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Introducción Poner en marcha una institución de salud es una tarea compleja que demanda una buena planificación. Objetivos Identificar los principales problemas para la puesta en marcha del primer Centro Especializado Ambulatorio en Cuba y determinar su orden de prioridad. Métodos Para la identificación de los problemas, se realizó una lluvia de ideas en la que intervinieron miembros del consejo de dirección y jefes de servicios seleccionados. Se aplicaron métodos de ponderación para reducir la lista de problemas y seleccionar un número determinado de ellos. Para la priorización de estos problemas se utilizó el método de ranqueo y para el diagnóstico causal se usó la técnica de Ishikawa o espina de pescado, que permitió definir cuáles de las causas son de carácter interno y cuáles de carácter externo. Resultados Se identificaron cuatro problemas fundamentales con el siguiente orden de prioridad: necesidad de la puesta en marcha de los servicios ingenieros, calculo de insumos médicos y no médicos, incorporación de los recursos humanos y departamentos que trabajarían en el Centro y por último, incorporación de los servicios médicos según objeto social previsto. Conclusiones La planificación realizada y los métodos utilizados garantizaron el cumplimiento de los objetivos propuestos y la puesta en marcha del Centro Especializado Ambulatorio Héroes de Playa Girón anexo al Hospital General Universitario Dr Gustavo Aldereguía Lima, en Cienfuegos(AU)

Introduction Putting into operation a health institution is a complex task requiring good planning. Objectives To identify the main problems for the putting into operation the first specialized outpatient service center in Cuba and to determine their order of priority. Methods For the problem identification, a brainstorming activity was performed in which members of the managing board and selected heads of services were involved. Several weighing methods to reduce the listing of problems and to select a certain number of them were used. The ranking method served to prioritize problems followed by the causal diagnosis, based on the Ishikawa or fishbone technique, which allowed defining both the internal and the external causes. Results Four fundamental problems were detected following the order of priority: need for putting engineering services into operation, calculation of the required medical and non-medical inputs, incorporation of the human resources and departments, and finally, the incorporation of the various medical services in line with the agreed social object of the institution. Conclusions The planning and the used methods assured the fulfilment of the objectives and the putting into operation of Heroes de Playa Girón specialized outpatient service center, attached to Dr Gustavo Aldereguía Lima general university hospital in Cienfuegos(AU)

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Introducción Poner en marcha una institución de salud es una tarea compleja que demanda una buena planificación. Objetivos Identificar los principales problemas para la puesta en marcha del primer Centro Especializado Ambulatorio en Cuba y determinar su orden de prioridad. Métodos Para la identificación de los problemas, se realizó una lluvia de ideas en la que intervinieron miembros del consejo de dirección y jefes de servicios seleccionados. Se aplicaron métodos de ponderación para reducir la lista de problemas y seleccionar un número determinado de ellos. Para la priorización de estos problemas se utilizó el método de ranqueo y para el diagnóstico causal se usó la técnica de Ishikawa o espina de pescado, que permitió definir cuáles de las causas son de carácter interno y cuáles de carácter externo. Resultados Se identificaron cuatro problemas fundamentales con el siguiente orden de prioridad: necesidad de la puesta en marcha de los servicios ingenieros, calculo de insumos médicos y no médicos, incorporación de los recursos humanos y departamentos que trabajarían en el Centro y por último, incorporación de los servicios médicos según objeto social previsto. Conclusiones La planificación realizada y los métodos utilizados garantizaron el cumplimiento de los objetivos propuestos y la puesta en marcha del Centro Especializado Ambulatorio Héroes de Playa Girón anexo al Hospital General Universitario Dr Gustavo Aldereguía Lima, en Cienfuegos

Introduction Putting into operation a health institution is a complex task requiring good planning. Objectives To identify the main problems for the putting into operation the first specialized outpatient service center in Cuba and to determine their order of priority. Methods For the problem identification, a brainstorming activity was performed in which members of the managing board and selected heads of services were involved. Several weighing methods to reduce the listing of problems and to select a certain number of them were used. The ranking method served to prioritize problems followed by the causal diagnosis, based on the Ishikawa or fishbone technique, which allowed defining both the internal and the external causes. Results Four fundamental problems were detected following the order of priority: need for putting engineering services into operation, calculation of the required medical and non-medical inputs, incorporation of the human resources and departments, and finally, the incorporation of the various medical services in line with the agreed social object of the institution. Conclusions The planning and the used methods assured the fulfilment of the objectives and the putting into operation of Heroes de Playa Girón specialized outpatient service center, attached to Dr Gustavo Aldereguía Lima general university hospital in Cienfuegos

