La nueva Ley de salud pública y la intervención del defensor del paciente una omisión subsanable J. Law Epistemic Stud. (January - June 2024) 2(1): 13-16 https://doi.org/10.5281/zenodo.14869108 ISSN: XXXX-XXXX ORIGINAL ARTICLE The new public health law and the intervention of the patient advocate a correctable omission  Mariceilys Morales mariceilys2002@gmail.com Universidad de Sancti Spíritus “José Martí Pérez”, Cuba. Received: 18 October 2023 / Accepted: 30 December 2023 / Published online: 10 January 2024 © The Author(s) 2024 Mariceilys Morales Abstract Within the current legal framework, this study analyzed the relationship between job performance and ad- ministrative processes in the Decentralized Autonomous Government of Quinindé, Esmeraldas Province, Ecuador. Factors limiting institutional efficiency were identified, and improvement strategies were proposed. A mixed-method ap- proach was used, including surveys, semi-structured inter- views, and document analysis. The study population consist- ed of 312 administrative employees, from which a sample of 164 participants was selected. The results indicated that a lack of clarity in organizational objectives and the absence of feedback negatively affected job performance. Although progress was observed in strategic and organizational plan- ning, internal communication and leadership deficiencies persisted—the scarcity of training programs and the limited adoption of technologies negatively impacted management. The internal control system was found to be insufficient to ensure transparency and operational efficiency. Strengthen- ing leadership, implementing training programs, incorporat- ing technologies, and improving internal control are recom- mended to optimize administrative processes. Finally, citizen participation was highlighted as a key factor in legitimizing institutional management and strengthening the government and community relationship. Keywords job performance, administrative processes, De- centralized Autonomous Governments, Ecuadorian legal framework, citizen participation. Resumen Este estudio analizó la relación entre el desem- peño laboral y los procesos administrativos en el Gobierno Autónomo Descentralizado de Quinindé, provincia de Es- meraldas, Ecuador, dentro del marco legal vigente. Se iden- tificaron factores que limitan la eficiencia institucional y se propusieron estrategias de mejora. A través de un enfoque metodológico mixto, que incluyó encuestas, entrevistas se- miestructuradas y análisis documental. La población de es- tudio fueron 312 empleados administrativos, seleccionando una muestra de 164 participantes. Los resultados indicaron que la falta de claridad en los objetivos organizacionales y la ausencia de retroalimentación afectaban el desempeño la- boral. Aunque se evidenciaron avances en la planificación estratégica y organizacional, persistían deficiencias en la co- municación interna y liderazgo. La escasez de programas de capacitación y la limitada adopción de tecnologías impacta- ban negativamente la gestión. El sistema de control interno resultó insuficiente para garantizar transparencia y eficiencia operativa. Para optimizar los procesos administrativos, se recomienda fortalecer el liderazgo, implementar programas de capacitación, incorporar tecnologías y mejorar el control interno. Finalmente, se destacó la importancia de la parti- cipación ciudadana para legitimar la gestión institucional y fortalecer la relación entre el gobierno y la comunidad. Palabras clave desempeño laboral, procesos administrati- vos, Gobiernos Autónomos Descentralizados (GAD), marco legal ecuatoriano, participación ciudadana. How to cite Morales, M. (2024). The new public health law and the intervention of the patient advocate a correctable omission. Journal of Law and Epistemic Studies, 2(1), 13-16. https://doi.org/10.5281/zenodo.14869108

J. Law Epistemic Stud. (January - June 2024) 2(1): 13-16 14 Introduction The doctor-patient relationship has been analyzed in va- rious disciplines, from bioethics to law. The asymmetry of knowledge and decision-making power between both par- ties has generated the need for mechanisms that balance the relationship and guarantee the patient’s rights (Martínez & Gómez, 2020). In this context, the patient advocate emer- ges as a key factor in guaranteeing respect for the patient’s autonomy and observing fundamental bioethical principles (Beauchamp & Childress, 2019). The recent approval of the new Public Health Law in Cuba represents a step forward in regulating health rights, aligning with the principles of equity and universality recognized by the World Health Organization (Navarro et al., 2008). Howe- ver, despite