Cuba has done wonders with what they have and the USA has now looked at some of their operations in an attempt to try and move the USA style of expensive, lengthy schools geared strictly toward specialty/high profit sectors of medicine into the Cuban style of prevention and neighbourhood teams. I believe they are experimenting with the way the Cubans work through medical school and if memory serves me right, the project is based out of New Mexico. Although medicine can be scarce in the country, Doctors do have a their disposal, herbal remedies that they can prescribe - their system is not without challenges, but to try and bring down their successes despite the difficulties they have had, not only clearly shows a lack of respect but again, putting one system down to raise your own up, is self agrandizing and unnecessary. Definitely there is work to be done - I think MEDICC and the Cuban people are the first to admit it - love Cuban healthcare? Funny how words get taken out of context and tossed up and manipulated - but some of us are trying to look at the healthcare in other countries and how things are done so that maybe we could all take something from it and make it better here. sammieswife.
By the 1980s, Cuba’s health system began to merit attention from the World Health Organization, UNICEF, and other international agencies anxious to identify viable models of health services in developing countries. It was also in this decade that tertiary care facilities and research received priority attention: medical specialization expanded to 55 fields, and national institutes were established to act as national reference centers (centers of excellence) for the rest of the country. This process included national programs for prenatal screening, installation of the first nuclear magnetic resonance equipment in Latin America, and an organ transplant program. By the end of the decade, Cuba had expanded medical education to 21 medical schools spread across the country.
The 80s was also the decade for two decisive developments which became hallmarks of Cuban medicine. The first was the takeoff of the biotechnology industry, which would put Cuba in the forefront of global vaccine research. The second was the introduction of the Family Doctor Program in 1986, which located doctor-and-nurse teams literally next door to their patients. By the early 90s, over 95% of Cuban families would receive primary medical attention in their own neighborhoods. (See Challenges for Cuba’s Family Doctor-and-Nurse Program, Reed, G. MEDICC Review; 2000:2(3).http://www.medicc.org/publications/medicc_review/II/primary/sloframe.html)
The Economic Crisis of the Nineties and Health Care
With the collapse of the socialist bloc, Cuba’s island economy lost 85% of its trade in two years, threatening the economy and the health system with collapse. What’s more, the Cuban Democracy Act (CDA) of 1992 tightened the US embargo on Cuba at this most vulnerable moment. (See: Denial of Food and Medicine: The Impact of the U.S. Embargo on Health and Nutrition in Cuba, Reed, G. and Frank, M. American Association for World Health, 1997. www.medicc.org/embargo.php ).
The results were devastating: from 1989 to 1993, Cuba’s economy shrunk by 35%; the hard currency available for medicines, equipment and supplies by 70%; and Cubans’ daily caloric intake dropped by 33%, proteins by 39%. Fuel shortages ground transportation and water pumping facilities nearly to a halt; blackouts extended to 16 hours a day in the heat of the summer; Cuban peso salaries became nearly worthless (reaching 145 to the US dollar); food was scarce and rationed; and urban dwellers headed for city parks in search of firewood for cooking fuel.
The remarkable paradox is that - with the exception of the 1992-93 neuropathy epidemic (5) and a few “early warning signs” such as increased low birth weight - Cuban health indicators held the line. In some cases, especially as the island began to find its way out of the crisis, they actually improved.
Infant mortality was 10.7 per 1,000 live births in 1990, down to 9.4 by 1995, and to 7.2 by 2000. Under-five mortality shows the same pattern: 13.2 in 1990, 12.5 in 1995, and 11.1 by 2000. Only life expectancy dipped slightly during the worst years: 75.2 in 1989, 74.8 in 1995, and back up to 76 by 2000. (Source:Annual Statistical Yearbook, Ministry of Public Health, Havana, 2003).
