December 2007

Total population: 11,269,000

Life expectancy at birth m/f (years): 75/79

Healthy life expectancy at birth m/f (years, 2002): 67/70

Probability of dying under five (per 1 000 live births): 7

Probability of dying between 15 and 60 years m/f (per 1 000 population): 128/83

Total expenditure on health per capita (Intl $[1], 2004): 229

Total expenditure on health as % of GDP (2004): 6.3

National GDP (2006- Intl $)[2]: 46.22 billion

Per Capita GDP (2006- Intl $)[3]: 4,100

Figures are for 2005 and sourced from World Health Statistics 2007 unless otherwise noted.

Cuba’s medical system is funded almost entirely through public municipal funds and it is made available to everyone in the population. The main emphases of the system are illness prevention and health promotion, with most doctor visits occurring on the family or community level. With the very few resources Cuba has to allocate to public health, their health indicators are comparable to countries that spend many times more per capita on medical services. The health system is able to function effectively and efficiently thanks to public health education and mobilization, active family-level healthcare, a thriving biomedical industry, and a high number of health professionals.

Cuban healthcare system overview:   

            There is only one health system operating in Cuba, called the Cuban National Health System. Similarly, there is only one health insurance provider, the Ministry of Public Health, which covers 100 percent of the island’s population.[4] According to a 1999 Pan-American Health Organization (PAHO) report on the Cuban health system, services covered by state-owned insurance include “health promotion and educational activities, early diagnosis, therapeutic, and high-tech resources, which are provided to the population with no discrimination whatsoever.”[5] The Cuban system is equipped to provide a full range of services, from general medicine, to surgery, gynecology, dentistry and ophthalmology. Furthermore, it is a regionalized and decentralized system, establishing three tiers of medical care throughout the entire island.[6] The Cuban National Health System is almost completely funded by municipal governments, which provide 92.4 percent of all public health costs.[7] The healthcare system is oriented towards health education and disease prevention,[8] using local medical service providers to educate the population on disease risks and warning signs, monitor local health environments, and collect nation-wide epidemiological data to direct research and health policy initiatives. It is organized into three tiers of care: neighborhood general physicians, community primary care polyclinics and larger regional hospitals. Depending on the health issue to be addressed, a patient would first go to their neighborhood doctor, then to a polyclinic if the issue requires more resources, and finally to a specialty hospital to get more complex or high-tech care for severe conditions. Cuba makes many of its own drugs and vaccines through its active biotechnology sector, some of which it exports to other countries. In 1987, the Cuban government created a healthcare sector specifically designed for foreign patients called SERVIMED. This program includes its own pharmacies, as well.

Health Indicators:

According to the World Health Organization, in 2002 Cuba boasted 66,567 doctors, totaling 5.91 doctors per 1000 people on the island.[9] This exceeds the doctor per capita totals of both the United States, with 2.56 doctors per 1000 people in 2000,[10] and the UK, with 2.30 in 1997.[11] Life expectancy and infant mortality rates are comparable to those of most industrialized countries, at 75 years for Cuban males and 79 years for Cuban females, as compared to 75 years for American males and 80 years for American females.[12] British males are expected to live 77 years, and British females 81.[13] As of 2007, the mortality rate of infants under one year old in Cuba was 6.04 per 1,000 live births,[14] comparable to 6.37 infant deaths per 1,000 live births in the United States,[15] and 5.01 in the United Kingdom.[16] Nonetheless, total per capita expenditure on healthcare in Cuba at the international dollar rate in 2004 came to $229.10, while in the United States it was $6,096.20 and in the UK it was $2,559.90.[17] In 2004, the total health expenditure totaled 6.3 percent of the Cuban GDP, while it was 15.4 percent of U.S. GDP and 8.1 percent of UK GDP[18].

Recent historical background:

Before the Revolution of 1959, Cuba enjoyed one of the most developed medical sectors in the region. Cuba had 6,500 well-trained doctors, respected medical training, and up-to-date health facilities.[19] The health infrastructure was, however, overwhelmingly concentrated in the Havana private sector, with two-thirds of Cuban doctors residing in the capital city.[20] There was only one university hospital and medical school, supporting a “rudimentary public system.”[21] By eight years after the Revolution, 3,000 of the 6,500 doctors had emigrated from the island, mainly to the United States, and the different segments of the health services system were grouped into a single branch of healthcare administrated by the Ministry of Public Health. The new Fidel Castro government saw good quality healthcare as a human right and considered it the legal responsibility of the government to provide it. Healthcare for even the most remote parts of the island, therefore, became a policy priority and remained so even in the worst of economic times.

