1. 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 Raúl Herrera-Valdés, MD, PhD Institute of Nephrology Havana – Cuba

2. Context of the Americas Health inequalities reflect socio-economic structural inequalities Health inequalities reflect socio-economic structural inequalities Values Equity – Excellence – Respect – Integrity Mission: Promote equity in health, combat disease, and improve quality of life and life expectancy in the region.

3. 34 countries Population: 76 million Poverty: + 40% Countryside: 45% 34 countries Population: 76 million Poverty: + 40% Countryside: 45% Wealthiest 20% INCOME Poorest 20% 16 times Central American and Caribbean Countries

4. Segregation Marginalization Stress Extreme living conditions Education Information Health Services Disease Poverty + - - - +

5. Illiteracy Central America 5%- 36% Latin Caribbean: 4%- 51% Latin Caribbean: 4%- 51% Non- Latin Caribbean: 2%- 19% Non- Latin Caribbean: 2%- 19%

6. Infant mortality rate: > 30 x 1,000 l.b. Life expectancy: < 70 years Infectious diseases Tendency Aging Non-Comm. Chr. Diseases Communicable Diseases Non- Communicable Morbidity – Mortality Health Picture

7. Near-poor population: Obesity epidemic Diabetes: 6% - 8% Hypertension: 8% - 30% IncreasingPrevalence Ethnic Composition / Socio-economic conditions Health Picture: Risk factors for Renal Disease

8. IncidencePrevalence Reg. L.A. de Diálisis y Trasplante.2001 Patients/MH País Patients/MH País Incidence & Prevalence of ESRD in RRT

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

10. Central America 6.2 to 15 per 10,000 inh. Nephrologists: < 20 p.m.p in vast majority of countries None in several non-Latin Caribbean nations Nephrologists: < 20 p.m.p in vast majority of countries None in several non-Latin Caribbean nations Physicians Non-Latin Caribbean 1.5 to 21.5 per 10,000 inh. Latin Caribbean 2.5 to 58.2 per 10,000 inh.

11. Central America Latin Caribbean Non–Latin Caribbean Hospitals per 100 000 inhab.1.52.13.0 Hospital beds per 1 000 inhab.1.42.83.6 Out-patient facilities per 10 000 inhab.2.55.41.6 Health Care Infrastructure No preventive strategies in place for chronic renal insufficiency No institution which acts as a regional reference center No preventive strategies in place for chronic renal insufficiency No institution which acts as a regional reference center

12. 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.

13. The health system is universal, public, and free-of- charge, with full coverage of the population. Cuba’s resource-scarce environment, coupled with public health principles, has reinforced a commitment to primary health care and prevention as the centerpiece of the system. Cuba’s National Health System

14. Total population11.251 million Percent urban population 75.4% Literacy rate 96.2% Average educational level 9th grade Infant mortality rate ( x 1000 live births) 6.5 Life expentancy 76.15 Physicians per 10,000 population 59.6 Total number of family physicians 31,059 Population served by family physicians 99.2% Hospital beds ( x1000 population) 5.0 Health Care Situation in Cuba. Basic Indicators 2002

15. International Cooperation in Health (2003) Cuban health professionals serving abroad: 14,691 in 64 countries Cuban health professionals serving abroad: 14,691 in 64 countries International medical students in Cuba: 9,023 from 83 countries International medical students in Cuba: 9,023 from 83 countries

16. TRANSPLANTATION PRIMARY PREVENTION SECONDARY PREVENTION TERTIARY PREVENTION HEALTHY POPULATION AND RISK GROUPS HEALTHY POPULATION AND RISK GROUPS CHRONIC RENAL INSUFFICIENCY CHRONIC RENAL DISEASES CHRONIC RENAL INSUFFICIENCY CHRONIC RENAL DISEASES ESRD CLINICAL NEPHROLOGY PRIMARY CARE: FAMILY DOCTORS DIALYSIS Cuban’s National Chronic Renal Disease Program:

17. TRANSPLANTATION CENTERS: 9 TISSUE TYPING LABORATORIES: 5 ORGAN PROCUREMENT CENTERS: 33 NEPHROLOGISTS: 385 Adult: 214 Pediatric: 66 Residents: 105 100% Free Health Care PHYSICIANS: 67,000 FAMILY DOCTORS: 31,000 NATIONAL COORDINATING CENTER NEPHROLOGY SERVICES: 34 OPENING: 13 Cuban’s National Chronic Renal Disease Program: Organization and Resources