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El conocimiento de las prevalencias de los principales factores de riesgos cardiovasculares y del síndrome metabólico en una comunidad, es determinante para establecer programas preventivos de salud. Objetivo: Determinar la prevalencia del síndrome metabólico en un área de salud de la ciudad de Cienfuegos, así como su relación con los principales factores de riesgo. Métodos: Se realizó un estudio de corte transversal del tipo descriptivo correlacional. La muestra se obtuvo mediante un método probabilístico y es representativa de la población mayor de 17 años del área de salud IV del municipio de Cienfuegos; se estudiaron 209 personas extraídas de un universo de 16577 individuos, se utilizó un porcentaje de prevalencia esperada del 18 por ciento, un intervalo de confianza (IC) del 95 por ciento, una precisión de ± 5 por ciento y una tasa de no respuesta del 35 por ciento. Resultados: La prevalencia de síndrome metabólico se determinó en 21,7 por ciento, la prevalencia de hipertensión arterial fue de 39,2 por ciento, la obesidad en 24,8 por ciento y la diabetes mellitus en 10,7 por ciento La prevalencia de síndrome metabólico en mayores de 40 años fue de 43,7 por ciento con una razón de prevalencia de 2,40 para el sexo masculino. Conclusiones: Existe una alta prevalencia de los principales factores de riesgo en la comunidad, la principal triada de asociación para el síndrome metabólico esta formada por la hipertensión, hipertrigliceridemia e hipocolesterolemia de HDL(AU)

Background: Knowledge on the prevalence of major cardiovascular risk factors and metabolic syndrome in a community is crucial to establish preventive health programs. Objective: To determine the prevalence of metabolic syndrome in a health area of the city of Cienfuegos, and its relation to major risk factors. Methods: A cross-sectional study of descriptive and correlational type was conducted. The sample was obtained using a probabilistic approach. It represents the population over 17 years old in health area # IV of the municipality of Cienfuegos. Out of a 16,577 people universe, 209 individuals were studied. The following numbers were used: expected prevalence percentage, 18 percent; confidence interval, 95 percent; accuracy, ± 5 percent and a non-response percentage, 35 percent. Results: Prevalence of metabolic syndrome was found in 21.7 percent of the studied cases (confidence interval 95 percent 14.5; 28.8 percent), prevalence of hypertension in 39.2 percent, obesity in 24.8 percent and diabetes mellitus in 10.7 percentPrevalence of metabolic syndrome in individuals older than 40 years old was 43.7 percent with a 2.40 prevalence ratio for males. Conclusions: There is a high prevalence of major risk factors in the community. The main triad associated to the metabolic syndrome is made up of hypertension, hypertriglyceridemia and HDL hypocolesterolemia(AU)

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The recommendations from the seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7) were compared with those of a recent article by Aram V. Chobanian, Chairman of the JNC 7. The purpose was to identify the changes that this author proposed and determine how they might affect clinical work, as well as the health services and public health implications. The JNC 7 and the article in question coincide on all essential points, except that the article is more flexible when it comes to the use of diuretics at the start of treatment for high blood pressure. Chronic disease management should take place in health systems with primary care approach, where the epidemiology of such diseases and scientific advances in prevention offer an excellent opportunity for redesigning the health services and making them more effective. High blood pressure, as a public health problem, demands health interventions aimed not only at reducing harm but modifying its etiologic determinants. The challenge is to recognize that an integrated approach to clinical medicine, health services, and public health would offer an attractive opportunity to interrupt and prevent the continuous and costly vicious circle that managing high blood pressure and its complications implies.

