Report from Cuba

NO ONE LEFT ABANDONED: CUBAS NATIONAL

HEALTH SYSTEM SINCE THE 1959 REVOLUTION
Pol De Vos

In spite of the economic hardships during the 1990s, Cuba has achieved health
indicators that are among the best in the world. This article describes the
development of the Cuban health system over more than four decades and
analyzes its dynamics. Four stages can be identified. The systems foundations were laid during the first post-revolutionary decade (19591970) and
consolidated during the succeeding decade (19701979). In the third stage,
from 1980 onward, the system reached its full expansion with the development of family medicine. Following the crisis of the 1990s, a fourth stage
began with reforms and adjustments to the new situation after the collapse
of the Soviet Union. Today, health care continues to be of high quality
and free for all Cubans. It remains exclusively in the hands of the public
sector, and privatization is not an option. This is exactly the opposite of what
is happening in other parts of the world where public services are underfunded
and people are made to believe that privatization is the only way to ensure
high-quality care.

Although Cuba is a small, developing country, its track record in health care,
education, and social welfare has been praised the world over. World Bank
president James Wolfensohn congratulated Cuba in 2001 for the great job it had
done in health care and education (1). The countrys GDP per capita (U.S.$1,100
in 2000) is only one-fifth of Mexicos, and yet Cubans have an average life
expectancy of 76 years (compared with 73 in Mexico), an infant mortality rate
of 7 per 1,000 (24 in Mexico), and a maternal mortality rate of 29 per 100,000
(109 in Mexico) (2, 3). These achievements are all the more remarkable because
they were reached in spite of the countrys hardships during the 1990s, which
were the result of the abrupt end to Cubas privileged economic relations with
the Soviet Union and of the intensification of the 40-year-old economic blockade
International Journal of Health Services, Volume 35, Number 1, Pages 189207, 2005
2005, Baywood Publishing Co., Inc.

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by the United States. Cuba achieved these stunning health indicators, which are the
best in the third world and among the best in the world (4, 5), without any support
from the World Bank, as it is one of the few countries that is not a member of the
International Monetary Fund or the World Bank. It even applied measures that
run counter to the Banks blanket impositions on most poor countries. This article
describes the development of the Cuban health system over more than four
decades, analyzes the dynamics of the health system, and provides some pointers
for comparison with other countries in Latin America.
THE DEVELOPMENT OF
CUBAS NATIONAL HEALTH SYSTEM
In the pre-revolutionary 1950s, Cubas health system was built on the same three
pillars that characterize most other Latin American health systems up to this day: a
private health system for the rich, a social security system for employees, and an
underfinanced public health care system for indigents. Private health services were
accessible to only a small wealthy elite. About 20 percent of the population was
covered by health insurance funds through their employer; about 45 percent of the
countrys hospital beds were covered by these insurance funds. The greater part of
the population had access only to the underfunded, low-quality, public health care
services. The three pillars of the system were concentrated in the cities, especially
in the capital, Havana. In rural areas, many people had never seen a doctor (6).
This situation reflected the sharp social and economic contradictions that
characterized Cuban society in general (and most of Latin America, for that
matter) and stirred the armed revolution against the Batista dictatorship (7). Under
the leadership of Fidel Castro, the revolutionaries were able to unite the people in
an anti-imperialist and democratic program that revolved around the Cuban
peoples aspirations to lead a healthy and productive life, with job security,
housing, education, and health care (8). Part of this program was already put
into practice by the Cuban guerrilla fighters during the period of armed struggle
in the Sierra Maestra mountain range (19571951), where the guerrillas own
rudimentary medical facilities also provided primary health care services to
the peasants in the area, many of whom used such services for the first time in
their lives (7).
The Revolution of 1959
First and foremost, the improvements in Cubas health indicators after the 1959
revolution must be attributed to the economic and social changes in Cuban society
that fundamentally altered its class composition. The Cuban people now acquired
a house of their own, an assured income, better nutrition, better education, and
other improvements in their living conditions, all of which are essential for health.
Although improvements in the health care services also played a significant role,

