Programa Nacional de Prevención y Control del Asma Bronquial

Objectives

Cuba’s National Programme for the Prevention and Control of Asthma is a permanent, nationwide framework for reducing asthma morbidity, disability and mortality, improving quality of life for patients and families, and ensuring efficient use of health-system resources. It builds on a multidisciplinary programme initiated in 1972 and is intended for people with asthma or at risk, all National Health System units, and relevant health institutions.[1][2]The programme responds to asthma’s substantial health and social burden, including frequent primary-care consultations, hospital use and mortality, particularly among younger people.[3][4]

• Improve prevention, early detection, diagnosis, treatment, rehabilitation and continuity of care across the full course of asthma.[2][5]
• Reduce annual asthma mortality by 10%, with an overall mortality target below 2%, while reviewing every asthma death to identify preventable factors.[2][6]
• Promote healthy lifestyles and reduce exposure to risk factors, including tobacco smoke, air pollution, occupational sensitisers and irritants, respiratory infections, domestic allergens and other environmental triggers.[1][7][8]
• Identify risk and protective factors in children under three years, register people with asthma, and prioritise children, adolescents and people at high risk of asthma-related death.[2][9][10]
• Achieve and maintain clinical control by preventing symptoms and exacerbations, preserving near-normal respiratory function and activity, minimising urgent care and admissions, limiting adverse medicine effects, and preventing death.[11][12]
• Strengthen patient, family, teacher and community knowledge of asthma, medicine use, inhaler technique, peak expiratory flow monitoring, trigger avoidance and written self-management plans.[2][13]
• Expand respiratory rehabilitation to improve symptom control, functional capacity, physical activity, quality of life and prevention of complications.[5][8]
• Develop research, surveillance and workforce capacity, including studies of morbidity, mortality, quality of care, environmental exposure, rehabilitation and the economic consequences of asthma.[2][14][15]

Implementation

Implementation is centred on primary care, where family doctors and nurses lead health promotion, prevention, early diagnosis, treatment, registration, follow-up and rehabilitation, supported by multidisciplinary hospital asthma groups and specialist services.[16][5][9]The Ministry of Public Health directs programme design, regulation, planning, evaluation and control; provincial health directorates adapt implementation locally, while municipal and health-area management structures oversee local delivery.[17][9]

• Deliver coordinated education through consultations, asthma schools, community activities, schools, workplaces, mass media and printed materials, involving patients, families, community leaders, teachers, clinicians, nurses and other sectors.[5][18][7]
• Maintain active asthma registers and systematic follow-up, particularly for children under 15 years and high-risk patients, and ensure discharge information reaches the family doctor after hospital, intermediate-care or intensive-care treatment.[9][10]
• Apply severity- and control-based assessment, using symptoms, activity limitation, exacerbations, reliever use and lung function, including peak expiratory flow or forced expiratory volume in one second where appropriate.[11][12]
• Provide stepwise pharmacological treatment, predominantly by inhalation, with periodic assessment of inhaler technique and adjustment to achieve control using the minimum necessary medication.[12][19]
• Deliver respiratory rehabilitation as an individualised multidisciplinary intervention combining education, inhaler training, smoking cessation, psychosocial support, breathing retraining, physiotherapy and graded physical exercise.[8][20][21]
• Ensure emergency services have trained personnel, appropriate equipment and medicines, assess attack severity promptly, initiate treatment according to clinical priority, and refer or admit patients with severe attacks, inadequate response, complications or high-risk features.[6][22][23]
• Coordinate urgent and inpatient care with primary-care follow-up, including specialist review after discharge and referral pathways for complicated, severe persistent, occupational or diagnostically uncertain asthma.[6][22][24]
• Investigate possible work-related asthma through detailed occupational history, exposure assessment and referral from municipal and provincial occupational-health services to the National Institute of Workers’ Health for confirmation or exclusion.[25][24]
• Train personnel through national, provincial and municipal programmes covering epidemiology, diagnosis, crisis and inter-crisis care, rehabilitation, communication and social participation, with asthma teaching incorporated into undergraduate and postgraduate education.[26][14]
• Operate governance through national, provincial and municipal asthma commissions, management councils, technical departments, specialist groups and collaborating organisations; hospitals are expected to sustain multidisciplinary asthma groups across emergency, inpatient, intensive-care and outpatient services.[17][14][27]
• Monitor delivery through epidemiological surveillance, periodic programme evaluation, five-yearly programme review, supervision visits, hospital-discharge analysis, death review and clinical-service indicators.[2][5][15]
• Review all asthma deaths at health-area level, notify hospital deaths within seven days, send area-level conclusions to provincial commissions within 15 days, and submit provincial death-review results to the National Commission within 30 days.[22][17][9]
• Track structural, process and outcome standards, including functioning provincial commissions, hospital multidisciplinary groups, surveillance participation, staff updating, asthma registration, physiotherapy coverage, hospital morbidity, case fatality and mortality trends.[27][28][29]

