Cuba’s Health Politics At Home, and Elsewhere
Julie Feinsilver, Ph.D Senior Research Fellow, Council on Hemispheric Affairs
Over the past fifty years Cuba has constructed a health care system lauded by international experts and the envy of and model for developing countries – and, in certain instances, developed countries as well. Despite considerable economic hardships, Cuba provides free universal coverage for its own population, and has achieved country health indices comparable to developed countries, but at a dramatically lower cost. In addition, Cuba is a global leader in providing medical aid and education to other countries through its ‘medical diplomacy’ program of South-South collaboration. From its initial days soon after coming to power, to the immediate medical aid it extended to Haiti after the January 12 earthquake struck Port-au-Prince with devastating results, Cuba’s revolutionary government evinced a strong ideological commitment to help other nations in an effort to repay a debt for the external support it received during the revolution. As a result, the provision of medical aid – the basis for the island highly successful medical diplomacy – to other developing countries has been a key element of Cuba’s international relations ever since the revolution.
This paper charts a brief history of the evolution of Cuba’s health system through five decades of health sector reform, the ideology underpinning it, the development and practice of medical diplomacy, the costs and benefits of improving relations with other countries through the provision of both medical assistance and medical education; and the inherent strengths and limitations of the Cuban public health system. Without ignoring some of the shortfalls of that system, this paper draws lessons that other countries could learn from the Cuban model, and suggests adapting specific policies and programs that are feasible for countries with very different political and economic systems.
The lessons from the Cuban experience are far from startling. Provide universal health coverage, preferably financed by a single payer, and focus on disease prevention and health promotion. In order to reduce health risks and achieve specific, cost-effective outcomes, it is essential to target vulnerable populations, and strictly prioritize resource allocation to focus on activities required to achieve the desired results. By performing these tasks, Cuba has succeeded in achieving developed country health indices despite the country’s overall economic plight. This experience, along with Cuba’s long-standing support to help Haiti develop its public health system, suggests that Cuba should be an important partner in the international effort to assist Haiti in its reconstruction. Moreover, the lessons from the Cuban model are relevant for any country interested in improving the health of their population and controlling costs at the same time. Thus, the United States should not be above learning from Cuba as well.
On the international front, Cuba’s investment in medical diplomacy over the past fifty years has paid off handsomely in terms of political support from beneficiary and other countries as well as from the United Nations agencies and the Organization of American States. At the present time, over thirty-seven thousand Cuban doctors are providing medical aid abroad, almost four hundred of which, along with another 500 Cuban trained Haitian physicians, are working in earthquake-battered Haiti. Moreover, Cuba’s medical capacity has led to aid, trade and credit from countries able to pay for its professional services. This is particularly true with regard to the oil-for-doctors agreements between Cuba and Venezuela, without which the Cuban economy might not have been able to stay afloat.
Cuba’s Health Politics: At Home and Abroad
Over the past fifty years Cuba has constructed a healthcare system lauded by international experts and the envy of developing countries – and some developed ones. Despite considerable economic hardships, Cuba provides free universal coverage for its own population, and has developed country health indices at a dramatically lower cost. In addition, it is a global leader in providing medical aid and education to other countries through its ‘medical diplomacy’ program of South-South collaboration. From its initial days in power, Cuba’s revolutionary government also evinced a strong ideological commitment (a duty) to help other nations in an effort to repay a debt for the external support it received during the revolution. As a result, the provision of medical aid – the basis for medical diplomacy – to other developing countries has been a key element of Cuba’s international relations ever since the revolution. This was first exemplified by the medical brigade sent to assist Chile in coping with the great earthquake of May 1960.
Although most governments supported the World Health Organization’s initiative of ‘Health for All by the Year 2000’ when it was announced in 1978, few have paid more than lip service to this ideal. By contrast, the Cuban revolutionary government has had an overwhelming preoccupation with health from the outset – almost two decades before the WHO initiative. The underlying philosophy has been that health is a basic human right and a responsibility of the state. Moreover, the Cuban approach to health is holistic (physical, mental and social); it sees health as linked to the material environment in which each person lives and not only focuses on the patient as a whole person, but also integrates prevention, cure and rehabilitation.
More than any other government, Cuba’s leaders consider health indicators, particularly the infant mortality rate and life expectancy at birth, to be measures of government effectiveness. As a result, the health of the population becomes a metaphor for the health of the body politic. This ideology constantly focuses government attention on both health conditions and the determinants of health. This unusual concern for the health of the population has proved politically beneficial because of its contribution to the regime’s legitimacy and, therefore, survival. Additionally, on the international level, it provides the foundation for a distinctive brand of medical diplomacy, which improves relations with other countries while improving the health of their populations, and gains prestige and influence (symbolic capital), and trade and aid (material capital) for Cuba. (1)
CUBA’S HEALTH IDEOLOGY
A fundamental ideological premise of the Cuban government since the 1959 revolution has been that medicine alone could not improve the population’s health. This required a significant socioeconomic transformation to eliminate the problems of underdevelopment. Health sector reform, therefore, was only one part of a larger societal transformation, which included, among other things, universal free education, a guaranteed minimum food ration, low-cost housing and universal social security. The guiding principles of the reform were: 1) equality of access to services, 2) a holistic approach to health (which required interdisciplinary teams to implement programs), and 3) community participation in health initiatives.
Equality of access refers to a myriad of factors, including legal, economic, geographic and cultural availability to advance health care. The right to health services, and the state’s obligation to provide them, were enshrined in the constitution. Economic access meant universal free services for all. Geographic access required a major redistribution of facilities and personnel to reach all citizens, no matter where they lived. Cultural access meant a decrease in the social class and educational differences between physicians and their patients. This was done through open enrolment for medical education, and, as far as possible, by training and stationing doctors in their home provinces. Open enrolment was ideologically appealing, but also necessary in order to train enough new doctors, in view of the exodus of approximately half of the country’s existing doctors shortly after the triumph of the revolution.