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Se contrastaron las recomendaciones contenidas en el séptimo informe del Comité nacional conjunto para la prevención, detección, evaluación y tratamiento de la hipertensión arterial (JNC 7) con un artículo reciente de Aram V. Chobanian, quien fuera presidente del JNC 7. El propósito fue identificar cuáles son los cambios propuestos por este autor y cómo podrían afectar la actuación clínica, así como sus implicaciones en los servicios sanitarios y la salud pública. El JNC 7 y el mencionado artículo coinciden en todos los puntos esenciales, con la excepción de que este último es más flexible en la utilización de diuréticos para iniciar el tratamiento de la hipertensión arterial (HTA). Se considera que la atención de las enfermedades crónicas debería inscribirse en sistemas de salud con un enfoque de atención primaria, donde la epidemiología de tales enfermedades y los avances en la prevención ofrecen una excelente ocasión para rediseñar y hacer más efectivos los servicios de salud. La HTA, como un problema poblacional, requiere de intervenciones sanitarias orientadas no solo a conjurar los daños sino a modificar sus determinantes etiológicos. El desafío es reconocer que un enfoque integrado de medicina clínica, servicios de salud y salud pública, proporcionaría una atractiva oportunidad para interrumpir y prevenir el continuo y costoso círculo que supone el manejo de la HTA y sus complicaciones.

The recommendations from the seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7) were compared with those of a recent article by Aram V. Chobanian, Chairman of the JNC 7. The purpose was to identify the changes that this author proposed and determine how they might affect clinical work, as well as the health services and public health implications. The JNC 7 and the article in question coincide on all essential points, except that the article is more flexible when it comes to the use of diuretics at the start of treatment for high blood pressure. Chronic disease management should take place in health systems with primary care approach, where the epidemiology of such diseases and scientific advances in prevention offer an excellent opportunity for redesigning the health services and making them more effective. High blood pressure, as a public health problem, demands health interventions aimed not only at reducing harm but modifying its etiologic determinants. The challenge is to recognize that an integrated approach to clinical medicine, health services, and public health would offer an attractive opportunity to interrupt and prevent the continuous and costly vicious circle that managing high blood pressure and its complications implies.

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Como una de las consecuencias más importantes de la transición epidemiológica que han sufrido las poblaciones en las últimas décadas, ha estado el incremento progresivo y geométrico de las personas que padecen enfermedades crónicas, con la particularidad de que alrededor del 80 por ciento de todos los que mueren de estas enfermedades, no residen en los países desarrollados. A un escenario con nuevas condiciones y estilos de vida no saludables, se une un envejecimiento poblacional creciente. En este artículo se insiste en que para un enfrentamiento exitoso de los servicios de salud en la prevención y el control de las enfermedades crónicas y en la atención de quienes las padecen, se requiere de una clara definición e identificación de este problema con sus particularidades, de una reorientación de los servicios y del rediseño de una formación de profesionales de la salud integrales; acciones que deberían llevarse a cabo de manera coordinada, tanto por salubristas y epidemiólogos, como por clínicos, en un contexto demográfico y epidemiológico sin precedentes en la historia de la humanidad(AU)

One of the most important consequences of the epidemiological transition that the populations have undergone in the last decades is the progressive and geometric increase in the number of persons suffering chronic diseases; particularly around 80 percent of people who die from these diseases do not live in developed countries. Growing population aging is added to a setting full of new conditions and unhealthy lifestyles. This paper emphasized that for the health services to be successful in the prevention and control of chronic diseases and the care of those affected by them, it is required to clearly define and identify this problem with its specificities, to re-direct the services and to re-design the formation of integral health professionals. All these actions should be carried out in a coordinated way by both public health specialists, epidemiologists and clinicians, within an unprecedented demographic and epidemiological setting in the history of mankind(AU)

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Como una de las consecuencias más importantes de la transición epidemiológica que han sufrido las poblaciones en las últimas décadas, ha estado el incremento progresivo y geométrico de las personas que padecen enfermedades crónicas, con la particularidad de que alrededor del 80 por ciento de todos los que mueren de estas enfermedades, no residen en los países desarrollados. A un escenario con nuevas condiciones y estilos de vida no saludables, se une un envejecimiento poblacional creciente. En este artículo se insiste en que para un enfrentamiento exitoso de los servicios de salud en la prevención y el control de las enfermedades crónicas y en la atención de quienes las padecen, se requiere de una clara definición e identificación de este problema con sus particularidades, de una reorientación de los servicios y del rediseño de una formación de profesionales de la salud integrales; acciones que deberían llevarse a cabo de manera coordinada, tanto por salubristas y epidemiólogos, como por clínicos, en un contexto demográfico y epidemiológico sin precedentes en la historia de la humanidad