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it is important to bear in mind that they are only a secondary factor. The preconditions for the improvement in peoples living conditions and health status
were provided by measures that, step-by-step, drastically restructured Cubas
economy and society.
In the first post-revolutionary years, basic industrial sectors were nationalized,
as were foreign trade and the financial sector, which had been almost completely
in the hands of foreigners. At the same time, a far-reaching land reform program
was implemented. With the help of the Soviet Union, Cuba was able to ensure
economic growth and development. The fruits of this economic growth, in turn,
allowed social development, including housing, reasonable wages, and improvement of nutrition. Electricity and safe drinking water were made available for
almost everyone, even in the most remote parts of the country. Inhumane working
conditions, once prevalent in the countryside, drastically improved, and wherever
possible production was industrialized.
Through a massive literacy campaign, illiteracy was almost eradicated in
an amazingly short time. The formal educational system, including primary
and secondary schools as well as universities, expanded spectacularly. At the
same time, vocational education for workers was introduced, and an extensive
program for adult education encouraged everyone to achieve at least the level of
secondary education. Arts, science, and sports were promoted among the general
population (9, 10).
Womens rights and welfare were given due attention by the socialist government. Beginning in the early 1960s, every woman had the right to 12 weeks
of pregnancy/maternity leave, with full pay. In 1974, this right was extended
to 18 weeks: 6 weeks before delivery and 12 weeks after. Since 1991, women
have been able to extend this leave up to 6 months after delivery, while retaining
60 percent of their salary (6).
The formation and expansion of various peoples organizations (neighborhood
committees, womens organizations, labor unions, youth organizations, and the
like) has contributed significantly to the countrys revolutionary transformation.
Neighborhood committees, for example, play an important role in health care
delivery. Today, neighborhoods have a health committee that works closely
with the local authorities and health care providers. This committee takes part
in the health needs analysis of the neighborhood, the planning of activities,
and preventive actions. It is also the organ through which people can air
their complaints about the health care system. The health committee can call
doctors and other health workers to account and, if necessary, request their
replacement. For Green (11), the Cuban example confirms the hypothesized
correlation between community participation in health care and the social
cohesiveness of a community. He adds that although community action is essential in defining health needs and in other areas related to health promotion,
only government action can provide the framework within which substantive
improvements can be made.

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Four Important Stages in the Development

of the National Health System
Four distinct stages can be identified in the development of Cubas national health
system. The systems foundations were laid during the first post-revolutionary
decade (19591970) and consolidated during the succeeding decade (19701979).
From 1980 onward, the system achieved its full expansion, with the development
of family medicine (12). Following the crisis of the 1990s, a fourth stage began,
with adjustments to the new situation after the collapse of the Soviet Union.
One of the first measures after the victory of the revolution was the drastic
reduction in the prices of medicines. In this post-revolutionary phase, private
clinics and pharmaceutical companies were soon nationalized. The principle of
free health care was seen as an essential measure to ensure equitable access to
the health system and was implemented immediately. Gradually, health service
providers were integrated into a single system that was expanded throughout
the country. A network of rural hospitals reached Cubas most remote corners.
A social and rural medical service sent doctors to those areas where no doctor
had been seen before. The quality of medical education improved drastically.
The principle of health as a universal human right and a state responsibility
became the systems cornerstone. In order to realize this, all services related
to health and health care were centralized under the Ministry of Health Care
(MINSAP). At the same time, responsibilities were decentralized up to the level
of regions and districts.
In this phase, Cuba was confronted with a situation that would have caused
chaos in any other country: in the first years after the revolutionary victory,
more than 3,000 of Cubas 6,000 doctors went abroad, including the majority
of the only Faculty of Medicines professors. This event was strongly influenced
by a propaganda campaign by the United States to undermine the young revolution. The result, however, was an even more vigorous mobilization of the
population and a stronger emphasis on the right to free, high-quality health care
for every Cuban.
In the second, consolidation phase during the 1970s, integrated planning
became a general principle for the entire health system, in order to improve its
performance. This principle of planning, in which the needs of the population
are analyzed and used as the basis for organizing health care, resulted in an
administrative reorganization. This was completed in 1976 when Cubas 14
provinces and 169 municipalities were divided into health zones, each under the
responsibility of a polyclinic. The health system was further decentralized up
to the level of the municipalities (6).
In this period, priority was given to the training of doctors and health workers
as well as to improving the quality of the system. From 1968 onward, the number
of medical faculties increased drastically; their number increased from 1 in 1959
to 21 today. From about 3,000 doctors immediately after the revolution, their

