increase to 45% the proportion of people (mayoresde two years old) with consumption of fats that contribution between 20 y30% of the total energy. Goal:

Baseline 2010 2015 19% 35% 45%

Source: Data obtained of the II National Survey of FR and NCD. Cuba, 2001. Indicator: Proportion of people (more than two years old) conun consumption of fats that contributes between 20 and 30% of the total energy. Purpose 18: Increase to 55% the proportion of people with unconsumo of sugar that contributes less than 15% of the total energy. Goal:

Baseline 2010 2015 32% 45% 55%

Source: Data obtained of the II National Survey of FR and NCD. Cuba, 2001. Indicator: Proportion of people with consumption of sugar that contributes less than 15% of the total energy. Purpose 19: Increase to 95% the proportion of people that noañaden salt to its food in the table. Goal:

Baseline 2010 2015 88% 90% 95%

Source: Data obtained of the II National Survey of FR and NCD. Cuba, 2001. Indicator: Proportion of people who do not add salt to its food enla table Purpose 20: Diminish to 15% the proportion of children less than 2 añosde age with iron deficiency anemia (Hb < 110 g/L).


Goal: Baseline 2010 2015

30% 20% 15%

Source: INHA Databases. 2003. Indicator: Proportion of children under 2 of age with anemiapor iron deficiency (Hb < 110 g/L). Purpose 21: Diminish to 19% the proportion of women of age fértilcon iron deficiency anemia (Hb < 120 g/L). Goal:

Baseline 2010 2015 30% 25% 19%

Source: INHA Databases. 2003. Indicator: Proportion of women of childbearing age with iron deficiency anemia (Hb < 120 g/L). Purpose 22: Diminish to 15% the proportion of pregnant women with iron deficiency anemia (Hb < 110 g/L). Goal:

Baseline 2010 2015 24% 18% 15%

Source: INHA. Surveillance system of the maternal and child nutritional status through sentinel sites. 2004. Indicator: Diminish the proportion of pregnant women with iron deficiency anemia (Hb < 110 g/L). Sedentary lifestyle The sedentary lifestyle is one of the most prevalent modifiable risk factors in the general population. The counterpart of the sedentary lifestyle is the physical activity. Irrefutable tests show that who live active life are healthier, live more time, and have a better quality of life than the inactive people. The physical activity is a broad term that encompasses activities that vary in regular-mind intensity from going up the stairs, to dance and walk, until running, installing bicycle, and practicing sports. A moderate physical activity can carry out it any person, at no cost and in addition, be adjusted to its daily routine. Epidemiological research has demonstrated protective effects of diverse consistency between the physical activity and the risk of suffering from several chronic diseases that include: ischemic cardiopathy, hypertension, non-insulin-dependent Diabetes Mellitus, osteoporosis, cancer of colon, anxiety, and depression. In accordance with the two national surveys of risk factors, the figure of prevalence of sedentary lifestyle found in 1995 was of 33%, clearly the difficult economic situation that passed through the country originated an increase in the physical activity in the population that was reflected in a reduction in the prevalence of the sedentary lifestyle and where the crisis of the transportation starting in 1990 was seen reflected in one // high prevalence of the use of the bicycle and of the walk with a predominance of the first in men and of the second one in the women, after this stage with an improvement of the economic conditions and of the conditions of the transportation in 2001, the prevalence of sedentary increased to 36.5%, especially at the expense of the female sex with 45.1% and masculine // with 27.5%, which behaved in the previous stage with 39.8% of sedentary of the female sex and 25.7 masculine%. Purpose 23: Increase to 40% the proportion of the adultaincorporada population to systematic physical activities. Goal:

Baseline 2010 2015 22% 30% 40%

Source: Annual Report on Systematic Practitioners. Indicator: Proportion of systematic practitioners in general population.


Purpose 24: Decline to 32% the prevalence of people sedentariasen population of 15 and more years. Goal: Baseline 2010 2015 General 37% 34% 32% Male 28% 25% 22% Female 45% 43% 40% Source: II National Survey of FR and NCD. Cuba, 2001. Indicator: Prevalence of sedentary people 15 years of age and older by sex in general population. Behavioural Factors – Directives

1. Promote behavioural changes in the population and groups exposed to risks due to smoking, alcoholism, and drug use, encouraging the adoption of healthy lifestyles and behaviours.

2. Discourage the social acceptance of smoking and encourage new generations not to smoke.

3. Promote legislation to protect people from second-hand tobacco smoke and disincentives for smoking.

4. Offer specialized assistance for persons who wish to give up smoking.

5. Continue epidemiological surveillance on the prevalence of smoking, alcoholism, and drug use in the general population.

6. Enhance the public information, education, and communications strategy on tobacco, alcohol, and drug use.

7. Promote inter sector participation in a program of regular physical fitness in the workplace and for the general population.

8. Increase public spaces and opportunities for general and specialized fitness activities and strengthen programs to encourage the population to visit recreational areas and sports facilities.

9. Expand the coverage of support groups with flexible scheduling and attendance of alcoholic patients at meetings.

10. Develop intervention strategies for risk groups other than alcoholics as a component of primary health care.

11. Include anti-anxiety drugs in the medical services network.

12. Guarantee the monitoring and rehabilitation of alcoholic patients, primarily through community-based actions.

13. Carry out prevention activities that facilitate the identification and control of risky behaviours and irresponsible alcohol consumption.

14. Promote healthy dietary practices, emphasizing moderate intake of fats, sugar, and salt.

15. Increase the availability of fruits and vegetables, following movements in the consumer price index.

16. Improve the availability of pharmaceutical iron supplements and fortified products aimed at these vulnerable groups.


III. Chronic Noncommunicable Diseases and Other Health Impairments Hypertension Hypertension (ETS) represents by itself a disease, as well as an important risk factor for other diseases, basically for ischemic heart disease, cardiac insufficiency, disease vascular brain, renal insufficiency and significantly contributes to retinopathy. The reduction of the diastolic blood pressure in 2 mm Hg will reduce the incidence of the coronary disease in 9% and that of Ictus in 15%. The control of the ETS diastolic reduces the incidence of Ictus in 40% in people aged 60 and over. The control of the ETS systolic isolated reduces Ictuses in 33%. The II National Survey on Risk Factors reported that 32.6% of the urban population over 15 years of age is regarded as hypertensive. By registry of dispensarizados to the close 2004, 24.0% of the adult population was registered as hypertensive, figure that should be greater, since there exists a difference of undiagnosed hypertensive individuals of 9%. The national prevalence of hypertensives for all ages is of 190.1 x 1 000 inhab, rate higher than that of the previous year (186.5 x 1 000 inhab.), being observed provinces that show values above the national average. Effective activities of intervention on this such frequent health problem will be decisive on the reduction of the leading causes of morbidity and mortality. Purpose 1: Increase in 30% the percentage of dispensarizados hypertensive adult patients. Goal: Baseline 2010 2015 24 15% 30% 24 27 31 Source: SIE of health. National Directorate of Statistics. 2004. Indicator: Percentage of hypertensive dispensarizados in population de15 years and more. Purpose 2: Improve in 45% the percentage of controlled hipertensosconocidos patients. Goal:

Baseline 2010 2015 51% 15% 45% 51 59 75

Source: II National Survey of Risk Factors. Indicator: Percentage of controlled known hypertensives that amounts to patients in effective treatment and with figures of arterial tension normal. Purpose 3: Decline the average of the arterial tension of the general population in 6 mm Hg. Goal: Baseline 2010 2015 TAMáxima 123.2 3 mm Hg 6 mm Hg 123.2 120.2 117.2 TAMínima 78.6 3 mm Hg 6 mm Hg 78.6 75.6 72.6 Source: II National Survey of Risk Factors. Indicator: Average of the maximum and minimum arterial tension. Schemic heart disease The Heart Diseases continue to be the leading cause of death in Cuba for more than 45 years and within them, the most frequent cause is the Ischemic Cardiopathy, that contributed 72.5% of the dead by Heart Diseases in 2004. The trend of mortality from Acute Ischemic Cardiopathy has been rising since the year 1980, with a peak in 1990 and another child in 1996, afterwards was downward until the year 2004 in which it rose slightly. In recent years some 15 000 deaths by Ischemic Cardiopathy are reported annually. In 2004 represented the18.8% of the total of dead of the country, with an increase


in mortality of2.3% with regard to the year 2003. The prevalence of Acute Myocardial Infarction is of 7.0 per 1 000 population over 15 years of age per year, its incidence in this last year was of 1.54 per 1 000 population over 15 years of age and extra-hospital mortality represents 57.5% of all the dead for this cause. In the previous decade, 8 years of life were lost on the average per every 1 000 population between 1 and 74 years for this cause. In 2004 there were reported 11 609 new cases of Ischemic Cardiopathy, that took to that in the country there currently exist 285 969 patient dispensarizados for this cause. The II ENFR detected that 50% of the people, 15 years of age and older of the urban area with ischemic heart disease, did not know its diagnosis. Purpose 4: Reduce in 15% mortality from ischemic cardiopathy. Goal:

