Journal of Internal Medicine and Health Affairs

Abstract

Introduction: the activity of the health sector and its exports require a comprehensive and systemic approach. Cuba has resources that affect the growth of health tourism. Marketing the services that are carried out every day in Primary Health Care is not integrated into the work system of its professionals. Objective: implement a strategy for the commercialization of Cuban Medical Services from Primary Health Care. Methods: an intervention study with a single study group was carried out between July 2022 and June 2023, in the municipality of Trinidad, Sancti Spíritus province. 90 participants were included. Qualitative and quantitative research techniques and procedures were integrated. The feasibility test was applied to reach a consensus among the specialists consulted. Results: the female sex predominated. Before applying the strategy, the level of information was 100% inadequate, and then it went to a 98.88% adequate level of information. The applied strategy solves the essential problems of the investigation. The opinion of the specialists was in favor of the applicability of the strategy. Conclusions: the strategy introduced positive modifications in the knowledge of those included in the study. It was considered very appropriate by the specialists consulted, so its application is viable.

Introduction

The activity of the health sector and its exports require a comprehensive and systemic approach. Given the current conditions of currency restriction that the country suffers, the export of health services can constitute an important source of financing.
For adequate marketing of these services, it is necessary to take into account parameters such as availability, accessibility and quality. There are several necessary aspects for successful health commercialization, ranging from government support to the logistics infrastructure that includes technology and transportation assurance, to the obligatory updated scientific preparation of the executing personnel. [1]
Cuba has resources that influence the growth of health tourism. Among them, the scientific advances in medicine, its international recognition, humane treatment and the cost-quality relationship stand out. They also favor the presence of Cuban doctors in several countries and the training of students at the Latin American School of Medicine (ELAM). [2]
In 1994, the provision of services began from a marketing point of view. Turismo y Salud S.A. emerged in that year, then its corporate purpose changed and it evolved until in 2011 it adopted the name Comercializadora de Servicios Médicos Cubanos S.A. (CSMC), until today.
Exports of health services depend on the infrastructure of the national public health system, mainly on its qualified personnel. [3] There is an extensive network of assistance centers, only a small part provides border export services. Medical education and improvement centers are added that guarantee the personnel of the system itself.
The Cuban Medical Services Branch of Sancti Spíritus provides and markets health services to foreigners in transit, residents in the country and Cubans residing abroad. Health-related academic services are included.
When people travel to resolve a situation related to their health, it is understood as health tourism. [4] To respond to this, the implementation of forms of marketing of health services at all levels is needed, including primary care. 
In Cuba since 1963 they have been working on the family medicine model, until reaching the current Family Doctor and Nurse Program. [5, 6,7] Its main objective is to improve the health status of the population. [8, 9,10] There is an infrastructure that covers rural, urban and Plan Turquino communities. (11) Cuban family medicine today faces new challenges for its improvement. [12]
The insertion of the different modalities offered by the CSMC could constitute one more possibility to publicize the benefits of Cuba. The accumulated results support this statement. [13,14]
Marketing the services that are carried out every day in Primary Health Care (PHC) is not integrated into the work system of its professionals. In the authors' opinion, a great possibility of increasing the country's income is being lost due to not having implemented the strategies or programs that cover the activities and actions that include the CSMC within the Family Doctor and Nurse Program. 
To do this, it is necessary for PHC staff to know how to market their services. Given this situation, the authors set the objective of implementing a strategy for the commercialization of Cuban Medical Services from Primary Health Care.
 