One of the most important consequences of the epidemiological transition that the populations have undergone in the last decades is the progressive and geometric increase in the number of persons suffering chronic diseases; particularly around 80 percent of people who die from these diseases do not live in developed countries. Growing population aging is added to a setting full of new conditions and unhealthy lifestyles. This paper emphasized that for the health services to be successful in the prevention and control of chronic diseases and the care of those affected by them, it is required to clearly define and identify this problem with its specificities, to re-direct the services and to re-design the formation of integral health professionals. All these actions should be carried out in a coordinated way by both public health specialists, epidemiologists and clinicians, within an unprecedented demographic and epidemiological setting in the history of mankind

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Cuba's public health system is well known for its integrated first line services based on family medicine. Less publicized is the country's experience in public hospital management. After a harsh economic crisis in the first half of the 1990s had brought the Cienfuegos hospital near to collapse, from 1996 onwards the hospital management team took advantage of the incipient economic recovery to launch an ambitious recovery process. This article reconstructs this endeavor, based on annual hospital reports, scientific publications by the hospital staff, and interviews with key decision-makers. First the endless waiting list for elective surgery was tackled through a more efficient use of the surgery department, and an increase of ambulatory surgery. Next, overall hospital efficiency was improved in the aim to drastically reduce the average length of stay, reaching a decrease from an average stay of 12 days to a little more than 6 days in 1999. Also the emergency department was reorganized, setting up a triage system based on a color code, linked to specific emergency protocols. Attention for improving the clinical efficiency for AMI and stroke coincided with a drop in their intrahospital lethality. Clinical guidelines for the most important diagnoses were collectively developed, adapting international evidence to the local setting. An individual and collective performance evaluation system was elaborated in a participatory way, and further evolved into a 'total quality management' process. This experience of Cienfuegos hospital provides an interesting example on how a public hospital--embedded in a well developed national public health system--can be effective and efficient, even in circumstances of limited resources.

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The first assessments of the Millennium Development Goals of the United Nations have been completed, and deliberations about world health are increasing. Now is an appropriate time to consider the case of Cuba, which has functioned under difficult conditions for many years, and followed its own path. Cuba's health indicators are much better than might be expected considering its level of income; in many cases the indicators compare to those of industrialized countries. These results should be viewed as the product of a well-defined strategy and the use of essential public health principles rather than as the accumulation of better numbers. The Cuban experience demonstrates that a population's health can improve in even the most adverse economic conditions. This is attainable when sound public health practices are implemented under the principle that health is a basic right and therefore a national priority. An understanding of the Cuban public health system can help other low-income countries adapt these practices to their own conditions and meet the Millennium Development Goals. If this were to occur, there would be substantial improvement in the world's health.

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Objetivos: Diseñar y aplicar una metodología para evaluar el grado de desarrollo integral de los servicios médicos hospitalarios. Material y método: Durante los meses de agosto y septiembre de 2004 se planificó y llevó a cabo una investigación en servicios de salud. Después de varias "tormentas de ideas", mediante el método de juicio grupal ponderado, y por aproximaciones sucesivas, se identificaron 10 factores que se consideraron relacionados con el grado de desarrollo de cada servicio. Se confeccionó y aplicó un formulario, aprobado por 10 jueces seleccionados, y cada factor o acápite se calificó de 0 a 10 puntos. Se hicieron 3 evaluaciones independientes: una autoevaluación por el jefe de servicio, una por el subdirector correspondiente y otra por un experto designado. Se obtuvo un promedio de las 3 que se tomó como la definitiva. Resultados: Se logró diseñar una nueva metodología fundamentada para evaluar integralmente cada servicio médico del hospital. Se aplicó exitosamente y se presentan los resultados parciales y finales de 36 servicios asistenciales. El rango de calificación osciló entre 53,4 y 89,6 puntos, lo que refleja que el método discrimina objetivamente lo que antes se hacía de modo subjetivo. En la división por cuartiles, las puntuaciones observadas fueron: 8 servicios en 89,9-80,6; 18 servicios en 80,6-71,5; 5, en 71,5-62,4, y 5, en 62,4-53,4 puntos. Conclusiones: La metodología original, diseñada y aplicada en el hospital, constituye una herramienta útil, flexible, barata y fácil de aplicar, permite programar actividades específicas para el mejoramiento continuo de cada servicio, según sus características particulares

