Is the Cuban Public Health Systema Model for the U.S.?

A Critical Examination

for

EMPH Hospital Management

R. Andrews, M.D.

7 August 2008

““An evaluation of 25 countries in An evaluation of 25 countries in

the Americas measuring relative the Americas measuring relative

inequalities in health revealed that inequalities in health revealed that

CubaCuba is the country with the best is the country with the best

health situation in Latin America health situation in Latin America

and the Caribbean. It is also the and the Caribbean. It is also the

country which has achieved the country which has achieved the

most effective impact with most effective impact with

resources, though scarce, invested resources, though scarce, invested

in the health sector”in the health sector”

(Study on Human Development and (Study on Human Development and Equity in Cuba, UNDP, 1999)Equity in Cuba, UNDP, 1999)

““An evaluation of 25 countries in An evaluation of 25 countries in

the Americas measuring relative the Americas measuring relative

inequalities in health revealed that inequalities in health revealed that

CubaCuba is the country with the best is the country with the best

health situation in Latin America health situation in Latin America

and the Caribbean. It is also the and the Caribbean. It is also the

country which has achieved the country which has achieved the

most effective impact with most effective impact with

resources, though scarce, invested resources, though scarce, invested

in the health sector”in the health sector”

(Study on Human Development and (Study on Human Development and Equity in Cuba, UNDP, 1999)Equity in Cuba, UNDP, 1999)

FACT OR FICTION

ANY GUESS

IS BIASED

IN THIS CURRENT STATE

OF

POLITICAL MISINFORMATION

““Of all the forms of inequality, injustice in health care is Of all the forms of inequality, injustice in health care is the most shocking and inhumane.” the most shocking and inhumane.”

- Martin Luther King Jr.- Martin Luther King Jr.

Geography

● Largest Caribbean Island:

111,000 sq km– 85% the size of England– 3 times the size of

Dominican Republic

● 3,700 km of coastline: greater than all Caribbean Islands combined– More than 1,000 fine

sand beaches

● 90 Miles from the U.S. Coast

● Population of 11.3 million

● 97% literacy rate

● Natural resources: cobalt,

nickel, iron ore, chromium,

copper, gold, salt, timber,

silica, petroleum, arable land

REPUBLIC OF CUBA

Head of state and government• Raúl Castro Ruz (replacing Fidel Castro Ruz)

Population• 11.3 million

Adult literacy• 99.8 per cent

• Amnesty international 2008 Report

• Fourteen provinces and one special municipality (the Isla de la Juventud)

compose Cuba.

The provinces are further divided into 170 municipalities

• 1Isla de la Juventud (Isle of Youth)• 2Pinar del Río• 3La Habana (Havana)• 4Ciudad de la Habana (Havana City)• 5Matanzas• 6Cienfuegos• 7Villa Clara

• 8Sancti Spíritus • 9Ciego de Ávila• 10Camagüey• 11Las Tunas• 12Granma• 13Holguín • 14

Santiago de Cuba• 15Guantanamo

The Irony of Cuban Health Care

“Because Cuba has so few resources, prevention has become the only affordable means of keeping its population healthy.”

Cuba: 48 years as a US enemy

• 1959: Fidel Castro: The Cuban government passed the first Agrarian Reform Law

• 1960: President Eisenhower imposed a partial economic embargo

• 1962: President Kennedy expands embargo and prohibits travel to Cuba

• 1992: Cuban Democratic Act (Robert Torricelli Act)• 1996: Cuban Liberty and Democratic Solidarity Act (the Helms-

Burton Act)• 2000: Trade sanction reform and export enhancement act

(TSRA)

Denial of Food & Medicine:The impact of the U.S. Embargo on Health & Nutrition in

Cuba Report from the American Association for World Health March 1997

TargetInitial Year

Type of Sanctions

Precipitating Event

Key Changes to Sanctions

Cuba 1960 Comprehensive trade

and financial sanctions

Castro-led takeover;

interventions in Africa (1980s); Repression of

opposition

Cuban Democracy Act restricts trade of U.S. subsidiaries abroad

(1992), TSREEA (2000)

•The Helms-Burton Act threatened U.S. subsidiaries. Mostly those operating in Europe, Canada and Mexico.