18. National Chronic Renal Disease Program: Basic Indicators HD Incidence 97.1 1088 CRF patients CRI Patients in follow-up * HD Prevalence Trasplants Incidence YEAR RATE PMP YEAR RATE PMP YEAR RATE PMP 880 134 19.5

19. Transplantation  PATIENT AND GRAFT SURVIVAL  MORBIDITY  SEPSIS  REJECTION Dialysis  MORTALITY  MORBIDITY Ca-P METABOLISM CONTROL  SEPSIS  HEART DISEASE  ANEMIA  NUTRITION  ADEQUATE DIALYSIS ESRD CRI CRD  EARLY REPLACEMENT THERAPY  VASCULAR ACCESS  HB VACCINATION  SYSTEMIC DETERIORATION  CONTROL OF PROGRESSION RISK FACTORS  ACTIVE FOLLOW-UP  CAUSAL TREATMENT  EARLY DETECTION  ACTIVE SCREENING  ADEQUATE TREATMENT  EARLY DIAGNOSIS Population´s Epidemiological Characterístics  CONTROL OF CAUSES AND RISK ACTORS  IDENTIFICATION OF RISK FACTOR GROUPS  POSITIVE LIFESTYLES  HEALTH PROMOTION  HEALTH EDUCATION Tertiary Prevention Tertiary Prevention Secondary Prevention Secondary Prevention Primary Prevention Primary Prevention QUALITYOFLIFEQUALITYOFLIFE Prevention Program: Specific Objectives

20. 47 Nephrology Services (Regions) 385 Nephrologists 444 Community Polyclinics ( Health Areas) 31 000 Family Physicians 99.2% Population National CRD Program: Implementation of Prevention Strategies

21. 1 Municipal Health Service 1 Nephrology Service 5 Nephrologists 3 Community Polyclinics-Health Areas 105 Family Physicians 81,000 Persons Objective: Epidemiological follow-up for chronic renal diseases in total population by studying family units over time. Isle of Youth National CRD Program: Epidemiological Laboratory

22. Total population Phases of the project Actions Outcomes Screening Dipstick for proteinuria Short questionnaire CRD Diagnosis confirmation. Etiology. Case-control study Follow-up study Intervention Surveillance Proteinuria (+) Proteinuria (-) CRD Cases Total Cases Cohort Therapeutic intervention Proteinuria (-) Dipstick for microalbuminuria in risk groups Microalbuminuria (+) Longer questionnaire Laboratory test Physical exam Laboratory test Physical exam Intervention Microalbuminuria (-) Surveillance system Control group Sample Cohort Preventive actions CRD Prevalence CRD Incidence CRD etiological risk factors CRD progression Identify risk factors for CRD Risk reduction CRD control Morbidity patterns Mortality tendencies Distribution dialysis and kidney transplant Community epidemiological laboratory for study of chronic renal disease (CRD). Isle of Youth project. Cuba.

23. Cuban School of Nephrology National Reference Center National Coordinating Center Institute of Nephrology National Chronic Renal Disease Program Raising the Level of Medical Care Training Specialized Human Resources Developing Scientific Research Prevention Clinical Nephrology Dialysis Transplantation Management Telenephrology Epidemiological Laboratory National CRD Program: National Coordinating Center

24. National Institute of Nephrology National Network of Nephrology Services. National Health System’s National Telematics Network (INFOMED)  Second Opinion Services.  Teleconferencing.  Distance learning.  Epidemiological control (PC). o Selection of donor-recipient pairs. o CRI and Dialysis. o Statistics. XML Web services National CRD Program: Telenephrology Network

25. 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.

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

27. “These are dangerous times for the well- being of the world. In many regions, some of the most formidable enemies of health are joining forces with the allies of poverty to impose a double burden of disease, disability and premature death on many millions of people. It is time for us to close ranks against this growing threat. “ Gro Harlem Bruntland M.D. Director – General World Health Organization Gro Harlem Bruntland M.D. Director – General World Health Organization The World Health Report. WHO. 2002

28. Thank You