Primary health care strategies for the prevention of end-stage renal disease in Cuba

Abstract

End-stage renal disease (ESRD) is a major health problem in the world, including Cuba. There is an increasing trend in both the incidence and prevalence of ESRD. Global projections consistently show an increase of patients in maintenance dialysis, and also an epidemic trend in diabetes mellitus and hypertension, two diseases that are leading causes of ESRD in most countries. A new paradigm is necessary to handle this major health problem, such as a public health model that integrates health promotion and disease prevention. In 1996, the Ministry of Public Health of Cuba launched a national program for the prevention of chronic renal failure (CRF). The progressive implementation of this program follows several steps: the analysis of the resources and health situation in the country; epidemiological research to define the burden of CRF; continuing education for nephrologists, family doctors, and other health professionals; and reorientation of primary health care toward increased nephrology services, intervention, and surveillance. The main outcomes of the program have been: a rational redistribution of nephrology services in corresponding health areas of primary health care; nephrologists being brought closer to the community; an improvement in the knowledge and ability of family doctors and nephrologists in the prevention of chronic renal disease; an increase in the number of patients with CRF (serum creatinine > or = 133 micromol/L or > or = 1.5 mg/dL, or a glomerular filtration rate < 60 mL/min) who are registered in primary health care every year, from a prevalence of 0.59 per 1,000 inhabitants at the beginning of the program in 1996 to 0.92 per 1,000 inhabitants in 2002, with a mean prevalence growth of 9.2% per year; a significant reduction (0.1%) in the incidence of viral hepatitis B in dialysis patients after the implementation of vaccination against viral hepatitis B in CRF patients who are registered in primary health care; and the implementation of CRF surveillance in primary health care, which provides periodic information on CRF burden, patterns, and trends to assist evidence-based public-health decision making, and measures the impact of interventions in the population. Primary health care is an essential tool, and the community is an appropriate social space for health promotion and the prevention of CRF and ESRD.