Cuban Health Care System:
By Talal Naeem

Abstract 

"Cubans are people who are born in a third world economy
and who sicken and die of first world pathologies!"
    -- Prof Theodore H. Macdonald, 1999 [1]

Today, Cuba claims to be a "world medical power" [2]. Cuban leaders have the country's health indicators, particularly a low infant mortality rate, high life expectancy and one of the highest doctor to patient ratios, to support this claim. In fact, in some areas their health standards even surpass those of developed countries. This paper is divided into three sections. Section I explores how a small developing country like Cuba could develop such a remarkable health care system, unmatched in the third world. In Section II, keeping in mind Cuba's successful strategies in their health sector, we analyzed how a developing country like Pakistan could think beyond folklores and implement similar strategies to improve the country's health standards. Finally, Section III serves as an appendix giving details regarding Pakistan's existing health structure.

Section I

Introduction to Cuba

Cuba, with an area of 110,922 square kilometers is the largest, and the most populous island-nation of the West Indies. [3] Its current population is approximately 11.25 million people, as reported by UNICEF in the 2004 Cuban demographic statistics. [4] Fidel Castro, who came into power on 16th February 1959, by becoming a prime minister of the revolutionary government, leads Cuba.3 From the very beginning Cuban leaders gave the country's health care system one of their highest priorities.

Following the 1959 revolution, Cuban leaders considered superior health statistics as adequate measures of a government's effectiveness; which explains why providing top quality health care to the masses has been one of their key policies. They aimed, for Cuba to become a "world medical power", which meant 'socioeconomic development, scientific achievement, a model health system and global influence.'* This would ensure that Cubans enjoy a good standard of living because of fulfillment of basic needs of life. Thus, Cuba has managed to significantly develop its human resources, having an impact world wide, in the form of Cuban doctors working all over the world in times of need.

Cuban health care system

Before Fidel Castro came in power, Cuban Health Care Statistics revealed a state similar to any other developing country. The country's health care system was marked by "urban-rural contradiction" with a majority of the doctors working in Cuba's urban regions, and the privileged upper class enjoyed a better quality medical treatment as compared to the rest of the public. [5] However, today Cuban health indicators reveal an enormous improvement in the infant mortality rates, and life expectancy at birth, since the revolution. Today, Cuban health statistics reveal the country's health care to be far more advanced than a developing country, in fact, Cuban health care can be considered at par with those of the industrialized world. According to the WHO, the patient to doctor ratio in Cuba is 1 to 170, making Cuba ahead of the US where the ratio is 1 to 188.[6] Cuba's life expectancy at birth is 75 years for males and 79 years for females.6 The CIA World Fact book for 2005, reports the infant mortality rate in Cuba as 6.33, being slightly lower than that of the United States, which is 6.50. [7] 

The main idea behind the revolution of the health system is evident from Fidel Castro's mission of making Cuba a 'World Medical Power'. He believes there can never be too many doctors and medical personnel and envisions having, "A doctor on every fishing boat, on every merchant ship, in every school, in every factory, on every block." [8] In addition, Che Guevara, an Argentinean doctor, one of the key revolutionary leaders of the 1956-59 Cuban revolution, also had a similar vision of providing high quality free health care to all citizens being the government's responsibility. These visions led to the eventual success of Cuba's health care system.

We believe that Cuba's health care system was implemented using an umbrella strategy. Henry Mitnzberg has defined an umbrella strategy as, "senior management setting out broad guidelines and leaving the specifics to others lower down in the organization. This strategy is not only deliberate (in its guidelines) and emergent (in its specifics) but it is also deliberately emergent in that the process is consciously managed to allow strategies to emerge en route." 8 Cuban leaders and visionaries, specifically Fidel Castro and Che Guevara, set these broad guidelines of providing high quality public health care to all. The actual specifics were in the hands of the Ministry of Public Health, which in turn set up an advisory commission that aimed towards elaborating "the conceptualization of community medicine." [9] Thus, Cuban leaders set out the deliberate strategy for Cuba's health care system, whereas the Ministry of Public Health and the appointed commission were involved in the periodic evaluation and assessment of the implemented strategies. This implies, that Cuba's health care strategy evolved through a process of continuous criticism and evaluation, rather than following hard guidelines.