Popular participation was envisioned as a means of involving the public, through their community-based organizations (Committees for the Defense of the Revolution, Federation of Cuban Women, trade unions, student organizations) in the planning, administration, implementation, and monitoring of health service delivery, in conjunction with local level health workers and institutions. Despite the rhetoric and initial government desire, community participation has primarily meant the implementation of government health initiatives, and this has been done with great success. It has extended the reach of the healthcare workers and reduced the cost of service delivery. Importantly, popular participation has given the public an opportunity not only to take matters into their own hands and see that they could solve some of their own problems, but it also has given them an education in certain health matters. This has been an important part of the government’s general efforts to enhance individual and community self-reliance, and a step toward community cohesion.
THE EVOLUTION OF THE CUBAN HEALTH SYSTEM
Ongoing reform has been a key characteristic of the Cuban health system. During each decade there has been a reassessment of progress and problems, and adjustments have been made accordingly in response to changing health, social, economic and political priorities over the half-century of the Cuban revolution. What follows is a brief discussion of those changes, decade by decade.
The 1960s: the establishment of a national health system
To achieve universal free health care, the Cuban revolutionary government began its health sector reform almost immediately after taking power in 1959. This decision was based on three important factors: 1) the revolutionaries’ experience of the abject poverty suffered by much of the rural population, and their provision of medical care for the population living in areas under their control during the revolutionary war; 2) the example of pre-revolutionary mutual aid societies that provided pre-paid (HMO-like) medical services to their members; and 3) the espousal of social medicine by progressive physicians in one of the two pre-revolutionary Cuban medical societies (the Cuban Medical Federation). Given these factors, the logical first step was to form the Rural Health Service in January 1960, thereby establishing medical care in the periphery where little or none had previously existed. To staff this service, new medical school graduates were required to serve in it for one year upon graduation.
Beginning in 1964, health centers were converted to polyclinics, each serving a population of between 25,000 and 30,000. These geographic areas were further subdivided into health sectors, with one internist per 5,000 adults, one obstetrician/gynecologist for every 3,000 to 4,000 women over age 15, and one pediatrician for every 2,000 to 3,000 children under age 15. A nurse trained in the corresponding discipline completed each basic team. Services were standardized and norms and methods laid down centrally. By 1967, the government had radically restructured the three health subsystems (public, mutual aid society prepaid plans, and private) into a regionalized and hierarchically organized National Health System, providing referrals from one level of care to the next and, most importantly, continuing to provide free universal coverage.
The 1970s: medicine in the community
Although decentralized medical education began in 1968, it did not truly take off nationally until the mid-1970s with the official introduction of medicine in the community and the conduct of part of each student’s medical education in a polyclinic. Medicine in the community was meant to be the ultimate realization of the ideological commitment to health as more than just the absence of disease. It deployed the medical teams from the polyclinic into the community to attend the populations they were responsible for in their homes, day-care centers, schools and places of employment. Importantly, the medical teams began their work by doing an in-depth diagnostic of the health conditions and determinants of health of their respective populations. These teams developed a database of information on morbidity, mortality and immunizations; assessing needs and resources available, as well as selecting at risk groups for targeted interventions. These diagnostics were to be updated and discussed by the medical staff and community representatives every two months, but this was often not done. By 1978 there was an evident disconnect between theory and practice with regard to the expected benefits of the medicine in the community model, particularly disease prevention, a reduction in the use of hospital emergency rooms for primary care, and continuity of care. (2)
The 1980s: the family doctor program
The inability of the ‘medicine in the community’ model to solve the problems mentioned above led to a reassessment and further decentralization, this time to the block level through the Family Doctor Program, which was first piloted in 1984. The intent was to further project the health systems’ resources into the community by putting a doctor and nurse team on every city block and by sending teams out to the remotest communities. Their task was (and still is) to aggressively investigate and monitor the health of the whole population, not just the infirm; to promote wellness; to detect risk factors; to prevent and cure disease; and to provide rehabilitation services. These were not new mandates, but it was thought they would be fulfilled better if the medical team lived in the community and provided care 24/7. Moreover, the population’s morbidity and mortality structures had changed from the diseases of poverty to diseases of development, requiring greater attention to health promotion, disease prevention, and chronic degenerative disease management.
This new model of health care provided a family doctor and nurse for every 120 to 150 families or about 600 to 700 people. Back-up was provided by an extensive network of health facilities of increasing levels of technological sophistication, from the polyclinic (with upgraded facilities) to tertiary care hospitals and research institutes. At the same time, emergent biotechnology and pharmaceutical industries were developed and later began to supply the system. Although the Ministry of Public Health provided norms for the whole family doctor program, there was considerable flexibility about implementing them and great encouragement to the teams to spend more time seeing people in their normal environment rather than in the office. This was, and is, particularly important because of the emphasis on health education to alter unhealthy lifestyles and on the promotion of physical fitness, particularly among the elderly.