Objectives: To design and apply a comprehensive methodology for the evaluation of hospital medical departments. Material and method: During August and September, 2004, research into medical departments was planned and carried out. After several brainstorming sessions and weighting the group's ideas by successive approximations, 10 factors were identified as being related to the level of development of each of the departments. A form was designed, which was approved by 10 selected experts, and each factor was evaluated on a scale of 0-10 points. Three independent evaluations were performed: a self-evaluation by the head of department, a second evaluation by the corresponding deputy director and a third by a designated external expert. The average of the three evaluations was considered as the final or conclusive evaluation. Results: A new methodology was outlined for a comprehensive evaluation of each medical department in the hospital. This methodology was successfully applied and partial and final results of the 36 medical departments were presented. The range of scores obtained was between 53.4 and 89.6 points, reflecting the methodology's discriminatory power. When the final scores were divided by quartiles, eight departments scored between 89.9 and 80.6 points, 18 departments between 80.6 and 71.55 points, five departments between 71.5 and 62.4 points, and five departments between 62.4 and 53.4 points. Conclusions: This original methodology, designed and applied in the hospital, is a useful, flexible, cheap and easy-to-apply tool for evaluating the level of development of medical departments. This methodology allows specific activities for the continuos improvement of each department to be planned, according to their particular characteristics

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The first assessments of the Millennium Development Goals of the United Nations have been completed, and deliberations about world health are increasing. Now is an appropriate time to consider the case of Cuba, which has functioned under difficult conditions for many years, and followed its own path. Cuba's health indicators are much better than might be expected considering its level of income; in many cases the indicators compare to those of industrialized countries. These results should be viewed as the product of a well-defined strategy and the use of essential public health principles rather than as the accumulation of better numbers. The Cuban experience demonstrates that a population's health can improve in even the most adverse economic conditions. This is attainable when sound public health practices are implemented under the principle that health is a basic right and therefore a national priority. An understanding of the Cuban public health system can help other low-income countries adapt these practices to their own conditions and meet the Millennium Development Goals. If this were to occur, there would be substantial improvement in the world's health.

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Las enfermedades cerebrovasculares constituyen la tercera causa de muerte y primera de discapacidad en Cuba. Se encuentran dentro de las tareas priorizadas por la Organización Mundial de la Salud y reciben especial interés en la provincia de Cienfuegos, por encontrarse en ella una de las poblaciones más longevas del país y mostrar tasas elevadas de mortalidad. Objetivo: Definir las líneas de tendencia según el tipo de enfermedades cerebrovasculares en la provincia de Cienfuegos, en los últimos seis años. Métodos: Estudio retrospectivo, descriptivo, de serie de casos. Se analiza la mortalidad para los distintitos tipos de enfermedades cerebrovasculares. Los datos se obtuvieron de los informes mensuales y anuales de la Comisión de enfermedades cerebrovasculares. Resultados: Se constató una tasa media de morbilidad de 108, 89 por 100 000 habitantes; la letalidad por infarto y hemorragia subaracnoidea disminuye, no así la hemorragia intracerebral en la que se observa un incremento. Aumentó el número de pacientes egresados vivos, con infarto y otras enfermedades cerebrovasculares, que por su condición generan carga de discapacitados a la sociedad. Conclusiones: La hemorragia intracerebral constituye el principal problema para la mortalidad y el infarto para la morbilidad(AU)

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The poorer countries of the world continue to struggle with an enormous health burden from diseases that we have long had the capacity to eliminate. Similarly, the health systems of some countries, rich and poor alike, are fragmented and inefficient, leaving many population groups underserved and often without health care access entirely. Cuba represents an important alternative example where modest infrastructure investments combined with a well-developed public health strategy have generated health status measures comparable with those of industrialized countries. Areas of success include control of infectious diseases, reduction in infant mortality, establishment of a research and biotechnology industry, and progress in control of chronic diseases, among others. If the Cuban experience were generalized to other poor and middle-income countries human health would be transformed. Given current political alignments, however, the major public health advances in Cuba, and the underlying strategy that has guided its health gains, have been systematically ignored. Scientists make claims to objectivity and empiricism that are often used to support an argument that they make unique contributions to social welfare. To justify those claims in the arena of international health, an open discussion should take place on the potential lessons to be learned from the Cuban experience.