Therefore, it is evident that Cuba's health care strategy was partially deliberate and partially unplanned; which also agrees with J. Moncrieff's model of strategy dynamics. [10] The planned element follows from the visions of Cuban leaders. However, the unplanned element comes from "emergent strategies" that resulted from the interaction of the implemented health care strategies with its environment. For a reflective account of the human experiences involved in Cuban medicine, the advisory commision sought for regular feedback from patients regarding their interaction with doctor, to recommend any positive changes in the prevalent strategies.  This led to the transition of the Cuban health care system, through three periods namely: early transition (1959-1964), consolidation and the policlinic phase (1965-1973) and the remaining years as the community medicine and the family doctor phase.9 Early transition addressed shortcomings of the medical-political imagination of the pre-Revolutionary healthcare system, leading to a unified national health system. Community medicine evolved in turn from the loopholes identified in the polyclinic phase.

In the transition phase, within a short period of time, the Cuban revolution almost ended private interest medical care and introduced a new ideology of health. This ideology consisted primarily of "social medicine". Social medicine can be defined as "the pursuit of integrated and implemented understanding of both health needs and health services, giving attention to physical environment and human biology, with primary focus on social equity in health." 9 Some of the significant proposed changes included rural health programs, regionalization of public health and hospitals, free medical care in all public institutions, creation of preventive medical care programs, free medical education etc.

As a result of this transition, almost half of Cuban physicians left to the United States leaving only 3000 doctors and 16 professors in the country's main medical college. [12] Their temporary replacements were done through doctors from different Latin American countries. In 1961, as a permanent solution to this shortage of doctors, the government planned to educate future doctors by converting a huge nuns' convent into a teaching hospital. [13] According to WHO, today there are 13 medical schools in Cuba. [14] 

Following the transition phase came the polyclinic phase, during which there was an integration of the changes proposed in the earlier phase. This included the development of rural hospitals and health centers, extension and regionalization of hospital system, integration of the private and public health centers and the development of national public health campaigns. The main focus of this phase was on 'area polyclinics', [15] which catered to the health needs of specific geographical areas.

Subsequently, came the community medicine phase which continues till today and explains the success of Cuban health care. This phase mainly consisted of an evaluation of the former phases through patient feedback. This period mainly addressed the shortcomings of the earlier phases, which included unsatisfactory appointments, insufficient medical facilities, overworked physicians, long waiting lists etc. Personalized health care was found to be the solution to these shortcomings; every community block was assigned a physician and a nursing team. This team was responsible for ensuring that all people within their community receive the appropriate healthcare. Moreover, it was the responsibility of the primary care physician to act as third party in consultations between patients and specialists and keep records of all patients' history.

The above-described phases through which the Cuban health system has been through, explains how Cuba's health care strategies evolved over time according to responses from the environment. Continuous changes were made to remedy any inequities in the country's medical system so as to ensure that a free and comprehensive health service is provided to each and every member of Cuban society. This explains how the health standards in Cuba have dramatically improved over the years, eventually coming to par with those of developed countries.

International medical aid

Frequently the Cuban leader, Fidel Castro has said he wants his country to become a 'world medical power'. This phrase refers to 'socioeconomic development, scientific achievement, a model health system, and influence in the international arena. [16] Cuba has managed to gain influence in the international arena by impacting various countries through programs designed to provide medical help beyond its borders; domestic success in the field of medicine encouraged Cuban leaders to make health play a key role in the country's foreign policy.

Despite its own economic difficulties, Cuba has provided assistance to many third world countries over the past two decades. According to the New York Times, Cuba sponsors possibly "the largest Peace Corps style program of civilian aid in the world." Surprisingly, Cuba has more doctors working abroad than does the World Health Organization. [17] At the beginning of 2006, it was reported that 25,000 Cuban doctors were involved in humanitarian missions in 68 different countries. [18] As part of their aid effort, Cuban medical aid workers have also been involved in training local workers, so as to prepare their replacements. Cuba has helped build first of their kind, medical schools in Yemen, Ethiopia and Guinea-Bissau, these medical schools were also staffed with experienced Cuban professors in their early years. 