Baseline 2010 2015 85.3 7% 15% 85.3 79.0 72.5

Source: Continuous Statistics of the National Directorate of Statistics. 2004. Indicator: Rate adjusted of mortality x 100 000 inhab. Purpose 5: Reduce in 15% mortality for the acute heart attack of the myocardium. Goal: Baseline 2010 2015 42.4 7% 15% 42.4 39.4 36.0

Source: SIE of health. National Directorate of Statistics. 2004. Indicator: Rate adjusted of mortality x 100 000 inhab. Purpose 6: Reduce in 25% extra-hospital mortality in the acute myocardium infarction. Goal:

Baseline 2010 2015 57.5% 12% 25% 57.5 53.5 48.9

Source: SIE of health. National Directorate of Statistics. 2004. Indicator: Extra-hospital mortality x 100 deaths from acute infarction of myocardium. Purpose 7: Diminish in 25% the hospital case-fatality from acute myocardium infarction. Goal:

Baseline 2010 2015 18.1% 12% 25% 18.1 15.9 13.6

Source: SIE of health. National Directorate of Statistics. 2004. Indicator: Case-fatality from Acute Myocardium Infarction x 100 discharges. Malignant neoplasm

Cancer in Cuba is the second cause of death for all ages since 1970. In recent years they are reported between 14 000 and 16 000 dead of malignant neoplasms annually. Being elevated to 18 000 people from 2003. In 2004 they represented 23.1% of the total of dead of the country, with an increase in mortality in this year of 2.2% with regard to the previous year. It causes leading years of life lost in the country. In recent years, there were lost on the average between 12.7 and 16.9 years of life per every 1 000 population between 1 and 74 years for this cause. Some localizations increase considerably: from 1980 to 2003 intestine cancer except for rectum was increased in 92.1%; windpipe, bronchia, and lung in 60.9%; breast of women 56% and prostate 134.7%. Experts coincide that 42% of the malignant neoplasms are preventable, curable 30%, and the quality of life of a person with cancer can


be improved in 30%. Tobacco is the one responsible of 30% of the neoplasms malignant, the inadequate diet of 30% the infections of 20% and the contaminants of 2% to 3%. Only to 10% of they are attributed him genetic causes. Purpose 8: Reduce in 15% mortality from cancer. Goal:

Baseline 2010 2015 115.3 7% 15% 115.3 107.2 98

Source: SIE of health. National Directorate of Statistics. 2004. Indicator: Rate adjusted of mortality x 100 000 inhab. Purpose 9: Reduce in 8% mortality from lung cancer. Goal:

Baseline 2010 2015 4% 8 %

General 27.3 26.2 25.1 Masculino 38.6 37 35.5 Femenino 17 16.3 15.6 Source: SIE of health. 2004. National Directorate of Statistics. Indicator: Adjusted rate of mortality by sex x 100 000 inhab. Purpose 10: Reduce in 20% mortality from decuello uterine cancer. Goal:

Baseline 2010 2015 5.3 10% 20% 5.3 4.7 4.2

Source: SIE of health. 2004. National Directorate of Statistics. Indicator: Rate adjusted of mortality x 100 000 inhab.

Purpose 11: Reduce in 8% mortality from decolon cancer. Goal:

Baseline 2010 2015 4% 8%

General 9.4 9 8.6 Masculino 9.5 9.1 8.7 Femenino 9.6 9.2 8.8 Source: SIE of health. 2004. National Directorate of Statistics. Indicator: Adjusted rate of mortality by sex x 100 000 inhab.

Purpose 12: Reduce in 15% mortality by cancer of breast in the female sex. Goal: Baseline 2010 2015 14.1 7% 15% 14.1 13.1 11.9 Source: SIE of health. 2004. National Directorate of Statistics. Indicator: Rate adjusted of mortality x 100 000 inhab.


Purpose 13: Reduce in 8% mortality from prostate cancer. Goal:

Baseline 2010 2015 26 4% 8% 26 25 23.9

Source: SIE of health. National Directorate of Statistics. 2004 Indicator: Rate adjusted of mortality x 100 000 inhab. Cerebrovascular diseases They have remained as third cause of death for all ages. In recent years they are reported between 7 000 and 8 000 dead from this cause annually, with a clear trend toward the rise. In 2004 represented the 10.2% of the total of dead of the country, with an increase in mortality with regard to the year previous (88 deaths more). It causes fourth years of life lost. In the previous decade, there were lost on the average between 4 and 4.9 years of life per every 1 000 population between 1 and 74 years, upon continuing the displacement of the disease to younger age groups and the female excess mortality, that presents a trend the rise. Both extra-hospital mortality and the hospital case-fatality are kept high. In 2004 there were reported 3 958 new cases of cerebrovasculaes diseases, that there increased the figure of the country to 52 717 patient dispensarizados by this cause (4.7 per every 1 000 population). It causes leading disability among the neurological diseases. The II ENFR showed that 37% of the people who have this disease have a disability. In addition to the physical limitations, there associate each other with problems in the emotional sphere with high frequency of (> depression 50%) and to cognitive deterioration of diverse degree (35%), being the second most frequent cause of dementia. The age is the principal non-modifiable risk factor and Hypertension is the principal modifiable risk factor. Purpose 14: Reduce in 25% mortality from disease cerebrovascular. Goal: Baseline 2010 2015 46.5 12% 25% 46.5 41 34.9 Source: SIE of health. National Directorate of Statistics. 2004. Indicator: Rate adjusted of mortality x 100 000 inhab. Purpose 15: Reduce in 30% feminine mortality porenfermedad cerebrovascular. Goal:

Baseline 2010 2015 44.6 15% 30% 44.6 38 31.2

Source: SIE of health. National Directorate of Statistics. 2004. Indicator: Rate adjusted of mortality x 100 000 inhab. of the female sex Purpose 16: Diminish in 30% the case-fatality from enfermedadcerebrovascular. Goal:

Baseline 2010 2015 19.9% 15% 30% 19.9 16.9 13.9

Source: SIE of health. National Directorate of Statistics. 2004. Indicator: Case-fatality rate x 100 discharges.


Diabetes mellitus

Diabetes mellitus was the eighth cause of death in 2004. The prevalence rate of diabetes have been maintained with increase in the past quinquennium. In recent years they are reported between 1 400 and 1 800 dead from this cause annually. In 2004 they represented 2.3% of the total of dead of the country, with a significant mortality increase with regard to the year 2003, with 153 deaths more. In the previous decade, they were lost on the average from 1 to 2 years of life per every 1 000 population between 1 and 74 years for this cause. In 2004 23 247 new cases of diabetes were reported which means that 342 371 dispensarizados patients are registered (30.5 per every 1 000 population). Is estimated that the rate expected from diabetics known for the country is of approximately 38 x 1 000 inhab, however by surveys more recent and what is observed worldwide is considered that the total prevalence rate could be around 60 x 1 000 inhab, which would cause that the proportion unknown diabetes/ known diabetes was around the unit. Practically in the all the countries there is an increase in the incidence and in prevalence, basically associated with the increase in the overweight and obesity as well as to population aging. It is a major cause of morbidity, disability, and mortality, in addition to constituting an essential risk factor in major causes of death in the country, as the myocardial infarction, the encephalic vascular accidents and the terminal renal failure. Purpose 17: Increase in 30.0% the diabetes mellitus diagnosis. Goal:

Baseline 2010 2015 30.5 15% 30% 30.5 35.1 39.7

Source: SIE of health. National Directorate of Statistics. 2004 Indicator: prevalence rate x 1 000 inhabitants. Purpose 18: Increase in 15% the controlled diabetics. Goal:

Baseline 2010 2015 70% 7% 15% 70 74.9 80.5

Source: Database of the Department of Epidemiology of the INEN from surveys. Indicator: Percentage of cases with glycosylated hemoglobin less than 7%. Purpose 19: Reduce in 30% mortality from Diabetes Mellitus. Goal:

Baseline 2010 2015 11.4 15% 30% 11.4 9.7 7.8

Source: SIE of health. National Directorate of Statistics. 2004. Indicator: Rate adjusted of mortality x 100 000 inhab. Purpose 20: Diminish the disabilities by diabetes mellitus. Goal: Baseline 2010 2015 Blindness/RetinopatíaAmputaciones 2.7%

3.3% 2% 2.6%

1.4% 2%

Fuente: Diabetes Drafting Group: Prevalence of small vessel disease and large vessel disease in diabetic patients from 14 centers. Diabetology 28:615-640. 1985. Indicator: Percentage of blind diabetics by diabetic retinopathy. Indicator: Percentage of diabetics with greater amputations.