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BACKGROUND: Pharmacologic control of hypertension is an essential component of the current strategy to control cardiovascular diseases. Much concern has been focused in recent years on the challenge that cardiovascular disease poses for developing countries. Available medical therapies should be equally effective in low- and high-resource settings; however, this has not yet been demonstrated. Cuba has a well-organized primary-care system and has made reduction of cardiovascular diseases a priority, particularly through detection and treatment of hypertension. METHODS: To determine current hypertension control rates a population-based sample of 1667 persons aged 15-74 years was examined in the city of Cienfuegos. RESULTS: The prevalence of hypertension, weighted to the age structure of the sampled population, was 20%. Among all hypertensives, 78% were previously aware of the condition, 61% were currently taking medications, and 40% had systolic/diastolic blood pressures < 140/90 mmHg (men = 29%, women = 49%). Among treated hypertensives, 62% had blood pressures < 140/90 mmHg. DISCUSSION: The level of control documented in this survey is higher than reported previously from population surveys in other countries. If confirmed in broader samples in Cuba, these findings would suggest that effective control of hypertension is highly feasible in low-resource settings.

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Objetivo: Presentar el modelo de proceso de evaluación del desempeño (ED) aplicado en un hospital cubano universitario general de 640 camas y que tiene una población de referencia de 400.000 habitantes. Métodos: Se convocó a un grupo de directivos y trabajadores del hospital para diseñar la metodología de ED y el formulario para la evaluación de los trabajadores de la institución. Se aplicaron encuestas a los presidentes de las comisiones de evaluación, así como una dinámica de grupo en la que participaron, tanto evaluadores como evaluados, para conocer sus opiniones acerca de este procedimiento de ED. Resultados: Se presentan los pasos que conforman cada una de las etapas del procedimiento de ED y el formulario de evaluación que se elaboró. El 34,5% de los encuestados señaló 5 ventajas y sólo 2 personas (3,6%) refirieron 1 ventaja. En lo referente a las dificultades y recomendaciones, predominaron los que señalaron 1 en cada caso (16 [29,1%], y 30 [54,5%], respectivamente), y un número considerable de personas no le encontró dificultades (14 [25,5%]), ni sugirieron recomendaciones (8 [14,5%]) a este proceso. Conclusiones: Se ha logrado, por primera vez en el Sistema Nacional de Salud de Cuba, diseñar e implementar un procedimiento de ED (incluyendo el formulario de evaluación que se utilizó) válido y ampliamente aceptado por evaluadores y evaluados, también por las organizaciones sindicales y políticas

Objective: To present a model of performance evaluation (PE) implemented in a Cuban university general hospital with 640 beds with a catchment population of 400 000 inhabitants. Methods: A group of hospital officials and workers was formed to design the PE methodology and the form to be used when evaluating hospital staff. The presidents of the Evaluation Commissions were given questionnaires, and a group dynamic with the participation of evaluators and evaluees was carried out to determine their opinions on this PE procedure. Results: The steps composing each of the PE procedures and the evaluation form designed is presented. A total of 34.5% of the individuals surveyed itemized 5 advantages and only 2 persons (3.6%) itemized one advantage. Concerning difficulties and recommendations, most participants pointed out one in each case (16 [29.1%] and 30 [54.5%], respectively). A considerable number of participants found no difficulties (14 [25.5%]), nor did they make recommendations for this process (8 [14.5%]). Conclusions: For the first time in the Cuban public health system, a valid PE (including an evaluation form) was designed and implemented. This evaluation was widely accepted by evaluators and evaluees, as well as by trade unions and political organizations

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