SELECTED STUDIES

Cuban Community Healthcare 
A Model For Developing Countries ?*

By Essam Farag

"My hope is that in the future there can be close cooperation between
 the scientific and medical community in Cuba and that in my own country."
 President Jimmy Carter in his landmark visit to Cuba (May 2002).

Prior to the 20^th century, health services were mediated in most countries as a commodity in exactly the same way that any other economic commodity was obtained. The sick looked for providers and the providers looked for customers who could pay. Coverage prices were low, equipment meager and results somewhat as one might expect. The rich could pay more and so tended to be better cared for, and therefore healthier.

 The healthcare system of a society may usefully be thought of as the collection of all health organizations in that society and their interrelations. By health organization is meant any organization (or sub-organization) that has its primary, defining, and justifying goal the positive transformation of directly health-related aspects of people and their environment. Hospitals, medical schools, dental clinics, and sanitation departments are examples. The health system, then, is the largest possible health organization, of which all other health organizations are parts.

Contemporary Health Care Models

Based on the analysis of many health service researchers, there appear to be four clearly defined primary models of contemporary healthcare services. First there is the socialist model that was applied in the former Soviet Union and today is best represented with modifications in the Canadian healthcare system which essentially ensures health coverage to all citizens to be supplied at the provincial level. Secondly, there is the public healthcare model, which has been applied best by the National Health Service (NHS) of the United Kingdom which differs slightly from the socialist model whereby the services are provided at the national level. The third model is that of private care that will be represented through the Medicaid and Medicare systems of the United States. The Chinese system of “barefoot doctors” represents the fourth model of community health primary care.

The American System (Private healthcare model)

• United States government spends much more on healthcare than does the UK, Canada, China or Cuba, however is involved in a smaller proportion of the financing of the total health bill.

·        Each individual pays for most medical services in the United States, from primary care to the most advanced high-tech medical intervention.

·        There are two public health instrumentalities, Medicaid and Medicare. The former is designed to meet some of the health needs of people below the poverty line. The latter is federally operated and is designed to serve the needs of old age pensioners.

The British System (National Health Service model)

·        Healthcare services are federal-governed and funded. Administrative costs are minimized due to the centralized nature of the services.

·        A plan for health care is devised on a regular basis to deal with the main health concerns at the national level.

The Canadian System (Reformed-Socialist healthcare model) 

·        Single payer national system (covered by federal/provincial taxes) – however the health care itself is provided provincially. A public authority on a non-profit basis carries out administration of the provincial health care insurance plan.

·        All insured persons in a province or territory are entitled to public health insurance coverage on uniform terms and conditions.

The Chinese System (“Barefoot Doctors” model)

·        China has a state organized healthcare system and the distribution of the “barefoot doctors” is monitored by the state. Administrative costs are greatly minimized due to the locally funded system, as well as the focus on primary care.

·        Focus is given to primary care and not on high-tech medical services through the use of traditional techniques: basic biomedical sciences, traditional herbal medicine, and acupuncture.

·        The “barefoot doctors” were worker-doctors, since their salaries, education, and medical equipment are financed through their local work units. This model has been sidelined for a more market-oriented health care following Mao Ze Dong’s death.

With my supervisor Prof. John Kirk in Cuba  during
 a collaborative Dalhousie-Havana Universities course (May 2000)

The Evolution of Health Care in Cuba

 Before 1959, shared health indicator levels in Cuba were typical of underdeveloped countries: Infant mortality rate was high (70/1000 live births), life expectancy was as low as 58 years, diarrheal diseases were the leading cause of death, and six out of ten rural residents suffered from malnutrition.  The health care system was characterized by two great contradictions: urban – rural in services, and excess personnel/facilities in Havana (capital city). In 1957, the doctor-to-population ratio was 1:998, making it the second best in Latin America at the time. More than 60% of all physicians lived and worked in Havana.

The three major components of pre-1959 health care were:

1)     Mutualist pre-paid medical services,

2)     Public services based in hospitals and some dispensaries for the poor, and

3)     Private practice.

 Post-1959, the new government offered a resolution for the rural-urban contradiction; resolution to the anarchy of urban concentration; and linking urban and rural areas in a single network of services. The evolution of the post-revolutionary medical services in Cuba could be divided into FOUR main phases:

1)     Early transformation (1959-1969) - focused on building rural health centers and re-organization of medical infrastructure.

2)     Introduction of polyclinics (1970-1974) - involved the formation of rural and urban primary healthcare centers (polyclinics) as the primary health services units.

3)     “Medicine in the Community” (1975-1983) - involved completing the regionalization by training medical teams (mainly consisting of a physician, nurse and social worker) to serve all communities through the polyclinics.

4)     Family/community doctor care (1984- present) - can be described as an improvement to the prior phase. It involves an increased focus on family practice rather than just primary care, as was the case in the previous phases.