The health policy of the new Cuban government in the 1960s focused mainly on broadening health coverage to previously marginalized groups, particularly in the countryside. Due to the loss of doctors and limited public infrastructure, emphasis was placed on training new health personnel and building hospitals and clinics in previously ignored remote and poor urban areas. The government built 50 hospitals in rural areas of the island, in addition to more than 160 health clinics in under-serviced areas of the main cities.[22] A nationwide program was also launched to improve sanitation and immunize all children in Cuba. By 1981, there were over 16,000 doctors operating in Cuba and, by 2004 over 68,000 physicians and more than 380,000 health workers.[23]

The 1970s saw an expansion of the community-based health system pioneered in the 1960s. The government increased the number, geographical distribution and capacities of community polyclinics, or clinics equipped to treat a wide range of medical issues, yet not designed to treat the most serious cases, which are redirected to hospitals. The agenda of the healthcare system in this decade shifted towards outpatient services provided at polyclinics, health education and illness prevention.[24].

In the 1980s, the healthcare system added a third tier of service focusing on family medicine and neighborhood environments. In 1984, the Cuban government created neighborhood health centers, called “consultorios.”[25] These general practice centers are staffed by a doctor and nurse team that make house calls, educate communities on health matters, and mobilize them to participate in government-sponsored campaigns to improve health conditions throughout the municipality or entire island. More emphasis was put on research capacities, allowing medical specialization in 55 fields in which “centers of excellence” were established as medical research centers.[26] Another major change of policy concerned the biotechnology sector, which was vigorously developed and expanded at that time.

The 1990s, however, brought about “the special period” – a time of severe economic depression due to the collapse of the Soviet Union and a tightening of U.S. embargo restrictions. As the Soviet Union collapsed, Cuba’s trade levels plummeted by 85 percent, shrinking the economy by 35 percent and, consequently, cutting 70 percent off of the budget available for pharmaceuticals and other medical supplies since they had to be purchased with hard currency due to embargo regulations.[27] The lack of medical supplies and strict food rationing led to some widespread health problems, most notably an island-wide neuropathy epidemic in 1992-1993. Besides increased incidence of general malnutrition, low birth weight and neuropathy, however, basic health indicators remained mostly constant, and some even improved as Cuba emerged from the economic depression.

In the later 1990s and into the 21st century, Cuba also began to focus its resources in sending medical teams to other nations, both to provide temporary disaster relief and continued medical care to rural areas. As the number of health professionals abroad increased to 30,000, and particularly after 20,000 doctors left to serve in Venezuela, Cubans started having to wait in line for medical services, one of the few things for which they did not previously have to stand in line. There have been complaints that some doctors offices are, consequently, severely understaffed in Cuba. Some rural clinics may not have a doctor present for weeks or months at a time, and there are doubts about the quality of new medical school graduates. With the exportation of doctors abroad rising dramatically  since 2000, some Cubans are, for the first time, complaining about unavailable health care services.

Three-tiered health system:

The Cuban healthcare system is organized into three levels of care: the neighborhood consultorios, the community polyclinics, and the regional hospitals and centers of excellence (medical research centers). It emphasizes primary care and focuses most of its scarce resources on prevention and health education. Healthcare on the island also embraces holistic medicine, including acupuncture. One example of the Cuban prevention-focused model is the level of vaccination each child receives. Cuban youths are immunized against 13 diseases: polio, typhoid, tetanus, diphtheria, pertussis (whooping cough), rubella, measles, mumps, tuberculosis, hepatitis B, haemophilius influenza B, meningitis B and meningitis C.[28] National vaccination campaigns began in 1962 with polio immunization. As a result of early vaccination, Cuba has managed to wipe congenital rubella syndrome and post-mumps meningoencephalitis from the island in 1989, and seriously reduce the threats of tetanus and haemophilius influenza since 1990 and 2003, respectively.[29] Today, Cuban citizens enjoy almost 14,000 consultorios, 445 polyclinics, 256 hospitals and 13 centers of excellence.[30]

