The Challenges of Health Care in Cuba

Photography by Kooklanekookla

Despite its economic struggles, Cuba has made some of the greatest achievements in health care in the world. However, this is much more complicated than first assumed, as an underlying problem is a health care system that also favors the rich, without providing adequate care for Cuba’s poor.

During the 1990’s Cuba very much resisted the health sector reforms in Latin America by the World Bank and as a result, have followed through with their own unique public health system, set up after the 1959 revolution. 3 The basis of this system is an entirely nationalized and liberalized one, providing free health care for all those that require it. 2

Fidel Castro recognized the importance of health care in a way that very much resisted western health system models, 4 and resisted the Latin American health sector reforms of the World Bank. 19 Using a bottom-up method of health care development, Cuba has placed priority on its primary health care producing a wide range of achievements unique to any other developing country. Its doctor to patient ratio which in 2006 was at one doctor for every 170 residents, ranks ahead of the US at 1 doctor to 188 residents. Its provision of free service, strong community-doctor relationships, low infant mortality rates and high life expectancy 17 are all examples of Cuba’s healthcare success, although this is not without its flip side.

Despite Cuba achieving their target of ‘free healthcare for all’ there is much more to this issue that needs to be addressed such as the equity, equality, quality, efficiency and scale with which such services are provided. Due to the indispensible role of health professionals providing the care that the Cuban government regularly boasts about, it is essential that the experiences, problems, challenges and opportunities for health professionals are examined if a valid assessment of this liberalized system is to be achieved.

Development of the Cuban Health Care System

Since 1959, the Cuban healthcare system has gone through many reforms throughout its development but it is only since the 1990s that it really started to take the shape of what we see today. Pre 1990, Cuba was very reliant on financial support from the Soviet Union, however with its collapse in the late 1980’s, Cuba was sent into an economic crisis to which it had to adapt. 7 This crisis was, and continues to be further exacerbated by the continuing US embargo from 1961, which forbids supplying Cuba with medical supplies. 20 In response to the crisis, Castro adopted a political stance recognizing the importance of national human capital, as opposed to dependence on international financial capital, typical of most other Western and Latin American countries. 21 Thus, the healthcare system was dealt with accordingly and a continued drive for the mass education and deployment of healthcare workers gathered pace, building on Cuba’s primary healthcare.

The Pharmaceutical Industry and Research

Despite the severe lack of available medical supplies coming into the country, Cuba has managed to establish a stable medical research and development sector. It is estimated 86% of Cuban-produced drugs and medication are consumed domestically, 18 and the pharmaceutical industry is one of Cuba’s main income industries along with others such as sugar, petroleum and tobacco 11. Particularly within the past 25 years, the Cuban government has also invested in the development of high tech medical equipment, further expanding their tertiary health sector. The West Havana Scientific Complex is home to the Cuban Neuroscience Center (CNC) and the Central Institute for Digital Research (ICID), which produces technology installed within Cuban hospitals that is also exported abroad. 8 With such an industry, this offers fantastic opportunities for health professionals to expand their career into medical research and development.

Quality of Health Care

However, challenges remain. Healthcare may be free and available for all Cuban citizens but medication is not. Pharmacies are often very poorly stocked and rationing of supplies is minimal. 13 There are claims that hospitals are often in poor conditions and doctors have to bring in their own supplies and equipment to allow them to treat their patients. 10 Despite the production of medical supplies and technology, it seems very little of this actually remains in Cuba. Every year Cuba exports huge amounts of medical aid, mostly to other Latin American countries for purely financial returns. 22 For example, Venezuela provides much-needed oil to Cuba and in exchange receives Cuban doctors and medical supplies. 14

Cuba’s dual economy has a lot to do with why such disparity exists. Medication and equipment is there and available but only to pay for in American dollars, of which the poor and middle classes of Cuba are very unlikely to have. 23 The ‘pesos pharmacies’ and local state hospitals are drastically under-stocked and thus access for the poor to needed medication is minimal, despite the service being free.