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number reached 6,000 in 1970. Today, 30 years later, Cuba has more than 65,000
doctors (13). New technical and scientific innovations were introduced widely
in day-to-day medical practice. In the 1970s, the use of medicinal herbs and
plants, or green medicine, was introduced in the health system.
By 1980, after 20 years of revolution, Cubas health care had improved
tremendously and the countrys epidemiological profile had undergone significant changes. The most important causes of mortality were no longer communicable diseases, whose impact had been drastically reduced, but chronic
degenerative diseases such as heart and vascular diseases and cancer, typical of
the industrialized world (13). Hence the popular Cuban joke, We live like the
poor but we die like the rich.
In the 1980sthe systems third, development phasethe so-called dispensarizacin was expanded throughout Cuba. This refers to a system of planning
of preventive and curative health activities for the entire population according
to individual needs. Modern equipment was likewise introduced widely, and
biomedical research was initiated in several centers. In 1984, far-reaching reforms
were initiated. General practitioners (literally, medico de familia, or family
doctors), once unknown in Cuba, now became the cornerstone of the health care
system. In the mid-1980s the concept was piloted with 12 GPs, assigned to clinics
in rural areas. On the basis of the first, very encouraging results, the system was
implemented throughout the country (14).
Here, again, the strength of the socialist system is evident in the way a wellplanned national health service is implementing policies aimed at the general
well-being. In ten years, the entire health system was reformed along these
new lines. In 1987, 22 percent of the Cuban population was covered; as early as
1995, 95 percent of Cubans had their own family doctor (6, 15).
Each municipality is still divided into several health zones of about 30,000
inhabitants covered by one polyclinic. Today, however, every polyclinic
coordinates dozens of GPs who work and live in the neighborhoods. Schools
and factories have their own doctors. These GPs work together in teams of 10 to
12 doctors with the support of specialized medical consultants, a sociologist, a
psychologist, and so forth. Together with a nurse, every GP is responsible for
first-line health careincluding prevention, health education, curative care, and
rehabilitationfor a population of 500 to 800 persons. Every GP knows exactly
which families are his or her responsibility, and every family knows the GP in
their area. Although patients are encouraged to consult their own GP, people are
free to see any other GP. The GP combines consultations in the clinic and
house calls, according to his or her planning (prevention, chronic care, annual
checkups) and patients requests.
When representatives of the Ministry of Health are asked whether such a
system doesnt encourage overconsumption, their answer is clear, and in contrast
to the situation in many countries where access to high-quality care is expensive
and therefore limited: The first priority is to make sure that health care is accessible

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to everyone. In the meantime, the risk of overconsumption is recognized