its progress, the legislation does not include a specific mechanism for defending patients’ rights in vulnera- ble situations, which represents a regulatory gap that could affect the effectiveness of its implementation (Hernández & Pérez, 2023). The concept of patient advocate has been adopted in se- veral health systems internationally, performing mediation, advisory, and rights protection functions. In countries such as Sweden and Spain, this figure has proven to be an effec- tive mechanism for resolving conflicts between patients and health service providers, reducing the judicialisation of con- flicts and improving trust in the health system (Lindberg, 2022; European Parliament, 2023). Colombia has implemented Latin America’s health user advocate figure to guarantee humanized and patient-centered healthcare. According to the Colombian Ministry of Health (2022), this figure has allowed for improved response times to user complaints and strengthened transparency in the pro- vision of health services. From a bioethical perspective, the patient’s right to quality medical care and informed decision-making is supported by autonomy and justice. According to Segura (2021), creating a figure that ensures these rights is not only a legal necessity but also an ethical imperative in the context of public health systems that seek to guarantee equity in access to health. In the Cuban case, the absence of a patient advocate in the new Public Health Law contrasts with incorporating other ri- ghts protection mechanisms in recent legislation, such as the family advocate and the advocate for people in vulnerable situations. However, the specificity of the health field and the complexity of the doctor-patient relationship make it neces- sary to have its regulation for this figure (González, 2022). This article will analyze the need to incorporate the patient advocate figure into Cuba’s new Public Health Law regula- tions. To this end, it will examine the models of doctor-pa- tient relationships, international experiences in implemen- ting patient advocates, and the feasibility of their application in the Cuban context. Based on these analyses, recommenda- tions will be presented to strengthen the protection of patient rights in the Cuban public health system. Methodology For the development of this article, a qualitative metho- dology was used with a focus on the comparative analysis of health legislation and the review of specialized literature. This approach allowed us to evaluate the relevance of incor- porating the figure of the patient advocate in the new Public Health Law of Cuba based on international experiences and relevant theoretical frameworks. An exhaustive search of bibliographic sources addressing the doctor-patient relationship, interaction models in health- care contexts, and the role of the patient advocate was con- ducted. The central databases consulted included PubMed, SciELO, and Google Scholar. The inclusion criteria were publications in Spanish and English, with an emphasis on studies published in the last five years to ensure the timeli- ness of the information. A comparative analysis was carried out of the regulations in force in selected countries that have implemented the figu- re of the patient advocate. This analysis identified similari- ties and differences in this figure’s regulation, functions, and powers. The countries selected for the comparative study were: Sweden: Recognized for its robust patient ombudsman model, with advisory, mediation, and rights protection func- tions. Colombia: Noted for implementing the health user om- budsman, aimed at guaranteeing humanized and patient-cen- tered healthcare. Spain has an institutionalized patient advocate focused on conflict mediation and defending the rights of healthcare sys- tem users. Relevant laws and regulations, official reports, and acade- mic studies evaluating the effectiveness and challenges of the patient advocate role were reviewed for each country. Semi-structured interviews were conducted with experts in bioethics, health law, and health professionals with experien- ce implementing the patient advocate role. These interviews provided practical perspectives and enriched the theoretical analysis with field experiences. The information collected was organized and analyzed using content analysis techniques, identifying thematic cate- gories relevant to the study. Particular attention was paid to the functions assigned to the patient advocate, the implemen- tation mechanisms, and the results observed in the countries studied. It is important to note that the availability of information