Chronic renal disease The Chronic Renal Disease (ERC) is emerging as an important and growing health problem in Cuba, it occupied in 2004 the position number thirteen as cause of death; reportandose 503 deaths, figure that represented 0.6% of the total of dead. The prevalence of dispensarizados patients who have progressed to the Chronic Renal Failure (HSR) nationally in 2004 it was of 9 761 patient, that is 0.87 per every 1 000 population. Epidemiological research has demonstrated that the prevalence expected by ERC is of 1 800 360 patients. Of them awaited with HSR 210 360 patients and with Terminal Chronic Renal Failure (IRCT) 3 360 patients, who are those which will require some substitutive treatment of the function renal (dialysis or renal transplant). It is evident that there exists a subdiagnosis of the disease. The incidence and the prevalence of patients in dialysis have a growing trend. The incidence has been increased on the average 14% annually, hiting 1 246 patient, 111 per million inhabitants and the prevalence has increased on the average 11% annually, hiting 1 666 patients, 149 per million inhabitants, in 2004. In that same year 186 renal transplants were carried out, 16.6 per million inhabitants. Purpose 21: Increase the diagnosis of chronic renal disease and chronic renal failure. Goal:

Baseline 2010 2015 ERC - 50 100 HSR 0.87 5.0 10.0

Source: SIE of health. National Directorate of Statistics. 2004. Indicator: Prevalence of patients dispensarizados x 1 000 inhabitants. Purpose 22: Diminish in 10% the incidence of patients in need of dialysis. Goal:

Baseline 2010 2015 111 5% 10% 111 105 100

Source: Center of National Coordination of the Program of ERC, Dialysis, and Renal Transplant. Indicator: Incidence of patients in dialysis. Patients per million of population (PMP). Purpose 23: Reduce in 50% mortality in dialysis. Goal: Baseline 2010 2015 31.7% 25% 50% 31.7 24 15.9 Source: Center of National Coordination of the Program of ERC, Dialysis, and Renal Transplant Indicator: Crude death rate per year (%). Purpose 24: Meet the total need of patients in dialysis. Goal:

Baseline 2010 2015 149 268 478

Source: Center of National Coordination of the Program of ERC, Dialysis, and Renal Transplant. Indicator: Prevalence of patients in dialysis PMP. Purpose 25: Carry out renal transplant to every patient who needs it. Goal:

Baseline 2010 2015 16.6 25 50


Source: Center of National Coordination of the Program of ERC, Dialysis, and Renal Transplant. Indicator: Rate renal transplants per year PMP. Purpose 26: Increase in 50% the survival of the renalprimario graft of donor carcass per year. Goal:

Baseline 2010 2015 60% 25% 50% 60 75 90

Source: Center of National Coordination of the Program of ERC, Dialysis, and Renal Transplant. Indicator: Rate of actuarial survival of the primary renal graft dedonante corpse to the year (%). Chronic diseases of the respiratory tract They were the seventh cause of death in 2004. In the previous decade they are reported between 2 000 and 2 500 dead from this cause annually. Amounting to 3 062 deaths in 2004, which represented 3.8% of the total of dead of the country with an increase in 154 deaths more with regard to the year 2003. It causes also fifth years of life lost. In recent years there were lost on the average between 1.2 and 2 years of life per every 1 000 population between 1 and 74 years for this cause.

Chronic diseases of the lower respiratory tract

Chronic obstructive pulmonary disease It is the leading cause of death from chronic diseases of the lower respiratory tracts. They represented of 8-10% of attendance at consultations of the family doctor and 35% of the consultations to pneumologists. A high prevalence in the male sex and a rising trend in women. Bronchial asthma From the year 1999, this entity has experienced an increase in the dispensing in primary health care. In 2004 most prevalent constituted the second disease, 87.4 x 1 000 inhab. (982 218 dispensarizados), figure that was increased in 1.4% in comparison with 2003; r epresentó the leading causes of hospital discharges within the non-communicable diseases. In 2004 the risk of dying from this cause was of 2.4 x 100 000 inhab. Extra-hospital mortality continues to fluctuate of a 50 to 64%, being higher in the cities. By age groups in 2004 the behavior was of one over 65 years of age 9.9 x 100 000 inhab and people under 65 1.5 x 100 000 inhab. Purpose 27: Reduce mortality from chronic pulmonarobstructiva disease in 5% in men and 8% in the women. Goal:

Baseline 2010 2015 Masculino 17.4 2% 5%

17.4 17 16.5 Femenino 11.4 3% 8%

11.4 11.1 10.5 Source: SIE of health. National Directorate of Statistics. 2004. Indicator: Rate adjusted of mortality x 100 000 inhab. Purpose 28: Reduce in 10% mortality from bronchial asthma. Goal:

Baseline 2010 2015 1.8 5% 10%

1.8 1.7 1.6 Source: SIE of health. National Directorate of Statistics. 2004. Indicator: Adjusted mortality x 100 000 inhab.


Purpose 29: Reduce in 45% extra-hospital mortality from bronchial asthma. Goal:

Baseline 2010 2015 64.4% 20% 45% 64.4 51.5 35.4

Source: SIE of health. National Directorate of Statistics. 2004. Indicator: Percentage of asthmatic that die outside the hospital. Purpose 30: Diminish in 25% the female excess mortality by bronchial asthma. Goal: Baseline 2010 2015 1.2 12% 25% 1.2 1.1 0.9 Source: SIE of health. National Directorate of Statistics. 2004. Indicator: Reason women dead of bronchial asthma/ men dead of bronchial asthma.

Mental disorders and self-inflicted injuries Depression It is presented with a prevalence of 4.9%. Primary care studies report that 25% of the people who demand health services are depressed and less than the 40% has received antidepressive treatment. It evolves toward the chronicity in 60% of people and relapses occur between 50% and 80% of patients. It is responsible for 52% of the loss of the productivity and the absenteeism and of 17% of the disability and suicide. Dementia and Alzheimer’s disease In recent years they are reported between 1 600 and 2 200 dead from this cause. In 2004 they represented 2.8% of the total of dead of the country, with the occurrence of 199 deaths more than in the previous year. It caused fourteenthly years of life lost in the country. In the previous decade, they were lost on the average from 1.3 to 2.3 years of life per every 1 000 population between 1 and 74 years for this cause. According to studies conducted in 2003, 99.4% of the dead with Dementia and Alzheimer were 60 years old or more, and of 100% of the dead, 89% belongs to the group of 75 years and more. The trend of this cause it is to the increase and it is calculated that there exist 250 000 patients of Alzheimer in our country for 2020. Schizophrenia In 2004 26 205 patients were dispensarizados, for a rate of 2.3 x 1 000 inhab. This cause reduces life expectancy of the individual in an average of 10 years. 80% of the schizophrenic patients remain in the community. Nearly 60% of the beds in psychiatric hospitals are occupied by these patients. Self-inflicted injuries They were in 2004 the tenth cause of death. In the previous decade some 1 500 deaths are reported for this cause annually. In 2004 they contributed 1.8% of the total of dead of the country, being reported 1 499 deaths. In recent years they were lost on the average from 3 to 4 years of life per every 1 000 population between 1 and 74 years for this cause. In 2004 11 503 on purpose suicidal new cases were reported (102.3 x 100 000 inhabitants). The suicidal attempt affects the ages above 9 years, in greater proportion with the increase in the age. Purpose 31: Increase up to 90% the proportion of schizophrenic patients incorporated to programs for community rehabilitation. Goal: Baseline 2010 2015

81% 85% 90%


Source: Provincial GOSMA. 2004. Indicator: Percentage of schizophrenic patients who remain in the community and have an individualized rehabilitation plan consonant with its degree of validísimo, capacities, and needs. Purpose 32: Reduce adjusted mortality by suicide in the general population. Goal:

Baseline 2010 2015 13.3 12.0 10.8

Source: Continuous Statistics of the National Directorate of Statistics. 2004. Indicator: Adjusted mortality x 100 000 inhabitants. Accidents and assaults Accident prevention can be considered a public health emergency and a social emergency due to high mortality, morbidity and disability that cause, as well as the high economic cost that directly or indirectly represent and by the enormous burden of human suffering that behave. In Cuba, for several decades, accidents appear among the leading causes of death for all ages, although with greater incidence in children, young people, and adults more than agreement to the type of accident, they occupied the fourth cause of general mortality until since 1999 they were displaced to the fifth place by influenza and pneumonia. In the children under one year of age they represent the sixth cause of death, the first in the group from 1 to 19 years, the second in that from 15 to 49 years and the fifth in that of 50 a64 years. The greatest incidence is in the male sex. The traffic accidents are those of greater severity and the falls are the most frequent causes of non-fatal injuries. Accidents occupied in 2004 the fourth place in potential years of life lost, with a figure of 9.6 per 1 000 population. Within the accidents, those of transit and the accidental falls are responsible for almost 70% of the dead and both represent the highest levels of violent deaths. The Assaults occupy place 12 º as cause of death in 2004, being observed a male excess mortality, with a total of 508 deaths and 150 of the female sex. Deaths are distributed in all the age groups, with the highest figures in the group from 15 to 39 years old, with a total of 421 deaths, than it represents 64% of deaths for this cause. In Potential Years of Life Lost (PYLL), it occupies the tenth position, being lost per every 1 000 population, 2.6 years of life for all ages, and both sexes, in 2004. In the group from 15 to 59 years old the highest rates are reported. The most frequent causes of homicides were the assaults by knife in 70.3% followed by the assaults by firearm and the strangulations, with 9.3% each one of them. An interesting datum results the fact that more than 50% of the cases of homicide, in which there was not hospital stay, they had positive blood alcohol.