Equity of Medical Education and Employment

Inequality exists also in the training of Cuba’s health professionals. The internationally acclaimed Latin American School of Medicine (ELAM) in Havana is one of the finest medical education institutes in the world. It provides a completely free education to students are sent from all over the world to train in medicine, however it is only available to international students. 6 Despite such an opportunity being deprived of potential Cuban health professionals this has not stopped a continued rise in the number of health professionals Cuba is able to produce. The current national health system has 70,594 physicians, 10,554 dentists and 25,022 with degrees in nursing amongst other health sector groups. 17 However, on graduation and completion of their training, students are under legal obligation to initially work for the Cuban government. Thus wherever the government decides they are to be sent- to a local polyclinic or abroad- they have no choice in the matter. 16 As a result many doctors end up defecting, due to the poor pay, conditions, and treatment in the developing countries to which they are sent. As for work in Cuba itself, the conditions (as previously outlined) and pay are often not much better. On average Cuban doctors are paid $15 a month of which is barely enough to support them. 12 This is a poor return for the restricted professional freedom of a Cuban doctor:

“Cuban doctors are not permitted to talk to foreign journalists or diplomats. They must seek permission to travel outside of their assigned municipalities, and doctors who have defected say Cuban and Venezuelan intelligence operatives kept close tabs on their whereabouts.” 24

In spite of this aspect the Cuban medical education is unique to any other in the world. Due to the emphasis on community integration in the primary healthcare sector, medical students are educated in a very holistic manner, learning about local cultures, indigenous medicines and effective community relations in practical conditions. This produces not just a professional adequate for providing healthcare but also a well rounded, valuable member of the local community.

Cuba’s Medical Diplomacy

Medical diplomacy, another key branch of the Cuban health care strategy, has not only improved Cuba’s relationship with other international governments but has also helped improve the health of millions of people. In 2005 Cuba was collaborating with 68 different countries 15 and also accepting international medical students into Cuban education (as previously mentioned). For Cuban doctors being sent abroad, many to the US, they have the opportunity to seek a better life. Many people escape Cuba every year for this very reason and for doctors sent to places such as the US this gives them a much better chance of seeking a visa to stay than if they had entered the county as escapees like many of Miami’s Cuban residents. 25 However, considering Cuban doctors and health professionals back in Cuba, due to the vast numbers being sent abroad in the name of medical diplomacy, a doctor shortage might result in the future -- putting more pressure on those left to work in Cuban hospitals, clinics and polyclinics. 5

Health Tourism in Cuba

The revenues of Cuba’s healthcare system come largely from booming health tourism in the country. People travel from miles around for the quality service in Cuba, available to those paying in dollars. Cosmetic surgery is the most commonly provided service along with other tertiary health care practices such as heart surgery and radiology. 9

For the doctors, physicians and nurses working within this sector, working conditions are superb and access to medication and supplies is not a problem due to their availability to pay for with dollars. 26 Seeing as this is such a main source of revenue for the Cuban government, such hospitals and clinics are well stocked and well subsidized, which in.

Despite the perks of working within clinics tailored for the needs of the wealthy abroad, ethical standards and morality integral within the healthcare sector are again brought into play. Cuban healthcare should prioritize Cubans. In a country where its citizens are still resorting to illicit migration to seek a better quality of life in other countries such as the US, 27 the state efforts of improvement in Cuba itself, should ethically not be invested into luxury medical services for wealthier foreigners.

Conclusion

In reference to a concept often used to describe the relationship between healthcare distribution and the actual need for it, the inverse care law is one that could indeed apply to Cuba. Curtis writes: “…. the ‘inverse care-law’ has often been used to summarize an inequitable situation in which the relative level of provision of care for local communities is inversely proportional to their relative need for health care. This is the reverse of the objective of equity, or territorial justice.” 1 Although Cuba has achieved free access to healthcare for 100% of the population, the means by which health professionals have to diagnose and treat the Cuban population is minimal and still not adequate. Despite the well developed infrastructure of the Cuban healthcare system, which does deserve of the accolades given by governments from around the world, it is still far from equitable, not only for the patients, but for the professionals themselves.

We have yet to see if and how the Cuban healthcare system evolves under Raul Castro’s administration. Most information on Cuba’s health care system is often unreliable and reliant on anecdotal evidence. Cuba without question has managed to create a health care miracle relative to the resources available to it, but both practical and ethical challenges remain as Cuba undergoes new reforms in a changing global economy.

Bibliography

Curtis, S. Tacket, A. (1996) “Health and Societies: Changing Perspectives”. Edward Arnold. London.

Gatrell, A C. (2002). “Geographies of Health: An Introduction”. Blackwell Publishing. Oxford.

Garfield, R. Santana, S. (1997) “The impact of the economic crisis and the US embargo on health in Cuba.” American Journal of Public Health. Vol. 87, No. 1, pp. 15- 20. Pub Med Central.