Data from PAHO website (http://www.paho.org/English/SHA/prflcub.htm).

 
The THREE goals for the Cuban community healthcare system

·        Centralization of health planning and decentralization of administration;

·        Involvement of social organizations such as the Federation of Cuban Women (FMC) and Committees to Defend the Revolution (CDRs) in health promotion;

·        Integrating service dimensions – preventive and curative, social and individual, environmental and personal.

 
Since the early 1990s, a new phase of biomedicine and biotechnology has emerged in Cuba to complement the Family/community doctor program. Cuba has placed an increased emphasis on biotechnology in order to find cures or vaccines for the few remaining infectious diseases in the country, with hope in also dealing with chronic illnesses such as heart disease and cancer, as well as the threat of AIDS.

“Exporting” the Cuban Health Care Model

Having achieved a successful health care system domestically, Cuba has adopted the role of making its health services available to other developing countries. The different reasons behind Cuba’s exportation of its model can be attributed to humanitarian reasons, ideological symbolic capital and medical diplomacy. The methods by which Cuba has embarked on “internationalizing” this model are hereby presented.

The exportation of the Cuban healthcare model or its services has taken several forms.

·        The first is the direct provision of medical care in the host country (There are approximately 20,000 Cuban health personnel working abroad today in 50 countries primarily in Africa and Latin America).

·        A second form of assistance would involve medical training and education of health personnel in the host country.

·        Thirdly, services also include undergoing sophisticated medical procedures for foreign patients in Cuba (Many Chernobyl victims were sent to Cuba to undergo radiation/cancer treatment).

·        Fourthly, there has been increased emphasis on providing full scholarships for foreign students to study medicine in Cuba (5,800 students enrolled from 24 countries in Latin America, the Caribbean and Africa).

·        A fifth form of aid is short-term crisis and disaster relief primarily to neighboring Latin American countries following earthquakes and hurricanes (About 800 Cuban health personnel were helping in Haiti alone, and over 120 doctors were sent to Honduras in 1998 following Hurricane Mitch).

·        Cuba has also donated medical equipment, supplies and complete medical facilities to countries with seriously weak medical infrastructures (Cuban involvement in South Yemen [now part of Unified Yemen] in the 1970s included providing nearly the entire healthcare delivery system and building the country’s first medical school in the city of Aden).

·        Cuba also hosts many international medical and biotechnological conferences.

·        Finally, exporting Cuban services comes also in a multilateral form through contracts made with international organizations (e.g. WHO and PAHO) to provide specific needs to Third World countries.  

Infectious & chronic disease mortality (per 100,000) in Cuba.

Data from Demers et al. 1993: 165 and PAHO website (www.paho.org)

Data from MacDonald 1999.

Data from MacDonald (1999), A Developmental Analysis of Cuba’s Health Care System Since 1959.

Cuba’s Biotechnological Venture

Despite the country’s lack of resources and a strong financial base, Cuban scientists have taken bold steps in certain biomedical research areas. They have acquainted themselves with the techniques as part of a nationally supported biomedical program and quickly mastered applying their knowledge.

It is interesting to note that the innovative biomedical products that Cuba has marketed have not been created through genetic engineering. The much-publicized Cuban meningitis B vaccine is a traditional (outer membrane protein or OMP) vaccine that does not involve any genetic engineering. The biotechnology products Cuba has marketed are those such as interferon, epidermal growth factor (EGF), and recombinant hepatitis B vaccine.

Although the majority of Cuban biotechnological advances are already existent techniques in developed countries, the potential of this industry for Cuba lies primarily in developing countries, which are for the most part excluded from these medical advances.

 
A Cuban Healthcare Model ? 

When it comes to addressing whether the Cuban healthcare system, specifically the community-based aspect, can be defined as a model, that is unquestionable. The Cuban healthcare system carries all the elements needed to view it as a model to be compared with the private system of the US, public system of the UK, reformed-socialist system of Canada, and the “barefoot doctors” model in China, since it has managed to provide comprehensive care to all its citizens and achieved internationally competitive health indicators. However, despite that reality, “exporting” the community-based model as a blueprint to other developing nations would probably be unsuccessful. Alternatively, “exporting” the Cuban healthcare model could be taken to mean exporting only aspects of the system, which is essentially what Cuba has embarked on already.

*        All information for this article can be found at the Department of International Development Studies (Dalhousie University - Canada), from the honors thesis by Essam Farag, “The Cuban Community Health Care System: A Model For Developing Countries?” April 2002. (www.dal.ca)

Essam Farag, BA (Dalhousie) is a graduate student and teacher's assistant of international development at the Department of Political Science in the University of Guelph, ON, Canada. Email: efarag@uoguelph.ca

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