The family doctor also acts as a patient-advocate for those referred to the next level(s) of care and manages their care after they are discharged. The fact that patients can be monitored so closely means that every bed in Cuba is now potentially a hospital bed. This greatly facilitates continuity of care, patient compliance, recuperation and rehabilitation, and at the same time decreases associated costs. Data for 2008 indicate that 99.7 per cent of the country was covered by 32,289 family doctors working in 10,717 family doctors’ offices. Only Holguin and Santiago de Cuba provinces had slightly less than 100 per cent coverage. (3)
Based on the practices of the some of the world’s best medical schools, both the structure and the curriculum of Cuban medical education were revised to produce the new type of medical professional required to meet growing domestic and international needs and goals. This meant a qualitative improvement in medical education, a curriculum change to a biological systems perspective (as opposed to the traditional disciplinary focus) the creation of a specialization in Comprehensive General Medicine (Family Medicine), and an integrated teaching, patient care and research approach to community-based medical education. All medical students, with very few exceptions, were (and still are) required to do a three-year residency in Comprehensive General Medicine first, even if they elect to do another residency later. Family doctors complete their residencies while on the job, where they conduct research on primary healthcare issues and attend seminars at the neighborhood polyclinic where they are on call once a week. In the case of doctors located in remote areas, the professors go to groups of them, rather than the reverse as frequently is the case elsewhere. (4)
The Family Doctor Program may be criticized as involving an excessive medicalization of natural processes such as childbirth and being costly to operate, sometimes coercive (women at high risk are sent to maternity homes prior to childbirth, or convinced to abort an unviable fetus), and possibly even a form of social control. Nevertheless, data indicate that the program has had various beneficial effects, for example, more effective prevention, which resulted in decreased hospitalizations, surgery, and emergency room use; lower morbidity and less use of medication among the elderly; and overall better patient compliance. All of this has led to decreased costs. More importantly, it has led to a considerable reduction in the infant mortality rate in rural areas, improved general health indices and, according to Ministry survey data, provided greater patient satisfaction. (5) The program also provides a sense of relief and security for patients as well as their families, which in turn leads to greater government legitimacy. Whether the benefits of this program outweigh the social and other costs remains debated. However, the financial costs of training and employing family doctors and establishing simple offices for them are much lower in a society where the state controls the economy (and therefore employment and compensation) and the education system, and can produce more doctors than otherwise would be required and direct them to work wherever they are needed.
At the same time that great emphasis was being placed on primary care, the government also made considerable investments in the expansion and upgrading of its hospital network and the chain of specialized and high technology research institutes, including the development of internationally significant biotechnology, genetic engineering and pharmaceutical research and production capacity. (6) Cuban doctors and medical scientists quickly learned sophisticated techniques and pioneered new ones. Cuba’s biotechnology, genetic engineering, and pharmaceutical research facilities began to develop products that would eventually replace imports and provide hard currency earnings from their exports. At the same time, the government invested heavily in the mass production of physicians, specifically for its medical diplomacy programs.
The 1990s: adjusting to economic crisis
The dissolution of the Soviet Union and the Eastern Bloc led to what Cubans called the ‘special period’. As trade relations collapsed at the beginning of the 1990s, the economy went into a tailspin. For decades Cuba had relied on the international socialist division of labor and subsidized trade or fair terms of trade. Suddenly, basic necessities were no longer available or if they were, it was only at world market prices in convertible currency. This situation was exacerbated by the long-standing US trade embargo, which continued to force Cuba to purchase supplies from much more distant countries, greatly increasing their final cost. The Cuban government estimates that this decreased its purchasing power by between 20 and 30 per cent. (7)
What had been problematic all along, such as shortages of some basic medicines and disinfectants, among other supplies, reached crisis proportions during the special period. All types of inputs for the medical system, including replacement parts for equipment, basic pharmaceutical ingredients, and infrastructure components, became extremely scarce. At the same time food supplies were also seriously decreased, making the population more vulnerable to disease. This dire situation left the Ministry of Public Health (MINSAP) with only one real option, to develop a strategy to improve operational efficiency in an effort to ensure the sustainability of the system.
MINSAP strategy, therefore, gave priority to the further development, deepening and/or expansion of a series of measures already in effect, which were not necessarily originally conceived for the purpose of cost containment, even though that was one of their results: 1) health promotion and disease prevention, 2) traditional or natural products medicine and alternative therapies, 3) decentralization, 4) community participation, and 5) epidemiological surveillance. For example, emphasis on health promotion and disease prevention had been a priority for decades, and one of the reasons for constant system reform. Greater use of natural products medicines and alternative therapies, such as acupuncture and ozone therapy, also had begun in the 1970s. Now, new emphasis would be placed on their standardization, reliability and ability to replace allopathic treatments.
Decentralization too had begun much earlier with the administrative subordination of the municipal level health facilities to the Municipal Assemblies of Peoples Power (local government). This arrangement, was supposed to but did not always, facilitate coordinated cross-sector activities and community participation. The new decentralization approach adopted the international ‘Healthy Cities’ strategy. By 1998 almost half of all Cuban municipalities belonged to the National Network of Healthy Municipalities, which encourages healthy living activities in schools, workplaces, markets, penitentiaries and cooperative centers. This effort further required that the community, both as individuals and as a group, take greater responsibility for their own and their community’s health. Finally, as a result of an optical neuropathy epidemic in 1993, epidemiological trend analysis units were created to improve the existing surveillance system and provide early warnings of disease outbreaks. (8)
Moreover, in response to the rapid deterioration of many of the islands’ health facilities, the lack of an effective management capacity in a number of health units, as well as patient dissatisfaction with services, MINSAP indicated that it would revitalize the hospitals’ operational aspects (and also downsize them, because a large number of hospital beds were no longer needed); give family doctors greater problem-solving capacity and some material improvements; and increase coverage, access and the quality of care. MINSAP would also seek external funding to bolster the work of state-of-the-art research institutes and clinical facilities. Change was necessary, but it had to be efficient. (9)
Despite the severe economic crisis the Cuban government ratified two basic principles of its public health system: the health system would continue to be government financed (free for the user), and it would provide universal coverage as a basic human right. Government health expenditures per capita had risen considerably over the years, but most, importantly, they continued to rise as the overall economic situation of the country deteriorated. The government correctly acted in a counter-cyclical fashion by increasing health allocations as a percentage of the state budget, with the exception of 1991 when there was a slight decrease. Between 1994 and 2000, government health expenditures increased by 59 per cent, with wages comprising the largest item. Central government spending fell as municipal government spending rose, as a result of increased decentralization and an even greater focus on primary care. (10) However, the crisis vastly diminished the convertible currency portion of the budget that was available for healthcare financing: from 1990 through 1996 it fluctuated between one third and one half of the 1989 pre-crisis amount in US dollars. (11) This left the system’s infrastructure and equipment in dire condition, except for what was used for health tourism (visitors coming to Cuba for treatment) and therefore earned hard currency that could be reinvested in the ailing public health system.
