ATC190220: Report of the Portfolio Committee on Health on a Study Tour to Cuba, from 01 to 05 October 2018, dated 20 February 2019
Report of the Portfolio Committee on Health on a Study Tour to Cuba, from 01 to 05 October 2018, dated 20 February 2019
The Portfolio Committee on Health (the Committee) having undertaken a study tour to Cuba from 01 – 05 October 2018, reports as follows:
The Committee decided on a study tour to Cuba so as to better understand the objectives of the National Health Insurance (NHI) and principles of primary health care. The Committee also wanted to learn from international best practice in terms of the overall health system and the implementation of universal coverage in Cuba. The success of Cuba’s system of universal health coverage and primary health care holds many lessons for effective implementation of NHI in South Africa.
The Committee sought to gain insight into how a health system of a developing country such as Cuba is able to achieve excellent health outcomes. Cuba has an effective PHC system that is aligned with the universal health coverage system envisaged in South Africa namely, the National Health Insurance. Moreover, to strengthen relations with Cuba as South Africa has a health bilateral agreement with Cuba.
The key focus areas of the visit included the following:
- How the Cuban Government managed to implement primary health care rated amongst the best in the world;
- The improvements in the health status of the Cuban population;
- Progress of the health bilateral agreement over the years and identify its positive aspects whilst highlighting its challenges; and
- Meet with the South African students studying in Cuba.
The delegation comprised of the following Members of Parliament:
- Ms ML Dunjwa, ANC (Committee Chairperson and the Leader of delegation)
- Ms CN Ncube Ndaba (ANC)
- Dr P Maesela (ANC)
- Mr TM Nkonzo (ANC)
- Ms P Kopane (DA)
- Ms ERL Wilson (DA)
- Dr S Thembekwayo (EFF)
The delegation was accompanied by the following Parliamentary Officials:
- Ms Vuyokazi Majalamba (Committee Secretary)
- Ms Lindokuhle Ngomane (Content Advisor)
- Facilities visited by the delegation:
- National Assembly of the People’s Power, Havana
The delegation met with Mrs Estela Cristina Luna Morales, President of the Health and Sports Commission of the National Assembly of the People’s Power, who welcomed the Committee and outlined the work of the Health and Sports Commission. The Health and Sports Commission consists of 38 members and deputies. The deputies work closely together with the society, in addressing the rights and interest of the people. They visit the polyclinics and hospitals to conduct oversight and to assess the level of satisfaction by the users and address concerns of the people. They also control and monitor all levels of these facilities as well as ensure that laws are implemented and that patients and people’s issues are resolved as soon as possible. The Commission is presided by the President and two Vice Presidents. Mrs Morales said that the Commission also rely on provincial commissions in provinces under the provincial assembly as well as municipal commissions to address dissatisfaction of the people at a local level. The 38 members has a plan of action which they use to supervise work of municipalities in all territories.
Mrs Morales informed the delegation that she used to be the Director of the Vedado Polyclinic for six years, one of Cuba’s 450 polyclinics. The visit to the polyclinic will provide the delegation an insight of how the Cuban primary health system work. Mrs Morales further explained that primary health care in Cuba is the pillar of the health system and that it is the first level of care. Polyclinics constitute the basic service in the health sector. The Polyclinics are subordinated to the local level and therefore subordinated to the municipal authority. The polyclinics provide all health services. There are more than 10 000 doctors’ offices nationwide and each doctor’s office consist of one doctor and one nurse who does consultations in both urban and rural areas.
Mrs Morales elaborated that between the doctor’s office and the polyclinic, there is an intermediary which is a connection between the two and it consists of a team of basic specialists like paediatrician, internal medicine, general obstetrics, psychologists, a statistics technician and a specialist in hygiene. They do not only provide medical assistant but the polyclinic is also a training school, where the doctors provides teaching to medical students and the nurses. The nurses that graduate in Cuba have a bachelor’s degree and they also have intermediary level of supervising. Mrs Morales informed the delegation that there are 13 medical universities across the country, of which doctors and nurses also graduate from these universities. Nurses can also train as doctors as they are offered the major of medicine if they want to study further. She highlighted that nurses in Cuba are the doctor’s right hand.
Mrs Morales highlighted that as of July 2018, they have trained more than 85 000 nurses in Cuba and there is no shortage of nurses in their country. The system is in compliance with the plan and in accordance with the necessities and the territories, it is then decided on the number of specialists and nurses to be trained. Mrs Morales further indicated that between 70 to 80% of all health issues are to be treated in the primary health care facilities. Nurses and doctors live within the communities so they interact with the community in a much direct way and examine the health conditions under which the people live in, in those communities. The primary focus is to continue to better the patient’s health and the quality of services as these core-exist.