J. Law Epistemic Stud. (January - June 2024) 2(1): 13-16 15 varied across the countries studied, which may have influen- ced the depth of the comparative analysis. In addition, the interpretation of regulations may be subject to cultural and contextual biases. This methodology gave a comprehensive understanding of the relevance and feasibility of incorporating the patient ad- vocate figure into Cuban legislation, providing evidence and well-founded arguments to support this proposal. Results and discussion The comparative analysis of international legislation re- vealed that patient advocacy is implemented in diverse health systems, playing key roles in protecting patients’ rights and improving healthcare quality. For example, in Sweden, the patient advocate is a mediator between the patient and the healthcare system, ensuring that complaints and concerns are effectively addressed. This model has proven effective in re- solving conflicts and promoting patient-centered care. In Colombia, the role of the health user advocate has been established as an essential mechanism to guarantee human- ized and patient-centered health care. According to the Co- lombian Ministry of Health, this role has improved response times to user complaints and has strengthened transparency in the provision of health services (Ministry of Health of Co- lombia, 2017). Health systems that have implemented the figure of the patient advocate have shown significant improvements in conflict resolution and quality of care. As seen in Table 1, countries such as Sweden, Colombia, and Spain have a high percentage of complaints resolved without legal action (over 78%) and a higher percentage of complaints resolved with- out legal action (over 78%). Patient satisfaction with the care received (over 88%). In contrast, Cuba, where there is no similar institutionalized mechanism, shows a complaint res- olution rate of 45%, with a satisfaction rate of 72%. Further- more, the average resolution time in countries with a patient advocate ranges between 10 and 14 days, while in Cuba, it reaches 30 days. Table 1. Comparison of indicators in health systems with and without patient advocates Country Complaints resolved (%) Patient satisfaction (%) Resolution time (days) Sweden 85 92 10 Colombia 78 88 14 Spain 82 90 12 Cuba 45 72 30 Sources: World Health Organization (2021), Ministry of Health of Colombia (2017), and Pan American Health Orga- nization (2022). These results suggest that including the patient advocate in Cuba’s Public Health Law could significantly improve citi- zens’ perceptions of the quality of health services and reduce conflict resolution times. Implementing this figure in Cuba would align with international best practices and strengthen the protection of patients’ rights. The comparison between countries shows that the exis- tence of a Patient Advocate contributes to greater efficiency in conflict resolution and a better perception of the health service. Furthermore, the World Health Organization (WHO, 2023) has recognized the importance of patient advocacy in promoting patient safety and improving the quality of health systems. In its “Global Action Plan for Patient Safety 2021- 2030,” the WHO highlights the need to strengthen patients’ and their families’ participation in health care, promoting the creation of mechanisms that facilitate their empowerment and protection. The omission of the patient advocate in Cuba’s new Public Health Law represents a missed opportunity to strengthen the protection of patients’ rights and improve the quality of health care. International evidence suggests that implement- ing this figure contributes significantly to conflict resolution, improved communication between patients and health pro- fessionals, and strengthened trust in the health system (Pan American Health Organization, 2023). The experience of Sweden and Colombia shows that in- stitutionalizing patient advocacy is feasible and beneficial for the health system. These countries have made significant progress in protecting patients’ rights and improving health- care quality by implementing this figure. WHO also supports the creation of mechanisms that pro- mote patients’ active participation in their health care, recog- nizing that this is essential to improving patient safety and the quality of health systems. Including the patient advocates in Cuban health legislation would align the country with in- ternational best practices and strengthen its commitment to protecting patients’ rights. Conclusions The experience of countries such as Sweden and Colombia shows that institutionalizing patient advocacy is feasible and beneficial for the health system as a whole. These countries have made significant progress in protecting patients’ rights and improving healthcare quality by implementing this fi- gure. The WHO also supports the creation of mechanisms that promote the active participation of patients in their heal- th care, recognizing that this is essential to improve patient safety and the quality of health systems. The inclusion of the figure of the patient advocate in Cuban health legislation would align the country with international best practices and