The twenty-first century: focusing on results
Economic recovery − a good deal of which can be attributed to the deepening of Cuba’s strategic alliance with Hugo Chavez’s Venezuela − allowed the Cuban government to begin to rebuild its broken health infrastructure. After a decade of neglect plans were drawn up to rehabilitate the more than 400 polyclinics island-wide, as well as at least 50 tertiary care institutions (hospitals and specialized institutes), and upgrade their technology. At the same time, approximately one-third of Cuban doctors went to Venezuela to provide health services in an oil-for-doctors exchange. Meantime, however, both the state of disrepair of the not-yet-upgraded facilities and the shortage of doctors in some areas in a country that has prided itself on having the highest rate of doctors per capita in the hemisphere (three times as many doctors per capita as the United States in 2005) has led to considerable discontent. (12)
Another problem that had become important by the twenty-first century was the greying of the population. As MINSAP planners reassessed the system, using evidence from their statistical databases and the comprehensive diagnostic of the health status of each community and sub-sector, it became clear that the population in some areas required some different services, based on their epidemiological profile, rather than simply following centrally determined programs. As a result, it was decided to make services more flexible, depending on local needs. To test this approach, a pilot program was established in one Havana polyclinic, which was given greater human and material resources in an effort to improve health outcomes while actually reducing costs. The polyclinic has once again become the cornerstone of the health system as well as a key medical teaching facility (policlínico universitario), while the family doctor program is being revamped primarily to conduct health promotion and disease prevention activities. (13)
Although from the outset of the revolution the Cuban government focused on ameliorating rural-urban and other social disparities, and has made enormous strides in this endeavor, some differences have remained. Recognition of continued inequalities in health led to the design of a system to monitor equity in the delivery of health services, in health outcomes, and in the determinants of health. (14) This is part of an increased emphasis on achieving results in terms of health outcomes (i.e., infant mortality, life expectancy, absence of disease, etc.), which always have been a priority, and not just outputs (such as the number of physician visits, vaccinations, clinical interventions, etc.). Outcomes, however, may depend as much or more on improved sanitation and nutrition (both of which deteriorated in the 1990s) as on increased and/or re-focused health service delivery. Greater equity in the determinants of health will have to be assessed in the coming years.
And in fact, this is part of the government’s long-term comprehensive plan for improving the determinants of health for the ten-year period from 2006 to 2015. This plan’s risk-based approach utilized data collected in the Second National Survey of Risk Factors and Non-transmittable Diseases, conducted in 2004, as well as other routinely produced data sets. Among other things, it identified important environmental and behavioral factors that contribute to ill health, but are not within the purview of the health system to allow to ameliorate, such as unstable and aging potable water and sewerage infrastructure. Because health is inter-sectoral, it was recognized as incumbent upon the Ministry of Public Health to demonstrate the health effects of situations and conditions lying beyond its control and to advocate their amelioration. Importantly, the plan sets out the strategic direction and objectives, the programs, targets, organization and functions, as well as the requirements for monitoring and evaluation at all levels of the system, based on results and impact. (15) Once again adjustments can be expected as data from implementation of the plan are analyzed.
Since 1960, Cuba has provided medical aid to other countries, despite the immediate post-revolution flight of nearly half of the island’s doctors and the domestic hardship this caused. The medical brain drain contributed to the government’s decision to reform the health sector, revamp medical education and vastly increase the number of doctors trained. These factors combined made possible a large-scale commitment to medical diplomacy and lent credibility to Cuba’s aid offers by demonstrating success on the ground in establishing and managing health systems, reducing mortality and morbidity rates, and training the necessary human resources. By the mid-1980s Cuba was producing numbers of doctors well beyond its own needs, specifically for its internationalist program. Data from 2008 indicate that Cuba has one doctor for every 151 inhabitants, a ratio unparalleled anywhere. (16)
Cuba as a medical power
Perhaps as a portent of things to come, as early as the 1970s and 1980s, Cuba implemented a disproportionately larger civilian aid program in Africa (particularly medical aid) than its more developed trade partners, the Soviet Union, the east European countries and China. This quickly generated considerable symbolic capital for Cuba, which translated into political backing in the United Nations General Assembly, as well as material benefits in the case of Angola, Iraq and other countries that could afford to pay fees for professional services rendered (although the charges were considerably below international market rates). (17)
The value of Cuban medical diplomacy for the beneficiaries is clear. Over the past almost fifty years, Cuba’s conduct of medical diplomacy has improved the health of the less privileged in developing countries while improving relations with their governments. Cuban medical teams had worked in Guyana and Nicaragua in the 1970s where governments were leftist, but by 2005 they were implementing their Comprehensive Health Program in Latin American and Caribbean countries that, with the exception of Bolivia and Venezuela, were not. Those countries are Belize, Dominica, Guatemala, Haiti, Honduras, Nicaragua and Paraguay. In 2000 Cuban medical teams worked in El Salvador to control a dengue epidemic, using their community participation model. Even the Salvadoran military collaborated with them. (18) They also had established two Comprehensive Diagnostic Centers, one on the island of Dominica and one on Antigua and Barbuda. In 2008 both Jamaica and Suriname’s health systems were bolstered by the presence of Cuban medical personnel. (19) Throughout the years, Cuba has also provided free medical care in its own hospitals for individuals from all over Latin America, and not just for the Latin American left.