• It further stated that no ship could dock in the United States if it had previously docked in Cuba.

Mariel Boatlift

• Cubans depart from Cuba's Mariel Harbor for US between April 15 and October 31, 1980

• downturn in Cuban economy - via United States embargo result in internal tensions on the island -10,000 Cubans asylum in the Peruvian embassy

• Cuban government- anyone who wants can go exodus with assistance of Cuban-Americans

• negative political implications for U.S. President Carter -some exiles had been released from Cuban jails and mental health facilities

• exodus ended by mutual agreement in October 1980 • up to 125,000 Cubans had made the journey to

Florida.

Healthcare Expenditures

• The Cuban health system is of special interest because of its developed-country health outcomes despite its developing-country economy.

• Cuba spends just 7.4% of its gross national product (GNP) on health care, compared with the 13.6% spent in the United States.

• Hood RJ. Cuban Health System offers an uncommon opportunity. J Natl Med Assoc 2000;92:547–9.

Expenditures

• Health expenditure per person is $193 in Cuba compared with $4540 spent in the United States

• Cuba’s GNP per capita is one of the lowest in the Western hemisphere

• Nonetheless, Cuba, unlike most Latin American countries, has achieved health outcomes comparable with those of the US

• World Health Organization [homepage on the Internet]. Geneva, Switzerland: World Health Organization;• c2005 [updated 2005; cited 2005 Mar 19]. Core health indicators: Cuba; [about 3 screens]. Available from:• http://www3.who.int/whosis/country/compare.cfm? countrycub&indicatorstrPcTotEOHinIntD2000&• Language English.

Comparison of Health Statistics and Gross National Product Cuba vs. U.S. and other

LatinAmerican Countries

Country Life Expectancy at Birth

Maternal Mortality(per 100,000 live births)

Infant Mortality(per 1,000 live births)

Gross National Productper Capita (US$)

Cuba 76.3 34.1 7.2 2,270

United States

77.2 7.1 7.2 31,910

Haiti 54.6 523.0 80.3 1,470

Guatemala 65.3 111.1 49.0 3,630

““Let's not forget that the Let's not forget that the ultimate goal of Medicare must ultimate goal of Medicare must be to keep people well rather be to keep people well rather than just patching them up than just patching them up when they get sick.”when they get sick.”

--Tommy DouglasTommy Douglas ""father offather of" the Canadian system of universal " the Canadian system of universal

public Medicarepublic Medicare

Cuban Medical & Public

Healthcare Infrastructure

Pre-Statehood

• As was true of the other indigenous societies of the Americas, Cuban traditional medicine existed before the Spanish conquest.

• High status traditional practitioners were called Bohiques.

Pre-Statehood cont.

• After colonization, Cuban medicine followed the Spanish tradition which was inherited from the Moors, who drew upon classical Greek and Roman medical practices.

• Chinese medicine has also been practiced in Cuba, the most famous was the 19th century doctor Cham Bom Biam or “El Medico Chino”.

““The battle against disease The battle against disease should be based on the should be based on the principle of creating a robust principle of creating a robust body – not creating a robust body – not creating a robust body through a doctor’s body through a doctor’s artistic work on a weak artistic work on a weak organism, but creating a organism, but creating a robust body through the robust body through the work of the whole collective, work of the whole collective, especially the whole social especially the whole social collective.”collective.”

Ernesto Guevara, M.D.Ernesto Guevara, M.D.

The Cuban Healthcare System

• Cuba - socialist country • Central form of government. • Ministry of Health (MINSAP)• National health programs

– implemented throughout country – -limited scope for deviation

Structure

• primary care is provided in Consultorios (clinics)

• secondary care in Policlinicos (specialty clinics)

• tertiary care in Hospitales and Institutos (hospitals and medical institutes).

Structure

• Consultorios address approximately 80% of the health problems and emphasize health promotion

• The current system of family medicine based in neighborhood consultorios was established in 1984.

Who Does The Work?

