PROEMDIS: Cuba's New Program for Professional Rehabilitation.

Since the end of the communist trading bloc in 1989 and the loss of Soviet subsidies in 1992, the employment situation in Cuba has been rapidly changing. Many new jobs have been added and old jobs deleted from the job market. Industry productivity has decreased. Factories are producing at 30% capacity because Cuba has lost 70% of its imports, much of which were raw materials. The labor market is in a period of transition with new industries being started. There has been rapid growth in the tourism industry. Tourism grew at an annual rate of 17% between 1991 and 1993. The number of free-lance workers (private enterprise) has also been expanding rapidly (Fedarko, 1995). According to Carlos Lage (Fedarko, 1995) Cuba's economy has ceased its free fall of 1993 and is now seeing positive growth. But this economic recovery is a slow process and persons with disabilities will have special problems in adjusting and adapting to many required changes. This challenge is being addressed by a new interdisciplinary Program for Professional Rehabilitation (PROEMDIS) which was implemented in all provinces of Cuba in 1996. PROEMDIS involves the interdisciplinary coordination of services by the Department of Work and Social Security, the Department of Education, the Department of Public Health, and non-governmental organizations for person's with disabling conditions. The Cuban Association for Physically and Motor Limited People (ACLIFIM) is the largest and most active of the non-governmental organizations.

Overview of the Cuban Public Health System

The current health care delivery system in Cuba was started on January 1, 1959, after a change in government systems. It is based on the whole political and social structural change that took place with the formation of the Republic of Cuba. Health care is viewed as a fundamental right of all human beings and is one of the guarantees contained in the Cuban Constitution in the following policy principle:

Article 49. Everybody has the right to health protection and care. The state guarantees this right:

"by providing free medical and hospital care through the rural medical service network, polyclinics, hospitals and preventive and specialized treatment centers" (Constitution of the Republic of Cuba 1981, Article 49)

A central plan was devised in the 1960's to integrate all formerly separate components of the private and public health care systems into the Ministry of Public Health. In the 1970's, this umbrella agency expanded its network to include professional education and the production and distribution of pharmaceutical materials (Iatridis, 1990). In an effort to increase efficiency, avoid duplication of services, and improve access to primary care, and insure complete geographical and population coverage, regional planning models were adopted. The following six hierarchical interrelated levels of medical care correspond to the country's administrative and political divisions: 1. The first level of primary care services is provided at the "Neighborhood" level through "mini" polyclinics and the "family physician" and serves approximately 600-700 people; 2. The second level of primary care, which is more specialized than those services provided at the first level, is provided at "sector" polyclinics and serves approximately 4,000 to 5,000 individuals; 3. The third level of primary care is provided at "area" polyclinics (health centers) at a more specialized level of services and serves approximately 25,000 to 30,000 persons; 4. Secondary care is provided at "municipality" specialized hospital centers and serves approximately 250,000 people; 5. Tertiary care in provided at "province" specialized hospital centers and serves approximately 1,000,000 persons; and 6. Quaternary care is provided at the "national" level at health institutes and super specialized hospital centers and serves about 10,000,000 individuals (Iastrides 1990). Each level of care contains services of different degrees of specialization, from primary care on the neighborhood level to highly specialized care on the national level. On the neighborhood level, there is the family doctor program begun in 1984 at the Lawton policlinic in Havana. The goal of this program is to further personalize medical care by having a family doctor who is responsible for the total health care of 120 to 140 specific families. Maximum health care includes social and mental factors, as well as physical health. Since the family doctor is part of the community, he/she is aware of the social, economic and health situation of the entire family (El Ministerio de Salud Publica de Cuba, 1991). A Cuban worker who incurs an injury is treated first at the nearest medical facility. If more specialized treatment is needed, the patient is referred to a speciality or municipal hospital. After being stabilized, the individual can begin rehabilitation in his/her own community while living at home. One of the goals of the family doctor program is to provide rehabilitation services to injured persons in the community in which they live. This program is called la rehabilitacion con base communitaria (El Ministerio de Salud Publica de Cuba, 1991).