During the 1970s and early 1980s, Cuba undertook very large civilian aid program in Africa to complement its military support to Angola and the Horn of Africa. With the withdrawal of troops and the geopolitical and economic changes occurring from the late1980s onward, Cuba’s program was scaled back, but remained in place. (20) Having suffered a post-apartheid brain drain (white flight), South Africa began importing Cuban doctors in 1996. In 1998 there were 400 Cuban doctors practicing medicine in townships and rural areas and in 2008 their number had increased slightly to 435. Later, the focus changed. Now (2009) 138 Cuban specialists work in 47 clinics and hospitals in eight of South Africa’s nine provinces. (21) South Africa also finances some Cuban medical missions in third-party countries. Agreements were reached in 2004 to extend Cuban medical aid to the rest of the African continent and to deploy over 100 Cuban doctors in Mali. A similar agreement was planned for Rwanda. Cuban doctors have worked or are working in some thirty African countries and in most cases are implementing their Comprehensive Health Program there. Cuban medical teams also have worked in such far-flung places as East Timor and the Solomon Islands, neither of which might be considered to be among Cuba’s strategic areas of interest.
Overall, since 1961, Cuba has conducted medical diplomacy with 103 countries, deploying 113,585 medical professionals abroad. (22) As of April 2008 over 30,000 Cuban medical personnel were collaborating in 74 countries across the globe. (23) Cuban data indicate that Cuban medical personnel abroad have saved more than 1.6 million lives, treated over 85 million patients (of which over 19.5 million were seen on ‘house calls’ at patients’ homes, schools, jobs, etc.), performed over 2.2 million operations, assisted 768,858 births, and vaccinated with complete dosages more than 9.2 million people. (24) Cuban medical aid has affected the lives of millions of people in developing countries each year. Moreover, to make this effort more sustainable, over the years more than 50,000 thousand developing country medical personnel have received free education and training either in Cuba or by Cuban specialists engaged in on-the-job training courses and/or medical schools in their own countries. Today, approximately 25,000 developing-country scholarship students are studying in Cuban medical schools, alongside a group of 110 less-privileged American students. And a similar number are studying medicine in their own countries through Cuba’s Virtual Medical School.
Since Cuba sent its first medical brigade abroad in 1960 it has utilized medical diplomacy to win the hearts and minds of aid recipients. Medical diplomacy has been a critical means of gaining prestige and goodwill, which can be translated into diplomatic support and trade or aid. It has been a way of projecting Cuba’s image abroad as an increasingly developed and technologically sophisticated country, and this is important for the country’s symbolic struggle as David versus the Goliath of the United States. The success of Cuba’s medical diplomacy has been recognized by the World Health Organization and other United Nations bodies, as well as by numerous governments, at least 103 of which have been direct beneficiaries in one form or another of Cuba’s largesse. It also has contributed to diplomatic support for Cuba and sharp rebukes for the United States in the United Nations General Assembly, where for the past 17 consecutive years, Members voted overwhelmingly in favor of lifting the US embargo of Cuba. In fact, only Israel, Palau and the Marshall Islands have supported the US position in recent years. (25) Furthermore, Cuba’s medical diplomacy was a key topic raised by Latin American and Caribbean leaders in their meetings with President Obama at the Summit of the Americas in April 2009, and one of the reasons why those same members of the Organization of American States, voted to readmit Cuba in their June 2009 meeting in Honduras, even though the Castro brothers indicated no interest in rejoining the OAS.
Since 1960, Cuba has also been quick to mobilize well-trained disaster relief teams for many of the major disasters in the world. Among its recent activities were medical brigades dispatched to Indonesia after the May 2007 earthquake, Peru after the December 2007 earthquake, Bolivia after the February 2008 floods and China after the May 2008 earthquake. (26) Cuban medical missions also provided post-disaster preventive and curative care in post-tsunami Indonesia and in post-2005-earthquake Pakistan. Cuba sent Pakistan a team of highly experienced disaster relief specialists, comprising 2,564 doctors (57 per cent), nurses and medical technicians. (27) The team was entirely self-contained, bringing with them everything they needed to establish, equip, and run those hospitals. The cost to Cuba was not inconsiderable. Two of the hospitals alone cost half a million dollars each. In May 2006, Cuba sent 54 emergency electrical generators, as well.
In the past, Cuba has also provided disaster relief aid to more developed countries as well as those that are less developed and this has won considerable bilateral and multilateral symbolic capital for Cuba. Beneficiaries include Armenia, Byelorussia, Moldavia, Iran, Turkey, Russia and the Ukraine, as well as most Latin American countries. For example, over a nineteen-year period, 20,000 children from Russia, Ukraine, Byelorussia, Moldavia and Armenia were treated free of charge in Cuba, mostly for post-Chernobyl radiation-related illnesses. (28) Cuba even offered to send over 1,000 doctors as well as medical supplies to the United States in the immediate aftermath of Hurricane Katrina. Although the Bush administration declined the offer, the fact that it was made by a small developing country that had suffered almost a half century of US hostility was highly symbolic and was not lost upon the international community. (29)
The Cuba-Venezuela-Bolivia connection
It is ironic that in 1959, Cuba unsuccessfully sought financial support and oil from Venezuelan president Rómulo Betancourt. It would take forty years and a stream of economic difficulties before another Venezuelan president, Hugo Chávez, would provide the preferential trade, credit, aid and investment that the Cuban economy desperately needed. This partnership is part of Venezuela’s commitments to its Bolivarian Alternative [to the US] for the Americas (ALBA) aimed at uniting and integrating Latin America in a social justice-oriented trade and aid bloc. ALBA has also created an opportunity to expand the reach of Cuba’s medical diplomacy well beyond anything previously imaginable – beyond even Fidel’s three-decade-long dream of making Cuba into a world medical power. (30)
By far the largest Cuban medical cooperation program ever attempted is the present one with Venezuela. The oil-for-doctors trade agreements allow for preferential pricing for Cuba’s exports of professional services in return for a steady supply of discounted Venezuelan oil, joint investments in strategically important sectors for both countries, and the provision of lines of credit. In exchange, Cuba provides medical services for un-served and under-served communities in Venezuela: the agreement is for 30,000 medical professionals, 600 comprehensive health clinics, 600 rehabilitation and physical therapy centers, 35 high technology diagnostic centers, 100,000 ophthalmologic surgeries, etc. In addition, the agreement provides similar medical services, on a smaller scale, in Bolivia, at Venezuela’s expense. (31)
To contribute to the long-run sustainability of these programs, Cuba has agreed to train 40,000 doctors and 5,000 healthcare workers in Venezuela and to provide full medical scholarships to Cuban medical schools for 10,000 Venezuelan medical and nursing students. An additional and later agreement includes the expansion of the Latin American and Caribbean region-wide ophthalmologic surgery program (Operation Miracle) to perform 600,000 eye operations over a ten-year period. To handle some of the demand and to reduce the strain on facilities at home, Cuba established fifty small eye surgery clinics in Venezuela and Bolivia as well as clinics in Ecuador, Guatemala and Mali, to handle both local cases and others from neighboring countries.
