A Different
Model — Medical Care in Cuba
Edward W. Campion, M.D., and Stephen Morrissey, Ph.D.
For a visitor from the United States, Cuba is disorienting.
American cars are everywhere, but they all date from the 1950s at the latest.
Our bank cards, credit cards, and smartphones don't work. Internet access is
virtually nonexistent. And the Cuban health care system also seems unreal.
There are too many doctors. Everybody has a family physician. Everything is
free, totally free — and not after prior approval or some copay. The whole
system seems turned upside down. It is tightly organized, and the first
priority is prevention. Although Cuba has limited economic resources, its
health care system has solved some problems that ours has not yet managed to
address.1,2
Family physicians, along with their nurses and other health
workers, are responsible for delivering primary care and preventive services to
their panel of patients — about 1000 patients per physician in urban areas. All
care delivery is organized at the local level, and the patients and their
caregivers generally live in the same community. The medical records in
cardboard folders are simple and handwritten, not unlike those we used in the
United States 50 years ago. But the system is surprisingly information-rich and
focused on population health.
All patients are categorized according to level of health
risk, from I to IV. Smokers, for example, are in risk category II, and patients
with stable, chronic lung disease are in category III. The community clinics
report regularly to the district on how many patients they have in each risk
category and on the number of patients with conditions such as hypertension
(well controlled or not), diabetes, and asthma, as well as immunization status,
time since last Pap smear, and pregnancies necessitating prenatal care.
Every
patient is visited at home once a year, and those with chronic conditions
receive visits more frequently. When necessary, patients can be referred
to a district polyclinic for specialty evaluation, but they return to the
community team for ongoing treatment. For example, the team is responsible for
seeing that a patient with tuberculosis follows the assigned antimicrobial
regimen and gets sputum checks. House calls and discussions with family members
are common tactics for addressing problems with compliance or follow-up and
even for failure to protect against unwanted pregnancy. In an effort to control
mosquito-borne infections such as dengue, the local health team goes into homes
to conduct inspections and teach people about getting rid of standing water,
for example.
This highly
structured, prevention-oriented system has produced positive results. Vaccination
rates in Cuba are among the highest in the world. The life expectancy of 78
years from birth is virtually identical to that in the United States. The
infant mortality rate in Cuba has fallen from more than 80 per 1000 live births
in the 1950s to less than 5 per 1000 — lower than the U.S. rate, although the
maternal mortality rate remains well above those in developed countries and is
in the middle of the range for Caribbean countries.3,4 Without
doubt, the improved health outcomes are largely the result of improvements in
nutrition and education, which address the social determinants of health.
Cuba's literacy rate is 99%, and health education is part of the mandatory
school curriculum. A recent national program to promote acceptance of men who
have sex with men was designed in part to reduce rates of sexually transmitted
disease and improve acceptance of and adherence to treatment. Cigarettes can no
longer be obtained with monthly ration cards, and smoking rates have decreased,
though local health teams say it remains difficult to get smokers to quit.
Contraception is free and strongly encouraged. Abortion is legal but is seen as
a failure of prevention.
But one should not romanticize Cuban health
care. The system is not designed for consumer choice or individual
initiatives. There is no alternative, private-payer health system. Physicians
get government benefits such as housing and food subsidies, but they are paid
only about $20 per month. Their education is free, and they are respected, but
they are unlikely to attain personal wealth. Cuba is a country where 80% of the
citizens work for the government, and the government manages the budgets. In a
community health clinic, signs tell patients how much their free care is
actually costing the system (see photo
Poster Indicating the Actual Costs of Care Provided Free of Charge to Cuban
Patients.), but no market forces compel efficiency. Resources are limited, as
we learned in meeting with Cuban medical and public health professionals as
part of a group of editors from the United States. A nephrologist in
Cienfuegos, 160 miles south of Havana, lists 77 patients on dialysis in the
province, which on a population basis is about 40% of the current U.S. rate —
similar to what the U.S. rate was in 1985. A neurologist reports that his
hospital got a CT scanner only 12 years ago. U.S. students who are enrolled in
a Cuban medical school say that operating rooms run quickly and efficiently but
with very little technology. Access to information through the Internet is
minimal. One medical student reports being limited to 30 minutes per week of
dial-up access. This
limitation, like many of the resource constraints that affect progress, is
blamed on the long-standing U.S. economic embargo, but there may be other
forces in the central government working against rapid, easy communication
among Cubans and with the United States.
As a result of the strict economic embargo, Cuba has
developed its own pharmaceutical industry and now not only manufactures most of
the medications in its basic pharmacopeia, but also fuels an export industry.
Resources have been invested in developing biotechnology expertise to become
competitive with advanced countries. There are Cuban academic medical journals
in all the major specialties, and the medical leadership is strongly
encouraging research, publication, and stronger ties to medicine in other Latin
American countries. Cuba's medical faculties, of which there are now 22, remain
steadily focused on primary care, with family medicine required as the first
residency for all physicians, even though Cuba now has more than twice as many
physicians per capita as the United States.4 Many
of those physicians work outside the country, volunteering for two or more
years of service, for which they receive special compensation. In 2008, there
were 37,000 Cuban health care providers working in 70 countries around the
world.5 Most
are in needy areas where their work is part of Cuban foreign aid, but some are
in more developed areas where their work brings financial benefit to the Cuban
government (e.g., oil subsidies from Venezuela).
Any visitor can see that Cuba remains far from a developed
country in basic infrastructure such as roads, housing, plumbing, and
sanitation. Nonetheless, Cubans are beginning to face the same health problems
the developed world faces, with increasing rates of coronary disease and
obesity and an aging population (11.7% of Cubans are now 65 years of age or
older). Their unusual health care system addresses those problems in ways that
grew out of Cuba's peculiar political and economic history, but the system they
have created — with a physician for everyone, an early focus on prevention, and
clear attention to community health — may inform progress in other countries as
well.
REFERENCES
1Keck CW,
Reed GA. The curious case of Cuba. Am J Public Health 2012;102:e13-e22
CrossRef |
Medline
2Drain PK,
Barry M. Fifty years of U.S. embargo: Cuba's health outcomes and lessons.
Science 2010;328:572-573
CrossRef |
Web of Science | Medline
3World
population prospects, 2011 revision. New York: United Nations (http://esa.un.org/unpd/wpp/Excel-Data/mortality.htm).
4The world
factbook. Washington, DC: Central Intelligence Agency, 2012 (https://www.cia.gov/library/publications/the-world-factbook).
5Gorry C.
Cuban health cooperation turns 45. MEDICC Rev 2008;10:44-47
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