The Case of Cuba
Cuba’s political history is brimming with dictators, powerful revolution, and smart governance. Cuba went from being a developing nation with poor healthcare systems in place under the rule of the authoritarian government led by President Fulgenico Batista to being a socialist nation with an healthcare system that rivals many. After the Revolution of 1959 led by Che Guevara and Fidel Castro, Cuba’s treatment of healthcare grew to be more impressive than several developed nations. Socialism has definitely shaped Cuba’s goals in health care and development. This piece overviews Cuba’s recent strides in development and health, it also highlights access to healthcare in rural communities.
Cuba, located in the Caribbean, is an upper-middle-income country. After the Spanish-American war in 1898 Cuba gained independence from Spain. They spent a large amount of time dealing with American interference in their political culture and then in the 1950’s the country was under the military dictatorship of Fulgenico Batista. Under his rule there was no publicly funded health care. There were also not enough hospitals, if any, in rural communities. Before Castro took over in 1959 Cuba had social injustice, poverty, political corruption, illiteracy, and economic inequality. There was a maternal mortality rate of 125.3 per 1000 live births, an infant mortality rate of 60 per 1000 live births, a general mortality rate of 6.4 per 1000 person, and a life expectancy of 65.1 years.
Fidel Castro made it so that in the Cuban constitution health is regarded as a right. The four basic principles of this philosophy are that health care is a human right, and not a product for economic profit. All Cubans have equal access to the nations health services and all of these services are free. The government believes that health care delivery is their responsibility, curative and preventative services come hand-in-hand with national social and economic development. Lastly, the people of Cuba participate in developing and maintaining their health care system.
|Table 1 Key demographic, socio-development and health indicators in Cuba|
|Total population (thousands)||11,224,190||2014|
|Population in urban areas||76.8||2014|
|Population growth rate (%)||0.1||2014|
|GDP growth rate (%)||2.7||2013|
|Human Development Index (Rank)||44||2014|
|Population under the poverty line (%)||No information on poverty found|
|Total expenditure on health as a % of GDP||8.8||2013|
|Physicians/1,000 of the population||6.723||2010|
|Under 5 mortality rate (per 1,000 live births)||6||2014|
|Maternal mortality ratio per 100,000 live births reported||39||2015|
|Total expenditure on health per capita||603||2013|
|Life expectancy at birth (yrs.)||79||2013|
|Total adult literacy rate (%)||100%||2014|
|Primary school net enrollment/attendance (%)||98%||2013|
|Immunization, measles (% of children ages 12-23 months)||99%||2014|
Source: Multiple as indicated.
Cuba has 11.39 million inhabitants spread across 168 municipalities, and 15 provinces. Their population is 994 males per 1000 females and they have been experiencing this feminization since 2012. For the population the urbanization percentage is 76.8% and 19.0% of the population is 60 and above. The reproduction and fertility rates have declined. The percentage of institutional births is 99.9%. In Cuba there are 152 hospitals. Eighteen percent of the hospitals have 400 or more beds. Sixty-two percent have between 100 and 399 beds, and twenty percent have less than 99 beds. The National Health System has 113 therapy intensive rooms, 111 dental clinics, 247 grandparents houses, 451 polyclinics, 138 maternity homes, 13 research institutes, 732 medical libraries, 143 nursing homes, 44 geriatric services homes, and 30 homes for the handicapped. The government spends 8.8 percent of the national GDP on health. The key socio-development and health indicators are shown in Table 1.
Death and Disease
In 2014 there was an increase by 4,055 in reported deaths when compared to the prior year. For 2014, 96,328 deaths were reported with the increase coming from the 65 years and older section of the population. The mortality rate is 8.6 deaths per 1,000 inhabitants. The causes of death per 100,000 inhabitants are ranked in descending order as chronic noncommunicable diseases as the highest at 712.4, communicable diseases (causes of perinatal, maternal, and nutritional death) 74.5, lastly mortality from external causes at 68.5.
