Health Policy and Planning Advance Access originally published online on May 2, 2008
Health Policy and Planning 2008 23(4):288-290; doi:10.1093/heapol/czn010
Cuba's health system: challenges ahead
1Institute of Tropical Medicine, Antwerp, Belgium.
2Intal, Brussels, Belgium.
3National Institute of Hygiene, Epidemiology and Microbiology, Havana, Cuba.
* Corresponding author. Public Health Department, Institute of Tropical Medicine, Nationalestraat 155, Antwerp 2000, Belgium. E-mail: pdevos{at}itg.be
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Abstract |
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 Top Abstract Cuba's health system: challenges...Current opportunities and...Addressing the challengesConclusionsReferences |
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Cuba's exclusively public health system has been quite unique in pairing limited resources with excellent results. It continued to perform well during the economic crisis of the 1990s, and now that the hardships are being overcome, new opportunities are developing—as well as threats: (1) economic recovery should permit reinforcing of the system's effectiveness; (2) Cuba's increasing international solidarity in health also poses it corresponding challenges at home; (3) the ageing of the population necessitates adjustments to the health care system. However, the original principles of the health care system are not under question. Cuba can be considered a unique laboratory, and deserves more attention from the international public health community.
Key Words: Health services, ageing, national health policy, international cooperation
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Cuba's health system: challenges ahead |
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TopAbstractCuba's health system: challenges...Current opportunities and...Addressing the challengesConclusionsReferences |
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For the past 50 years, Cuba has developed an exclusively public and integrated National Health System providing adequate and accessible health services (Feinsilver 1993
; De Vos 2005). Preventive and curative quality care in an equitable societal context (Eisen 1996; Dugas and Van Dormael 2003) has led to remarkable health outcomes. Cuba's health indicators rival those of much better-off countries (Ministerio de Salud Pública, Dirección Nacional de Estadística 2006).
The economic crisis of the 1990s, a consequence of the collapse of the Soviet Union and the blockade of Cuba by the United States, posed particular threats (Garfield and Santana 1997; Rojas-Ochoa and Lopez-Pardo 1997). In the health sector, it led to a shortage of drugs and other medical supplies, and the inability to replace broken or obsolete equipment (Nayeri and Lopez-Pardo 2005). However, due to the system's resilience, the prioritization of health as a basic human right, and a well-planned rationalizing and rationing of the available resources (De Vos et al. 2005), the overall health situation did not deteriorate (Chelala 1998).
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Current opportunities and challenges |
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TopAbstractCuba's health system: challenges...Current opportunities and...Addressing the challengesConclusionsReferences |
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During the past few years, new developments have brought about important opportunities and challenges for the health system. First, the country's economy has begun to recover. Bilateral agreements with Venezuela have enabled Cuba to ensure sufficient oil supply for its power production, its transport sector and its economy's most urgent needs. At the same time, mutually beneficial trade relations with China and a growing number of other countries are developing at a smooth pace, leading to economic growth of 11.8% in 2005 and 12.5% in 2006 (CEPAL 2007
; Terrero 2007).
Secondly, Cuba's international cooperation in health has expanded dramatically since 1998. The growing number of programmes with a variety of countries seems to indicate that the quality of Cuba's health personnel is being recognized, and that the terms of the collaboration are well accepted by governments of the southern hemisphere. A few countries, especially Venezuela, are also interested to learn from Cuba's health care model. The number of Cuban doctors working abroad jumped from about 5000 in 2003 to more than 25 000 in 2005. They serve in 64 countries, but some three-quarters of them work in Venezuela (Feo and Siqueira 2004). Currently, for the national health system the implications of these international health collaboration programmes seem mainly to be limited to a relatively high turnover of doctors and other health care workers. In some places, one family doctor now has to take care of 1500 people, instead of 600–800 persons previously. Although these figures might still compare favourably with most other poor countries, they represent a strain on the comprehensive curative, preventive and health promotion approach of Cuba's health care concept.