As part of its medical diplomacy, Cuba also donates medical equipment, supplies, and even complete facilities to countries in need. These include, the donation to Bolivia of fully operational pediatric intensive-care units in the 80s, and the donation of six rural hospitals to Peru.17  The Cubans have also been involved in providing significant medical aid to countries following major earthquakes.

Furthermore, just recently (September 2005), Cuba created a 1,586-strong international medical contingent that works against disasters and serious epidemics. [19] This body is prepared to cooperate in relief work needed by any nation of the world.
The international brigade is under the name of Henry Reeve, a US citizen who gave up his life while fighting for Cuban independence.18 This brigade is directly under the leadership of Cuba's revolutionary leader Fidel Castro. Following Pakistan's devastating October 8^th 2005 earthquake, an army of doctors from the Henry Reeve International Contingent, arrived in Pakistan on October 14^th to give humanitarian aid to the victims of the catastrophe. By the end of January 2006, over 2,000 Cuban medical staff was working in around 30 field hospitals in the earthquake-hit areas of Pakistan. 18  Up to date, they have treated around 1,043,125 patients in various regions of the country. 21

In addition to the medical assistance, free medical education is also part of Cuba's international aid. The number of foreign students in Cuban medical schools, at the end of 2005, totaled to 12,000 from 83 different countries. [21] Unlike other countries offering scholarships to international students, it is interesting to note the Cuban policy, which requires foreign students to return to their own countries on the completion of their studies.

Furthermore, the development of the Cuban health sector is encouraged by the government so as to enable Cuba to earn foreign currency by exporting its health services. Initially Cuban aid was non-repayable, however since 1977 Cuba has been charging countries based on their ability to pay. [22] Poor countries receive aid for free, whereas oil-rich countries like Libya and Iraq paid in hard currency but at prices lower than those charged by other Western countries. According to an advisor to the Cuban vice president, Cuba charges eleven hundred dollars per month for a generalist medical doctor with eight years' experience;22 these charges are significantly lower than the amount charged by other international donors.

Moreover, the Cubans have also earned a significant amount of foreign currency by providing medical care to individuals from various Western countries. Cuba has heavily advertised "sun and surgery" and "health tourism" to those people who find the price of medical services at home unaffordable.23 Patients from various Latin American countries, often come to Cuba for specialized treatment that is not available in their home country.  In addition, the Cuban government in affiliation with the Venezuelan leader initiated a "free eye care program" for all Caribbean who could not afford the prices charged by private doctors in their region.24 The most symbolic example of Cuba's international health aid is the free treatment given to an eight-year-old British girl whose family could not afford paying for her treatment in their home country.23

Obstacles to the existing health system

One of the main obstacles to the Cuban health system was the imposition of a United States economic embargo in 1961, which continues till today. [23] The effects of the embargo were heightened after the dissolution of the Soviet Union, since the Cubans had hardly any support from the rest of the world. Thus the Cuban model health care system has become threatened by shortages of medical supplies, which are mainly provided by the United States.

Section II

To adequately understand the prevalent health system crisis in Pakistan we need to analyze Pakistan's conditions at a macro level.  In our opinion, the deplorable condition of the health care system in Pakistan cannot just be seen as the failure of implementation or the lack of proper policy making by the government but as the failure of the system, which over the years has evolved in Pakistan. Moreover, the quality of public medical services seems to be deteriorating over time, as an ever growing and over priced private medical sector gains prominence in the country. We will analyze each of these weaknesses and present our solutions to them, in light of the lessons learnt from Cuba's health strategies. We are going to analyze some of the most popular ones and compare them with Cuba's healthcare strategies.   

One of the most famous folklore championed by the liberal school of thought is the inefficiency of public institutions. These inefficient institutions in their opinion should therefore be replaced by the more efficient and competitive private sector in order for development to take place. Pakistan's economy heavily relies on loans from international intuitions. These institutions grant loans to Pakistan on the condition that Pakistan would in turn abide by the policies drafted by these intuitions. The largest of these donors are World Bank and the IMF. The World Banks in its "recommendations"⁴ has directed the government of Pakistan to encourage the private sector to play a more active part in the health care system. It has advised the government to further decrease its stake in the health care system and to merely restrict its role to that of a regulator in the health care sector. USA is often cited as a successful example of such policy implementations. Various regimes over the past therefore have hailed the slogan of privatization in an unsuccessful attempt to imitate their masters.  