The top ten diseases affecting Cuban citizens have remained constant for the past three years. They are:
- Malignant neoplasms (23,729)
- Heart disease (23,626)
- Cerebrovascular diseases (9,256)
- Influenza and pneumonia (6,280)
- Accidents (5,252)
- Chronic diseases of the airways (3,938)
- Diseases of arteries, arterioles and glasses capillaries (2,921)
- Diabetes mellitus (2,210)
- Intentionally self-inflicted injury (1,430)
- Cirrhosis and other chronic liver diseases (1,420)
There is access to healthcare for all Cuban citizens. The piece Access and equity: Evidence on the extent to which health services address the needs of the poor the author Natasha Palmer discusses healthcare as a tool for social justice while explaining her concepts of equity and access. Equity and access go hand in hand. While elaborating on what equity is, Palmer discusses how access plays a role. For Palmer equity may not be treating everyone equally but also having to treat some people differently. One concept discussed is ‘gaining access’, which is when the services are available and physically accessible but are not utilized as a result of difficulties faced by potential patients. There may be financial barriers, patients may avoid facilities because of the way they are treated once there, they may doubt the competence of the medical staff, and the ethics of the medical staff is also called into question because bribery is sometimes an issue.
The problem of gaining access no longer occurs. In the 1970s multiple medicine-in-the-community programs were implemented. These programs were designed to take the emphasis away from hospitals and place them on communities striving for wellness. Cuba designed a system of polyclinics where communities were divided into sectors and each sector had an established family doctor team. By doing this the residents get the opportunity to know the doctors in the community. No resident lives more than 600 yards away from a physician. Healthcare in Cuba is free, accessible, and trustworthy for the residents. Those factors are important when keeping a population healthy. Table 4 shows the doctors and hospital breakdown by province.
Source: Registros Administrativos del Departamento de Atención Primaria en Salud. MINSAP.
|Table 4 Access indicators. Doctor’s location by province 2014|
|Province||Family Doctors||Coverage Percent||Hospitals||Population|
|Pinar del Río||684||100||5||588,975|
|Ciego de Ávila||472||100||3||429,737|
|Santiago de Cuba||1,274||100||18||1,055,646|
|Isla de la Juventud||86||100||1||84,834|
Given the data collected by various sources, and the fact that the Cuban government is not a particularly wealthy state, the socialist model of healthcare appears to have several benefits that ought to be looked at for further study. .
There is consistent evidence that “the direct costs of healthcare impose a far greater burden on poor families than on higher income households… A study in Thailand found that annual household direct costs were equivalent to 21.2 percent of annual household income in lowest income quintile, but only 2.1 percent of higher income quintile.” When Castro first began his rule Cuba had a very high rate of poor families. Also, removing the fee’s associated with health care increases utilization.
Whether or not people utilize medical services can be predicted by; perceived financial situation, gender, extra-household resources, the price of a private consultation, and mental and physical health. Therefore, by integrating free health centers into the fabric of the community where preventative care and wellness were primarily promoted, utilization of health services increased over time after the revolution.
Cuba has avoided putting its people in debt by eliminating out-of-pocket health expenses. They avoided having residents pay catastrophic payments towards health care like other Latin American countries partially by eliminating their risk factors for this situation. Those factors are the availability of health services requiring payment, lack of prepayment or health insurance, and low capacity to pay. By having a system that is fully funded by the government Cuba avoids bankrupting their residents with out-of-pocket health costs.
Many of the strides that Cuba has made in health are due to their preventative community based programs. Their vaccination rates are parallel to those of developed nations. This may be a result of the fact that the Cuban government does not treat healthcare as a means of income for the state, but it believes that health is a fundamental human right. If more nations took such a stance we might have generally healthier populations. Not being able to afford adequate healthcare is a concern in both developed and developing nations. Taking the cost directed to the patient out of health care and making it a right that all citizens deserve would be monumental in the United States. Investing in healthcare and focusing on preventive care keeps the population healthy and the costs of health care low. There are lessons to be learned in the developed world from Cuba.
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