and addressed, and appropriate, mainly educational measures have been taken
to prevent it, with, once again, the GP in a key role. Sometimes, however,
overconsumption is merely an expression of other problems. In big cities,
for example, the elderly consult their doctor more often, not only because they
need more care but also because they feel isolated or bored. The GP is usually
well aware of the social problems and can find a solution together with the
patientsuch as, for example, a daycare center for the elderly (16).
The Pharmaceutical Industry and Biotechnology (6, 17)
Before 1959 the Cuban pharmaceutical industry was comprised of hundreds
of small companies that produced and distributed medicines, yet only a few
of the manufacturers applied acceptable quality standards. The pharmaceutical
industry could be divided into two groups of companies. Local branches of
foreign pharmaceutical enterprises, almost all from the United States, controlled
70 percent of the market, while the 110 small Cuban enterprises, the national
pharmaceutical industry, catered to the remaining 30 percent. Among the local
companies there were so-called ethical enterprises, while others were known
as chiveros or hustlers. The former tried to guarantee certain quality standards,
whereas the latter encouraged self-medication and quackery with special
potions and ointments.
In the first years after the revolution, a transformation took place in the
pharmaceutical sector. In September and October of 1960, all North American
pharmaceutical enterprises were nationalized. Later, the national pharmaceutical
industry also was expropriated. A process of organization and integration
of a public, national pharmaceutical industry began. From 1966 onward, this
industrial sector came completely under the responsibility of MINSAP. Fourteen
companies were selected in which material, installations, and personnel were
concentrated to diminish the costs and to increase efficiency. Small enterprises
were often assigned to provide specific production processes and supply one of
the 14 main companies.
After 1970, new equipment was purchased and investments were aimed at
further concentration and expansion of production capacity, mechanization and
computerization of the production process, and systematization of the production
lines. These measures were to ensure that the country could supply its own
needs as much as possible according to the economic principle of import substitution, or replacement of imported products by locally produced equivalents.
In the early 1980s, growing concern arose in developing countries over many
aspects of the use and the flow of medicines. Already at that time, the Cuban
approach was seen as a clear example of how a national policy could deal with
these problems, through important structural changes in its pharmaceutical sector.
The importance was stressed of linking these reforms to a broader political

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commitment to achieving social benefits, in conjunction with integrated reforms

of the entire health system within a socialist framework (18).
The Union of Companies of the Medical Pharmaceutical Industry was established in Cuba in 1984, comprising 11 companies for the production of medicines,
pharmaceutical raw materials, bandages, and other medical supplies; two distribution companies, one for medicines and one for medical instruments and
supplies; a company for foreign trade; and a central maintenance enterprise.
Additionally, the Technical Drugs Laboratory is in charge of quality control and
supervision of the production, import, and export of medicines. Today, more than
1,000 different medicines are in use in Cuba, 80 percent of which are produced
locally. However, because Cuba doesnt have a chemical industry of its own,
the country remains dependent on the import of basic raw materials. The Cuban
government considers development of the production capacity for pharmaceutical
raw materials one of the most important challenges for the future.
Cubas pharmaceutical industry is also very active in the field of biotechnology. In 1981, after training abroad, a group of Cuban scientists started to
produce interferon. In those days, interferon was produced in only eight industrial
countries; it was considered a potential therapeutic alternative for the treatment of
cancer. The Cuban production of interferon through genetic engineering became
a success, and interferon is now used to treat cancers and viral infections. Today,
Cuba is the second largest producer of alpha-interferon in the world, and the
only developing country that produces interferon on an industrial scale. Cuba
is also a leader in the application of interferon in medicine.
The Center for Genetics and Biotechnology, established in 1986, has enhanced
the countrys ability to apply the latest developments in biotechnology. Knowledge in the field of biotechnology and genetic engineering has led to the
production of new vaccines and medicines, and the development of advanced
diagnostic procedures. Through biotechnology, Cuba was able to produce three
proteins of the HIV virus, which are used in the diagnosis of AIDS. The country
introduced a national HIV screening program using domestically produced kits,
as an important part of a well-developed HIV public health program (19, 20).
Cuba has succeeded in controlling the HIV/AIDS epidemic. In 2002 the Cuban
government reported an HIV prevalence of 0.03 percent, about one-eleventh of
that in the United States. Among other factors, its success relies on the existing
health care system and intervention at an early stage, for which the diagnostic
kits are essential (21, 22).
Cuba has also applied biotechnology to the production of antibodies, which
is considered the most advanced diagnostic and therapeutic application of
biotechnology, and the development of vaccines. Moreover, the results of Cubas
biotechnology research are immediately available to the Cuban population free
of charge and are also used in most parts of Latin America (23). Every Cuban
child can be (and most are) vaccinatedat no costagainst 13 important infectious diseases. Routine immunizations include BCG, polio, myelitis, diphtheria,