Purpose 33: Reduce in 20% mortality from accidents. Goal: Baseline 2010 2015 28.2 10% 20% 28.2 25.4 22.6 Source: SIE of health. National Directorate of Statistics. 2004. Indicator: Adjusted mortality x 100 000 inhab.

Purpose 34: Reduce in 20% mortality by accidental falls. Goal:

Baseline 2010 2015 13.1 10% 20% 13.1 11.8 10.5

Source: SIE of health. National Directorate of Statistics. 2004. Indicator: Rate adjusted of mortality x 100 000 inhab.


Purpose 35: Reduce in 20% mortality by accidents links-two to the transit. Goal:

Baseline 2010 2015 10.8 10% 20% 10.8 9.7 8.6

Source: SIE of health. National Directorate of Statistics. 2004. Indicator: rate adjusted of mortality x 100 000 inhab.

Purpose 36: Reduce in 25% mortality by assaults. Goal:

Baseline 2010 2015 5.1 12% 25%

5.1 4.5 3.8 Source: Continuous Statistics of the National Directorate of Statistics. 2004. Indicator: Rate adjusted of mortality x 100 000 inhab. Preventable blindness

According to estimates of the World Health Organization, in the planet, the prevalence of blindness for all the causes currently amounts to 50 million blind people with an annual increase in 2.5 million, of those which 90% are in developing countries. In Cuba it is considered that the magnitude of the problem can be in 60 000 blind for all the causes, that is 1: 200 inhabitants, of them 33 600 by cataracts. A rapid survey of prevalence of blindness due to cataract in patients older than 50 years in City of Havana, applied in 2005, showed the following results: from a total of 2 713 people older than 50 years examined it was concluded that the prevalence of blindness, for all the causes, was of 2.3%. The causes were the following ones: 50% blindness due to cataract, 26% by glaucoma and 9% by diabetic retinopathy. The leading causes of preventable and treatable blindness in Cuba are: cataract, glaucoma, diabetic retinopathy, corneal disorders, and retinopathy of the prematurity. The frequency of cases of retinopathy of the prematurity in Cuba is of 1 per 10 000 live births and currently constitute 20% of the students registered in schools of ambliopes and weak visual. Purpose 37: Eliminate preventable blindness.

Indicator Baseline 2010 2015 Prevalence of Blindness 2.3% to Eliminate to Maintain Cataracts 50% to Eliminate to Maintain Glaucoma 26% to Eliminate to Maintain Diabetic Retinopathy 9% to Eliminate to Maintain Continuation. Purpose 37: Eliminate preventable blindness.

Indicator Baseline 2010 2015 Corneal Disorders 12% to Eliminate to Maintain Retinopathy of the Prematurity 20% to Eliminate to Maintain Macular Degeneration related to the age 15% to Control to Maintain Source: RACSS National Survey, National Program of Eye Health. Indicator: Percentage of population.

Osteoarticular diseases According to the Health study Welfare and Aging (HE KNOWS), carried out to a sample of adults more than City of Havana in 2000:


a) 55.6% of the older adults report suffering from arthrosis. b) The female sex reports suffering from arthritis in a frequency higher than the one

aforementioned by men (66.8% and 39.5% respectively). A study in City of Havana in population between 18 and 60 years showed that 39% of the people had had, at least once previously, a sacrolumbalgia, which produced them different affectations of its quality of life. There do not exist in the Cuban scientific community other studies of prevalence of this disease. However, it is consensus of all the experts, the elevated prevalence of this entity in the population, which implies a significant impact on the use of services and the increase in the charge of disability. With regard to osteoporosis, the prevalence studies in the Cuban population are also limited. Purpose 38: Reduce in 20% mortality from Hip Fracture. Goal:

Baseline 2010 2015 8.4 10% 20%

8.4 7.5 6.7 Source: SIE of Health. National Directorate of Statistics. 2004. Indicator: Adjusted mortality x 100 000 inhab. Chronic Noncommunicable Diseases and Other Health Impairments – Directives

1. Develop an information, education, and social communication strategy for the prevention and control of chronic noncommunicable diseases and other health conditions.

2. Strengthen inter sector and community participation, the role of the polyclinic and hospital, emphasizing excellence medical care as well as health promotion, prevention, treatment and rehabilitation activities associated with chronic noncommunicable diseases and other health conditions.

3. Enhance the surveillance system for risk factors, chronic noncommunicable diseases, and other health conditions to facilitate the timely implementation of intervention activities.

4. Improve interdisciplinary efforts to control the main chronic noncommunicable diseases and other health conditions by strengthening technical advisory commissions and bolstering the participation of the national research institutes at the different levels of the National Health System.

5. Improve the allocation of supplies to patients with chronic noncommunicable diseases and other health conditions, ensuring adequate screening, control, and continuity of care for these patients.

6. Implement new guidelines for the prevention and control of the main chronic noncommunicable diseases and other health conditions, with emphasis on the primary health care approach.

7. Improve the national cardiology, oncology, and diabetic care centre networks.

8. Improve and modernize diagnostic and therapeutic technologies used to improve the prevention and control of chronic noncommunicable diseases and other health problems, such as the causes of violence.

9. Carry out comprehensive early and community-based rehabilitation activities for people with chronic noncommunicable diseases and other health problems aimed at reducing disability rates increasing their social rehabilitation.

10. Improve the quality of death certificates of those who succumb to chronic noncommunicable disease, using clinical, anatomic-pathological, electrocardiographic, and enzymatic criteria, as well as background information regarding the deceased’s chronic noncommunicable disease(s).


11. Carry out monthly analysis of all deaths at the polyclinics and hospitals, with particular emphasis on those occurring as a result of acute myocardial infarction, cancer, cerebrovascular disease, diabetes mellitus, chronic obstructive pulmonary diseases, bronchial asthma, renal failure, suicide, accidents, violence, and other major causes, in order to identify relevant factors and carry out the appropriate interventions.

12. Promote and support specific projects that help prevent the most common types of violence in our environment, that educate the community on the causes and effects of violence, and that encourage people to abandon the notion that violence in unavoidable.

13. Promote compliance with current legislation associated with accidents, assaults, and their risk factors.

14. Implement a surveillance system on the risk factors, chronic noncommunicable diseases, and other health problems associated with causes of preventable blindness.

15. Improve the National Ophthalmology Network through the introduction of new technologies and ongoing training opportunities for professionals and technical personnel.

16. Set up a national program for the elimination of preventable blindness with a presence at all levels of the National Health System.

IV. Oral Diseases Dental caries, an infectious and preventable disease associated with lifestyles and affecting 98% of the world’s population, is considered to be the most prevalent disease worldwide. The international indicator used for its comparison among countries is the average index of decayed, missing and filled teeth at the age of 12 (DMFT). The World Health Organization (WHO) recommends a DMFT value of less than 3 for children 12 years of age. In Cuba, 90% of the population has had some experience with caries. By age 5, some 2% of children have caries. Children 12 and over are the group most affected. It is the leading cause of tooth loss. Gum disease, whose causes are considered complex, in nevertheless reversible. Gingivitis is currently the most prevalent oral disease, and can be found in practically 100% of the population with teeth. The prevalence of periodontal disease among adults in the United States has been estimated to be as high as 70%, and in Germany the prevalence is 3.6% for adults aged 35 to 44, and 2.6% for those aged 65 to 74, while the corresponding figures for Japan are 4.2 and 3.6, respectively. These diseases are strongly linked to lifestyle and socioeconomic status, and are the second leading cause of tooth loss. In Cuba, some 52% of the total population is affected to some degree. The most affected group is ages 35 to 44, with a prevalence of 74.5%. The female population has greater prevalence than their counterparts (54%). Occlusion disorders can cause aesthetic and functional alterations: chewing, swallowing, speech, and breathing. Furthermore, these disorders make the individual susceptible to dental traumas, caries, gum and periodontal diseases, as well as muscular and articular dysfunctions. Malocclusion patterns worldwide fluctuate in the range of 35% to 75%, differing by sex and age. In Cuba, according to a 1998 national health survey of 1,197 children ages 5, 12, and 15, malocclusions affected 20%, 44%, and 35%, respectively (total of 33.2%).

