The Cuban Experience: Better health on a budget?
Levelling the playing field in an effort to provide ‘health for all’ is effective and noble, but is it sustainable?
‘WE WERE so poor growing up. I started picking coffee when I was 11, like all my siblings – there was no school or doctor. When somebody got sick, we had to carry them 16 miles on mountain trails to reach the nearest hospital,” says 72-year-old Algimiro Ortíz of Cruce de los Baños in eastern Cuba.
“I was 54 when I was diagnosed with breast cancer. Since then I’ve had a tumour and my lymph nodes removed, radiotherapy, and more than 50 follow-up consultations. I benefited immeasurably from the compassion and skill of my doctors. And it was all free. It’s heart wrenching to hear of other women whose cancer treatment leaves their families in debt,” says Marta Nuñez of Havana.
These two experiences illustrate how Cuba, an isolated, resource-scarce country of 11 million, has been able to achieve health indicators on par with developed nations, including life expectancy, infant mortality and low HIV prevalence.
However, the Ortíz and Nuñez stories also point to major challenges facing Cuba’s public health system – namely, a rapidly ageing population paired with crippling chronic disease, both of which require more, increasingly specialised, care.
As the global economic crisis laps at the island’s shores, stakeholders are faced with the uncomfortable question: can we sustain the strides in health we’ve made until now? And if so, how?
A SIMPLE STRATEGY FOR BETTER HEALTH
It seems incongruous that a developing nation should have achieved such enviable health outcomes when governments the world over grapple with uneven care, re-emerging and non-communicable diseases, and shortages in human resources for health.
Upon closer analysis, however, Cuba’s approach to whole population health is as simple as it is sound: prevention and early detection combine with community-based primary care to limit more costly upstream interventions.
Secondary and tertiary care, meanwhile, are offered at municipal and specialty hospitals respectively, and supported by 14 institutes which conduct research and provide clinical services.
Achieving universal coverage is possible due to the island’s free education system and a decade-long commitment to training health professionals at 25 medical schools across the country.
CUBAN HEALTH: A SNAPSHOT
The backbone of primary care in Cuba is a national network of more than 36,700 family doctors located throughout the island – including in the most remote and rural areas.
Each doctor attends 375 families (some 1,500 individuals) in their catchment area. These are supported by multi-service clinics, known as polyclinics, which offer specialised consultations and services such as dentistry, physical rehabilitation and diagnostic procedures.
Introduced in 1984, Cuba’s community-based family doctor system champions concepts outlined in the Declaration of Alma Ata on primary health care (1978) which recognises health and wellbeing as a fundamental human right. Embedding family doctors and nurses in communities serves a dual purpose: it provides access to care but, as importantly, accords the opportunity to conduct neighbourhood health diagnoses to better understand the health picture in individual catchment areas. Neighbourhood diagnoses are conducted twice a year.
This approach is complemented by a continuous assessment and risk evaluation (Care; or dispensarización in Spanish) – whereby the local doctor classifies residents by disease and risk factors.
Together, these tools enable health policy-makers and professionals to tailor services to individual neighbourhoods; identify and prioritise vulnerable populations; design relevant health promotion and prevention campaigns; practise proactive, outcome-oriented epidemiology; and recognise social determinants adversely affecting health.
This last assesses health not only according to traditional indicators, but incorporates factors such as housing, geography, gender and environment in order to better attend the biopyscho-social health of patients.
Doctors are required to visit each home in their catchment area at least once a year; patients with chronic disease are seen four times annually.
Maternal and child health illustrates how this approach works in practice. From the neighbourhood diagnosis, doctors know how many expectant mothers live in their area.
This ensures a full intake exam is performed by the ninth week of pregnancy, along with a minimum of 12 prenatal visits and a battery of standard tests through the gestational period. Should any risk factors be identified, such as anaemia, malnutrition, hypertension or obesity, the woman can elect to be remitted to a maternity home, located near a maternity hospital, in either live-in or ambulatory modalities.