The Results: Explaining the Paradox
Analysts have explained Cuba’s health results in the face of adversity by pointing to the following key components:
- During the worst years of the crisis, the health status of the population remained a fundamental government priority. In fact, the Cuban Parliament actually increased the health sector budget in Cuban pesos and the share of GDP earmarked for health care at the expense of spending for the military and state administration. At the same time, the health sector hard currency budget was forced down by two-thirds as a result of dropping exports.
Table 1: Cuba’s Public Health Budget – 1990, 1995, 1998
Year | Health Budget* | Per Inhabitant | % of GDP | % of Natl. Budget |
1990 | 1,045.1 | 98.6 | 5.3 | 7.4 |
1995 | 1,221.9 | 111.3 | 5.8 | 8.8 |
1998 | 1,473.1 | 132.4 | 6.4 | 13.1 |
*in millions of Cuban pesos
Source: Ministry of Finance, Havana.
- Although scarcities abounded, they were shared, prompting a report published by the UNDP in 1999 to state, “An evaluation of 25 countries in the Americas, measuring relative inequalities in health, revealed that Cuba is the country with the best health situation in Latin America and the Caribbean. It is also the country which has achieved the most effective impact with resources, although scarce, invested in the health sector.” (Study on Human Development and Equity in Cuba. UNDP,1999: p.103).
- Key medical resources were centralized and moved to where they were most critically needed. In this context, the Minister of Public Health initiated a Tuesday morning meeting of all major health sectors to assess the exact amount of hard currency available that week, and decide which purchases were possible and essential (often only the life-saving ones were made). Similar weekly sessions were held in all Cuban hospitals, to tally the medications on hand and send out an SOS for those patients not covered by current stocks. A program soliciting international donations at one point yielded some USD$20 million annually in medicines and equipment, under the consistent proviso that international agencies could inspect end-use facilities to see their donations were getting to the intended patients.
- The educational status of the Cuban population itself worked for continued hygiene measures and health education. While many of the other “social determinants of health” spiraled downward, the average educational level of Cubans by 2002 was ninth grade (Source: Libro Blanco 2006. MINREX;2006, Havana, Cuba.); secondary school (through 9th grade) was required; and over 99% of young people (ages 15-24) who graduated from secondary school were going on to high school. (Source:Objetivos de Desarrollo del Milenio: Cuba, Segundo Informe, July, 2005; Instituto Nacional de Investigaciones Económicas, La Habana, p. 33). As has been amply demonstrated in international reports, the educational level of a population (and especially of women) augers well for health promotion and disease prevention, and this was certainly the case in resource-scarce Cuba in the 1990s and remains so today.
- The dedication of Cuban health professionals, working under the most stressful conditions, was without doubt, indispensable for the Cuban population to emerge from the worst of the crisis with their health status essentially intact. Heart surgeons, riding to work on bicycles, would wait half an hour for their hands to stop shaking before entering the operating room. Nephrologists were working round-the-clock to dialyze ever-more patients on ever-fewer artificial kidneys. Clinicians in hospitals across the island were phoning each other, the Ministry and colleagues abroad to find life-saving antibiotics for their patients.
- The health status of the Cuban population, vastly improved by the health care system since 1960, provided a sound foundation which could not be easily eroded. By the 90s, Cuban children were being vaccinated against 13 childhood diseases -- more than any other country in the world, including the United States. A host of diseases had been eradicated altogether, infectious diseases were at a minimum, and Cubans were dying of the same chronic conditions described in the mortality charts of industrialized countries. A significant socio-political corollary was that the majority of Cubans trusted the health care system to work for them.
- Perhaps the most important single catalyst determining the positive outcome from the precarious 1990s was the presence of a solid community-oriented primary care network accessible to virtually every family in Cuba. The family doctor-and-nurse teams, responsible for the health of some 150 families in a given neighborhood, concentrated their attention on health promotion, prevention of disease, environmental cleanup, priority attention to children and the elderly, prenatal care, and early detection of infection and chronic disease. Most of these activities required little in the way of material support, but they went a long way towards keeping the levels of disease from reaching the already over-extended hospitals wards and emergency rooms.