Consultorios

A team of a doctor and nurse occupy family physician offices throughout Cuba, called consultorios. This is a neighborhood-focused level of care with a clinic on the lower level, and living quarters for the doctor and nurse above, allowing them to be a part of the community they serve.[31] Each office attends to 600-800 patients, many of them during house calls.[32] Indeed, one of the responsibilities of consultorio doctors is to make at least one yearly, surprise house call to evaluate overall health and living conditions for each member of the community. It is also the responsibility of the consultorio to gather data to allow for community-level and regional epidemiological assessment, and to conduct “tailored interventions and programming” to improve the health education of the community based on the particular risks it faces.[33] When there is a widespread threat, the neighborhood doctors also mobilize the community. During the 1997 outbreak of dengue fever, for example, the government was able to mobilize the population to spray the breeding grounds of the aegypti mosquito that carries the disease, thereby containing the public health threat. They are also highly influential in organizing the population, along with other community groups, to administer vaccines. The neighborhood consultorios provide 97.6 percent of primary care and are overseen by polyclinics, with each polyclinic providing primary care to the other 2.4 percent of the population and overseeing approximately 30-40 consultorios.[34]-[35] 

Polyclinics

Polyclinics are designed to address the more serious health needs of the community. They are 24-hour centers that can perform a whole range of services without having to travel to a hospital, including dentistry, minor surgery and X-rays. Due to the severely limited resources available to Cuban patients, the health system not only stresses illness prevention to reduce health costs, it also aims for fewer hospital admissions and briefer lengths of stay, building strong outpatient capabilities, and increasing the number of outpatient surgeries and early discharges.[36] Consequently, many surgeries are performed at local polyclinics. Health cases that require resources beyond the capabilities of polyclinics feed into one of the regional hospitals, or centers of excellence.

Hospitals and Centers of Excellence

The third tier of the Cuban healthcare system is occupied by a system of regional hospitals and centers of excellence. A center of excellence is a hospital that specializes in a particular area and, consequently, serves as a research center and reference to all other hospitals for cases within that specialty. Hospitals are where the most serious cases come for treatment that involves specialty care, high-tech machinery, or more advanced procedures than those found at the polyclinics.

Foreign-targeted healthcare - SERVIMED:

A separate health system was developed in 1987 to provide healthcare to foreign visitors: SERVIMED. This state-owned service provides healthcare to tourists, who pay for it in hard currency. SERVIMED, operated by the Grupo Cubanacán corporation, uses the national healthcare network to offer the gamut of health treatments, in addition to specially designed “quality of life centers” that boast thermal baths, cosmetic treatments, drug addiction rehabilitation and stress management help.[37] This is one method of attracting the cash inflow necessary to maintain a universal free healthcare system for the rest of the island.

Biotechnology:

Cuba has a thriving biotechnology sector, having directed substantial resources to build it up in the 1980s. The U.S. embargo against Cuba made it difficult and costly to import many medicines and vaccines. Consequently, Cuban biotech companies began to develop their own versions of many would-be imports, even pioneering some new vaccines, such as the Meningitis B vaccine. The 1999 PAHO report asserts that, between 1995 and 1997, “904 pharmaceutical products were marketed annually. Of these, 730 were produced nationally and 174 were imported.”[38] All of the drugs used in Cuba in 1999 were generic, rather than brand names.[39] Cuba also uses biotechnology exports to bolster their GDP and, thus, fund their public health system, along with foreign-targeted health services. Because the biotechnology center is overseen by the Cuban government, the decisions on which vaccines or medicines to develop tend to come from the political, rather than scientific sphere, and are often based on treating afflictions relevant to the Cuban population. The government works with consultorios and polyclinics to determine which health issues pose the greatest risk to society, fund research and development to address this risk, and finally implement the strategies to deal with that risk, regionally, nationally, or internationally, forming a “closed-loop” research cycle[40].

