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FINAL VERSION – 20th of April 2004 - PDV accepted for publication in Social Science and Medicine- May 2004

planned publication: first trimester 2005

Shifting the Demand for Emergency Care in Cuba’s Health System Author Pol De Vos Department of Public Health - Institute of Tropical Medicine - Antwerp - Belgium Co-authors Pedro Murlá National Institute for Hygiene, Epidemiology & Microbiology - La Habana - Cuba Armando Rodriguez National Institute for Hygiene, Epidemiology & Microbiology - La Habana - Cuba

Mariano Bonet National Institute for Hygiene, Epidemiology & Microbiology - La Habana - Cuba Pedro Màs National Institute for Hygiene, Epidemiology & Microbiology - La Habana - Cuba Patrick Van der Stuyft Department of Public Health - Institute of Tropical Medicine - Antwerp - Belgium Department of Public Health - Institute of Tropical Medicine Nationalestraat 155 - 2000 Antwerp - Belgium tel : 32 3 247 62 85 – fax : 32 3 247 62 58 - email : pdevos@itg.be Instituto Nacional de Higiene, Epidemiología y Microbiología Infanta n° 1158 e/ Llinas y Clavel 10300 Ciudad de la Habana – CUBA tel : 537 78 14 79 – fax : 537 66 24 04 – email : director@inhem.sld.cu

Formatted: Width: 595,35pt, Height: 842 pt

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Abstract

Cuba developed a programme of quality improvement of its health services, which included

an extra muros emergency care system in which policlinics and general practitioner networks

play an important role. Using routine health information from the decentralised first line

emergency units (FLES) and from the hospital emergency service (HES) for the period 1995-

2000, we evaluated the effects of the emergency care subsystem reform on the utilisation rates

of first line and hospital services in Baracoa and Cerro, a rural and a metropolitan

municipality respectively.

In the self-contained health system of Baracoa, the reform of the emergency subsystem

resulted in a first phase of increased utilisation of the FLES, followed by a second phase of

gradual decrease, during which there was an increased utilisation of general practitioners. In

contrast, the overall results of the reform in Cerro were unclear. Proximity of a hospital seems

to be the most important element in the patient’s decision on which entry point to the Cerro

health system to use. A potential adverse effect of the reform is an increased emergency

services utilisation in situations where GP care remains below patients’ expectations. Given

the current world-wide trends in health care reform, the organisational alternatives developed

in the Cuban health system might remain specific to the local contextual setting.

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Key words

Cuba

Health-service-organisation

Health-sector-reform

Emergency-care

Decentralisation

First-line-health-services

4

Shifting the Demand for Emergency Care in Cuba’s Health System

Introduction

In many countries the historical function of hospital emergency departments was to care for

patients who did not have the financial means to consult private physicians (Blackwell &

Cantab, 1962). Once social security systems and financially accessible first line health

services were developed, the function of emergency departments shifted towards ensuring

adequate response to accidents and legitimate medical emergencies. However, many patients

continue to visit emergency departments for problems that could have been solved at the level

of a family doctor or health care centre. Extensive literature documents the inappropriate use

or even the abuse of emergency services (Davidson, Hildrey & Floyer, 1983; Davies, 1986;

Foster, Dale & Jessopp, 2001; Fouroughi & Chadwick, 1989; Murphy, 1998; Myers, 1982).

Proposals to improve emergency systems traditionally focused on either effectiveness

(improve the quality of human resources, physical structure and technical capacity) or

efficiency (decrease workload by separating ‘real’ emergencies from ‘inappropriate’ demand)

(Olesen & Jolleys, 1994). It is well recognised that direct involvement of emergency medical

specialists is one of the most critical determinants of effectiveness (Bickell, 1994; Falk,

1993). Likewise, infrastructure, medical supplies and transport facilities are essential.

Unfortunately, even after introducing a broad array of initiatives to canalise non-emergent

patients to a corresponding level of care, inappropriate use of emergency services continues to

be a problem (Hull, Jones, Moser & Fisher, 1998; Rund, Nemer, Robertson, Moeschberger &

Garraway, 1992). Cuba’s national health system is also confronted with this problem.

At the beginning of the 90’s, radical changes in the terms of trade with the former Soviet

Union and the tightening of the USA embargo drastically reduced the national income.

5

(PAHO, 1998) Health care spending dropped and scarce resources were concentrated

(Kirkpatrick, 1996). This resulted in patients, who could have been appropriately attended by

family physicians, overcrowding hospital emergency units, perusing scarce resources and

receiving sub-optimal care (Bolibar, Balanzo, Armada, Fernandez, Foz, Sanz et al., 1996).