Methods

An intervention study was carried out with a single study group, between July 2022 and June 2023, in the municipality of Trinidad, Sancti Spíritus province. We worked with the Basic Health Teams (BHT) of the 45 urban clinics of the municipality, as it is the main tourist area and facilitates the collection of information. 90 participants were included. 
Qualitative and quantitative research techniques and procedures were integrated with the use of a pre-experiment with pre- and post-test examinations. [15] The study went through several stages. In the first, the level of information of the medical and nursing staff in PHC on the commercialization of health services was described, which was re-evaluated once the strategy was designed and implemented. 
Theoretical level methods were applied. The system approach to strategy algorithm design. Deduction, [16] as logical reasoning. 
The design of the strategy was based on the information obtained from the characterization of those studied according to their level of information and the bibliography consulted. It was complemented with the authors' knowledge about the commercialization of health services and the experience gained by other researchers. [17] Systematization allowed the structuring and organization of knowledge, as well as its organization.
From the empirical level the bibliographic analysis, to form the theoretical framework. The survey was used to know the level of information about the commercialization of Cuban medical services. This was applied before and after the strategy was implemented. In both moments it was the researchers who formalized it.
The feasibility test was applied to reach consensus among the consulted specialists. Plausibility, justification, appropriateness and the possibility of success were taken into account.
The responses issued by the selected specialists were evaluated blindly by the researchers, which avoided possible biases due to prior identification of the issuer of the criteria. The actions and activities included in the strategy were also assessed. 
Percentage analysis was used as a statistical method. This allowed us to reach conclusions about the proposed strategy. The data obtained were stored in the Statistical Package for the Social Sciences (SPSS) program, [18] based on a rating.
The dependent, qualitative ordinal dichotomous variable was the level of information of the staff about the commercialization of Cuban medical services (CCMS). This variable was evaluated as adequate or inadequate according to the results of the survey applied. It was defined as the level of accumulation of primary data collected but not processed or analyzed. 
Feasibility is the analysis to determine the probability of being able to carry out a project taking into account plausibility, justification, adequacy, and success. It is a qualitative, nominal, dichotomous variable (Yes/No). 25 specialists were consulted, 13 linked to the PHC and 12 to Cuban medical services (CMS).
The management strategy for marketing Cuban medical services (MSMCMS) in PHC constituted the independent variable. It is defined as the system of actions, as a process, aimed at training on the commercialization of Cuban medical services in PHC. 
The work sessions were planned from the Sancti Spíritus Medical Services Branch. The actions and activities included in the strategy were directed by the researchers who developed the themes developed in this regard.
Two teams were prepared to implement the strategy. These were each made up of five members, all with more than 15 years of experience in the PHC, good scientific preparation demonstrated by their research career and assistant or auxiliary teaching status, who assumed a health area of the municipality. 
The teams held the 100% BHT preparation meeting for each polyclinic on the regulatory documents and explained the objectives of the strategy. Daily equipment exchange was carried out according to the activities to be carried out.
The strategy was implemented in the afternoon without interfering with the care of the population. Variations were assumed in the way of addressing the topics taking into account criteria of those studied. 
Gaps in knowledge or situations to be resolved related to the topic investigated were identified. A system of improvement activities was designed in essential aspects with a coherent and systemic nature, for the adequate work of the BHT, where those dedicated to the implementation of the CCMS were included with greater emphasis. 
From an ethical point of view, the study was analyzed and approved by the Ethics Commission of the Scientific Council of the Provincial Health Directorate in Sancti Spíritus. Written informed consent was obtained from each of the members. The primary data, as well as the research results, were used in the strictest confidentiality. The provisions of the Declaration of Helsinki were taken into account at all times. [19]
 

Resultados

Results
The population included in the research was characterized. The female sex predominated with 54.4% (49) of a total of 90 participants.  The highest percentage of ages was between 25 and 55 years with an average of 35 years. 
Before applying the strategy, the level of information about the marketing of medical services was inadequate in 100% of those studied. The results were then reverted to positivity with a 98.88% adequate information level. The results are shown in Table 1.
 
Table 1. Description of the level of information on the commercialization of Cuban Medical Services from Primary Health Care before and after applying the strategy. Trinidad, Sancti Spíritus. 2022/2023
 

 Of the 90 participants, 100% had an inadequate level of knowledge about the CCMS before applying the MSMCMS. Once put into practice, 88 participants, for 97.78%, presented an adequate level of knowledge. Only two remained with inadequate levels, which coincided with an BHT who did not regularly attend the training provided. It is important to remember that the evaluation is done comprehensively. 
The strategy itself constituted an educational and training process with social repercussions. It was articulated in the development of functional skills according to profiles and teachers. From the social point of view, it contributes to the health sector by raising the level of information and therefore knowledge.  Manages to incorporate the CCMS into the PHC work system.
Tutors from the teaching offices were trained to implement the course and training system for sales in 100% of the basic equipment. This increases the satisfaction of the population to which it is directed.
The questionnaires were sent to the selected specialists via email without knowing each other so that they could issue their criteria. The technique covered plausibility, justification, appropriateness and possibility of success.
The group of specialists consulted admit that the proposed strategy constitutes the alternative for the implementation of the CCMS. They agree that qualitative methodology provides a way to obtain broad and detailed information. The experiences and experiences of the executors provide solid elements for the construction and improvement of the CCMS in the PHC. They issued criteria that the theoretical data form a gear that leads to the MSMCMS. 
The analysis of the specialists' discourse led to assessing the EGCSMC as viable through consensus. The results are presented in table 2.
 
Table 2. Evaluation of specialists in relation to the viability of the strategy

 Source: Feasibility survey

The opinion of the specialists was in favor of the applicability of the strategy. The feasibility of introducing the proposal into the PHC was, for the most part, very adequate. 
In relation to the need to introduce the proposed actions and activities in the PHC, the criterion was unanimous that they were very appropriate, as was the timeliness and scientific level of the proposed actions and activities. The relevance of the proposed actions and activities was mostly very appropriate.
Proposals were made to put into practice in the territory. These were perfected among the participants, training teams and health managers. They defined which ones would have the greatest possibilities of implementing. 
Several actions were aimed at training courses to transmit the experience achieved in Cuba in PHC. These courses would be linked to tourist packages coordinated with hotels in the area. The holding of virtual scientific events was proposed as a rapid dissemination of information about the research being carried out in the territory. 
Specialized care in selected offices to apply Traditional Natural Medicine (TNM) and massage therapy with related relaxation techniques was another of the accepted modalities.  Likewise, the option of offering health wellness services was adopted.