According to Ida Hilda Escalona del Toro, President of ACLIFIM, (personal communication, May 28, 1993), when more specialized rehabilitation services are needed, the individual is referred to special rehabilitation hospitals which are available in all provinces and at the national level. The Julito Diaz National Center for Rehabilitation is located in Havana and those requiring specialized services are transferred from the provincial or municipal hospitals to the National Center. Individuals who need less specialized and intensive services can receive rehabilitation in special rehabilitation departments located in each provincial hospital. Municipal hospitals with 50 to 60 beds also have rehabilitation services available for local residents who require minimum rehabilitation.

There is a department at the Julito Diaz National Center for Rehabilitation that is directly responsible for reintroducing the individual into the work force. This department consists of a team composed of a physician who is a specialist in physical medicine and rehabilitation, a third year resident specializing in the same area, occupational therapists, psychologists, vocational placement manager, and social workers (Ida Hilda Escalona del Toro, personal communication, May 28, 1993).

ACLIFIM

The Cuban Association for Physically and Motor Limited People (ACLIFIM) is a non-governmental organization established March 14, 1980. One of its purposes is to assure both the physical and mental rehabilitation of its members. ACLIFIM also represents its members at state organizations, social institutions, and national organizations that can supply necessary services. Its goal for members is total integration into society and its main emphasis is the return to work.

Some of the stated objectives of ACLIFIM are:

1. To guide its members in resolving their difficulties and achieving maximum independence.

2. To assist with social rehabilitation of its members by guiding their families in using the services of diverse organizations and institutions in Cuban society.

3. To assist its members to develop their interest in study, work, and appropriate use of free time; participation in social, cultural, sports, and recreational activities.

4. To guide its members in their duties and rights as participants in the economic and social development of the country.

5. To work for the solution of labor problems, which interfere with the hiring of people based on their aptitudes and abilities.

(Secretaria de Divulgacion Comite Ejecutivo Nacional ACLIFIM, 1992).

ACLIFIM had approximately 42,000 members in 1995. It has members in every province and municipality in Cuba (Secretaria de Divulgacion Comite Ejecutivo Nacional ACLIFIM, 1995). Since 1994 Cuban governmental committees have been covering part of ACLFIM's operating expenses. When a disabling accident occurs, a municipal (local) representative of ACLIFIM is immediately notified. The representative visits the family and explains what is happening with the patient, choices that need to be made, and available options. The family is assisted in accepting and supporting the patient upon his/her return to the home. ACLIFIM provides material support by supplying necessary equipment, such as wheelchairs. It intervenes at the job site to have the individual's job held open for him/her while in rehabilitation and they offer peer counseling to the individual to help with his/her adjustment.

ACLIFIM helps its members when they are in labor conflict resolution procedures. The Constitution of the Republic of Cuba's Article 48 guarantees that an individual who has an accident on the job or is affected by an occupational disease has the right to medical care and to compensation or retirement in those cases in which temporary or permanent work disability ensues. If a person with a disabling condition has a problem in their rehabilitation process, ACLIFIM tries first to get it resolved on the municipal level with the appropriate agency. If resolution is not obtained, they proceed to the provincial level. If there is still no resolution, they proceed to the agencies' national organization for a final decision. Every three months the provincial officials of ACLIFIM meet with government representatives of agencies where members have experienced problems since the last meeting. ACLIFIM presidents from each province and municipality are present at the meeting. Which government representatives are present depends on the problems to be resolved. Possible government agencies that may be represented are Transportation, Culture, Sports, Education, and Public Health.

ACLIFIM also has a fleet of buses in all provinces in Cuba for transporting individuals who have disabling conditions. ACLIFIM's first international conference was attended by delegates from ten different countries, including Japan, Spain, and the United States where information was shared.