Thirdly, the drastic decrease of infectious diseases and improvements of the socio-economic conditions since the revolution have resulted in a spectacular increase in the life expectancy of the population—rising to 78 years in 2005 (UNICEF 2007). The accompanying decrease in the birth rate has lead to a slow decline in the total population, and an accelerated demographic ageing process. According to UNFPA estimates, 16.2% of the Cuban population is over 60 years of age. Cuba will soon join Barbados as the countries with the most elderly populations in Latin America and the Caribbean (UNFPA 2007). This evolution, combined with changing lifestyles, has lead to an epidemiological transition with a rising incidence of chronic and degenerative diseases.
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Addressing the challenges |
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TopAbstractCuba's health system: challenges...Current opportunities and...Addressing the challengesConclusionsReferences |
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Economic recovery has augured well for the health sector. In a few years time, all 444 polyclinics of the country will have been renovated and supplied with modern medical equipment including X-ray, endoscopy, ultrasound, etc. A programme for the renovation of hospitals has started. Supply of essential drugs has improved significantly. Medical personnel have enjoyed modest wage increases.
At the same time, centralized priority setting is combined with a renewed policy of decentralization, allowing for more flexibility in service delivery and resource utilization at the municipal level according to the local needs. This approach implies the reorganization of health service delivery into sectors of about 6000 inhabitants served by a basic health team—involving family doctors, nurses, specialists and paramedical personnel—combined with the further enhancement of community participation (Green 2003).
To avoid potential shortages that might be caused by the massive involvement of health personnel in international missions, the training of new Cuban health personnel is being accelerated by generalizing a system of decentralized teaching (Ledo and Morales 2005). In the polyclinics, on-site training—according to standardized training models—is directly linked to extensive contact with services and patients right from the start. A particular challenge, however, will be to maintain the academic quality of this education. Also, Cuba is offering medical training to thousands of students from developing countries, both on the island and in their home countries, to replace or reinforce the Cuban ‘internationalists’ abroad (De Vos et al. 2007).
Finally, the 2006 ‘National Health Plan towards 2015’ recognizes the ageing of the population as the key challenge for the coming decade, necessitating a shift (or extension) of services from cure to care, with the corresponding development of human resources (Ministerio de Salud Pública 2006). A first step is the increase of day care homes for the aged, integrated in the neighbourhoods. Besides this, the need to assure adequate care for the growing number of people with chronic diseases is being addressed with a technical upgrade of diagnostic and treatment capacities at the level of the polyclinics, in close cooperation with family doctors in the neighbourhoods and with the other care levels.
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Conclusions |
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TopAbstractCuba's health system: challenges...Current opportunities and...Addressing the challengesConclusionsReferences |
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Although the challenges at hand are huge, the basic principles of Cuba's health care system are not under question. Its public character, its financial accessibility—remaining free of charge at the point of care delivery—and its integrated, quality care for the whole population in a vast network of health facilities are in stark contrast with the trends in many other countries towards implicit privatization through health sector reform since the early 1990s.
All new policies are developed within this framework. Their implementation and results are monitored critically by the Cuban government. Health authorities have never been afraid of innovations and new approaches, nor are they shunning corrections of earlier decisions. Health systems research towards a more evidence-based policy is encouraged.
From a public health perspective, Cuba remains an interesting social laboratory as its experience, which defies the prevailing discourse of neo-liberal health reform (De Vos et al. 2006), could provide novel insights into the relationship between reforms, socio-economic conditions and catalysts for change. The international public health community cannot but give more attention to Cuba's health system and its recent developments.
Contributors: PDV (public health researcher) and PVDS (epidemiologist) are researchers at the Institute of Tropical Medicine in Antwerp, Belgium, and have participated in research within the Cuban health system for more than 10 years. WDC is project manager at the NGO Intal in Brussels, Belgium, which has been active in development cooperation with the Cuban health services for 15 years. MB is the director of the National Institute for Hygiene, Epidemiology and Microbiology (INHEM) in Havana. The authors declare they have no competing interests.
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Accepted for publication 18 March 2008.
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