Discussion

Authors of studies consulted found that the level of information was inadequate or partially inadequate before receiving training on the subject under investigation and reverted to an adequate level once instructed. [20-22] The results achieved in the present investigation coincide with those mentioned above. 
Carreño, [23] suggests that the commercialization of health services, in his case academics, is an opportunity to enter the market. What is irrevocable is that competitive, quality and humanistic services are needed. 
In the case of Cuba, this has translated into state financing for the national health system, as a way to guarantee high coverage, universal access and sustainability of different programs; with quality. To maintain and improve the results achieved, it is essential to promote the generation of income from the export of medical services.
The need for constant training of health personnel in PHC to increase the possibilities of financing so necessary for the sector is indisputable. To contribute to this purpose, the EGCSMC is implemented in PHC. 
Burguet and Campaña, [24] by applying strategies to raise the quality of work, achieved improvement in professional performance. The authors agree with the aforementioned as well as with what was stated by Serra and others. [25]
Durán and Martínez, [26] point out the need to implement actions that increase the capacity for action in health personnel in the different spheres in which they develop. This conclusion is also assumed by the researchers once the results achieved have been analyzed.
It coincides with the need to deepen the potential for the export of health services to expand income, taking advantage of the physical and human capabilities developed in the country with the connections that the activity has with other services and associated goods. [27] Health services Health provides a supply that does not accumulate over time, its final product materializes only when it is demanded. 
For this reason, these services must be the result of the interaction of a system with its users. It includes collateral activities (educational services, events, licensing fees, computer applications, among others), which contributes to the competitiveness and image of a country. It is necessary to have the responsibility and commitment to provide knowledge based on this objective.
Cuba has an extensive network of healthcare centers, but only a small part provides export services. Once the implementation of this form of financing is achieved, different forms of exports may be used.
It will be necessary to increase multilingual language preparation, constant updating in treatments and technologies, use of Natural Medicine in its different modalities, among others. Gradually, the private sector should be included in these service export possibilities.
To achieve this goal, the work to be done will not be easy. It is necessary to confront the competitiveness that exists where all economic sectors are involved. 
This shows the relevance of the proposal since the majority of specialists considered that the actions and activities of the strategy favor CCMS in PHC. The specialists issued a favorable evaluation of the different indicators submitted to their evaluation criteria, which was corroborated in the statistical results obtained.
Studies consulted demonstrate that training strategies constitute tools to be used systematically. [28, 29] The specialist criteria can guarantee the success of the modality that will be applied. [30] These opinions facilitate actions to perfect or remodel the proposal before introducing it. in practice, to avoid or reduce as much as possible the risk of making errors, as demonstrated by the results consulted.[31-33] The authors of this research agree with the criteria issued in the cited bibliography.
Consulting specialists does not constitute an element of definitive validation because it is subjective. The final validation can only be the introduction into practice of the proposal made and its final evolution.
The achievements, strengths and attractions of Cuba as a safe destination for health tourism constitute a distinction supported by recognition on a global scale. The WHO considers the Cuban health system a model in terms of healthcare centers with international certification, highly qualified personnel, medical advances and quality service at reasonable prices. [34]
Studies show that on many occasions, destinations for health tourism are chosen taking into account the state of health of the country and the quality of medical care they may receive. [35] It is necessary to take into account offers that include alternatives to improve the quality of life of tourists in new scenarios.   
The export of services includes the online route. Telemedicine may provide the possibility of second opinions or services provided. This aspect is a way that could be very useful given the accelerated increase in the use of information technology and computing (ITC) by the general population. [36] This makes it possible to increase the radius of action to exchange experience between members of the scientific community in the world. 
The prestige achieved by health personnel in Cuba makes it possible to provide teaching services and their international trade. The increasing training of students from other latitudes is undoubtedly a possibility of expanding marketable services in the academic area. This option, which includes tourist and health tourism offers, would attract both graduates and their families. 
Adequate preparation and operation procedures are required to successfully apply the proposals made, taking into account the preparation that exists on the subject. [4] It is also necessary to guarantee actions to optimize prices and processes based on the commercialization of services. Any decision regarding the export of health services must keep in mind the need to respond to the multidisciplinary vision of the subject.
The limitation of the research is that it was carried out in the same territory with a small sample. Despite this, it is considered that the strategy contributes to expanding the number of clients interested in health tourism who can benefit and demonstrate its feasibility and effectiveness.
Similar studies should be carried out. It is necessary to systematically evaluate the marketing modalities that are put into practice through the groups trained by the branch in Sancti Spíritus.

Conclusions

The management strategy on the commercialization of Cuban Medical Services from Primary Health Care introduced positive modifications in the knowledge of the members of the EBS included in the study. The strategy was considered very appropriate by the specialists consulted, so its application is viable.

Conflict of interest

The authors declare that they have no conflict of interest.   

Author contributions

Yanara Oviedo Cornelio and Juan Carlos Mirabal Requena: conceptualization, data curation, formal analysis, research, project administration, writing the original draft and Writing – review and editing.
José Alejandro Concepción Pacheco: Methodology, Validation, Writing – review and editing.  
Belkis Alvarez Escobar: Conceptualization, data curation, Writing – review and editing.
 

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