The human development report published by the Mahbub-ul-Haq human development center (HDC) in 2005 ranked all the countries of the world according to their health index. Only one (USA) out of the top ten countries in this list had a health system that relied primarily on the private sector. Cuba's fully nationalized health care system with its limited resources and heavy embargos was ranked at number seven ahead of developed countries like USA, UK, France, Japan, Italy, and Switzerland etc [24]. Health system in Cuba is fully nationalized. In our opinion, the reasons for this overwhelming dominance at the top positions of countries that rely heavily on the public health sector, over countries where private sector dominates the health care system is because of the inherent characteristics of the private sector. The private sector is always driven by the profit motive. Its services therefore, would be directed towards those activities and individuals who could maximize its profits. Recently, Hurricane Katrina's survivors suffered from a severe shortage of doctors, the reason being that most of them had private practices. Due to this, the doctors of New Orleans fled to neighboring states leaving behind victims of the Hurricane, as there was no profit motive for them to stay back and treat the survivors. [25]  The government on the other hand is responsible for its citizens and would cater to their health needs irrespective of the profits they would make. Secondly governments usually have more resources at their disposal compared to private individuals. It can therefore spend more and in a much planned way on the health care system. Thirdly, income disparities in developing countries like Pakistan are enormous. With 32% of its population under the poverty line⁵, dependence on the private health care would deprive more than a third of the population from access to health services. Pakistan's first priority therefore should be spending more on the public health care sector and raising its standard at par with the private health sector. It should then further strive to improve its services in order to provide quality health care to the vast majority of the population who cannot afford private health services.   

Moreover, money perceived as the only motivator is another folklore common amongst policy makers. One of the most commonly cited reasons for doctors not joining the public sector is that private hospitals pay more compared to government hospitals. Money is the only criteria given for people joining the profession of a doctor. The Cuban doctors on the other hand have demonstrated that this is entirely untrue. In addition, Cuban doctors are not highly paid, and a number of times they have to put in long hours to cater to the needs of their patients. In addition, the Cuban doctors are sometimes also referred to as 'doctors of the world.' This is because they are willing to serve in any part of the world they are needed in and that too, free of charge. Currently Cuba has over 25,000 health professionals providing aid in 68 countries, including Latin American, African and Asian nations.⁶   

So what is it that motivates the Cuban doctors to work selflessly for humanity? As indicated above the Cuban doctors are not very highly paid so money is out of the question. In our opinion it is the human nature itself, which motivates them to work this way. It is also the system prevalent in Cuba that has helped the Cubans to bring forth this aspect of human nature. If a country guarantees its people food, clothing, shelter, employment, education and entertainment, people of that country do not have to worry about the basic necessities of life anymore. It is then that they truly experience the feeling of being human and exploring what human beings are truly capable of. Moreover, the system run in Cuba is not based on the excessive profits and larger market shares, as is the case in capitalist societies. As a result, the post-revolution generations have been brought up in a society that strives to work selflessly for the welfare of the collective rather than individuals. This is the ideology with which the Cubans believe in and look up to. They truly want to live the revolution and carry it forward. They believe that selfless help of the humanity would only make them true socialists.  

The government of Pakistan therefore needs to motivate the people of our country and provide them with material condition similar to those in which the Cuban doctors were brought up not only to get a better health care system but also to build a better country. They need to emancipate the masses from their suffering and distress by providing them with all the basic necessities of life like the Cuban government does. It is only then that we would be able to produce doctors like those of Cuba. These changes would take a long time to come into effect, as they require the entire system of Pakistan to be replaced. To make the health system better in the shot term the government needs to provide the doctors serving in the public sector with non-monetary benefits. A few of the proposed benefits are listed below. 