The system comprises of four main branches, namely, healing, promotion, prevention and rehabilitation. The services that are offered in the polyclinic include ultrasound, endoscopy and Intensive Care Unit (ICU). All these are offered by primary-based doctors because they can perform both in polyclinic and in consults because they have qualifications in other areas associated with health care. There are some specialities that require patients to go to the hospital to get treatment from specialists. Specialists do visit polyclinics to perform some duties which also assist in decongesting the hospitals which also strengthens the primary level of the health care system.
- Vedado Polyclinic, Havana
The delegation visited Vedado Polyclinic to learn their best practices and to see how primary health services in Cuba are operated.
It was reported in a presentation that the objectives of the polyclinic are to promote, prevent, treat and rehabilitate. Services offered at the facility were reported as follows:
- Comprehensive rehabilitation
- Medical emergencies
- Electrocardiography emergency and elective
- X-rays, simple and contrasted
- Family planning
- Minor surgery
- Comprehensive care for women, children, elderly, diabetic and cancer patients
The delegation was informed that there was zero maternal-foetal HIV and congenital syphilis transmission for ten consecutive years. The life expectancy in men in 2017 was at 77.4 years and 81.5 years in women. Over 60 years old population represents 32.91%.
The main causes of death in all ages as of 2017 were indicated as follows:
- Heart diseases – 79%
- Malignant tumours – 58.3%
- Cerebrovascular diseases – 10.1%
- Influenza and pneumonia – 5.6%
- Accidents – 0%
The took went on a tour around the polyclinic.
- Juan B Contreras Teaching Polyclinic, Municipality of Ranchuelo, Villa Clara
The delegation visited Juan B Contreras Polyclinic and met with Dr Ivette Molinatinares, Dr Belkys Lorenzo Gonzals and Dr Elsa Mania Svarez.
The following services are provided to the population: clinical laboratory, ultrasound, X-rays, Endoscopy, Allergy Laboratory, Optometry, EKG, Traumatology, Emergency, Cures, Observations and injections, Life support, Thrombolysis, Menstrual regulation, Sterilization, Ophthalmology, Genetics and Minor surgery.
In the municipalities, community projection of the following secondary care specialists at both polyclinics are carried out; Angiology, General Surgery, Neurology, Nephrology, Cardiology, Rheumatology, Endocrinology, Ear Nose and Throat, Immunology, Allergy, Oncology, Orthopaedics and Urology.
The Committee was informed that life expectancy in Cuba is at 76.5 years in men and 80.45 years in women. The general mortality rate is 233.2 per thousand inhabitants. The main causes of death are heart diseases, malignant tumours and cerebrovascular diseases.
The total births were at 408, zero maternal deaths and deceased minors under one year at three. It was reported that no evidence of transmission of arboviruses in the municipality. Efforts are made to focus on Aedes aegypti mosquitoes in both health areas supported by the Municipal Directorate.
The delegation toured the polyclinic and visited the rehabilitation centre and the traditional medicine consultation room. The delegation also visited the doctor’s office.
- Medical Sciences University of Villa Clara
The delegation visited the University of Villa Clara and met with Dr Ida Santana Perez, Dr Rokselz Vigo Rolugez, Julia Guijaly Rotizy and Ms Eugue Bermdey.
The delegation visited the University where some of the South African Medical Students are trained. It was then reported that the city of Santa Clara was founded in 1689 under the name of Glorious Santa Clara and it was the capital of the Las Villas region until it finally adopted its current name.
The university has 417 students from 30 countries, of which 222 are undergraduates and 195 postgraduates. There are 84 South African Students studying in Cuba and 87 students are in the 6th year in South Africa. There are 265 South African students who have graduated from the University of Medical Sciences of Villa Clara between 2004 and 2018.
Comprehensive training activities carried out with South African Students are as follows:
- Participation in activities organized by the University together with the solidarity brigade.
- Sports activities such as the Soccer Cup of the UCM.
- Participation in the Provincial Solidarity Cup between universities.
- Walk on the first of December for World Aids Day.
- Joint activities with ICAP, especially in defence of just causes.
- Celebration of the commemorative dates of each nationality and that of their countries.
- Participation in cultural festivals in the festivals in the faculties and at university level where they have obtained prizes.
- Participation in marches and events called by the university.
- Encounters of reflection and exchanges with the Board of Directors chaired by the rector.
- Meeting with South African students studying at the Medical Sciences University of Villa Clara
The delegation met with the South African medical students studying in Cuba. The students shared with the delegation their experiences and issues of concern.
- The students were concerned that they always raise their challenges with different South African delegations visiting Cuba and there is no follow-up on issues they raise instead they are expected to raise the same issues every time a new delegation visits.