PROEMDIS: Program for Professional Rehabilitation

With the goal of both social and work integration of the individual, a new program of vocational rehabilitation was implemented throughout Cuba in 1996. It is called the Program for Professional Rehabilitation (PROEMDIS) (Ministerio de Trabajo y Seguridad Social, 1995). It presently serves individuals who have physically disabling conditions, hearing impairment and those who are blind. In the future, those with mentally disabling conditions will also be eligible for its services (Conrado Valladares, personal communication, December 30, 1995). The major goal of PROEMDIS is to provide a comprehensive and integrated program of services to facilitate total social and vocational habilitation and rehabilitation of individuals with disabling conditions. PROEMDIS is an interdisciplinary program. It is overseen by the Ministerio of Work and Social Security and coordinates that department's services and those of the Department of Education and the Department of Public Health. On the local level, included in this infrastructure are the private associations for individuals with disabling conditions: ACLIFIM for those with physical disabilities, ANSO for those with hearing impairment, and ANCI for those with blindness. Local labor unions and local industries also participate in this program.

Prior to its implementation on the national level, PROEMDIS was piloted in 1994 in the municipalities of Boyeros, in Havana, and Santa Clara, in the province, Villa Clara (El Ministerio de Trabajo y Seguridad Social, 1995). PROEMDIS served 17,000 persons with disabling conditions and placed 62% in regular jobs during the pilot period (Conrado Valladares, personal communication, December 30, 1995). Twenty-six percent of the persons had a disabling condition of blindness; 38% had physically disabling conditions, and 36% had the disabling condition of deafness (Conrado Valladares, personal communication, December 30, 1995). The fact that 62% were placed in regular jobs was viewed as a positive result. PROEMDIS was found to be more successful than what was in place previously. Although it is more time consuming, it leads to more security for the workers with disabilities (Conrado Valladares, personal communication, December 30, 1995). In Cuba, as in the United States, the goal for persons with disabling conditions is complete integration into work and social environments.

The process of vocational rehabilitation or habilitation begins at the local level with the identification of persons with disabilities by the family doctor. Family doctors are aware of each family's medical history and are the first in the PROEMDIS program to be aware of the occurrence of a work accident or congenital disability. At age five, a child born with a disability, can begin studying at the special schools for students with that specific disability. Prevocational training begins at an early age in these school. The type of training offered is determined by existing employment demands to insure that students will be able to be employed upon graduation (Conrado Valladares, personal communication, December 30, 1995). The provincial level of the Ministry of Work and Social Security coordinates between these special schools and the entire provincial employment market (El Ministerio de Trabajo y Seguridad Social, 1995).

When a disability is the result of an accident or illness, the family doctor refers identified cases to the local social worker. The social worker is the case manager for the individual until successful job placement has been achieved. After the person with the disabling condition is identified, the social worker registers pertinent data on that individual with the local Labor Resource Center of the Agency for Work. Persons with disabling conditions may self refer and register with the Labor Resource Center which also serves special schools that register their graduates and also various associations for persons with disabilities that register their members who are in search of work. Individuals currently working in sheltered workshops who would like to seek regular employment also register with this center.

After the job seeker is registered, an assessment of the functional capabilities is done to evaluate work potential. The local labor advisor and social worker are responsible for this assessment, in special cases, the services of a psychologist are utilized. The social worker may use the services of the Commission of Medical Inspectors for a functional analysis of the client to determine the client's residual capacities for work. The team analyzes the assessment data that was gathered and interviews the client to determine if vocational and social re-integration is a possibility. The social worker may visit the home to assess the socio-economic situation of the client and determine any unmet needs (Ministerio de Trabajo y Seguridad Social, 1995). If the home situation is deficient, services of the Social Assistance Agency are provided to assure that the client's needs are met during the period of transition to work. All Cubans who are not able to work or are laid off receive a pension of 70 to 80 percent of their former salary (Conrado Valladares, personal communication, December 30, 1995). All Cuban employees who are unable to work because of work related accidents, receive a subsidy of 70 to 80 percent of their salaries. If they are hospitalized, this subsidy may be increased an additional 20% in special situations that are considered exceptional.

