Cuba’s Healthcare System: It’s “White Coat Army”
Cuban Medical Brigades. Photo from The Cuban Embassy in South Africa.
When looking at the relationship between the efficiency of global health systems and the per capita cost of health services, the 2015 Bloomberg Ranking of Healthcare Efficiency shows that Cuba achieves a higher ranking of healthcare system efficiency compared to the United States even with investing much less.
There are a few factors that contribute to Cuba’s healthcare system and the population’s trust in it. The island of 12 million inhabitants has more than 100,000 doctors (nine for every 1,000 inhabitants) and 85,000 nurses. It is not uncommon for most citizens to have a general understanding and knowledge of pharmacology and clinical solutions for common diseases. All healthcare services are free and accessible to the entire population, with Cuba possessing the highest health standards in Latin America that are comparable to many developed countries. But what accounts for the overall success of the Cuban healthcare system?
Cuban healthcare is based on four fundamental factors which contribute to it being a well-functioning system. These factors include the government’s identification and action plan to make national healthcare a priority in the country’s development, a rigorous hands-on, training program, strong focus on preventative and primary care (which has been praised on more than one occasion by the World Health Organization), and a system of international medical cooperation.
REVOLUTIONARY HEALTHCARE MODEL
The leaders of the Cuban Revolution possessed an interest in the development of science and technology in the country, specifically in the medical field. In a speech in 1966, Fidel Castro stated, "No social revolution could lead to socialism without a technical revolution." The vision of this new government was also influenced by the revolutionary and physician, Ernesto “Che” Guevara, when he proposed a series of principles for the "revolutionary medical system" that coincide with the principles of the current Cuban National Health System, which is "to provide public health services for the greatest possible number of persons, institute a program of preventive medicine, and orient the public to the performance of hygienic practices. "
The Cuban healthcare model was modified several times starting in 1959 without losing its focus on its free, fully accessible, preventive care approach. The model began its integration into a single system in the 1960s with a focus on the development of medical technology, rural medical services, and community polyclinics; an emphasis on research in the 1970s; and the implementation of its preventive and primary care model in the 1980s.
In the early 1960s, the Rural Medical Service and the Comprehensive Polyclinic were implemented which brought health services to the most rural and remote areas of the country, and polyclinics serving as the basic medical facility of the Ministry of Public Health to address preventive and first-level care. These initiatives addressed the inequitable access to basic medical services that prevailed in Cuba before 1959, especially due to the gap of healthcare access between city and rural dwellers, and the lack of medical services in more remote mountainous communities.
A polyclinic in Cuba. Photo from Radio Guantánamo.
With the triumph of the Revolution, the country experienced a mass exodus of 50% of the nation’s doctors leaving Cuba which left fewer than 6,000 remaining. Despite this, the Revolutionary government managed to train and recruit volunteers and doctors who helped implement a nationwide vaccination campaign in 1960 aimed to eradicate more than four contagious diseases.
Throughout the 1960s, Cuba continued to expand its public health policies. In 1965, Cuba became the first Latin American country to legalize abortion. In 1970, the country rolled out a campaign and program directed to improve maternal and prenatal care to reduce infant mortality rate. To demonstrate the government's commitment in 1976, the Cuban Constitution ratified the right for every Cuban to have free and equal access to quality health services.
In the 1970s, the model of localized medicine was proposed which implied community involvement and cooperation in providing healthcare. This decade marked achievements including better control of non-communicable diseases and research focused on preventive and primary care. In 1984, the Cuban government implemented the model of family medicine that continues to this day.
FAMILY MEDICINE IN CUBA
What does Cuba’s model of family medicine entail and what has attributed to its success?
Cuba’s model of family medicine is a highly centralized system that guarantees access to medical services and medical surveillance of the community from the local level. To do this, the Cuban government devised a four-level tiered model aimed to avoid the inundation of hospital services and attempts to solve health problems at the primary level of care. The four levels include family doctors who serve a specific community, comprehensive polyclinics, general hospitals, and finally, institutes that function as research and medical training centers. Additionally, there is a strong emphasis on preventive care which is promoted in the mass media and on a local level in communities.
The family doctor lives and works in a designated community. Typically, the family doctor resides at the community clinic in a separate living space. The Cuban government established this model to ensure that a family doctor is localized and available, and better able to get to know the community he or she is serving. Family doctors are trained to approach healthcare from a holistic perspective, where a patient is looked at as a whole, attempting to understand not only their ailment but other factors including a patient’s environment and psychological and physiological factors affecting their overall health.
Cuban stamp from 2009 celebrating the achievements of family medicine.
Typically, each community is allotted one doctor and nurse for every 120 families. A family doctor is obliged to conduct at least one home visit per year to understand the health status of each member of the community.