Health Diplomacy:

Cuba first initiated a policy of foreign health diplomacy in 1960 when the government sent physicians to Chile to aid in disaster relief after a destructive earthquake, despite the lack of formal diplomatic relations between the two countries. Because of its limited financial resources, yet abundant human resources, Cuba sends its doctors to areas that are in need of medical service during times of emergency, rather than other forms of aid. In 1963, the Algerian government requested Cuban doctors to come into the country in order to address its dire need for medical care. Since that time, 100 other governments have arranged for Cuban medical professionals to practice in their countries, with almost half of such exchanges occurring in the 1990s.[41] The increase in Cuban nurses and doctors abroad in the past 15 years has been due in large part to the new global health initiatives launched by the government, as well as disaster relief professionals deployed after hurricanes Georges and Mitch who have stayed in certain Central American countries to provide ongoing care. One initiative was termed Operación Milagro, or Operation Miracle. This was a program that provided free ophthalmologic surgery for citizens of several Central and South American and Caribbean countries at Cuban health centers. Another initiative is the Henry Reeve Disaster Response Contingent - a medical team trained in disaster relief that is sent to areas that have been hit by a natural disaster. The team was first dispatched in October 2005, to Pakistan after a devastating earthquake, and consisted of 2,500 health personnel and 32 field hospitals.[42] The five-month stay of the Henry Reeve Brigade led to the opening of a Cuban embassy in Islamabad. Cuban doctors have been dispatched for more than political goodwill, however. In a program often called “doctors for oil,” Cuba agreed in 2003 to send about 20,000[43] general practitioner doctors to Venezuela in exchange for 90,000 barrels of Venezuelan oil a day[44] at highly subsidized prices.

Total Personnel Collaborating Abroad by Geographic Region as of April 30, 2006:

North America (2 countries): 2

Latin America (17 countries): 25,309

Caribbean (23 countries): 991

Africa (40 countries): 1,996

Europe (15 countries): 5

Asia (14 countries): 361

Total (111 countries): 28,664

The personnel working through the Public Health Ministry comprises 76.8 percent of all Cuban personnel working abroad.

Source: Keck, William C, “Cuba’s Contribution to Global Health Diplomacy,” Global Health Diplomacy Workshop, March 12, 2007.

Medical education

Although Cuba had only one medical school and six nursing schools in 1959, it now has enlarged its medical education capacities to include 22 medical schools and 34 nursing schools.[45] Furthermore, the Latin American Medical School, or ELAM, was created in 1999 to provide free medical training to students from underprivileged areas throughout the world. In 2005, the school boasted an enrollment of 10,000 students from 29 countries.[46] These students receive medical training under the understanding that, once they become certified doctors, they will return to their home country to practice in an underserved community.

Effect of the U.S. Embargo:

The U.S. embargo against Cuba, initiated in 1961, became more restrictive with the collapse of the Soviet Union. At once, Cuba lost the funding and trade that the USSR provided and also faced having to pay for all foreign goods imported from the United States in hard currency. All trade between the United States and Cuba was made illegal, making food and medicines bought from other countries far more expensive due to greater shipping costs. Not only were other trading partners geographically further away, the Cuban Democracy Act passed in 1992 allowed neither foreign subsidiaries of American companies, nor foreign companies with American subsidiaries, to trade with Cuba under U.S. law. Additionally, any ship that docked in a Cuban harbor was restricted from U.S. ports for 180 days, severely limiting the number of partners who were willing to ship supplies to Cuba. Import costs soared as the island had to buy its supplies from far away, or in hard currency in a global market that refused it credit. With the Trade Sanctions Reform and Export Enhancement Act of 2000, President Clinton legalized the export of agricultural and medicinal products for humanitarian reasons. Although Cuba began to purchase these goods, remaining U.S. regulations continued to make them difficult to buy and import. As approximately half of all patented drugs since 1975 come out of the United States, new medicines have been difficult to acquire in Cuba.[47] They must be bought through an intermediary company, and are often beyond the price range of the Cuban government (or citizens). Legal, economic and transportation barriers to importing food have led to poor nutrition and, consequently, lower average weights and birth rates during the difficult economic times of the early 1990s. Scarce medical supplies, including special child-sized needles, many anesthetics and pain relievers, and disposable products, mean fewer surgeries and shots, as well as the reuse of needles, surgical gloves and other medical equipment. Furthermore, a shortage of such consumer goods such as soap and water purification materials have led to an epidemic of esophageal stenosis in toddlers who ingested lye while it was being widely used instead of soap, and a 1994 attack of the Guillain-Barrè syndrome that was caused by contaminated, un-chlorinated water.

Written by: Danielle Barav

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