• Family physicians, paired with nurses, serve approximately 600 patients or 150 families in a defined geographic area surrounding their consultorio.

• The family physician and nurse live in housing units adjacent to their consultorio and are integrated into the community they serve.

How They Do the Work

• Health promotion and disease prevention are emphasized, i.e. public health concepts are integrated with clinical practice

• In the morning family physicians typically attend to patients in their consultorio

• Afternoons are reserved for home visits to patients with acute care needs, rehabilitation of chronic conditions, and primary prevention

Higher Level of Care

• Patients requiring care beyond the scope of the consultorio are referred to a policlinico

• There are 440 policlinicos throughout Cuba, and each policlinico serves 30 to 40 consultorios (30-60,000 people)

Higher Level of Care

• Consisting of interdisciplinary teams, policlinicos offer specialty care in areas e.g. social work, pediatrics, internal medicine, dentistry, physical therapy, cardiology, pulmunology, endocrinology, ophthalmology, neurology, dermatology, and psychiatry.

Higher Level of Care

Many family physicians spend a half-day per week joining their patients for specialist visits

in policlinicos

*Providing continuity of care

*Building collegial relationships between family physicians and specialists

Economic constraints and restrictions on medicines have

forced the Cuban health system to incorporate alternative and herbal

solutions to healthcare issues *more accessible and affordable to a

broader population

In the 1990’s, the Cuban Ministry of Public Health officially recognized

natural and traditional medicine and began its integration into the already well established Western medicine

model

What is called complementary and alternative medicine & viewed as separate and not equal in the United States is designated “natural and traditional medicine” and essential in Cuba and is increasingly available throughout the country.

Children begin studying the multiple uses of medicinal plants in primary school, learning to grow and tend their own plots of aloe, chamomile, and mint.

• Alternative techniques used by the clinics and hospitals include: flower essence, neural and hydromineral therapies, homeopathy, traditional Chinese medicine (i.e. acupuncture anesthesia for surgery), natural dietary supplements, yoga, tai chi, electromagnetic and laser devices.

Aspects of Public Health in Cuba

•Highly integrated with therapeutic medicine

•Polyclinic teams of primary care doctors, dentists, nurses

– Provide health education, preventive care– Health workers live in the community– Physicians required to see every patient

every year– Records of preventive services

Aspects of Public Health in Cuba cont.

•Prenatal, immunization, cancer screening, etc.– Aggressive follow-up of missed

appointments– Vaccination rates 99% (+)

•Community reinforcement of public health– Neighborhood Committees for Defense

of Revolution (CDR), Cuban Federation of Women, Circulos de Abuelos

•Surveillance data system to province to state

• 3,400 medical students from 23 Latin American, African, and Caribbean countries are being trained in Cuba, at Cuba’s expense

• In 2001, 8 American students, all from low-income minority families, began their free medical education in Cuba, on the condition that they return to their communities for service. Current enrollment is 93 US students.

Fidel Castro has said that up to 500 American medical students may enroll eventually.

Source: Canadian Medical Association Journal, 2001, 164(10): 1477and IFCO Medical School Scholarship Program @ Latin American School of Medicine

Medical Education and Diplomacy

Scaling up: The Latin American Medical School (1998)

• 29 countries

• 10,000 students, 3,000 first graduates (05-06)

• 100 indigenous populations

• 51% women

• Low-income students

• Commitment to serve

• Sustainability in countries of origin

Scaling up: The Latin American Medical School (1998)

• 29 countries

• 10,000 students, 3,000 first graduates (05-06)

• 100 indigenous populations

• 51% women

• Low-income students

• Commitment to serve

• Sustainability in countries of origin

The Latin American School of The Latin American School of Medicine: (ELAM)Medicine: (ELAM)

• Free six-year medical Free six-year medical education.education.

• Received over 11,500 Received over 11,500 students since 1998.students since 1998.

• Graduated over 4,000 since Graduated over 4,000 since 20052005

• Students are all foreigners Students are all foreigners from 29 different countriesfrom 29 different countries

• 101 ethnic groups are 101 ethnic groups are represented.represented.