Cuba’s second largest medical cooperation program is with Bolivia. By February 2008 the Cuban medical brigade in Bolivia had 1,921 collaborators, as they are now called, of whom 1,323 were doctors, the remainder being paramedics, technicians and other personnel. (32) In July of the same year Cuban health personnel were working in 215 of Bolivia’s 327 municipalities, including remote rural villages. It was reported that over the two-year period of medical diplomacy in Bolivia, Cuban doctors had saved 14,000 lives, conducted over 15 million medical exams, and had performed eye surgery on approximately 266,000 Bolivians and their neighbors from Argentina, Brazil, Paraguay and Peru. (33)
Additionally, Cuba offered Bolivia 5,000 more full scholarships to educate doctors and specialists in Cuban facilities as well as other health personnel at the Latin American Medical School (ELAM) which Cuba established in Havana after the 1998 Central American hurricanes. ELAM was developed as a means of helping other countries produce community service-oriented medical personnel to make their own health systems sustainable. As a result, ELAM also helps make Cuba’s medical diplomacy sustainable. In 2006, there were some 500 young Bolivians studying at the school (about 22 per cent of the total foreign scholarship student body) while another 2,000 had started the premed program there. The six-year medical school program is provided free for low-income students who commit to practice medicine in under-served communities in their home countries upon graduation. In the 2006-2007 academic year, 24,621 foreign medical students were enrolled at ELAM. (34) Between 2005 and 2008, the school graduated 6,575 medical professionals from 56 countries, of whom 6254 were doctors. (35)
Going beyond past practice, the new medical education model is based on students being immersed in the clinical setting (in the mornings) as of the second year, initially as observers. This is supplemented by both classroom training (in the afternoons) by a Cuban medical professional and the use of specially prepared distance-learning materials, such as lectures on DVD and CDs by top Cuban medical professors and a dedicated website for the Virtual Medical School (Universidad Virtual de Salud or UVS). The UVS was established in 2006 as a means of mass-producing community-based family doctors by further extending Cuba’s free medical education system beyond the capacity of its existing physical facilities. It also enables students to live, study and work in their own communities, which greatly decreases costs. At the same time, these students progressively provide assistance to the Cuban medical personnel attending to their low-income communities, which further extends the services provided and decreases costs. Moreover, this model of community-based medical education produces doctors who are committed to working in their own and/or other poor communities. This type of training is now being provided not only in Venezuela (in 2008 there were about 23,000 students in the Mission Sucre school of Integral Community Medicine), but also in Cuba itself alongside an ongoing traditional medical education, as well as in Bolivia, Guinea Bissau, Equatorial Guinea, Gambia, Guatemala, Honduras and Nicaragua, among other countries. (36)
There are concerns about the mass production of doctors and the quality of this new type of medical education. Medical associations in much of Latin America and the English-speaking Caribbean at times question whether those who graduate from the UVS are really qualified as doctors. They also have resisted the certification of ELAM graduates, although the latter have gained recognition in numerous countries. Because their training is focused on primary care, it is difficult for some graduates to pass medical boards that require the deeper knowledge needed for hospital-based practice without specific exam preparation or further training; exam success rates in the English-speaking Caribbean have not been high. This could also be a function of the graduates’ socioeconomic status, and poorer prior education than that received by traditional medical school students.
Nevertheless, some US graduates of ELAM, however, routinely have passed the US Foreign Medical School Graduates exam. (37)
In this connection it is worth remembering that about 95 per cent of the medical problems for which patients see their primary care physicians in any country are problems these doctors normally can handle and for which they are trained. The issue may therefore not be so much whether ELAM graduates are competent to manage primary level patient care, but whether competitive barriers are being defended that produce doctors who are over-trained for what they actually have to do most of the time. Despite the controversy over credentials, both the humanitarian and the symbolic benefits of the Cuban medical
program are enormous. Moreover, the political benefits could be reaped for years to come as students trained by Cuba, with some financial aid from Venezuela, become health officials and opinion leaders in their own countries. Of the 50,000 foreign scholarship students who have trained in Cuban universities, 11,811 as doctors and nurses since 1961 are now in positions of authority and increasing responsibility in their home countries. (38) With the plan to train 100,000 new doctors by 2015, this potential influence on health care in the developing world would increase rapidly.