After assessment and evaluation are complete, the team and injured person develop a rehabilitation plan according to the interests of the person and his/her capabilities (El Ministerio de Trabajo y Seguridad Social, 1995). The current labor situation in the individuals' community determines what employment is available to the person (Conrado Valladares, personal communication, December 30, 1995).

The team studies the requirements of the job training courses, as well as the demands of any available work where the client will be placed in order to decide upon a job placement goal. Their analysis includes geographic location and transportation available to the job site. An accessibility analysis is conducted for the work-site to determine modifications necessary to make the site fully accessible to the client (El Ministerio de Trabajo y Seguridad Social, 1995). The objective of the team is to help the client obtain and maintain suitable employment and progress toward full social integration. The government requires each company to have at least three percent of its workforce comprised of persons with disabling conditions.

Alternate Forms of Employment

When the individual cannot be successfully placed in an ordinary work situation, he/she can be assisted to "work at home" or in a special workshop. These work situations are supported by local companies of the various industries, and the social worker. There are currently 134 Special Workshops in Cuba. In 1994, 27% of individuals with disabling conditions were placed in special workshops and 11% were placed in "work at home." Of those individuals placed in special workshops, 31% had a hearing impairment, 30% had the disability of blindness, and 39% had a physically disabling condition. In "work at home", 24% had a hearing impairment, 41% had the disability of blindness, and 34% had a physically disabling condition (Conrad, 1995). These alternatives are reserved for persons that are not competitive in regular employment. The immediate goal for them is productive activity. Whenever possible, the long term goal is integration into regular employment. To help assure placement, the government subsidizes companies that employ persons with disabling conditions who are unable to meet a normal workload (El Ministerio de Trabajo y Seguridad Social, 1995). When the individual is ready to be placed in regular employment, he/she or the social worker may register him/her with the Local Labor Resource Center of the Ministry of Work.

Follow-Up

After job placement, the social worker monitors the client by making periodic visits to the training or work site. During these job site visits, the social worker interviews the administration and the labor union representative to determine the support they are providing to the client and to determine the client's progress. They observe and interview the client to determine job satisfaction or problems that confront them, their relations with other workers, and other job related needs. When applicable, they interview the training instructors to determine the client's progress and difficulties with the training activities. The results of the visit are analyzed and appropriate action is taken to resolve any client difficulties (El Ministerio de Trabajo y Seguridad Social, 1995).

Discussion

Sams, Saxon and Spitznagel (1994) suggested that changes in the Cuban work world "may require more focus on three significant areas; 1. Vocational Diagnostic, 2. Vocational Evaluation, and 3. Personal and Work Adjustment Counseling." When rehabilitating the injured worker, the PROEMDIS concept seems to be moving in a direction that considers these factors. PROEMDIS team members who are responsible for the injured worker returning to work should be skilled in four areas: 1. In-Depth Work History Interviewing, 2. Transferable Skills and Abilities Profiling, 3. Job Analysis and 4. Worker Job Adjustment.

Included in the initial diagnostic interview would be the collection of pertinent job information. Relevant data would include a description of each job on which the individual has worked; the processes required; the materials used; the equipment, tool and apparatus used; the length of employment and the thing most and least liked about the job. With this information, a transferable skills and abilities profile can be developed (Saxon & Spitznagel, 1995). The team member responsible for job placement now has a good foundation of inform/ttion for understanding the injured worker's work skills and abilities and personal needs. When the injured worker has the skills and abilities to perform the job requirements and the job is personally satisfying, everyone wins. The worker is productive and happy.