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tetanus, pertussis, hepatitis B, hemophilus influenzae B, meningococcus B and C,

rubella, mumps, measles, and, at primary school age, typhus (24). The last
confirmed polio case in Cuba was diagnosed in 1962in Canada it was 1977; in
the United States, 1979; and in Mexico, 1990 (25). The following diseases have
also been eliminated in Cuba, thanks to this program: diphtheria since 1980;
measles, 1993; pertussis, 1994; and mumps and rubella, 1995. Through the
vaccination of pregnant women and optimal obstetric care, neonatal tetanus
has been eliminated since 1973 (26). Complete immunization coveragethat is,
children who have received all their programmed vaccinesin children below
the age of two is 98.5 percent (26).
The best example of Cubas success in the application of breakthrough biotechnology research is the meningitis B vaccine; no such vaccine is available as
yet in Europe and the United States. When the incidence of meningitis B increased
in the United States in the late 1990s, the U.S. government had to give in to
public demand to allow the British-American multinational SmithKline-Beecham
to enter into a joint venture with Cuba to further develop and commercialize
the meningitis B vaccine, in spite of the economic blockade (27).
THE CRISIS OF THE 1990S
During the first three decades of the revolutionary period, the development of the
health services benefited from the increasing government budget. Development
of the economy, increasing production, and profitablc trade relations with the
socialist countries formed a solid economic basis to ensure the improvement of
public health. The 1980s were called a lost decade for developing countries,
because most poor countries were burdened by debilitating foreign debts and the
IMFs imposition of cost-cutting measures. But in Cuba, the number of hospital
beds increased by 2,800 each year, from 53,417 in 1980 to 77,000 in 1990. In the
same period the number of doctors and dentists also doubled and the abovementioned GP program was introduced (26). In 1989, the executive director of
UNICEF, James F. Grant, confirmed that if the Cuban health system had existed
throughout Latin America, 700,000 of the child deaths in 1988 would not have
occurred (28). Cuban economist De Llano added: In Cuba we saved hundred
thousands of children that would have died without the revolution. And they do
not only survive, they all have food, education and different possibilities for an
integral development. This is not unimportant when comparing figures. In 1989
some 165 million Latin-Americans, or about 38 percent of the population, lived
in total misery. And 50 million Latin-Americans can neither read or write (7).
In 1990, the international situation changed abruptly, with severe consequences
for Cuba. The downfall of socialism in Eastern Europe and the collapse of
the Soviet Union reduced Cubas foreign trade by almost 80 percent in just a
few years. Between 1989 and 1993, the gross national product (GNP) dropped
34 percent and the budget deficit increased to 37 percent of GNP. In a short period,

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the peso, Cubas national currency, lost its parity with the dollar and reached
(at the parallel market) exchange rates of up to 150 pesos to the dollar (29). On top
of this economic disaster, the United States tightened its 30-year economic
blockade. With the Toricelli and Helms-Burton Acts, the United States tried to
strangle Cuba completely. Other countries were pressured to join this criminal
economic blockade (30). In this critical period there was no shortage of foreign
advisors who told Cuba that the only solution was shock therapy, with structural
adjustment programs similar to those imposed by the IMF on the rest of the
developing world.
In spite of the crisis, Cubans remained steadfast and pursued their own course.
Step by step, economic and social measures were taken to counter the crisis and to
secure the achievements of Cuban socialism. The Cuban government called this
phase the special period. Before any measures were implemented, they were
discussed widely in the factories and neighborhoods. Only measures supported by
a broad social consensus were implemented. The use of the dollar was legalized,
certain taxes were introduced, farmers markets were reintroduced, and prices of
telephone, gas, and electricity were increased. These measures were taken with
the support of the people and without massive lay-offs (29). Despite the crisis,
the budgets for the national programs for scientific research and technological
renovation were increased. Scientific government institutions were told to focus
their research on solutions for the crisis. Almost all other sectors, including health
care, had to cope with a reduction of 50 percent or more of their investment
budgets. The army was called in to take part in production to supply the local
market and ensure self-sufficiency.
The importation of medical supplies and medicines slumped to one-third of that
in 1989. Not only did the lack of foreign currencies affect the availability of
imported medicines, but local production of pharmaceuticals stalled because of
the difficulty of importing raw materials. Pressure by the United States on other
countries and multinationals to stop trading with Cuba led to the suspension of
many contracts for medicines, medical equipment, and spare parts. Cuba had to
search worldwide for suppliers of lifesaving products, and this often increased
the prices. In 1994, U.S.$5.2 million was paid for the transport of medicines and
medical supplies from Europe and Asia, whereas the same supply from the United
States would have cost only $1.4 million, or about 73 percent less (29).
The impact of the crisis was immense. The nutritional status of the Cuban
population deteriorated and this, in turn, was one of the most important causes of
the resurgence of such diseases as tuberculosis and diarrhea, especially among the
elderly. The deterioration of general sanitation due to the shortage of detergents,
the worsening quality of water and sewage systems, and the widespread practice
of raising backyard livestock all contributed to an increase in the prevalence of
diarrhea (3133). Vitamin deficiency led to an epidemic of neuropathy, a disease
that causes gradual loss of eyesight and even blindness. In order to address
this dramatic situation, an extra budget of more than U.S.$100 million was allotted

