Public hospital management in times of crisis: Lessons learned from Cienfuegos, Cuba (1996–2008)

Abstract

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.

Introduction

Defined by the United Nations Development Program (UNDP) as the decade of globalization [1], the 1990s showed a complex socio-economic evolution of the Latin-American and Caribbean (LAC) region, in which state reform and trade liberalization were omnipresent [2]. In most countries, market oriented reforms were also applied to the health sector [3], [4], [47]. Financial limitations and managerial problems within the public health sector have been used as triggers for privatization policies, claiming that private medical care offers better quality and efficiency, while alleviating national government budgets [5]. Meanwhile, strong evidence exists that these claims are ideologically biased [6], [7].

In the past century, public health systems have had a decisive impact on the favorable evolution of the health status of populations in developing countries. While this need for a well developed public health system remains essential, since decades many public health institutions suffer from limited resources, but also poor management. The option to further develop rational planning and efficient management of the public sector – rather than privatizing health systems – has long time been marginalized within the international health policy debate.

Cuba is a noteworthy exception. Cuba, a small and singular nation in the LAC-region, was extremely hit by the breakdown of the Soviet Union, which led to a sudden reduction of the country's foreign trade by almost 80% and a fall in gross national product (GNP) of 34% between 1989 and 1993. The United States reinforced the now almost 50-year economic blockade, deepening the suffering of the Cuban people [8].

Nevertheless, Cuba is well known to have been able to limit the social and health consequences of this dramatic period, with the health system playing a pivotal role [9], [10]. At international level Cuba remains one of the notable exceptions of maintaining an exclusive public health system with a strong community oriented health services network and a well developed and quite effective primary care [11]. Ample bibliography exists by now on Cuba's public health strategy of answering this crisis by the further development of its first line health services through full coverage of the population by family doctors and nurses, ensuring direct accessibility, free services and integrated care [12], [13].

Less known – but definitely also important – is the Cuban experience in public hospital management. During the 1990s also the Cuban hospitals came under strain, and – not unlike the rest of society – had serious difficulties to cope with their function. The experience of the main public hospital of Cienfuegos provides interesting elements on how public services – embedded in a well developed national public health system – can cope with such socio-economic constraints.

This article presents an analysis of the initiatives that were developed in the main hospital of the Cienfuegos province from 1996 onwards, taking the incipient socio-economic recovery as an opportunity to improve the output of the hospital.