J. Law Epistemic Stud. (January - June 2024) 2(1): 13-16 16 strengthen its commitment to the protection of patients’ ri- ghts. Therefore, it is recommended that Cuban health autho- rities consider incorporating the patient advocate figure into the new Public Health Law regulations. This measure would not only strengthen the protection of patients’ rights but also contribute to improving the quality of health care and stren- gthening the population’s confidence in the health system. References Beauchamp, T. L., & Childress, J. F. (2019). Principles of Biomedical Ethics (8.ª ed.). Oxford University Press https://global.oup.com/ushe/product/principles-of-bio- medical-ethics-9780190640873 Cáceres, R. (2021). El defensor del paciente en los sistemas de salud contemporáneos. Ed. Jurídica Latinoamerica- na. González, L. (2022). La figura del defensor del paciente en el contexto latinoamericano. Derecho y Salud, 34(2), 89- 102. https://www.ajs.es/index-revista-derecho-y-salud Hernández, P., & Pérez, M. (2023). Análisis crítico de la nueva Ley de Salud Pública en Cuba”. Revista Cubana de Salud Pública, 49(1), 12-25. https://revsaludpublica. sld.cu/index.php/spu/issue/view/64 Lindberg, E. (2022). Patient Advocacy in Sweden: A Model for Improved Healthcare Communication. Scandina- vian Journal of Public Health, 50(4), 456-463. https:// eithealth.eu/wp-content/uploads/2023/10/Implemen- ting-the-European-Health-Data-Space-in-Sweden.pdf Martínez, A., & Gómez, R. (2020). Evolución histórica de la relación médico-paciente. Historia y Medicina, 35(2), 145-160. https://medicina.udd.cl/centro-bioetica/fi- les/2016/11/JP-Beca-Relacion-clinica-boletin2015.pdf Ministerio de Salud de Colombia. (2017). El defensor en Sa- lud: Consideraciones para el diseño y desarrollo. https:// www.uexternado.edu.co/wp-content/uploads/2017/01/ cuaderno_9.pdf Ministerio de Salud de Colombia. (2022). Informe anual so- bre la defensoría del usuario en salud. https://www.min- salud.gov.co/sites/rid/Lists/BibliotecaDigital/RIDE/ DE/PES/informe-gestion-2022-minsalud.pdf Navarro, M. D., Muñiz, G. G., & Jovell, A. J. (2008). Los de- rechos del paciente en perspectiva. Atención Primaria, 40(7), 367-369. https://www.elsevier.es/es-revista-aten- cion-primaria-27-pdf-13124131 Organización Panamericana de la Salud. (2022). Strategic Fund Country Success Stories. Stories published in PAHO’s 2020 and 2021 Strategic Fund annual reports. https://www.paho.org/en/paho-strategic-fund/strate- gic-fund-country-success-stories Parlamento Europeo (2023). Regulación de los derechos de los pacientes en la UE. https://health.ec.europa.eu/ cross-border-healthcare/overview_es Parlamento Europeo. (2023). Regulación de los derechos de los pacientes en la UE. Bruselas: Oficina de Publicacio- nes de la Unión Europea. https://eur-lex.europa.eu/le- gal-content/ES/TXT/PDF/?uri=CELEX:52023DC0298 Segura, A. (2021). El defensor del paciente en los sistemas de salud contemporáneos. Editorial Jurídica Latinoa- mericana. World Health Organization (WHO). (2023). Patient safety. https://www.who.int/news-room/fact-sheets/detail/pa- tient-safety World Health Organization (WHO). (2021). Plan de acción mundial para la seguridad del paciente 2021-2030. https://apps.who.int/gb/ebwha/pdf_files/wha74/a74_ r13-sp.pdf Conflicts of interest The author declares that she has no conflict of interest. Author contributions Mariceilys Morales: Conceptualization, data curation, for- mal analysis, investigation, methodology, supervision, va- lidation, visualization, drafting the original manuscript and writing, review, and editing. Data availability statement The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request. Statement on the use of AI The author acknowledges the use of generative AI and AI-assisted technologies to improve the readability and cla- rity of the article. Disclaimer/Editor’s note The statements, opinions, and data contained in all publi- cations are solely those of the individual authors and con- tributors and not of Journal of Law and Epistemic Studies. Journal of Law and Epistemic Studies and/or the editors disclaim any responsibility for any injury to people or pro- perty resulting from any ideas, methods, instructions, or pro- ducts mentioned in the content.