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in 1993. The country started to produce Neovitamin II, a multivitamin preparation,

to counter nutritional deficiencies. For more than a year this product was provided to the entire population free of charge. From 1995 onward, it was sold at
drugstores at subsidized prices, as are other medicines (3436).
The trends in the incidence rate of tuberculosis illustrate both the depth of
the crisis and the efficacy of the governments response. After the rapid reduction of the number of TB infections in the 1960s and early 1970s, Cuba maintained an average yearly decrease of 5 percent between 1973 and 1991, and
tuberculosis was almost eradicated (13). After 1992, however, the number of
TB cases shot up because of the difficult living conditions under the economic
crisis. Unlike most other countries that experienced a resurgence of tuberculosis, factors like AIDS and multi-drug resistance were not significantly
related to the increasing incidence in Cuba. Health care still functioned efficiently. While the number of TB cases rose, the mortality caused by tuberculosis
did not change and remained at one death per 100,000 inhabitants. The
health services reacted promptly, and since 1995 the trend has been reversed
(Figure 1) (13, 37).
Statistics on the proportion of infants with low birthweight (less than
2,500 gram) show a similar pattern. The proportion of low birthweight steadily
decreased until 1989, when it reached a low of 7.3 percent. Then the rate rose
to 9 percent in 1993. The socioeconomic crisis had a direct impact on the general
nutritional status of the Cuban population. Together with the improvement of
the economic situation, special programs for the control and prevention of low
birthweight were able to improve these statistics, and in 1998, the rate of children
with low birthweight fell again, to 6.7 percent (Figure 2) (13). As the evolution
of these and other health indicators shows, the harmful effects of the crisis on
the general public health were rather limited after all (30, 38, 39).
STRUCTURAL ADJUSTMENT OF
CUBAN HEALTH CARE
In 1994, the deterioration of the Cuban economic situation was halted and
gradually reversed. In 1995, 1996, and 1997 the economy grew again, with
2.5 percent, 7.8 percent, and 2.5 percent growth, respectively. As soon as the tide
started to turn and the economic basis was in place to ensure the future of a
socialist Cuba, thoroughgoing strategies were devised to solve the problems that
had occurred. How was this done? What was the political basis of these solutions?
Unlike in other Latin American countries (e.g., Ecuador in 19982000 and
Argentina in 20012002), the crisis did not cause hunger revolts or a widespread
loss of confidence in the government and in the political system. The Cuban
communist party (PCC) maintained and even consolidated its credibility, because
of its strong links with the people and the massive participation of workers in the
formulation of remedial measures. Nevertheless, the deterioration of the economic

Figure 1. Tuberculosis incidence rate in Cuba, 19701998. Source: MINSAP, Direccin Nacional de Estadstica, 2001.

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Figure 2. Low birthweight in Cuba, 19741998. Source: MINSAP, Direccin Nacional de Estadstica, 2001.