Purpose 1: Achieve a 40% decrease in the prevalence of caries among the Cuban population.

Goal:

Baseline 2010 2015 % of children with dmf-t + DMFT index = 0 at age 5

55% 10% 20% 55 49.5 44

DMFT index at age 12 1.6 25% 40% 1.6 1.2 1.0

% of population [1] teeth 76% 10% 20% 76 83.6 91.2

Average missing teeth of age [2] 6.6 10% 40%


6.6 5.9 3.9 Average missing teeth of age [3] 20.6 13% 17%

20.6 18 17 Source: National Oral Health Study. Cuba. 1998. National Bureau of Stomatology. MINSAP. Purpose 2: Achieve a 15% increase in the percentage of population without gum and periodontal diseases.

Goal:

Baseline 2010 2015

48% 7% 15%

48 51.3 55.2

Source: National Oral Health Study. Cuba. 1998. National Bureau of Stomatology. MINSAP. Indicator: % of population without gingival or periodontal problems.

Purpose 3: Achieve a 12% increase in the percentage of child and adolescent population without malocclusions.

Goal:

Baseline 2010 2015

66.8% 5% 12%

66.8 70.1 74.8

Source: National Oral Health Study. Cuba. 1998. National Bureau of Stomatology. MINSAP. Indicator: % of child population (up to age 15) without malocclusions.

Oral diseases – Directives:

1. Educate the population on the importance of oral health and how to maintain it.

2. Strengthen prevention activities, primarily fluoridation of consumer salt, systematic use of fluorine mouthwash and lacquer fluorine applications; ensure the availability of toothbrushes at schools and early detection of inadequate habits.

3. Strengthen the content of oral health promotion in curricula of the Medical Sciences.

4. Maintain and increase the stability of human resources in dentistry.

5. Rehabilitate dental care services with a view to improving coverage and access to oral health services.

6. Carry out early detection activities for oral cancer through active screening, improving the quality of examinations and diagnosis, and monthly forensic examinations of those who succumb to this cause at dental care services.


V. Communicable, Emerging, and Re-emerging Diseases Influenza and Pneumonia

Influenza and pneumonia are the fourth leading cause of death for all ages. In recent years, between 5,000 and 6,900 deaths have been reported annually due to this cause. In 2004, these deaths represented 8.1% of the country’s total deaths, reflecting a 16.4% increase in mortality over the previous year. It is also the fifth leading cause of life years lost. Over the past decade, average life lost due to this cause ranged from 1.5 to 2 years per 1,000 of the population between the ages of 1 and 74 years. The population over age 65 is most affected (56.4%) and of this group there were 1,405 deaths of those over age 85, representing 53%. Over the past three years, 5 million medical consultations have been reported annually due to this cause, and it accounted for 30% of hospitalizations. In 2004, a total of 4,570,926 medical consultations were reported for this cause, a rate of 407 per 1,000 pop.

Purpose 1: Achieve a 40% reduction in mortality due to influenza and pneumonia in the population over age 65.

Goal:

Baseline 2010 2015

500.3 20% 40%

500.3 400.2 300.2 Source: Health Statistics Information System (SIE). National Bureau of Statistics. 2004.

Indicator: Mortality per 100,000 pop. over age 65.

STI/HIV/AIDS In Cuba, the HIV/AIDS epidemic has maintained slow but sustained growth since 1996. Between 1986 and December 2004, a total of 6,025 HIV positive individuals have been diagnosed with HIV, 2,535 of which have gone on to develop full-blown AIDS, and a total of 1,222 individuals have succumbed to the disease. During 2004, a total of 768 new infections were diagnosed as opposed to 740 in 2003, representing an increase of 28 cases. In 2004, the epidemic grew by 3.8% with respect to the previous year, while there was a 14.9% increase in 2003 with respect to 2002. Syphilis and blennorrhagia have been continuing a downward trend, and several factors have been identified as determinants of this trend: self-medication, underreporting of cases, and deficient laboratory diagnosis.

Purpose 2: Achieve a 14% reduction in the incidence of HIV/AIDS in the population between the ages of 15 and 34.

Goal:

Baseline 2010 2015

13.8 7% 14%

13.8 12.8 11.9 Source: Epidemiological Surveillance Annual Report, Bureau of Epidemiology, MINSAP, 2004.

Indicator: Incidence rate of HIV per 100,000 pop.

Purpose 3: Achieve a 13% reduction in mortality due to HIV/AIDS. Goal:

Baseline 2010 2015

0.7 7% 13%


Indicator: Adjusted rate of mortality from HIV x 100 000 pop.


Enteric Diseases Acute Diarrheal Diseases (ADDs) In 2004, a total of 674,401 medical consultations were sought for ADDs, accounting for a morbidity index of 60 per 1,000 pop., and resulting in 241 deaths for a general mortality rate of 2.1 per 100,000 pop. ADDs are one of the leading causes of disease and death among children under age 5 in the developing countries, responsible for approximately 1,500 million episodes in children under 5, and resulting in 3.2 million annual deaths in that age group. Recorded morbidity due to intestinal infectious diseases over the last 15 years has not exceeded 0.2 medical consultations per child per year. The group with the highest demand for such care are children under age 1. In our country, mortality due to intestinal infectious diseases is very low among children under age 15, with 1.0 deaths per 100,000 population under age 15, and 0.1 deaths per 1,000 live births among children under age 1.

Purpose 4: Achieve a 25% reduction in morbidity due to Acute Diarrheal Diseases (ADDs)


60 12% 25%

60 53 45 Source: Health Statistics Information System (SIE). National Bureau of Statistics. 2004.

Indicator: Index of medical care for ADDs per 1,000 pop.

Hepatitis A Virus The greatest incidence of hepatitis A is found in the developing countries, especially in tropical regions, where poor hygienic conditions favour transmission of the virus. In these countries, infection is endemic and 100% of children are infected before age 10. Countries with a high degree of development are considered to have low endemicity, and, consequently, only a limited number of Hepatitis A cases are detected. Each year, 10 million cases are reported worldwide. Natural epidemic cycles appear in the developed countries every 10 years, and every 3, 5, or 10 years in the developing countries, resulting in economic losses on the order of US$3 billion annually. Prior to 1989, all viral hepatitis in Cuba was reported only as viral hepatitis, because serotype classification was not carried out. Beginning that year, classification of hepatitis B began on the basis of surface antigen identification (HBsAg), whereas IgM anti-VBc and the remainder were classified with this diagnostic criterion, in addition to clinical and epidemiological criteria, under Hepatitis A. In 1998, the diagnosis of hepatitis C was introduced on the basis of anti-VHC; so any hepatitis not classified as B or C were considered hepatitis A through exclusion criterion. Currently, laboratory diagnosis of hepatitis A is carried out on all pregnant women who develop viral hepatitis and on cases admitted to hospital due to this disease. Moreover, confirmation is carried out on between 5 and 10% of cases resulting from outbreaks nationwide. In the period between 1989 and 2002, of a total of 274,092 reported cases of viral hepatitis, 77.4% were type A; 6.6% type B; 0.3% type C; and 15.5% were unclassified.

Purpose 5: Achieve a 60% decrease in the incidence of Hepatitis A. Goal:

Baseline 2010 2015

90.6 30% 60%

90.6 63.4 36.2 Source: SIE Health Statistics Information System (SIE). National Bureau of Statistics. 2004.

Indicator: Incidence rate per 100,000 pop.


Eliminated, Emerging, and Re-emerging Diseases The growing inflows of foreign personnel to the country from endemic areas and outflows of Cuban personnel for destinations abroad, in addition to the inherent conditions in our environment that facilitate the emergence and re-emergence of these diseases, require us to keep close watch over this situation.

Malaria: Morbidity from malaria in 2004 consisted of 26 imported cases, of which Cubans accounted for 53.8% (14 cases) and foreigners, for 46.1% (12 cases). It took the form of local outbreaks of varying intensity.