Gilpin, M. (1991). “Update: Cuba: On the Road to a Family Medicine Nation”. Journal of Public Health Policy. Vol. 12, No. 1, pp. 83 – 103. Palgrave Macmillan Journals.

Mechanic, D. Rochefort, D A. (1996) “Comparative Medical Systems”. Annual Review of Sociology. Vol. 22, pp. 239 – 270. Annual Reviews.

Spiegel, J M. Yassi, A. (2004) “Lessons from the margins of globalization: appreciating the Cuban health paradox”. Journal of Public Health Policy. Vol. 25, No. 1, pp. 85 – 110. Palgrave Macmillan Journals.

Maps of the World (2008). World Economic Classification of Countries. Available at: http://www.mapsofworld.com/thematic-maps/economy-maps/world-economic-classification.html,

WHO (2008) 'Country Profile: Cuba', Available at: http://www.who.int/countries/cub/en/

WHO Statistical Information System (2008) Available at: http://www.who.int/whosis/data/Search.jsp?countries=[Location].Members


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  3. De Ceukelaire, W. De Vos, P. Van der Stuyft, P. (2006). “Colombia and Cuba, contrasting models in Latin America’s health sector reform.” Tropical Medicine and International Health. Vol. 11, No. 10, pp. 1604 - 1612. Blackwell Publishing Ltd.
     

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  6. Huish, R. (2008). “Going where no doctor has gone before: The role of Cuba’s Latin American School of Medicine in meeting the needs of some of the world’s most vulnerable populations”. Journal of the Royal Institute of Public Health. Vol. 122, pp. 552 – 557. Elsevier Ltd.  

  7. Monreal, P. (2002) “Development as an unfinished affair: Cuba after the “Great Adjustment” of the 1990s”. Latin American Perspectives. The Cuban Revolution Confronts the Future, Part 1. Vol. 29, No. 3, pp. 75 – 90. Sage Publications Inc.  

  8. Riera, L. (2008). Havana, January 18th. “Cuba exports medical equipment all over the world”. Granma International. Available at: http://www.granma.cu/ingles/2008/enero/vier18/4indmed.html,  

  9. Solomon, L. (2003). April 15th. “Bad Cuban Medicine.” Capitalism Magazine. Available at: http://www.capmag.com/article.asp?ID=2538  

  10. The Associated Press (2004). “Doctor will take supplies to Cuba”. Available at: http://www.latinamericanstudies.org/cuba/doctor.htm  

  11. CIA. The World Fact Book (2008). Cuba. Available at: https://www.cia.gov/library/publications/the-world-factbook/geos/cu.html  

  12. Forero, J. (2007) February 25th. “Cuban doctors defect from Venezuela posts: Castro's program to aid Chavez opens way for 'desertions”. San Francisco Chronicle. Available at: http://www.sfgate.com/cgi-bin/article.cgi?file=/c/a/2007/02/25/MNGN4O8FAC1.DTL,  

  13. Vincent, I. (2004) July 7th. “For Cubans, a bitter pill.” National Post. Available at: http://www.cubaverdad.net/references/for_cubans_a_bitter_pill.htm  

  14. Council on Hemispheric Affairs (2006) “Cuban Medical Diplomacy: When the left has got it right.” Available at: http://www.coha.org/2006/10/cuban-medical-diplomacy-when-the-left-has-got-it-right/  

  15. Feinsilver, JM. (2008) “Oil-for-Doctors: Cuban Medical Diplomacy gets a little help from a Venezuelan friend”. Available at: http://www.nuso.org/upload/articulos/3537_2.pdf,  

  16. Siglo XXI (2005). “Medical journal exposes Cuba’s failed doctor diplomacy.” U.S Newswire, Available at: http://www.sigloxxi.org/Archivo/failed.htm  

  17. PAHO (2008). Country Profile: Cuba. Available at: http://www.paho.org/English/DD/AIS/cp_192.htm  

  18. PAHO (2007). Cuba. Health in the Americas. Available at: http://www.paho.org/hia/archivosvol2/paisesing/Cuba%20English.pdf  

  19. De Ceukelaire, 2006  

  20. CIA Factbook, 2008  

  21. De Ceukelaire, 2006  

  22. Riera, 2008  

  23. Vincent, 2004  

  24. ibid  

  25. Forero, 2007  

  26. Vincent, 2004  

  27. CIA Factbook, 2008  

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