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situation was a major challenge. During my visits to the country in the early 1990s,
I observed that absenteeism and lack of motivation, for example, became a
problem among some health personnel and contributed to the deteriorating quality
of the health service. The same kind of problems occurred in other sectors.
The economic revitalization after 1994 (and especially 19951996) gave the
PCC a solid basis to mobilize for a political rectification campaign, and it
claimed, Even if we have many difficult years ahead of us, we can say that
the most difficult phase of this special period is already behind us. Through
this experience . . . our country can state in all modesty but with appropriate
pride that not a single citizen was abandoned and that our country has a healthy
and united people, which has confidence and faith in what it can achieve in
the future (40).
In our cooperation with Cuban health institutions, we experienced how a
series of reforms were initiated. The health care system continued to offer free
preventive, curative, and rehabilitation services at the different levels of care
(41, 42), while developing plans for rationalizing health care and increasing
efficiency. The principles of state responsibility, equity, and universal coverage
were ratified (38). Priority was put on the further development of primary health
care, setting up a program of quality improvement, strengthening family and
preventive medicine, and further developing decentralization, intersectoral action,
and community participation. The emphasis was on maternal and child health,
chronic noncommunicable diseases, communicable diseases, and care of the
elderly (32, 38, 43, 44). Measures implemented to strengthen family medicine
included improving drug availability and follow-up of patients. A program of
home hospitalization was reinforced, and an extra muros emergency care system
was set up, in which first-line polyclinics and GP networks played a central role
(45, 46). Table 1 shows how, despite the crisis of the 1990s, the Cuban health
system has been developing (47). After graduation, 97 percent of doctors work
as a GP. For three years they receive training in integrated general medicine
or family medicine. Special programs ensure that more attention is given to
preventive activities, that emergency medicine is extended, that the supply
of medicines is improved, and so forth. In hospital care, new programs have
focused on improving hospital supplies as well as the quality of hospital care.
The latter program includes training and research, the expansion of committees for hygiene, the prevention of hospital infections, and the development
of standards and procedures.
Continuous Renewal
Cubas health system is far from perfect. In spite of the reform and rectification
campaign, challenges remain huge. Although the family doctor is supposed to be
the first entry point into the health system, more than 25 percent of first-contact
consultations occur at the emergency system of hospitals and polyclinics. Despite

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Table 1

Developments in the Cuban health system during the crisis period of the 1990s

Medical infrastructure
Hospitals
Polyclinics
Family doctor offices
Dentist offices
Research institutes
Blood transfusion centers
Homes for elderly people
Homes for disabled people
Medical personnel
Doctors
Family doctors
Nurses
Dentists
Technical personnel
Other personnel

1989

2000

263
420
6,000
163
11
23
153
23

284
438
14,965
166
12
27
210
29

38,690
N.A.
69,060
N.A.
N.A.
N.A.

65,873
29,942
84,685
10,073
56,521
114,037

the already huge shift away from hospital and polyclinic consultations toward
family doctors, there is a need for further enhancement of the family doctors
role (48). Health authorities are well aware of these problems. Administrative
authorities and research institutes (with their international partners) are mobilized
to do research on possible improvements.
The crisis of the 1990s resulted in a general deterioration of medical equipment and facilities. An accelerated plan is now in place to upgrade the
equipment and infrastructure of the polyclinics and family doctors clinics.
The emphasis is on enhancing the family doctors technical capacities, backstopped by specialists at the polyclinic, to reinforce the integrated approach
of curative community health care. With broad participation of family doctors
and other health workers, the functions of the first-line health workers are
being reexamined in order to ensure the necessary autonomy and responsibility
at local levels to answer local needs, within the framework of the National
Health Service.
These structural adjustments run counter to the health care reform programs
imposed by the IMF and the World Bank on most other countries. Socialist Cuba
sticks to the basic principles of its National Health Service. That means, in the
first place, that health care, like other social programs such as education, is not
subject to cost cutting but remains a national priority.