Dengue: By the end of 2004, a total of 112 cases of dengue in people evacuated from Venezuela, and 17 imported cases of dengue were reported. It took the form of local outbreaks of varying intensity.

Rubella: A rubella outbreak occurred in 2004. A total of 141 cases were detected in foreigners, resulting in transmission to 18 Cubans. Transmission of rubella depends on the levels of immunity we achieve through vaccination and imported cases.

Leptospirosis: In 2004, a total of 294 cases were confirmed, resulting in a rate of 2.6 per 100,000 pop. A total of 29 deaths were attributed to this cause, for case-fatality of 10.4%. Endemic epidemic disease in Cuba is closely linked to the rainy season and transmission to people through contaminated water.

Parotiditis: During 2004, several outbreaks of Parotiditis were reported.

Rabies: In 2004, a total of 111 cases of animal rabies were reported. The risk to humans of contracting the disease remains high, inasmuch as the reported number of people bitten by animals each year is very high.

Purpose 6: Ensure that eliminated diseases do not remerge, and continue to reduce morbidity and mortality rates due to infectious diseases, primarily leptospirosis, tuberculosis and infectious diseases of the nervous system.

Indicator Baseline 2010 2015

Incidence of diphtheria Eliminated Maintain Maintain

Incidence of whooping cough Eliminated Maintain Maintain

Incidence of neonatal tetanus Eliminated Maintain Maintain

Incidence of measles Eliminated Maintain Maintain

Incidence of poliomyelitis Eliminated Maintain Maintain

Incidence of rubella Eliminated Maintain Maintain



Incidence of Parotiditis 2.5 Eliminate Maintain

Incidence of tuberculosis 6.6 Decrease Decrease

Incidence of leptospirosis 2.6 Decrease Decrease

Incidence of meningococcal meningitis 0.2 Decrease Decrease

Incidence of Hib meningoencephalitis 0.1 Decrease Diminish

Incidence of leprosy 1.9 Decrease Decrease

Incidence of tetanus 0 Maintain Maintain

Incidence of syphilis 24.0 Decrease Decrease

Source: 2004 Statistical Yearbook

Indicator: Rate per 100,000 pop.

Purpose 7: Prevent the introduction of exotic diseases to our country such as malaria, dengue, SARS, avian influenza, West Nile fever, cholera, and others.


Incidence of malaria 0 Maintain Maintain

Incidence of dengue 0 Maintain Maintain

Incidence of SARS 0 Maintain Maintain

Incidence of avian influenza 0 Maintain Maintain

Incidence of West Nile fever 0 Maintain Maintain

Incidence of cholera 0 Maintain Maintain

Source: 2004 Statistical Yearbook

Indicator: Rate per 100,000 pop. of introduced and/or indigenous cases.

Infections in health institutions Hospital-acquired Infections (HIs) are an international health problem. Anywhere from 6 to 12% of hospitalized patients acquire HIs. Case-fatality due to these infections is 5%, but varies by hospital and health service. WHO studies indicate average incidence rates of 8.7%. Approximately 1.4 million people acquire one HI each year. The most common HIs are associated with surgical wounds, urinary tract, and lower respiratory tract infections. HIs are most often contracted by ICU, surgical, and orthopaedic patients. HIs are also a health problem in Cuba, acquired by between 2 and 3 patient per 100 discharges. HIs most frequently occur at health services that provide intensive care. Due to the deterioration suffered by hospitals during the Special Period in Peacetime, both with regard to organizational structure and specialized surveillance personnel, in addition to the weakening of microbiology, it is estimated that underreporting of HIs may mean that the total infections of this type were actually as much as 25% higher.

Purpose 8: Achieve a 20% reduction in the indicator of hospital-acquired infections at health institutions.


Goal:

Baseline 2010 2015

5 10% 20%

5 4.5 4 Source: Estimated rate. National Bureau of Epidemiology.

Indicator: Index of hospital infection x 100 discharges.

Purpose 9: Decrease the incidence of risk (intensive care) at the health services.

Goal:

Baseline 2010 2015

ICU 6 7% 15%

6 5.6 5.1

PICU 4 8% 15%

4 3.7 3.4

NICU 10 12% 25%

10 8.8 7.5

Source: Estimated rate. National Bureau of Epidemiology.

Indicator: Hospital infection rates for risk services.

Purpose 10: Achieve a 10% decrease in case-fatality due to hospital infections in intensive care units.

Goal:

Baseline 2010 2015

5% 10%

ICU 11.8 11.2 10.6

PICU 12.7 12.1 11.4

AICU 14.2 13.5 12.8 Source: Estimated rate. National Bureau of Epidemiology.

Indicator: Case-fatality rate for hospital infections.

ICU: Intensive care unit (adults)

UTIP: Paediatric intensive care unit

NICU: Neonatal intensive care unit

Communicable, Emerging, and Re-emerging Diseases – Directives 1. Immunization coverage a. Over 95% of child population with triple viral (MMR); b. Over 95% of child population with tetravalent (DPT/hepatitis B); c. Over 95% of adult population with tetanus toxoid; d. 100% of pregnant women with tetanus toxoid; e. Over 95% of children under age 1 with antimeningococcal; f. Over 95% of children under age 1 with Haemophilus influenza; g. Achieve 95% revaccination of groups vaccinated according to established priorities; h. Over 98% of newborns with BCG; i. Ensure all over age 60 receive flu shots; j. Ensure exposed population receives vaccination for leptospirosis;


k. Introduce the pneumococcal conjugate vaccine (PCV) for children under age 1 and for the general population at age 60; l. Continue vaccination with MMR of sixth graders (age 11); m. Introduce booster vaccination of ninth graders with adult tetanus and diphtheria (Td), and continue to administer booster vaccination every ten years thereafter at that age, to include the general population of all ages; and n. Carry out hepatitis-A vaccination campaigns targeting the main school-age risk groups, and incorporate the vaccine into the vaccination series from age 1.

2. Continue annual vaccination campaigns against poliomyelitis, maintaining surveillance and analyzing each case of flaccid paralysis;

3. Fortify the surveillance system for measles, rubella, and Parotiditis. Introduce IgM-Elisa diagnostic techniques for these diseases at selected Provincial Centres for Hygiene and Epidemiology in all three regions of the country.

4. Incorporate the pentavalent vaccine (DTPw-HB/Hib) into the national vaccination series by 2007.

5. Conduct monthly forensic analysis of patients age 65 and older who succumb to pneumonia.

6. Develop, with the participation of all social sectors, an HIV/AIDS social communication strategy aimed at groups vulnerable to the epidemic (i.e., men who engage in sexual activity with other men, adolescents and young adults, and women).

7. Enhance medical care for persons living with HIV and reorient the health strategy. Complete the decentralization of the health services, and perform testing, monitoring, and evaluation of the infection/disease.

8. Strengthen the HIV/AIDS epidemiological surveillance system at all levels, with a view to implementing timely intervention activities.

9. Carry out epidemiological and socio cultural research on vulnerable groups with emphasis on men who have sex with other men.

10. Enhance production of antiretroviral drugs in the country, with a view to ensuring that all people living with HIV who need them will have access to these drugs.

11. Enhance the social strategy for promoting condom use in the country.

12. Strengthen the work of the Operational Groups to Combat and Control AIDS (GOPELS).

13. Ensure that 80% of early screening for tuberculosis is performed at the primary care level, and strengthen the work of the tuberculosis control program.

14. Ensure that 90% of early screening for leprosy is carried out at the primary care level. Maintain therapy with multiple drugs in 100% of leprosy patients.

15. Strengthen the national microbiology network.

16. Guarantee the optimal safety and quality of the blood and blood products and all related processes.

17. Strengthen and enforce all regulations associated with biological safety at health institutions.

18. Strengthen national epidemiological surveillance and the system of international information on infectious diseases in general, particularly for countries maintaining relations with our country.

19. Increase national response capacity in emerging situations owing to the introduction of exotic diseases.

20. Guarantee the actions of the international sanitary control program, especially with regard to implementing the control system at the source of all endemic countries where we have collaborators.

21. Develop local programs at each institution to address the problems and factors identified, with a view to preventing hospital-acquired infections.


22. Institute guidelines for good clinical practice at each medical service to ensure standards and procedures are in place to prevent hospital-acquired infections.

23. Actively participate in the remodelling, rehabilitation, and/or repair of hospitals and primary care institutions to ensure their construction complies with hygiene and sanitary requirements.

24. Institute a program to revitalize disinfection procedures, including the necessary quality control inputs for disinfection.

25. Develop a policy for antibiotics geared toward the characteristics of infection patterns at each hospital, based on microbiological maps and guides of good practices for managing infections.