• 51 percent of students are 51 percent of students are women.women.

• Focus on social & Focus on social & environmental environmental determinants of healthdeterminants of health

• Trained to work in Trained to work in low-tech environmentslow-tech environments

• ELAM Institutional ELAM Institutional ethics of service are ethics of service are stressedstressed

Prevention and promotion require relationships – not purchasing

power.

Different from Previous Scholarships:Aiming for SustainabilityDifferent from Previous Scholarships:Aiming for Sustainability

• Student selection: poor, indigenous, marginalized

• Bridging program

• Training geared to country of origin

• Looking for commitment to underserved

• Eventually replace Cuban doctors in-country

100,000 Cuban health professionals in 101 countries

February, 2007: 29,809 Cuban healthprofessionals in 69 countries

Cuban International Medical CooperationCuban International Medical Cooperation1963-2001963-2006Cuban International Medical CooperationCuban International Medical Cooperation1963-2001963-2006

Source: International Cooperation Unit, Ministry of Public Health, Havana

Region Countries

Africa 38

Americas 37

Europe 8

Asia/Mideast 18

TOTAL 101

Training Doctors for Global Health

“I think the Cuban system of training could serve as an example to the rest of the world if we wish to have functioning health systems in the future. The Cuban system trains doctors for communities, willing to sacrifice for the welfare of others. I think there is a need for such a paradigm shift.”

Nestor Shivute, MD, WHO Country Representative, Gambia

Training Doctors for Global Health

“I think the Cuban system of training could serve as an example to the rest of the world if we wish to have functioning health systems in the future. The Cuban system trains doctors for communities, willing to sacrifice for the welfare of others. I think there is a need for such a paradigm shift.”

Nestor Shivute, MD, WHO Country Representative, Gambia

Workforce• The size of the Cuban workforce relative to its

population is several times larger than the UK’s. • The doctor: patient ratio – 1:172 in Cuba*

(1:480 in the UK)

-Advantage in administering free & universally accessible healthcare to its population.

-Contrasts with parts of Latin America where only wealthy afforded decent healthcare.

*World health organization. 2000 world health report. WHO 2000

Physicians per 10,000 Population

279

582

186

0

100

200

300

400

500

600

U.S. Cuba Mexico

Switzerland: 1 physician for every 277 people. Switzerland: 1 physician for every 277 people.

That’s 25,921 doctors for 7.2 million peopleThat’s 25,921 doctors for 7.2 million people

Malawi: 1 physician for every 50,000 people. Malawi: 1 physician for every 50,000 people.

That’s 266 doctors for 12.8 million people.That’s 266 doctors for 12.8 million people.

WHO REPORT, 2006WHO REPORT, 2006

• Cuba has the highest family physician-to population ratio in the world, and it has a family physician-per-patient ratio of approximately 1:600.

• In 2001, only 35% of Cuban residency graduates specialized further (including 8% who graduated in general internal medicine and pediatrics).

• In the United States, only a third of physicians are primary care physicians, (i.e., family practice, internal medicine, and pediatrics physicians).

• Only 11% are family physicians.

• In the United States, the average family physician-per-population ratio is approximately 1:3200.

Number of surgeons per 100,000 population

Cuba 56United States 51Japan 31Sweden 29Germany 13China 10Columbia 7United Kingdom 6South Africa 6Philippines 1.5Kenya 0.6Tanzania 0.3

Bulletin of the American College of Surgeons, 1987J. Perez, personal communication, 2000

Vital Statisitics

“We have enough knowledge, money & technology to overcome most of the

world’s health calamities.”

Prevalence of HIV+ Prevalence of HIV+

Percentage of Population by nationPercentage of Population by nation

-World Health Organization -World Health Organization Annual Report, 2006Annual Report, 2006

““Many public [health care] Many public [health care] systems are underserviced, systems are underserviced, inefficient, and at times, inefficient, and at times, dangerous.”dangerous.”

Infant Mortality RateSource: PAHO 2000

8 newborns per 1,000 die in the U.S. 8 newborns per 1,000 die in the U.S.

That’s 18.6 per 1,000 for the African American population.That’s 18.6 per 1,000 for the African American population.