The benefits and risks of medical diplomacy
The economic benefits of Cuba’s medical diplomacy have been very significant since the rise of Hugo Chávez in Venezuela. Trade with and aid from Venezuela in a large-scale oil-for-doctors exchange has bolstered Cuba’s ability to conduct medical diplomacy and helped keep its economy afloat. Earnings from medical services (which includes the export of doctors) equaled 28 per cent of total export receipts and net capital payments in 2006 – US$2,312 million − a figure greater than that for both nickel and cobalt exports and tourism. (39) The export of professional services (primarily but not exclusively medical) accounted for 69 per cent of Cuba’s 2008 balance of trade in services (US$8.2 billion), which helped offset its balance of goods deficit (US$10.7 billion). (40)
The financial costs charged by Cuba to beneficiary countries are relatively low because the Cuban government pays the doctors’ salaries and the host country or Venezuela pays for airfares and stipends of up to US$180 per month plus room and board. (41) This is far below the costs of medical recruitment in the international marketplace, although it can still be a strain on cash-strapped economies such as Haiti’s. Perhaps more important are the non-monetary costs, and the risks, which are significant. Cuban doctors serve the poor in areas in which no local doctor would ordinarily work, make house calls a routine part of their medical practice, and are available free of charge, 24/7. This is changing the nature of doctor-patient relations in the host countries. As a result, they have forced a re-examination of societal values and the structure and functioning of the health systems and the medical profession within the recipient countries. In some cases, such as in Bolivia, Guatemala, Honduras and Venezuela, this different way of practicing has resulted in strikes and other protest actions by the local medical associations, who feel threatened by these changes, as well as by what they perceive to be competition for their jobs.
The costs for Cuba, however, are more complicated, partly because of the government’s long-term investment in the education of medical personnel. Although Cuba pays the doctors’ salaries, the pay scale is very low. In Cuba, doctors earn the equivalent in Cuban pesos of about US$25 per month. While abroad, they earn much more, in some cases up to ten times their Cuban salary. (42) When they return to Cuba their salaries double, to the equivalent of US$50 per month and they get access to certain otherwise unobtainable goods. (43) Since the Venezuelan agreement began, a significant amount of the cost for Cuba has been covered by Venezuela, both for medical services and education in Venezuela, and such services provided to third countries. Previously, these were fully funded by Cuba. Money is fungible and any aid Cuba receives could be channeled to this activity.
A recent added cost has been that of the state’s investment in the education and development of professionals who defect from Cuban medical diplomacy programs in third countries. Material conditions of life in Cuba are very difficult and salaries are a fraction of those that can be earned abroad. More importantly, doctors earn a fraction of what less well-educated Cuban tourist industry workers earn, leading some to moonlight in various tourist-related jobs. (44) Despite education and values that promote socialist ideology, and a real concern for improving the lot of those they serve, defections are still inevitable. After fifty years of pent-up demand at home as well as difficult conditions in the host countries, some Cuban doctors decide that defection is their preferred option. (45) A little stimulus from the Bush administration also contributed in no small part to the estimated 1,000 doctors who are reputed to have defected in recent years. (46) Under the August 2006 Cuban Medical Professional Parole Program, Cuban doctors serving abroad are granted fast-track asylum processing and almost guaranteed entry into the United States. (47) Although this program has encouraged more defections and has even provided a reason for some Cuban doctors to go abroad in the first place, some have found that they are held in limbo in Colombia or other points of arrival, without the promised fast-track visa approval and with little or no funds. (48) Hard data is not available on the number of defections, but Cuban planners build in a 2 to 3 per cent defection rate, which would be about 600 to 900 doctors based on current numbers.
Any thaw in the relations between Cuba and the US under the Obama administration may make defection less likely. That would radically change economic conditions on the island, and eventually could even lead to a willingness on the part of US insurance companies to reimburse US citizens for less costly medical procedures performed in Cuba. Of course, normal relations would also allow for medical professionals’ exchanges and/or legal immigration, without the hardship of defection and the often tough consequences for families remaining behind.
STRENGTHS AND LIMITATIONS
Two important strengths of the Cuban health system are its flexibility and the rapidity with which it can adjust to changes in health conditions and needs, medical technology, and international good practice, as well as domestic and/or international economic or political exigencies. The key facilitating factors have been political will and a vision of the future in which the health of Cubans would compare favorably with that of the US population, at least on key indicators. Certainly as compared with other countries with more complex polities and economies, the ability and willingness of Cuba to make substantial changes to the health system every decade has been striking.
As mentioned at the beginning of this essay, the Cuban government uses key health indicators to measure (metaphorically) the health of the body politic. These key indicators, include the infant mortality rate and life expectancy at birth, which are used as surrogates for socioeconomic development because of the many and varied inputs in their composition. Despite its economic difficulties Cuba rates very highly on both indicators. Cubans acknowledge the shortfalls in their health system and publish statistics that show fluctuations in the most important health indices, particularly the infant mortality rate at birth and the under-five-mortality rate. Its officials also admit the periodic deterioration of various morbidity and mortality rates subsequent to outbreaks of disease or to economic difficulties that have led to suboptimal nutrition and sanitation. With the economic crisis of the 1990s, the infant mortality rate rose slightly in 1994, then fell and rose again, finally resuming a downward slope in 2006 when it reached a rate of 5.3 per 1000 live births, which would be enviable in the most developed of countries. By the end of 2008, the rate had decreased to 4.7 per 1000 live births. A downward movement in the under-five-mortality rate paralleled that of the infant mortality rate. (49) Of course, many factors contribute to the low infant mortality rate, some of which, like female education, are outside the remit of the Ministry of Public Health (although education is another area where Cuba excels).
One factor may have a Big Brother tone to it: the health system’s intense focus on infant mortality has led to the Ministry insisting that childbirth take place in a health system facility. To make this possible, maternity homes were established where women with high-risk pregnancies, or who live far from an appropriate institution in which to give birth, are sent one to two months prior to their due dates to ensure a safe delivery. While this is viewed as positive by health officials both within Cuba and by many abroad, some Cuban women object to being sent away from their homes and families for that length of time. Moreover abortion is encouraged where the viability of the fetus is questionable. In these matters, there is little or no choice because any infant death is the subject of careful scrutiny by Ministry officials.