It should first of all make medical education free for all students aspiring to become doctors in the public health sector. These doctors should then be required by law to work for public hospitals; failing to do so should result in severe legal action. The government could also draft policies, which would make working in rural areas for a certain period during their service tenure, mandatory. In our opinion besides free education if doctors working in public hospitals were given all the facilities given to doctors of the armed forces of Pakistan like free housing, no electric or telecom charges, quality education for children at discounted rates, access to cheap entertainment (club memberships), a chance to get a specialization at no cost etc there would be a significant increase in the number of people opting to join public hospitals. The immediate argument that one might be confronted with on the proposition of these changes might be that how could a developing country finance these reforms? A simple answer could be if Cuba with all its embargos and limited resources could do it, so can we. All we have to do is free some of our resources from the defense budget and allocate them towards social welfare. To move even further we can follow Castro's footsteps and convert some of our state mansions into public universities, for the benefit of the public.       

Ricardo Semler in his article 'managing without managers' says: "As we have seen, a key assumption in planning is that of detachment, particularly of strategy from operations, and, as a result, of what is called strategic management from operating management"⁷. He refers to it as the 'fallacy of detachment'. This is in our opinion is another folklore which strategy formulators strongly believe in. Semler in his article points out that it is usually the corporations which are victims of this folklore. In our opinion his analysis can be extended to governments, and the government of Pakistan is one of the victims of this folklore. To further aggravate the situation Pakistan's political environment is plagued with extreme political stability. Frequent military coups and rapid over throw of civilian governments has resulted in the Pakistani population witnessing different rulers every now and then with totally contrasting agendas. Therefore, instead of learning from past mistakes and building on the past, as in Cuba's case, we have seen new governments to totally dissolve the plans of preceding governments and engage in a "heroic" effort to start from the scratch. 

The policy makers of our country should be people, who interact with the common man in public hospitals on daily basis, rather than ministers or bureaucrats who in their whole live have never seen what a public hospital looks like. These people should ask patients to give recommendations regarding ways in which they could improve current public medical sector. In addition these people should themselves observe the conditions of the medicals sector and come up with innovative ideas and suggestion to improve or adapt with time. New policies for public health care sector should be formulated in accordance with these observations and feedback. The observers should be the ones who should formulate these policies in order to avoid the fallacy of detachment. This body of policy makers should be democratically elected. It should be autonomous and all decisions regarding policy making or changing should be subjected to their approval. Another obstacle which hampers effective policy formulation is the colonial bureaucratic culture in our society. Because of this culture, the lower staff in public hospitals is subjected to treatment similar to what the blacks experienced in the apartheid. They have to adhere to orders strictly and little deviations or innovation on their part could lead to punishments varying from verbal and physical abuse to job termination. As a result of this attitude people have stopped thinking out side the box. They just adhere to the directions given by their superiors. These are the people who interact most with the common man and they themselves are part of the common people of Pakistan. Their input and innovative ideas could play a pivotal role in the evolution of a better health strategy. These people should therefore be brought into the lime light and they should be encouraged to adapt to the situation. Instead of imposing sever penalties important lessons and significant insights should be drawn from their mistakes.            

The fact that Pakistan spends only 0.8% of its GDP on health services⁸ is heartening. With an ever-increasing population and such statistics, one should not expect to see improvement in the health sector. In Cuba every community block has a 'family doctor.' This means that there is one doctor for approximately 170 patients⁹. The doctors know their patients personally and frequently provide services at their doorstep. If such arrangement could be made in Pakistan i.e. we could have a family doctor for every community block and that doctor would know the people of the locality personally people would be able to get quality health care irrespective of their geographic location or their social status.  

These were some of the folklores, which the government believes in and all of which have been proven wrong by the revolutionary country of Cuba. If the Pakistan's government wants to raise the level of its health standard at par with that of Cuba it too like Cuba, has to think out of the box. The long term solution in our opinion, as pointed out earlier, for these problems is the replacement of the decadent system currently prevalent in Pakistan. People would only be able to think outside the box and truly act as human beings once they are emancipated from the struggle of procuring the basic necessities of life. This long term solution can only be provided by a revolutionary government like that of Cuba. Observing the material conditions of Pakistan no such revolutionary party is strong enough to challenge the state. This solution would therefore take a long time. To provide temporary relief to the masses the government should at least think beyond the common folklores and try implementing the reforms pointed above. While these reforms, in our opinion, might not be successful in healing the wounds inflicted by the system but they may help pacify the pain.          

ORIGINAL SOURCE FOR THIS PAPER:
http://groups.yahoo.com/group/cmkp_pk/message/4716