VI. Disability In the period from 2001-2003, a psychosocial study was conducted of people with disabilities, psycho pedagogical, social, and genetic aspects of the mentally retarded. The study examined all people with disability (PCD), excluding those with minor disabilities, somatic disabilities (except for chronic renal insufficiency not suitable for dialysis) or those of a temporary nature. Accordingly, the prevalence of disabilities is believed to be greater than reported below. This constitutes an emerging problem that today’s society needs to address. Studies of the problem report a disability rate of between 7 and 7.5%. The rate of prevalence of some type of disability was of 3.2% (366,864 individuals), and the mental retardation rate was 38.9% (140,489 individuals). The prevalence of other disabilities includes: physical/motor 25.2% (92,506 individuals); visual 12.6% (46,455 individuals); mental 10.05% (36,869 individuals); mixed 6.8% (25,094); and auditory 6.4% (23,820 individuals). Of particular interest is disability among the elderly. According to data of the City of Havana, the prevalence rate of disabilities among seniors ages 60 to 74 is 13.8%, and is more than double (30.7%) among seniors age 74 and older. With respect to the basic activities of daily life, prevalence rates are higher: 16.9% for the former group and 45.2% for the latter. In both cases, the rates for women are nearly twice that of men.

Purpose 1: Increase the rehabilitation rate of people with low vision.

Goal:

Baseline 2010 2015

71% 80% 85%

Source: Ongoing statistics of the provincial services for low vision.

Indicator: Percentage of people with low vision rehabilitated.

Purpose 2: Increase screening for auditory losses in newborns and children under age 3 at risk.

Goal:

Baseline 2010 2015

30% 70% 85%

Source: Ongoing Statistics of the Neonatology services.

Indicator: Percentage of newborns and children under 3 at risk of auditory losses surveyed.

Purpose 3: Achieve a 25% increase in the effectiveness of rehabilitation services for accident victims.

Goal:

Baseline 2010 2015

5% 12% 25%

Source: Ongoing statistics of the rehabilitation services.

Indicator: Percentage of accident victims rehabilitated.


Disability – Directives 1. Implement a national system of statistics on disability and rehabilitation in all provinces of the

country. 2. Apply the new International Classification of Functioning, Disability, and Health as a tool for

statistical and research applications, as well as for social, educational, clinical policy. 3. Apply the system of disability assessment, recognition, and certification. 4. Implement the observatory on disability. 5. Improve the results obtained at the rehabilitation services. 6. Expand the application of programs for early detection and care, especially for children with

developmental disorders, disabilities, or high risk. Improve screening systems for auditory losses and low vision.

7. Expand support services and specific required by persons with disabilities, especially for the most critically disabled, in coordination with the social services of the Ministry of Labour and Social Security.

8. Decentralize the system for distributing technical devices and delivering other services to people with disabilities, with a view to improving their geographical access.

9. Apply the Cuban Standards for Access to physical spaces, in both new construction and the repair and remodelling of SNS installations, in a way that eliminates barriers to access to such facilities and nearby public infrastructure.

VII. Special Environments Healthy Schools The school environment is of great concern for the country because it is where children and young children are, the country is immersed in efforts designed to improve the Cuban Educational System, as a part of the Battle of Ideas. There are elements that are necessary to have in mind and pay attention to; the potential dangers from accidents the difficulties in complying with food sanitary and nutrition standards, and inadequate collection systems for solid and liquid wastes. School plumbing and sewage infrastructure is in a precarious state, resulting in leaks and seepage of liquid waste. Lighting is deficient in 41% of schools, primarily due to a lack of lighting fixtures. Additionally, our schools suffer from ventilation problems, owing to inadequate resources for artificial ventilation systems. With regard to sexually transmitted diseases and tobacco use, some studies have demonstrated that adolescents are aware of these issues, but do not have a perception of the risks involved or attempt to modify their behaviour accordingly.

Purpose 1: Reduce the main communicable and noncommunicable disease among young people between ages 1 and 24.

Goal:

Problem 2010 2015

Accidents at school 50% 90%

Hepatitis A 15% 20%

FBD 20% 25%

Lice 15% 20%

Scabies 30% 50%

STI 5% 10%

Self-inflicted injuries 5% 10%

Source: Provincial and municipal centres of hygiene and epidemiology.

Indicator: Rate per 1,000 schoolchildren.


Purpose 2: Rehabilitate all schools operating with precarious sanitary infrastructure.

Goal:

2010 2015

100% Maintain

Source: Provincial centres of hygiene and epidemiology.

Indicator: Number of schools. Occupational Health Exposures to physical, chemical, biological, and psychosocial risk factors in the workplace are actually very commonplace. These factors can affect workers’ health in the short, medium, or long term, as well as morbidity, mortality, and the quality of life of the population, and adversely impact the economy, workers and their families, the workplace, and all of society. According to statements of the WHO and ILO issued in 2005, the risk of contracting occupational diseases has become the most common hazard facing workers on the job, causing some 1.7 million work-related deaths annually, thus surpassing fatal accidents by a 4:1 ratio. Occupational injuries and diseases account for nearly 4% of global GDP in worker compensation payments and workplace absences. The diagnosis of occupational diseases is grossly underreported. In 2004, a total of 433 cases were diagnosed, amounting to 0.1 per 1,000 workers. Fatal workplace injuries in 2004 were the highest in the last 4 years, reaching 4.3 per 10,000 workers (132 cases). In 2005, the number of workers exposed to risks subject to specific surveillance also increased: lead (8,457); mercury (5,271); pesticides (9,780); silica sand (3,744); noise (29,122); leptospirosis (708,003); and hepatitis B (130,838). Among the most frequent occupational diseases in the country, an increase in chronic nodular laryngitis among teachers was observed above other expected health impairments, in keeping with the pattern of current occupational risks, such as hypoacusia. The increase in service industry labour activities (i.e., tourism, trade, education, and health), requiring greater demands on mental processes and posture due to the massive use of computer terminals in all sectors of the economy, has increased risk in this sector.

Purpose 3: Improve the quality of man-work-health relationship and control workplace risk factors.

Goal: Indicators Baseline 2010 2015

Noise pollution & In accordance with Under 95% Under 85%

other physical, workplace environment

chemical, biological risk factors of workplace

environments adjusted

to tolerable limits pursuant to

workplaceType

Coverage of workforce In accordance with Above 95% Above 95%

with control of labour- workplace environment

specific health,

according to workplace

risk factors

Source: Provincial and municipal centres of hygiene and epidemiology.


Purpose 4: Improve reporting of occupational diseases.

Goal:

Baseline 2010 2015

1 - 10% 85% 95%

Source: EDO. SIE Health Statistics Information System (SIE). National Bureau of Statistics. 2004. Indicator: Incidence of occupational diseases.

Special Environments – Directives

2. Reduce risk factors and increase protective factors in the school environment, and by extension, the family and community.

3. Strengthen the presence of the State Sanitary Inspection Service (ISE) in schools and the workplace.

4. Improve the surveillance system by implementing comprehensive strategies and actions targeting school health and sanitary quality in the workplace.

5. Improve monitoring of new and international schools.

a. Evaluate and enforce programs for the prevention and control of communicable/noncommunicable diseases at schools on:

b. Morbidity and mortality of students and workers

c. Outbreaks of hepatitis A and food-borne disease

d. Lice and scabies

e. STI

f. Self-inflicted injuries

g. Chronic nodular laryngitis

6. Control physical and chemical risks at health laboratories.

7. Monitor 100% of workers exposed to occupational risks.

8. Improve management of occupational diseases.

VIII. Special Groups Paediatric age groups The increase in life expectancy in Cuba over the last 30 years has primarily been the result of declining infant mortality. However, for the period 2001-2003, children account for only 9% of the years lost, and in the coming years their contribution will be smaller still. Consequently, any improvement in Cuban life expectancy can essentially be attributed to improvements in mortality conditions of other age groups, regardless of continued efforts to reduce infant mortality to the possible minimum value, taking into account that: - infant mortality is one of the key indicators for evaluating the health conditions of the population; and that

- although reducing infant mortality will not make a significant impact in terms of increasing life expectancy, any increase in the latter will result in a significant decrease in the former.

Since 1970, the probabilities that Cuban children would be born healthy and live to see their fifth birthday have been constantly increasing. Consequently, we see that since 1997 more than 99% of children survive through age 5. In 2004, infant mortality was 5.8 per 1,000 live births, on a par with that of the most developed countries, where mortality is primarily due to: disorders originating in the


perinatal period, followed by congenital birth defects, chromosomal deformities and abnormalities, influenza and pneumonia, and sepsis, with heart disease constituting the fifth leading cause. Despite our achievements, we are compelled to continue our work and incorporate actions that will lead us to achieve better results.

