Presentacin de PowerPoint

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Implementation of Strategies Relevant to National
Health Care and Specific Centers in the Emerging
World
The View of Central American and Caribbean
Countries
Raúl Herrera-Valdés, MD, PhD Institute of
Nephrology Havana Cuba
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Context of the Americas
Mission Promote equity in health, combat
disease, and improve quality of life and life
expectancy in the region.
Health inequalities reflect socio-economic
structural inequalities
Values Equity Excellence Respect Integrity
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Central American and Caribbean Countries
Wealthiest 20
16 times
INCOME
34 countries Population 76 million Poverty
40 Countryside 45
Poorest 20
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Stress Extreme living conditions Education
Information Health Services
Segregation Marginalization
Poverty
Disease
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Illiteracy
Latin Caribbean 4- 51
Central America5- 36

Non- Latin Caribbean 2- 19
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Health Picture
Communicable Diseases
Non- Communicable
Morbidity Mortality
Infant mortality rate gt 30 x 1,000 l.b.
Life expectancy lt 70 years Infectious diseases
Tendency Aging
Non-Comm. Chr. Diseases
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Health Picture Risk factors for Renal Disease
Near-poor population Obesity
epidemic Diabetes 6 - 8
Hypertension 8 - 30
Increasing
Prevalence
Ethnic Composition / Socio-economic conditions
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Incidence Prevalence of ESRD in RRT
Incidence
Prevalence
Patients/MH
Patients/MH
País
País
Reg. L.A. de Diálisis y Trasplante.2001
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Human Resources

• Situation
• Not enough professionals trained to meet health
  care needs.
• Existing resources are inequitably distributed,
  concentrated mainly in the big cities.
• Low salaries.
• Internal and external migration.
• Imbalance in the composition of healthcare
  workforce.
• Minimal development of information resources.
• Oriented towards curative care rather than
  prevention.

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Physicians
Latin Caribbean2.5 to 58.2 per 10,000 inh.
Central America6.2 to 15 per 10,000 inh.
Non-Latin Caribbean1.5 to 21.5 per 10,000 inh.

• Nephrologists
• lt 20 p.m.p in vast majority of countries
• None in several non-Latin Caribbean nations

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Health Care Infrastructure
No preventive strategies in place for chronic
renal insufficiency No institution which acts
as a regional reference center
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In the Central American and Caribbean context,
Cuba shares many of the economic limitations of
other countries, and at the same time, has
advanced along the route of equity described by
PAHO as critical to improving health in the
region, as one of the countries with the least
social disparity.
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Cubas National Health System
The health system is universal, public, and
free-of-charge, with full coverage of the
population. Cubas resource-scarce environment,
coupled with public health principles, has
reinforced a commitment to primary health care
and prevention as the centerpiece of the system.
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Health Care Situation in Cuba. Basic
Indicators 2002
Total population 11.251 million Percent urban
population 75.4 Literacy rate
96.2 Average educational level 9th
grade Infant mortality rate ( x 1000 live
births) 6.5 Life expentancy
76.15 Physicians per 10,000 population
59.6 Total number of family physicians
31,059 Population served by family physicians
99.2 Hospital beds ( x1000 population)
5.0
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International Cooperation in Health (2003)
Cuban health professionals serving abroad 14,691
in 64 countries
International medical students in Cuba 9,023
from 83 countries
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Cubans National Chronic Renal Disease Program
TRANSPLANTATION
TERTIARY PREVENTION
DIALYSIS
ESRD
CHRONIC RENAL INSUFFICIENCY CHRONIC RENAL DISEASES
SECONDARY PREVENTION
CLINICAL NEPHROLOGY
HEALTHY POPULATION AND RISK GROUPS
PRIMARY PREVENTION
PRIMARY CARE FAMILY DOCTORS
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Cubans National Chronic Renal Disease
ProgramOrganization and Resources
NATIONAL COORDINATING CENTER
NEPHROLOGY SERVICES 34
OPENING 13
100 Free Health Care
PHYSICIANS 67,000
FAMILY DOCTORS 31,000
NEPHROLOGISTS 385 Adult 214 Pediatric
66 Residents 105
ORGAN PROCUREMENT CENTERS 33
TISSUE TYPING LABORATORIES 5
TRANSPLANTATION CENTERS 9
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National Chronic Renal Disease Program Basic
Indicators
CRF patients
HD Incidence
RATE PMP
880
97.1
RATE PMP
1088
YEAR
CRI Patients in follow-up
YEAR
HD Prevalence
Trasplants Incidence
RATE PMP
RATE PMP
134
19.5
YEAR
YEAR
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Prevention Program Specific Objectives
QUAL I TY OF L I FE
Tertiary Prevention
Secondary Prevention
Primary Prevention
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National CRD Program Implementation of
Prevention Strategies
47 Nephrology Services (Regions)
385 Nephrologists 444 Community
Polyclinics ( Health Areas) 31 000 Family
Physicians 99.2 Population
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National CRD Program Epidemiological Laboratory
Isle of Youth
1 Municipal Health Service 1
Nephrology Service 5 Nephrologists
3 Community Polyclinics-Health Areas
105 Family Physicians 81,000 Persons
Objective Epidemiological follow-up for chronic
renal diseases in total
population by studying family units over time.
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Community epidemiological laboratory for study of
chronic renal disease (CRD). Isle of Youth
project. Cuba.
Total population
Phases of the project
Actions
Outcomes
Screening

• Dipstick for proteinuria
• Short questionnaire

Proteinuria ()
Proteinuria (-)
CRD Diagnosis confirmation. Etiology.
Dipstick for microalbuminuria in risk groups
CRD Prevalence
Proteinuria (-)
Microalbuminuria ()
Microalbuminuria (-)
Longer questionnaire Laboratory test Physical exam
Case-control study
Identify risk factors for CRD

• CRD Incidence
• CRD etiological risk factors
• CRD progression

Follow-up study
Cohort
Laboratory test Physical exam
Cohort
Preventive actions
Therapeutic intervention

• Risk reduction
• CRD control

Intervention
Intervention

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

Surveillance
Surveillance system
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National CRD Program National Coordinating
Center
Institute of Nephrology

• Cuban School of Nephrology
• National Reference Center
• National Coordinating Center

National Chronic Renal Disease Program
Raising the Level of Medical Care
Training Specialized Human Resources
Developing Scientific Research

• Management
• Telenephrology
• Epidemiological
• Laboratory

• Prevention
• Clinical Nephrology
• Dialysis
• Transplantation

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National CRD Program Telenephrology Network
XML Web services

• National Institute of Nephrology
• National Network of Nephrology Services.
• National Health Systems National Telematics
  Network (INFOMED)

• Second Opinion Services.
• Teleconferencing.
• Distance learning.
• Epidemiological control (PC).

• Selection of donor-recipient pairs.
• CRI and Dialysis.
• Statistics.

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We place this modest Cuban experience at the
disposal of our Central American and Caribbean
colleagues and of nephrology societies
internationally, inviting them to share with us
their observations, reflections and expertise.
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Conclusions

• To prevent chronic renal disease in Central
  America and the Caribbean, we must
• Reduce poverty
• Increase equity
• Improve nutrition
• Advance education
• Develop health services
• Formulate prevention policies
• Create reference institutions

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• These are dangerous times for the well-being of
  the world. In many regions, some of the most
  formidable enemies of health are joining forces
  with the allies of poverty to impose a double
  burden of disease, disability and premature death
  on many millions of people. It is time for us to
  close ranks against this growing threat.

Gro Harlem Bruntland M.D.Director
General World Health Organization
The World Health Report. WHO. 2002
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Thank You