Despite the economic crisis, the authorities did not turn to privatisation of health care services

nor cost recovery schemes. The Cuban health care system continued to offer free preventive,

curative and rehabilitation services at the different levels of care (Delgado, 1998; Feinsilver,

1993). It developed plans for rationing health care and increasing efficiency, while ratifying

the principles of state responsibility, equity and universal coverage.

The Ministry of Health set up a programme of quality improvement, strengthened family and

preventive medicine, and introduced decentralisation, inter-sectorial action and community

participation. Emphasis was put on maternal and child health, chronic non-communicable

diseases, communicable diseases, and care of the elderly (PAHO, 1998; Rojas & López, 1997;

Van der Stuyft, De Vos & Hilderbrand, 1997; Veeken, 1995).

Measures implemented to strengthen family medicine included improving drug availability

and follow up of patients. A programme of home hospitalisation was reinforced, and an extra

muros emergency care system was set up, in which first line policlinics and general

practitioner networks played a central role (MINSAP, 1996; PAHO, 2002).

In the framework of an inter-institutional collaboration between Belgian and Cuban research

institutes, the authors have been studying Cuba’s first line health care reform since the mid-

nineties. They researched the effects of this reform of the emergency care system on the

utilisation rates of first line and hospital level services. (MINSAP, 1996).

Material and methods

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The emergency system reform

Cuban municipalities are divided into health areas, in which a policlinic organises the first

line health care for about 30.000 inhabitants (MINSAP, 1996; PAHO, 1998). It covers the

whole population with a family doctor ( general practitioner – GP) Program (one family

doctor and one nurse per 700-800 inhabitants), and ensures the necessary diagnostic support

and specialist backstopping.

Until 1996, only hospital emergency services (HES), covering about 150.000 inhabitants,

offered an acceptable quality of emergency care. From then onwards, adequately equipped

and supplied first line emergency services (FLES), with well trained personnel, were

gradually set up. Each municipality had an associated principal emergency policlinic (a

central first line emergency service), combined with a variable number of emergency centres

(smaller and more peripheral care centers) (Chang, Alemán, García & Miranda, 2000;

MINSAP, 2002).

Selected study sites

Baracoa and Cerro, a rural and a metropolitan municipality respectively, were selected to

evaluate the effects of the reform. Baracoa is situated on the northern coast of the

Guantánamo province of Cuba. This municipality has a population of 85.000 inhabitants. It is

composed of an urban, peri-urban and rural, mostly mountainous zone, of which some parts

have difficult accessibility. In Baracoa, roughly 190 physicians are working in three health

areas. The municipal hospital is located near the principal emergency policlinic. Baracoa is

geographically isolated from the rest of the province and from the provincial reference

hospital situated in Guantánamo, the provincial capital. An ambulance takes two and a half

hours to cover the distance of 170 km between the two towns.

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Cerro is one of the central municipalities of Havana, Cuba’s capital. The municipality is

densely populated with a total of about 122.000 inhabitants. It is divided into four health

areas, covered by an estimated 185 general practitioners. Cerro is characterised by a complex

and open metropolitan health services network comprising of two hospitals, and three others

situated just across the municipal boundaries. Hence the majority of its inhabitants live within

walking distance from a hospital. The principal emergency policlinic is in Maceo, the health

area most distant from the aforementioned hospitals.

Data collection

For the period 1995-2000 we established the number of patient contacts with first line

services (general practitioners), decentralised FLES and HES. The research team extracted the

raw data from the routine health information system, acknowledged by UNDP to be of good

quality (UNDP, 2002). Utilisation rates were calculated with yearly-adjusted population

figures provided by the Ministry of Health (MINSAP, 1995-2000).

In 1998 the definition of ‘real emergencies’ was standardised and a training programme was

developed for all doctors working in emergency services. At the FLES, ‘real emergencies’

include all health problems that are either immediately or potentially life-threatening or acute

(MINSAP, 2002). From July 1999 onwards, information on the emergency status of patients

was collected on a specially designed form by the physicians who attended the patients. The

research team ensured adequate supervision of the data collection process, through revising a

sample of the forms with the health staff during the monthly site visits and by systematic

checks for inconsistencies after data entry. The complex geographical distribution of HES and

FLES in Cerro, described above, made us collect patient-origin specific utilisation figures for

the HES from Cerro and neighbouring municipalities. The research team performed a

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secondary analysis of routine hospital data, differentiating between inhabitants of Cerro and

other users of the hospitals in this municipality to calculate correct utilisation rates. For three

other hospitals in neighbouring municipalities that attract patients from Cerro, we also

collected specific HES utilisation data and calculated patient origin specific utilisation rates.