Women The trend of mortality and potential years of life lost (PYLL) due to premature death reveal significant differences between men and women. Despite a continuing trend of excess male mortality, a decrease of the differential by sex is observed, due to an increase in the risk of death among women. This trend was observed in a study on the fifteen leading fifteen causes of death in the country between 1994 and 2003. In four of the diseases studied (cerebrovascular disease, dementia and Alzheimer’s, diabetes, hernia, and intestinal obstruction without mention of hernia) excess female mortality is observed; and women have a much increased risk of death due to causes such as influenza and pneumonia, malignant neoplasm, and chronic lower lung diseases. Worthy of mention is the significance of direct causes in maternal mortality, with 27 such deaths reported in 2004. Life expectancy at birth by sex is 78.97 for females and 75.13 for males. However, upon comparing these data to that of other countries with similar life expectancy at birth, a disadvantage is observed for Cuban women: the results suggest that there may be possibilities of raising survival rates. Older Adults The death rate for older adults has increased in recent years. In 2003, people over age 60 accounted for 77.7% of deaths, increasing to 78.7% in 2004. This fact is attributable to the country’s changing demographic profile as well as improvements in sanitary conditions that help extend life, and, consequently, people are dying at more advanced ages. People over age 60 account for nearly 8 of every 10 deaths in Cuba.

According to studies conducted in 2003, the statistics for this age group are as follows:

- 86.4% mortality from ischemic heart disease;

- 77.3% mortality from cancer;

- 98.9% mortality from hip fractures

- 73.5% mortality from cerebrovascular diseases;

- 92.4% mortality from influenza and pneumonia;

- 65.6% mortality from glomerular and renal diseases;

- 76.6% mortality from diabetes mellitus;

- 71.4% mortality from CLRTIs;

-98.5% mortality from dementia and Alzheimer’s.

Bearing in mind the aforementioned results, and the fact that by 2015 more than 20% of the population will be age 60 or older, we consider these ample reasons to begin making the necessary health and social changes to accommodate the country’s demographic trends.

Purpose 1: Decrease infant mortality to 4 per 1,000 live births Goal:

Baseline 2010 2015

5.8 5 4 Source: Health Statistics Information System (SIE). National Bureau of Statistics. 2004.

Indicator: Infant mortality rate per 1,000 live births.


Purpose 2: Decrease under-5 mortality to 6 per 1,000 live births.

Goal:

Baseline 2010 2015

7.7 6.5 6

Source: Continuous Statistics of the National Bureau of Statistics. 2004.

Indicator: Under-5 mortality per 1,000 live births.

Purpose 3: Decrease maternal mortality to 10 per 100,000 live births.

Goal:

Baseline 2010 2015

21.2 15 10 Source: Health Statistics Information System (SIE). National Bureau of Statistics. 2004..

Indicator: Maternal mortality rate x 100 000 live births.

Purpose 4: Diminish in 15% the mortality between 60 and 75 years.


18.6 7% 15%


Indicator: Mortality between age 60 and 75 per 100,000 pop.

Special Groups – Directives

1. Reinforce the low birth weight program.

2. Improve prenatal diagnosis of birth defects and congenital metabolic disorders.

3. Strengthen puericulture. Increase monitoring and control of child development, as this will lay the foundation for child health.

4. Promote exclusive breast-feeding for the first six months of life. Increase requirements for “mother-and-baby-friendly” certification of hospitals, physician’s offices, and polyclinics, with a view to increasing their numbers.

5. Ensure effective health system and community protection of very-low-birth weight newborns and malnourished infants. Set up nutritional recovery services in paediatric hospitals. Establish breast milk banks in referral hospitals for very-low-birth weight newborns.

6. Consolidate the national cardio paediatric network.

7. Ensure the early diagnosis and timely treatment of acute infectious diseases.

8. Strengthen the national accident prevention program for people through age 20.

9. Improve the results of paediatric intensive care and neonatology services.

10. Promote educational campaigns to decrease the incidence of unwanted pregnancy and abortions, as well as improving surgical abortion techniques and menstrual regulation. Develop medical methods for terminating pregnancy.

11. Identify and monitor the female population with preconception risks and improve the quality of prenatal care.


12. Improve perinatal care by strengthening the operations of emergency, risk, perinatology, delivery, and puerperium services.

13. Improve the quality of medical care for children, women, and older adults through strengthening of the technological, organizational, and clinical management model.

14. Reinforce the contents of geriatric curricula and medical science specializations.

Areas of Key Results to be Implemented

- Public and state health policies: Formulation and implementation of health policies, analysis and trends, health statistics, health program management, and health legislation.

- Comprehensive health care of the individual, family, and community: Reorientation of

services, strengthening of the polyclinic, and excellence in comprehensive medical care. Programmatic integration in the Program of Comprehensive Family Care. Reorientation of the Family Doctor Program, focusing on health promotion and disease prevention.

- Health surveillance and health protection of the population: Strengthening of the

integrated and comprehensive National Health Surveillance System, with special emphasis on analysis, forecasting, systematization, and management of information and knowledge to facilitate public health decision-making, with a view to preventing threats and promoting the health of our population within the framework of our country’s needs and strategies.

- Human resources management and education: Enhancement of curricula. Transformation

of the polyclinic into a teaching institution. Institutional accreditation of programs and careers. Evaluation of competence and performance. Management and development of scientific and scientific–pedagogical personnel.

- Management of information and knowledge: Share information and experience of health

personnel with a view to strengthening health system organization. Mass communication and dissemination. Development of scientific and technical publications, audiovisual aids, multimedia and software, and educational programs for television. Communication services networks.

- Health research: Scientific and technological innovation management, research on health

systems and services, evaluation of health technologies, intellectual property, research and development projects; Science and Technique Forum, scientific associations.

- Cooperation, international relations, and contributions to international public health:

Comprehensive health program and contribution to field of international public health. International collaboration. International relations and agreements. Relations with international organizations.

- Financial management and resource mobilization: Resource and financial planning.

Accredited accounting. Resource mobilization projects. Audit and control. - Logistics and infrastructure management: Logistical support. Management of support

services. Refinement of the business system. Investments and maintenance. Internal management and physical protection.


Implementation, Control, and Evaluation Strategies

1. Activities for Improving Cuban Public Health by 2015 is a highly complex programming exercise in terms of its conceptual underpinnings and elaboration, but even more so in terms of its implementation, development, and scope.

2. These projections make up the strategy or program of the National Health System which integrate, nourish, and enhance the specific programs, strategies, and actions of the sector.

3. Its great importance and comprehensive nature require scientifically structured processes and organizational methods that are flexible, dynamic, participatory, interdisciplinary, and integrated.

4. These projections will steer the entire comprehensive and integrated National System of Health beyond the structures of traditional areas, agencies, levels, or units.

5. Responsibility for its implementation, fulfilment, and monitoring lies at the highest level of each structure of the organization.

6. Each area and agency will have specific responsibilities with regard to the implementation, development, and monitoring of these projections, based on their specific functions within the National Health System.

7. The projections will be led and controlled by the organizational structure of the National Health System at the highest level of the System.

8. The Minister of Public Health, as the maximum national authority, will lead, monitor, and evaluate these projections.

9. The Minister will designate a Vice Minister to coordinate this endeavour as well as an executive steering committee executive, comprised of staff of the Ministry of Public Health, to oversee the management and tactical/operational control of this endeavour.

10. This organization will be replicated in the remaining structures of the System.

11. Each area of the Ministry, in collaboration with its agencies, will prepare specific contents and participate as one in the strategy, based on its structure, organization, functions, responsibilities, and actions within the System.

Evaluation These projections will be evaluated in each service, unit, and level of the National Health System. The evaluation methodology and content of the evaluation will be adapted to the specific conditions present in the place under evaluation.

The evaluation system will be structured by level. The units will evaluate institution-specific problems; the municipalities and provinces, the specific aspects of each health problem, and the Nation, the directives and projections in its general capacity.

This evaluation does not substitute or contain systematic evaluations of the programs, plans, health actions, administrators, or others carried out by each organizational unit in the course of routine work.

The evaluation will consist of two approaches:

Administrator: To be carried out by the Ministry of Public Health, its areas, and agencies, guided by the general and specific directives for health problems, the evaluation system of the provinces and subordinate national units, and the results in terms of impact.

Technician: To be carried out by the institutes, national groups of experts, national technical-advisory commissions, and national reference centres, guided by the goals and projections for health problems, specific programs, and specific directives.


The evaluation will be carried out by comprehensive evaluation panels at the following intervals:

1. Monthly: Unit

2. Quarterly: Municipalities and provinces

3. Semi-annual: Nation

4. Annual: All levels

The content of this evaluation will prioritize the goals (impact), directives (processes), and organization (structure).

cuban public health projections for...

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