283 newborns per 1,000 die in Sierra Leone283 newborns per 1,000 die in Sierra Leone

Infant Mortality* in 2000

7 7.214.5

83

0

10

20

30

40

50

60

70

80

90

U.S. Cuba Mexico Haiti

*per 1,000 live births

Europe: 1 mother dies for every 20,000 live births.Europe: 1 mother dies for every 20,000 live births.

Africa: 1 mother dies for every 100 live births.Africa: 1 mother dies for every 100 live births.

Life Expectancy at BirthSource: PAHO 2000

Life Expectancy* in 2000

76.8 76.372.8

52.4

0

10

20

30

40

50

60

70

80

U.S. Cuba Mexico Haiti

*years

In Canada, life expectancy is 80 years.In Canada, life expectancy is 80 years.

In Haiti, it’s 54.In Haiti, it’s 54.

Indicators of Cuba’s accomplishments in public health

• First country to eliminate polio—1962• First country to eliminate measles—1996• Lowest AIDS rate in the Americas• Most effective dengue control program in the

Americas• High physician allocation-1 physician per 120–160

families• Highest rates of treatment and control of

hypertension in the world• Reduction in cardiovascular mortality rate by 45%• Crude infant mortality rate of 5.8 per 1000

Indicators of Cuba’s accomplishments in public health• Development and implementation of a

‘comprehensive health plan for the Americas’• Free medical education for students from Africa

and Latin America• Support of 34 000 health professionals in 52 poor

countries• Creation of a national biomedical internet grid

(INFOMED)• Indigenous biotechnology sector; producing the

first humanpolysaccharide vaccine

Example of Cuban Public Health AIDS

• Initial quarantine of HIV-positive patients

– Started with HIV+ soldiers returning from Africa

• Compulsory quarantine lifted, HIV sanitariums became voluntary

– Sanitariums in 13/14 provinces

• 70-80% newly diagnosed choose ambulatory treatment

• Epidemic helped by quarantine, travel restrictions. Lowest HIV rate in hemisphere

• Active screening, 2 million annual HIV tests

• “Jinaterismo” (prostitution) raises many issues

Cuban Public Health:A Model for the U.S.?

• Cuba is a socialist system…….not transplantable to the U.S. !

• No private health care! • No Financial Incentives!

• Surveillance requires intrusive social institutions ……………….e.g. CDR!

• Public health may involve “coercive” policies, e.g. AIDS quarantine!

NO

Cuban Public Health:A Model for the U.S.?

• There is no intrinsic reason for the separation of treatment and preventive (public health) services in the U.S.

• Integrated primary care is a cost-effective model (if we can get there)

• Prioritizing health resources to achieve social objectives (e.g. eliminate health disparaties) is effective

• Improving surveillance systems at the primary care level is important and possible

Could be?

“We are still challenged to be dissatisfied”

Let us be dissatisfied until every man can have food and material necessities for his body, culture and education for his mind, freedom and human dignity for his spirit.…

Let us be dissatisfied until the empty stomachs of Mississippi are filled, and the idle industries of Appalachia are revitalized.

Let us be dissatisfied until our brother of the Third World—Asia, Africa, Latin America—(is) lifted from the long night of poverty, illiteracy and disease.

Let us be dissatisfied until brotherhood is no longer a meaningless word at the end of a prayer, but the first order of business on every legislative agenda.”

Dr. Martin Luther King, JrFebruary 23, 1968

“We are still challenged to be dissatisfied”

Let us be dissatisfied until every man can have food and material necessities for his body, culture and education for his mind, freedom and human dignity for his spirit.…

Let us be dissatisfied until the empty stomachs of Mississippi are filled, and the idle industries of Appalachia are revitalized.

Let us be dissatisfied until our brother of the Third World—Asia, Africa, Latin America—(is) lifted from the long night of poverty, illiteracy and disease.

Let us be dissatisfied until brotherhood is no longer a meaningless word at the end of a prayer, but the first order of business on every legislative agenda.”

Dr. Martin Luther King, JrFebruary 23, 1968