Universal health care, of course, is a key contributor to Cuba’s remarkable health outcomes, and is itself a major achievement of the Cuban revolution. Cuba’s enviable doctor-population ratio and its network of health facilities provide the necessary means to carry out the government’s policies and programs. In keeping with the rationalization of facilities and ever-increasing focus on preventive medicine, there was a further decrease in the number of hospitals to 217 in 2008 (from a high of 267 in 2004) and an increase in the number of primary care facilities to 571 polyclinics (up from 444 in 2004), 335 maternity homes (up from 280 in 2004) and 156 homes for the aged (up from 141 in 2004). At the same time, the rationalization of family doctors’ offices has led to an almost 30% decrease between 2004 and 2008.(50)
But even more important than numbers of physicians and medical facilities is the willingness to experiment, to assess the system’s strengths and weaknesses and to make changes. The current system may be over medicalized and too costly for strict emulation, but aspects of it can serve as a model for others to adapt to their own circumstances. In that regard, it has had traction with the World Health Organization as well as with Venezuela and other countries receiving Cuban medical aid, many of which are implementing Havana’s Comprehensive Health Program.
Community participation has also contributed to Cuba’s ability to produce impressive health indicators and has been critical for the success of mass vaccination campaigns, rural and urban sanitation drives, mass screening of women for cervical cancer, the early detection of pregnancy, the provision of prenatal care, blood and organ donations, and the dengue fever campaigns. Not only did community participation have a positive effect on health promotion and the reduction of disease, making possible a vastly expanded coverage of campaigns, but it also led to quicker and less costly results, community self-reliance, and greater social cohesion. The political significance of social cohesion generated by community participation should not be underestimated.
The overarching limitations of Cuba’s health system are not specific to the health system, but belong rather to the economy as a whole: shortage of money and access to physical inputs and supplies. The latter is very much affected by the US embargo. As a result, the Cubans have become very adept over the years at doing more with less. However, there are very serious limitations resulting from inadequate resources. Although some infrastructure rehabilitation and equipment replacement projects have been undertaken recently, much remains to be done to repair all that crumbled and/or became dysfunctional during the special period. Medicines and other basic supplies and inputs into the system are still in short supply, forcing both doctors and patients to find an unofficial or black market way of getting them (‘resolver’). Favors and gifts are commonplace forms of appreciation for doctors who must work very hard for very little, and are considered to be investments in future treatment. (51)
Insularity resulting from the limited accessibility of basic telecommunications and the inability to travel abroad freely also slows progress, although the Ministry makes both locally and internationally-produced medical journals and texts available online through the Pan American Health Organization’s Virtual Health Library, as well as through its own efforts. Scarce resources included limited computer and cell phone accessibility. Despite all these limitations, the health system has been capable of producing good results on key indicators by investing in what matters most to achieve them. It has targeted and prioritized resource allocation to assure essential services for women, infants and children, and (in recent years) senior citizens, within the context of universal coverage. (52) And the population has found ways of getting needed medication and supplies through family connections abroad, foreign donations, purchases at dollar
facilities for tourists, barter with friends and colleagues, and purchases on the black market, among other strategies.
The Cuban model cannot easily be transferred wholesale to another country. However, as already noted, it offers valuable lessons, particularly for countries with less developed private sector provisions of care. One is that it pays to emphasize disease prevention and health promotion, in terms of both health outcomes and cost containment. This is hardly surprising, but without a public health system, it is unlikely that these will be given sufficient attention because of their lower profitability for private sector providers. It is even more cost-effective to prioritize and target health promotion activities for women and children (particularly maternal-infant care), the elderly, and those with, or at risk of, chronic diseases. Prevention and targeting require planning, which in the Cuban case is extensive and based on detailed health conditions and diagnostics of geographic areas conducted by family doctors. This then results in a national database that provides good epidemiological trend data, facilitating data-driven health policy decision-making. This type of community diagnostic and constant update is facilitated by Cuba’s single-payer, regionalized, hierarchically-organized healthcare delivery system.
Disease prevention and health promotion can be prioritized and certain populations targeted without the extensive service delivery network that Cuba has, and without the same rigorous planning. It is more difficult, less accurate, and the outcomes are likely to differ, but it can be done.
Although community-based medical education is conducted by a number of medical schools in industrialized as well as less developed countries, the depth of insertion into the community and into the medical curricula differ. The mass production of doctors and their deployment to the remotest areas of the country as well as to every city block under the family doctor program, is not feasible for most countries, perhaps not even for Venezuela. However, the new type of community-based family doctor that is being trained using the tutorial method, coupled with distance learning, could make possible a far larger scale of medical training.
There would be repercussions with regard to accreditation and the acceptance of credentials by local medical associations, and some type of negotiated non-threatening settlement would have to be achieved. Popular participation could be organized via willing NGOs, although their coverage and modus operandi would differ from that of Cuban mass organizations because of their differing political structures and relations with the government.
A final reflection concerns the already mentioned increased dissatisfaction on the part of Cuba’s own population, as medical staff go abroad, leaving some local health facilities and programs with insufficient staff (or medicines and supplies), despite the impressive ratio of qualified doctors to population. A population accustomed to having a doctor on
every block is finding that waiting times are now longer for some procedures, and that where doctors are overworked, the quality of care declines. Recognizing this problem, Raúl Castro announced in April 2008 the reorganization of the Family Doctor Program on the island to create greater efficiency. This has meant rationalizing the number and dispersion of Family Doctors’ offices, while increasing the official hours of operation for those dwelling outside Havana. Operating hours would also to be extended in Havana when a sufficient number of medical staff became available. (53) If insufficient attention is paid to the domestic health system, it could significantly contribute to a de-legitimization of the regime. That said, the Cuban health system’s limitations have often been overcome by the inventiveness and adaptability of both the doctors and patients within it.
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