Monitoring & Evaluation

The National Asthma Programme combines population surveillance, service monitoring, clinical follow-up, periodic evaluation and multi-level accountability. It aims to monitor asthma morbidity, mortality, service use, care quality, rehabilitation and patient registration across the National Health System.[2][5][15][29]

• Establish epidemiological surveillance at all levels to receive, process and periodically analyse information on asthma patterns, complications, and environmental, individual and healthcare-related risk factors.[10]Register and communicate morbidity and mortality through the primary-care information system, analyse trends, disseminate findings and initiate research in response to identified problems.[30]
• Record new and returning asthma consultations, identify community morbidity and mortality events, and require hospitals to process discharge data and report asthma attacks managed in emergency and urgent-care services.[10][30]
• Evaluate the programme periodically and conduct a formal review every five years.[2]Provincial asthma commissions undertake monthly programme evaluation and control, report periodically to Provincial Management Councils, and coordinate supervisory work with epidemiology and specialist groups.[17]
• Investigate every asthma death through health-area or hospital review, post-mortem examination, and clinical discussion.[9][22]Send health-area conclusions to provincial commissions within 15 days, require hospitals to notify Municipal Health Directorates within seven days, and require provincial commissions to submit death-review results to the National Commission within 30 days.[6][22][17]
• Analyse hospital discharges by municipality, their causes and associated risk factors, and discuss asthma management through municipal emergency councils.[6]Discuss critical morbidity among children and adolescents as part of clinical review.[6][22]
• Monitor programme structures through provincial asthma commissions, hospital multidisciplinary asthma groups and institutional participation in epidemiological surveillance.[27]The planned standards are 100% for provincial commission establishment, 80% for their functioning, 80% for multidisciplinary hospital groups, and 100% for institutional surveillance participation.[27]
• Assess administrative and clinical processes through provincial and municipal management councils, quarterly supervisory activities, monthly multidisciplinary reviews, quarterly service assessments, death investigation, hospital mortality and discharge records.[28]
• Track impact through weekly and annual mortality disaggregated by age, sex, province and municipality; quarterly hospital case fatality; hospital and paediatric morbidity; emergency and outpatient care; respiratory physiotherapy coverage; and asthma registration.[29]Planned standards include hospital case fatality of 0.1%, hospital morbidity below 5%, physiotherapy coverage of 50%, and asthma registration of 80%.[29]
• Strengthen workforce monitoring through annual asthma-update training for doctors and nurses, each with a planned 25% standard, and assess achievement of planned care-quality indicators against a 75% standard.[29]
• Conduct annual National Commission supervisory visits involving family medicine, allergology, internal medicine, paediatrics, pneumology, rehabilitation, psychology, epidemiology and nursing.[15]Build local capacity to interpret programme evaluation indicators and undertake research.[14]
• Use clinical monitoring to guide individual care, including symptom frequency, night-time symptoms, activity limitation, rescue-medicine use, exacerbations and lung function measured by peak expiratory flow or forced expiratory volume in one second where appropriate.[12][19]Reassess stepwise treatment every three to six months and consider treatment reduction when control is achieved.[31][32]
• Assess rehabilitation through recorded multidisciplinary baseline assessment, reassessment after six weeks, asthma quality-of-life measurement, spirometry with bronchodilator testing, respiratory-muscle strength and the six-minute walking test.[20]

The indicator tables set planned standards but do not supply actual performance results, ratings, a consolidated national reporting format or a fully explicit accountability mechanism beyond commission, council and supervisory review.[27][28][29]

Costing & Financing

The programme emphasises efficient use of available resources and recognises asthma’s social and economic burden, but the supplied material does not provide a Cuban programme budget, expenditure allocation, financing source, resource-mobilisation target, funding gap or costing methodology.[1][2][26][15]

• Optimise available resources and improve effectiveness as part of efforts to reduce costs associated with asthma care.[1]
• Ensure the availability of trained staff, appropriate equipment and medicines for emergency asthma care, including urgent-treatment medicines and equipment at family-doctor surgeries.[22][9]
• Recognise external evidence that asthma creates substantial economic burden, with costs reported as exceeding those of tuberculosis and HIV/AIDS combined.[3]In developed economies, asthma may account for 1% to 2% of health-care budgets, while reported annual patient financial burdens in Western countries range from 300 to 1,300 United States dollars.[3]
• Report cited European annual asthma costs for 2003 of approximately 17.7 million euros, including 3.8 million euros in ambulatory costs and 3.6 million euros for antiasthmatic medicines.[3]These figures are contextual evidence rather than a Cuban programme allocation.[3]
• Identify research on asthma costs and economic losses as a planned area of inquiry, without a monetary estimate.[15]
• Describe respiratory rehabilitation as potentially reducing health-service costs by stabilising or reversing systemic disease manifestations, without quantifying savings.[8]
• Characterise the six-minute walk test as low cost and not requiring specialised equipment, without specifying an amount.[21]

No quantified financial plan is specified for asthma schools, surveillance, training, rehabilitation, medicines, equipment, research, emergency care or occupational-health referral pathways.[18][26][15]