Since this detailed information was not available through the routine health information

system, the collection of these data was limited to 1999.

3. Results

During the 5 years after the decentralisation of emergency services (January 1996 in both

municipalities), the utilisation of the HES in Baracoa gradually decreased 30% from 0,88

contacts per person and per year (cpy) to 0,62 cpy (Figure 1). The utilisation rate of the FLES

increased 70% from 0,31 cpy to 0,53 cpy between 1995 and 1997, and then again decreased to

0,39 cpy during the following years. The total emergency utilisation rate, after a temporary

rise, decreased 18% from 1.23 cpy in 1996 to 1.01 cpy in 2000. Over the same time span, the

utilisation rate of family doctors or gradually rised 39% from 3,6 cpy to 5 cpy.

The ratio of emergency services / family doctors fell from 0,33 in 1995 to 0,20 in 2000. Over

the same period, the total number of patient contacts (family doctors, HES and FLES) raised

from 4.83 cpy in 1995 to 6 cpy in 2000.

The emergency status of the patients was analysed for a 2 year period (July 1999 to June

2001). The decreased utilisation rates of FLES over that period was mainly due to a 27%

reduction of non-emergencies (from 4944 to 3597 contacts per trimester), while the number of

cases defined as “real emergencies” remained stable around 3750 contacts per trimester. The

proportion of contacts evaluated by the medical staff as “real emergencies” hence increased

from 42% in the third trimester of 1999 to more than 50% in the second trimester of 2001.

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While the total utilisation rate for the different health care entry points was similar in all three

areas of Baracoa (between 5.1 and 5.7 cpy), there was a difference in the specific utilisation

rates (Table 1). In Tamayo, the area where the hospital is situated, we calculated a hospital

emergency care utilisation rate of 0.66 cpy, while that figure was 0.45 cpy in the nearby Turey

area and 0.23 cpy in the mountainous area of Jamal. This is compensated in Turey by a higher

use of FLES, while in the mountainous Jamal area with more difficult access to emergency

services, the family doctor utilisation rate was higher.

In the metropolitan Cerro municipality, the HES utilisation rates only slightly decreased by

8% (from 1.4 cpy to 1.3 cpy) after the introduction of the decentralised emergency system in

1996. The FLES utilisation rates increased more than 55%, from 0.6 cpy to 1.0 cpy, and the

family doctor utilisation increased with about 10% from 4.2 to 4.6 cpy. The total utilisation

rate varied between 6.2 and 7 cpy (Figure 2).

To fully understand the health services utilisation patterns in Cerro, we differentiated between

inhabitants of Cerro and other users of the hospital emergency services. While the uncorrected

emergency services utilisation rate of both hospitals in Cerro is 1.26 cpy in 1999, the area

specific utilisation rates of the ‘General Hospital Salvador Allende’ and the ‘Paediatric

Hospital of Cerro’ is 0.83 cpy (Table 2). Over the same year, the inhabitants of Cerro had 0.58

cpy in two general hospitals and one paediatric hospital, located near Cerro. A geographical

analysis of the patient flow showed a quite diverse utilisation pattern by area (Figure 3). The

total utilisation rates of the different entry points into the health care system varied from 5.3

cpy in Abel to 8.3 cpy in Maceo. While the family doctor contacts per person and per year

varied from 2.4 in Abel to 6.0 in Maceo, the emergency services (ES) utilisation rates varied

only slightly between 2.3 cpy in Maceo or Girón and 2.9 cpy in Abel. On the other hand, the

FLES / HES-ratio showed a clear variation, from 0.3 in Cerro to 2.3 in Maceo. The

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emergency services / family doctor-ratio was between 0.4 and 0.6, except in Abel where the

low family doctor utilisation rate pushed the ratio to 1.2.

4. Discussion

The political priority given to health in Cuba, in the form of good quality services free of

charge at the point of delivery, explains the high utilisation rates found at all levels of the

system. Due to its specific socio-political context, Cuba is thus not confronted with the

essential problem that most developing countries are facing: ensuring accessible health

services of acceptable quality for all (Segall & Gryseels, 2003). Today, the country’s priority

is to consolidate these accomplishments in a difficult international economic and political

environment. To that objective, structural reorientation of patient demand to the adequate

level of care is central to improving the efficiency of the system.