If a patient needs care beyond the scope of a family doctor or nurse, they are directed to the second level of care, a polyclinic. Polyclinics are designed to manage more complex cases and have specialists who are trained in areas such as dentistry, prenatal care, psychology, etc. When a patient requires more advanced care and technology, they are sent to the third level of the chain, general hospitals.
This tiered structure is designed to facilitate quick access to the appropriate level of required health services. However, it doesn’t mean a patient must go through the entire chain to receive care in a general hospital, for example. There are exceptions where this medical protocol is not followed, however, most medical cases in Cuba are resolved at the primary level of care.
MEDICAL TRAINING AND INTERNATIONAL COOPERATION
Due to Cuba’s limited access to medical resources (which is attributed to multiple factors including scarce natural resources and the embargo established by the United States, for example), the government recognized that its greatest resource for healthcare lies in its national workforce. Today, Cuba has more than 62,000 medical students distributed in a network of 13 medical universities, 29 medical science schools, four dentistry schools, four nursing schools, and four health technology schools. Additionally, Cuba has the National School of Public Health (Escuela Nacional de Salud Publica) and the Latin American School of Medicine (Escuela Latinoamericana de Medicina) where more than 29,000 foreign students have studied to become doctors.
Students from around the world study at The Latin American School of Medicine in Cuba. Photo from the Embassy of Cuba in Trinidad and Tobago.
Since 2000, Cuba’s international medical services have exceeded the profits garnered from the nation’s tourism sector. For over 50 years, Cubas has provided medical services to more than 160 countries with more than 407,000 health workers aiding abroad.
The Cuban government has capitalized on providing international medical services as a means for political propaganda and foreign diplomacy. Hence, Fidel Castro named the Cuban international medical brigade the “white coat army" in contrast to the United States military deployed throughout the world.
IMPACTS OF THE U.S. EMBARGO ON CUBA’S HEALTHCARE SYSTEM
The development of Cuba’s healthcare system has not been without obstacles and challenges. The economic and financial blockade imposed on Cuba by the United States embargo has created serious effects on the development of this sector. Some examples include:
Lack of cytostatics and other drugs, prostheses, and supplies, mainly in pediatric oncology therapy.
Difficulty in obtaining gene sequencers.
Difficulties in obtaining retroviral drugs.
Difficulty in obtaining parts for medical equipment due to the inability to negotiate with North American firms that sell them.
Need to go through third-party countries for the purchasing of medical equipment and reagents that possess a percentage of North American components.
All of these restrictions have impacted the development of Cuba’s healthcare system but above all, they have affected the lives of individual Cubans who need these resources to lead healthy lives.
CUBA’S HEALTHCARE SYSTEM TODAY
Cuba’s healthcare system has been greatly impacted by COVID-19 with a stoppage of pharmaceutical production due to the inability of importing raw materials, which has led to a drug crisis in the country. This has alarmed the Cuban population who normally enjoy readily available access to medicine in well-stocked local pharmacies.
A Cuban doctor with a vial of the experimental Soberana 02 vaccine for COVID-19 being developed in Havana. AP Photo by Ramon Espinosa.
Along with the pandemic, Cuba is in the midst of an economic crisis as the socialist economic model is still closed-off to the global market which has influenced the national economic reform to open the private sector. Despite these challenges, Cuba has managed to be one of the leading Latin American countries to control the pandemic and is the only Latin American country developing a free national vaccination program using its own vaccine candidates to be rolled out in May 2021. Cuba is a country that has grown accustomed to overcoming adversity and despite the hurdles that 2020 posed and 2021 continues to bring, the nation’s ingenuity and perseverance carry on.
Sources
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“¿Cuánto personal médico hay en cada país?” El Orden Mundial. Accessed April 21, 2021.
“Consultorio del Médico de Familia.” Ecured. Accessed April 21, 2021.
“Efectos del bloqueo económico, financiero y comercial de Estados Unidos en el Sistema Nacional de Salud.” (2013) Revista Cubana de Salud Pública.
Desarrollo histórico de la salud pública en Cuba. (1998) Delgado García.
“El Sistema de salud cubano.” (2004) Revista de Ciencias Médicas de Pinar del Río. Pedro Mujica Pérez.
“El Sistema de salud cubano: una Mirada a su forma de financiamiento.” Laura Galeano Zaldivar y Arelys Esquenzi Borrego.
Fragmento de ensayo “Sobre la medicina revolucionaria.” Ernesto Guevara de la Serna.
Discurso pronunciado por el comandante en jefe Fidel Castro Ruz en el acto de graduación de los primeros 425 técnicos del consejo del plan de enseñanza tecnológica de suelos, fertilizantes y ganadería, en la escalinata de la universidad de la Habana, efectuado el 18 de diciembre de 1966.