- The lack of standardisation of the programme from the sending provinces.
- Students raised concern about the quality of food provided at the dining hall.
- The monthly stipend is no longer sufficient to accommodate their growing needs.
- Payment for extra luggage as the airline allows one piece of luggage. Students complained that one luggage allowance is insufficient as sometimes they are coming back from holidays or they are leaving Cuba.
- The lack of psychological support when they arrive in Cuba to deal with expectations and to assist them to deal with being far away from home.
- The students raised the issue of language, that they are being thought English by a Spanish speaking teacher.
- The students indicated that they require medical material in 5th year which is going to assist them to better prepare for 6th year in South Africa.
- Students raised concern about the lack of support from the South African Embassy, in terms of commemorating South African historic days.
- Students indicated that they depend on Cubans for stationery and uniform, uniform is always not available.
- Students further indicated that students who are expelled loose on their careers and that they should be given an option of considering other qualifications.
- The issue of provinces being put under administration was also affecting them as this result in delayed payments.
- The Committee observed with concern inappropriate conduct and behaviour of some of the students which is not a good reflection of South Africa.
- Center of Molecular Immunology
The Committee visited the Center of Molecular Immunology and received a presentation from Mr Angel Mauro Alfonso Fernandez. He informed the Committee that the vision of the center is to produce innovative biotech drugs to be sustainable. The focus of the center is cancer research and other non-communicable diseases.
The center has a therapeutic vaccine for advances NSCLC after 1st line Chemotherapy as switch maintenance. The vaccine is approved in Cuba, Peru, Paraguay, Colombia, Argentina, Kazakhstan and Bosnia-Herzegovina. It was reported that there are 5000 patients who have been treated in Cuba in 20 years.
It was also reported that there is Biosimilars, which they also use to treatment of Neutropenia associated to Myelosuppressive chemotherapy in solid tumours, leukemia, lymphomas and Bone marrow transplant, AIDS. The Biosimilars were approved in Cuba in 2002 and listed in Essential Medicine. This can transform advanced cancer into a chronic condition.
- Meeting with the Ministry of Public Health
The Committee met with the Dr Marcia Cobas, Deputy Minister of Public Health. Other officials of the Ministry were: Dr Jorge Goneg, Dr Miladys, Maria Diay, Dr Alex Carens and Dr Rolando Piloto.
Dr Cobas outlined the Cuban Health Care System and noted that there are 450 polyclinics in Cuba, 10 782 medical doctors, 91 000 nurses, 150 elderly homes, 287 Elderly day care centres and 12 research institutions.
One doctor is responsible for 127 inhabitants, one stomatologist is responsible for 620 inhabitants and one nurse is responsible for 128 inhabitants. It was also reported that life expectancy for women is at 80.45 years and 76.5 years in men.
The main causes of death in Cuba are heart disease (177.5), malignant tumours (167.0), cerebrovascular diseases (65.2), influenza and pneumonia (57.3) and accidents (4.9). Six eradicated diseases in Cuba are poliomyelitis, diphtheria, measles, mumps, pertussis and rubella. The two serious clinical forms are neonatal tetanus and TB Meningitis. Two serious complications were reported as congenital rubella and mumps meningitis. Another nine diseases do not represent a health problem.
Human resources training is as follows:
- Universities of Medical Sciences – 13
- Medical Sciences faculties – 25
- Stomatology faculty – 4
- Nursing faculty – 1
- Faculty of health technology – 1
- Faculty of technology and nursing – 1
- Subsidiaries in all municipalities – 15
Dr Cobas further highlighted that Cuba has medical collaboration with other countries. More than 367 973 workers are in 111 countries. In an effort to strengthen ties between the two countries, the Ministry raised major concern that the South African Ministry of Health have not honoured any of its invitations.
- Center of Genetic Engineering Biotechnology
The Committee met with Ms Lic Ana B Torres Minkova who made a presentation to the delegation. She informed the delegation that the center is part of the group of Biotech and Pharmaceutical Industries. It comprises of 38 enterprises and more than 22 000 qualified professionals. The group manufacturers generic drugs, therapeutic and prophylactic vaccines, biomedicine, diagnostic systems and high-tech medical equipment. It also does research on neuroscience and neurotechnology. Ms Minkova informed the Committee that of the 881 generic drugs used in Cuba, 583 are manufactured in the country.
Ms Minkova explained that there was an outbreak of Dengue Fever in Cuba in 1981 whereby 344 203 people had the fever and 158 died, and of the 158, 101 were children under 15 years.