With regard to adequate use of emergency services, the definitions of ‘minor problems’ and of

the category of ‘inappropriate user’ in emergency care continue to be controversial (Smith,

Lattimer & George, 2001). While a body of literature on the subject claims that the majority

of these patients would be better off by consulting a competent general practitioner instead of

emergency services, explicit objective criteria for ‘inappropriate’ use are frequently lacking

(Walsh, 1995). Besides, the patients’ perception should be included to define what constitutes

an ‘inappropriate’ visit to the emergency department (Hewstone & Antaki 1988; Sbaih, 1993).

The ‘health belief model’ takes into account that patients perform a personal cost-benefit

analysis when deciding to utilise a particular service (Jones, Jones & Katz, 1991; Rosenstock,

1974). When financial considerations are of marginal importance, as is the case in Cuba, the

decision to visit a family doctor might depend on the perception of the problem or disease

experienced (Irwin & Jessop, 1993; Knaus, Draper, Wagner & Zimmerman, 1993), the

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personality of the patient and his confidence in the physician, and the perceived technical

ability of the physician, his accessibility and the existing material conditions in which he

works (Singh, 1988; Wood & Cliff, 1986). The patient’s decision is also largely influenced by

his personal expectations and preferences. From this point of view, “inappropriate use” is the

result of a rational process that requires adequate evaluation by family doctors and hospital

emergency departments (Andersen & Gaudry, 1984; Dale, Green, Reid & Glucksman, 1995;

Lang, Davido, Diakite, Agay, Viel & Flicoteaux, 1996; Mallon, Cullen, Keenan, Kiberd &

Matthews, 1997; Murphy, 1998; Siddiqui & Ogbeide, 2002). Restructuring to promote

patients’ use of adequate entry points to the health system should therefore be based on the

integration of hospital and first line health care, optimal care quality and accessibility, better

communication, and health promotion (Anonymous, 1979; Hadfield, Yates & Berry, 1994;

Swerissen, 2002).

The evolution of the utilisation rates between 1995 and 2000 can not be explained by

economic change, evolutions in disease patterns, epidemics or natural disaster. In the closed

and self-contained health system of Baracoa, the reform of the emergency subsystem initially

resulted in increased utilisation of the decentralised emergency units. This was followed by a

gradual decrease of this FLES utilisation rate, with a concomitant increased utilisation of the

general practitioners. Measures taken to reinforce the first level of care, and in particular the

decentralisation of emergency services, seem to have resulted in a ‘two-step’ channelling of

demand for non-urgent health care towards family doctors. Our findings suggest that the

decentralisation of the emergency services is, at least in a closed setting, a useful strategy to

diminish the pressure on the HES and to improve the use of the first line services as entry

point.

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The overall results of the reform in Cerro, a complex metropolitan health system, are, in

contrast, unclear. The total emergency utilisation rate (HES + FLES) remains high, and on top

of this the decentralised emergency service in the Maceo area seems to function as a ‘small

hospital’. Furthermore, the family doctor utilisation rates differ sharply from one area to the

other. The proximity of a hospital appears to be the most important element in the patient’s

decision on which entry point to the health system to use.

Only a contextual analysis, taking into account the specific features of the Cuban social and

health system, can lead to a full understanding of the local impact of the Cuban emergency

care system reform, and create opportunities to further adapt the system to the patients’

problems and needs. In Baracoa a well functioning family doctor programme has been in

place for more than 15 years in both the urban and rural parts of the municipality. The family

doctors mostly live in the community they serve. This may be essential to ensure a gradual

shift of the patient flow from emergency services to family doctors. Also, a systematic and

well-organised GP-involvement in the emergency network may ensure a growing confidence

of the FLES-patients towards ‘their’ family doctor and his technical skills. Together with a

sufficient technical and an adequate drug provision, this may enhance the attractiveness and

utilisation of this level of care. In the metropolitan setting of Cerro, however, the family

doctor programme has been implemented more recently. It has also suffered from the lack of

stability of family doctors. Furthermore, because of lack of adequate facilities, most family

doctors practise in the premises of polyclinics, not necessarily located in the neighbourhoods

they serve. This can compromise the quality of the relationship with the population. More

importantly, the introduction of a decentralised emergency service can result in an adverse

effect of increased ‘emergency’-contacts in situations where the first line care remains below

the patients’ expectations.