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Cuban Medicine on Three Continents

International medical assistance has always been an important aspect of the
Cuban health system. As early as 1962, 56 Cuban doctors went to Algeria
to work in this newly independent country for 14 months. Since then,
cooperation with other countries of the South has only increased. There were,
and still are, tens of thousands of doctors, specialists, professors, nurses, and
technicians active in dozens of developing countries, especially in Africa and
Latin America.
In the first place, medical assistance was provided following or during natural
disasters or armed conflicts, as in Syria, Angola, Ethiopia, and Vietnam, for
example. After hurricane Mitch, which caused a lot of damage in Central America
in 1998, international cooperation was reorganized and systematized as the
Program for Integral Medical Service for Latin America and the Caribbean and
for Africa. This program started in November 1998 and, after only one year,
coordinated medical cooperation between Cuba and 14 countries on three
continents (including Asia). Besides the many young GPs from all over Cuba,
specialists, professors, and researchers with years of experience in neurology,
surgery, gynecology, epidemiology, and pediatrics participate in this project.
In many African countries they help local medical faculties or even assist them
in getting started (49).
Complementary to this cooperation abroad, Cuba has also set up international programs at home. Since 1990 the country has been treating children
affected by radiation fallout, at the Ciudad de Pioneros Tarara, a treatment
facility set up outside Havana for the child victims of the Chernobyl disaster.
Cuba is still receiving and treating these radiation victims, and is the largest
donor country in the world providing health care for these children. More
than 19,000 children have been treated since the program started. Cuban doctors
in Ukraine select those who would benefit the most from the treatment, depending
on their sickness. But because of the U.S. embargo, Cuba has had to limit
the number and variety of children brought there for treatment. The embargo
has made it increasingly difficult and expensive for Cuba to bring in the
much needed drugs used to fight leukemia and lymphomas through chemotherapy (50).
Another initiative of importance is the Latin American School for Medical
Sciences, which opened in Havana in 1999. Currently, the more than 5,000
students are mostly poor campesinos (farmers) and indigenas (indigenous
peoples) from Latin America and Africa. During the first two years of their
training they are enrolled in the international school close to Havana. Afterward,
they study at national medical faculties spread over the 14 provinces of the
country. After graduation, these young people go back to their home countries
to serve in regions with a lack of doctors, or to replace Cuban doctors who
went there temporarily.

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The dean of the Latin American School for Medical Sciences, Dr. Juan Carrizo,
explained in 2001 the importance of this international program for Cubas own
health system (51):
The confrontation with the poverty and misery of the excluded in those parts
of the world, where people have to survive in miserable circumstances, gives
our doctors not only an enormous satisfaction in their medical work, but also
strengthens their insight in the terrible contradictions of this world and
sharpens their political and ideological conviction that Cubas socialism is a
great force that is able to realize wonderful things. The presence of thousands
of medical students from other third world countries, all over the country, does
not only give us the opportunity to make a contribution to their training. Their
presence here, their stories about their home countries, and their enthusiasm
about our society are, for our population, a source of pride and strengthen
our political conviction.

FINAL COMMENTS
In Cuba, the organization of an integrated health system is upheld as a central state
responsibility. Moreover, health care continues to be free and of high quality.
Except for first-line medication, which is offered at subsidized prices, all costs of
health care are covered by the state through revenues from the state economy
and taxes. Every Cuban has the right to health care according to his or her needs.
User fees or copayments are completely unthinkable, because they would
immediately cause inequality in the access to health care. Cuban doctors explain
with vehemence, As free health care was an important principle in times when
everything went reasonably well, all the more is this so during this period of
economic crisis. Consequently, health care remains exclusively in the hands of
Cubas public sector. Privatization is not an option for Cuba, and the private
practice of medicine is prohibited by law. As quality health services are available
free of charge to the entire population, there is no significant demand for private
medicine. This is exactly the opposite of what is happening in other parts of
the world where the public service is underfunded and people are made to believe
that the private sector is the only alternative to ensure high-quality care. Comparing the situation in Cuba with the rest of Latin America, we clearly see that
the opposite holds true.
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Direct reprint requests to:

Dr. Pol De Vos
Department of Public Health
Institute for Tropical Medicine
Nationalestraat 155
2000 Antwerp
Belgium
e-mail: pdevos@itg.be