The next area in which the team member needs information is understanding the demands of the new job. This can be accomplished by analyzing the job. An in-depth job analysis can be conducted using the Revised Handbook for Analyzing A Job which is published by the U. S. Department of Labor, Washington, D. C. Another very useful book, Job Analysis and the ADA: A Step by Step Guide, published by Elliott & Fitzpatrick in Athens, Georgia, provides a detailed format for this process.

Once the team member has detailed worker and job information, the job placement event can take place with the optimal possibility of success. After the job placement event, the worker must be contacted, on a regular basis, by the team member so that any problems concerning the new job and adjustment to the job can be resolved. The worker may have feelings that need to be expressed about the job, the supervisor or co-workers. It should be remembered that in beginning a new job the worker is usually in a group of strangers. He/she is learning the demands of the job without close friends for support. These factors can cause stress which can interfere with the job adjusting process. The team member can assist the worker with these concerns, if they exist.

Conclusion

The current economic situation has produced a challenge to individuals with disabling conditions, but PROEMDIS seems to have the potential to make a very positive impact on the lives of the injured workers in Cuba. There are several interesting factors in the total PROMEDIS concept which parallel changes in our delivery of health and rehabilitation services. Cuba's integrated hierarchical health care system seems to have factors common with our medical managed care organizations concept. The "neighborhood" physician seems to function similarly to our "gatekeeping" physician. Kongstvedt (1993) defines the gatekeeper as" an informal, though widely used term that refers to a primary care case management model health plan. In this model, all care from providers other than primary care physician, except for true emergencies, must be authorized by the primary care physician before care is rendered." An individual is seen by a physician who then determines which appropriate level of medical care is needed. Hopefully, this will assure that the patient will receive the most appropriate level of cost effective care. Recently, the trend in health care, in The United States, has been toward integrated delivery systems, levels of specific care, and populations being served within one system (Aron, 1996). By receiving a comprehensive and integrated program of medical, vocational rehabilitation, and other needed services, the individual's goal of successful rehabilitation is enhanced. PROMEDIS involves the "team" concept in the coordination of interdisciplinary services to enhance the successful outcome of the process. Although, there are many differences between Cuba's and the United States' systems of vocational rehabilitation, the PROMEDIS concept seems to contain many common factors.

References

Aron, L. J. (1996). Integrating health and disability: 24 hour coverage. Case Review, 2, 15-16.

El Ministerio de Salud Publica de Cuba (1991). El plan del medico de la familia en Cuba. Mexico: Author.

El Ministerio de Trabajo y Seguridad Social, (1995) Programa de Empleo para las personas discapaciladas: PROEMDIS. Mastergraf srl, Cabildo, Cuba.

Fedarko, K. (1995, February 20) Open for business, Time, 51-59.

Iatridis, D. (1990). Cuba's health care policy: Prevention and active community participation. Journal of Social Work, 35(1),29-34.

Kongstvedt, P. R. (1993) The managed health care handbook (2nd.ed.). Gaithersburg, MD: Aspen.

Ministry of Justice (1981). Constitution of the Republic of Cuba. Havana, Cuba.

Sams, G. C., Saxon, J. P., & Spitznagel, R. J. (1994). The Cuban "vocational" rehabilitation system: An overview with implications for vocational evaluation. Vocational Evaluation and Work Adjustment, 27(3), 69-74.

Saxon, J. P., & Spitznagel, R. J. (1995) Transferable skills and abilities profile: An economical approach in the vocational placement process. Vocational Evaluation and Work Adjustment, 28(3), 61-67.

Secretaria de Divulgacion Comite Ejecutivo Nacional ACLIFIM (1995), What is ACLIFIM?. Havana, Cuba.

Secretaria de Divulgacion Comite Ejecutivo Nacional ACLIFIM (1992). Que es la ACLIFIM?. Cuba: Author.

Geraldine Cosby Sams
Miami-Dade Community College

John P. Saxon
University of Florida

Geraldine Cosby Sams, M.H.S., CRC,. Department of Extended Studies, 11380 Northwest 27th Ave., Miami-Dade Community College, Miami, FL 33167.3