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The Cuban experience with decentralising emergency services in direct collaboration with the

first line health services, could be useful for other countries seeking a strategy to alleviate the

pressure on overcrowded hospital emergency services and to reinforce the first line health

services. However, given current world-wide trends in health sector reform, the organisational

alternatives developed in the Cuban health sector may be specific to the local context. First,

the Cuban authorities had no recourse to financial barriers to deter patients from non-

appropriate health care seeking behaviour at the level of the emergency services. Furthermore,

the existence of a unified public health system, without parallel insurance and/or private

service delivery, facilitates government stewardship in planning and restructuring (Murphy,

Leonard, Plunkett, Bury, Lynam, Smith et al, 1997; Rojas & López, 1997).

Finally, while in many countries health care and social services are affected by the

introduction of cost recovery schemes and privatisation (Estrada, Barilari, Sepulveda & Soto,

1998; Iriart, Merhy & Waitzkin, 2001; Stocker, Waitzkin & Iriart, 1999), Cuban health

services remain public and free at the point of delivery. Cuba also continues to rely on the

state as ‘organiser’ and not just as ‘regulator’ of comprehensive and integrated health care.

In a world where scarce economic resources are increasingly constraining the development of

social policies, the results of Cuba’s alternative health system reform should contribute to the

international debate on health sector policies.

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Acknowledgements

We thank the health personnel of the research areas and the Ministry of Health in Havana for

their invaluable support. This research was financially supported by INCO-DEV programme

of the European Commission (contract n° IC18-CT98-0348).

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Table 1: Utilisation rates, per health area, of family doctors and Emergency services

at First line (FLES) and Hospital (HES) level (Baracoa, 2000)

Utilisation rates

Area

Population HES FLES family doctor Total Tamayo 36 121 0.66 0.32 4.71 5.69 Turey 30 295 0.45 0.43 4.21 5.09 Jamal 18 861 0.23 0.35 5.02 5.60 Total 85 277 0.62 0.39 4.6 5.61

Figure 1: Utilisation rates of Family doctors and Emergency services at First line and Hospital level (Baracoa 1995-2000)

0,00

0,10

0,20

0,30

0,40

0,50

0,60

0,70

0,80

0,90

1,00

1995 1996 1997 1998 1999 2000

year

cont

acts

per

per

son

per y

ear

emer

genc

y se

rvic

es

0,00

1,00

2,00

3,00

4,00

5,00

6,00

cont

acts

per

per

son

per y

ear

fam

ily d

octo

rs

hospital emergency services first line emergency services family doctors

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Table 2: Area specific Utilisation rates of family doctors and Emergency services at First line (FLES) and Hospital (HES) level (Cerro 1999)

Area Municipalityof CERRO Maceo Cerro Girón Abel

TOTAL Utilisation Rate 7.0 8.3 6.7 7.8 5.3 Family Doctors U.R. 4.6 6.0 4.2 5.5 2.4 Emergency Services U.R. 2.4 2.3 2.5 2.3 2.9 First Line ES 1.0 1.6 0.6 0.9 1.4 Hospital ES 1.4 0.7 1.9 1.4 1.5 HES Cerro 0.8 0.3 1.9 0.5 0.2 Hosp. Salv. Allende 0.45 0.10 1.02 0.32 0.13 Paed. Hosp. Cerro 0.38 0.16 0.92 0.14 0.07

F ig u r e 2 : U t i l i s a t io n r a t e s o f F a m i ly d o c t o r s a n d E m e r g e n c y s e r v i c e s a t F i r s t l i n e a n d H o s p i t a l l e v e l ( C e r r o 1 9 9 5 - 2 0 0 0 )

0 ,0 0

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h o s p i t a l e m e rg e n c y s e rvic e s fi rs t l in e e m e rg e n c y s e rvic e s fa m i ly d o c t o r

21

HES outside Cerro 0.6 0.4 0.0 0.9 1.3 Hosp. 10th of Oct 0.34 0.00 0.00 0.57 0.98 Hosp. J. Alb. 0.09 0.43 0.00 0.00 0.00 Paed. Hosp. Ct.Hab. 0.15 0.00 0.00 0.34 0.33 Ratio Em.Serv./Fam.Dr. 0.5 0.4 0.6 0.4 1.2 Ratio FLES/HES 0.7 2.3 0.3 0.6 0.9

22

Figure 3: Geographical representation of the utilisation rates of the different hospital

emergency services in Cerro, 1999. ABEL GIRÓN CERRO MACEO

HPC

HS H10

HPd

HJ HPCH = Paediatric Hospital of Centrohabana HSA = Salvador Allende Hospital H10O = Hospital of the 10th of October HPdC = Paediatric Hospital of Cerro HJA = Joaquín Albarrán Hospital