The main products that are manufactured at the center include:
- Pentavalent vaccine
- Rec. Hepatitis B vaccine
- Rec. IFN Alpha -2b, PEG – Heberon
- Rec. GSF (Hebervital)
- Rec.tick vaccine (GAVAC)
- Heberferon (IFN a and y)
- Heberprot P
- Conugated Hib vaccine
- Rec.IFN gamma
- Rec. Streptokinase
- Diagnostic kits
Diseases surveillance is also conducted at the Center. Incidence of acute Hepatitis B cases in children under 5 and 15 years old and adults is conducted at the Center.
Ms Minkova elaborated on a product called Herbeprot-P, and said that it is a unique product worldwide that is used in Cuba for the treatment of patients with advanced diabetic foot ulcers (DFU) with high risk of amputation. Severe DFU is a limb-threatening and also a life-threatening, among more aggressive types of cancer. Every 30 seconds a leg is lost to diabetes somewhere in the world. Deaths from DFU or DFU related amputation is equal or exceed deaths from prostate cancer, breast cancer and Hodgkin lymphoma combined. 15% of diabetic patients would be affected by DFU, 30%of DFU patients never heal the ulcer with standard therapy, 15% of DFU patients would be amputated as a consequence of the DFU and 50% of amputee patients died in five years. Heberprot-P has however assisted in treating patients with DFU. There are more than 330 000 patients treated in Cuba and abroad. Ms Minkova highlighted to the delegation that diabetes is becoming a public health challenge in South Africa. Three and a half million South Africans have diabetes and five million have pre-diabetes while 78% is undiagnosed. Patents have been granted to United States, European Union, Australia, Hong Kong, Singapore, South Korea, South Africa, Russia, China, India, Indonesia, Ukraine, Mexico, Malaysia and Cuba.
Ms Minkova indicated that haemorrhoids is one of the rectal pathologies with the highest worldwide incidence. About 50% of people over 50 years will develop haemorrhoids. Cuba is using a product called Proctokinase for treatment of haemorrhoidal.
Ms Minkova indicated that the Center also provides treatment for non-melanoma skin cancer using Heberferon. Heberferon decreases the rate of appearance of new lesions in patients with non-melanoma skin cancer. The Center also treats Rheumatoid Arthritis. CIGB-814 is used for Rheumatoid Arthritis treatment. The CIGB 814 peptide was safe in the three different doses evaluated. The inclusion of other therapeutic drugs was not necessary. Preliminary evidence of clinical efficacy was obtained. Thirteen patients out of 18 improved their score.
- Lessons learnt
Having conducted the study tour in Cuba, the Committee learned the following lessons from the visit:
- The Cuban health system is organized and functional with very limited resources.
- The basis of the Cuban health system is primary health care (family medicine approach) which is organized and in line with the foundation of the South Africa National Health Insurance.
- Polyclinics are run by doctors and nurses, and also serve as training platforms.
- Polyclinics are fully equipped with medical equipment such as ultrasound and X-ray, which means that patients do not have to go to hospitals for these services.
- Polyclinics serve as a secondary platform for treatment, aimed at reducing congestion in hospitals.
- Success in preventing communicable diseases and special attention to maternal and child health.
- Outstanding health outcomes that can be learned from Cuba include the following:
- high vaccination rate;
- high life expectancy;
- eradication of maternal mortality;
- eradication of mother-to-child transmission of HIV; and
- 80% reduction in diabetic amputations.
- Coordinated use of complementary medicine at primary health care level.
- Impactful research innovation, such that eight percent of the medicines used in Cuba are manufactured within the country.
Having concluded the study tour, the Committee recommends that the Ministers of Health and of Higher Education and Training should ensure that the respective departments:
- Continue to strengthen the primary health care system as the basis of health service delivery to ensure improvements in health indicators with available resources.
- Strengthen the role of primary health care facilities in order to ensure that community-based care, clinics and community health care centres serves as secondary platforms for health care to decongest hospitals thus changing the emphasis from treatment to prevention.
- Provide adequate primary care givers, physicians and nurses at primary health care facilities.
- Develop a robust medical education and training programme in order to ensure adequate trained health workforce.
- Ensure that clinics and hospitals guarantees that 100% of the population have access to medical attention and drugs in line with universal health coverage.
- Strengthen partnerships with the Cuban government on molecular medicine, manufacturing of vaccines, cancer and diabetes treatment and research innovation.
- Centralise the South Africa-Cuba medical training programme under the Departments of Health and Higher Education and Training in order to improve its coordination. This will also assist in dealing with the issues of uniformity amongst students.
- On-going engagement between provinces sending students to train in Cuba and that the appropriate support is provided to students.
- Facilitate an orientation programme led by former South African Cuban-trained doctors to students before embarking on the programme.
- Provide on-going psychological support to the South African students studying in Cuba.
- Provinces provide students with feedback on their concerns and challenges.
Report to be considered.
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