Health Systems Paper: Health System in Cuba

Abstract

This paper will address the health care system in Cuba and the main challenges that the system faces.  This analysis will include the costs, quality, access to care and innovation issues of the overall health care system in Cuba. A system thinking analysis of domains will be included with strategic policy recommendations. The health care system in Cuba will also be compared to the health care system in the United States with a summary of lessons with emphasis on how the US can improve their system.

Overview and Challenges

In Cuba, the health care system is a national priority and health care is considered a human right for all of the citizens. Cuba offers free health services for all its citizens after the Cuban government began overhauling their for-profit health system. The development of what the system looks like today began in 1959. The Cuban health system in the 1960s was a medicinal system mostly based in hospitals but then shifted in the 1970s and 1980s into a health care system that was based largely in the communities (Latridis, 1990). In the 1960s to 1970s, Cuba attempted to expand the health care system to as much of the population as possible. The number of rural hospitals increased from 1 to 59 which led to bringing millions of people into closer proximity to emergency health services for the first time (Johnson et al, 2018). In 1970, access to health care became a constitutional right in the country. Then in the 1970s and 1980s, emergency services were established across many communities, followed by extensive medical training and primary care availability. Today, almost every significantly inhabited area in Cuba has access to comprehensive health services, provided by doctors and nurses who were trained in that community (Johnson et al, 2018).

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Although Cuba has an extensive health care system, this also proves its own challenges. Cuba currently has a large and growing population of people. In December 2014, the World Health Organization (WHO) listed Cuba’s population as 11.3 million, making it the most populous country in the Caribbean (Johnson et al, 2018). About one-third of all citizens in the Caribbean are living in Cuba. Cuba’s population has roughly 101 people per square kilometer and is the 78th densest country in the world with the highest population concentration living in and around Havana, which is home to roughly 2.7 million people (Johnson et al, 2018). The majority of the population are Caucasian (64%), with the remainder being mostly Mestizo. Spanish is the official language spoken in Cuba. The consistency of culture and dispersed geographic distribution of the majority of Cuba’s citizens have heavily influenced the healthcare system that developed to serve them (Johnson et al, 2018).

Cost, quality, access, and innovation issues

Due to the widely distributed network of doctors and health clinics, Cuba’s healthcare resources are extremely accessible. Quality performance is measured in Cuba by health outcomes, including the past and present health issues, infrastructure standards, and the social commitment to overall healthcare services.

According to the World Health Organization (WHO), the average salary in 2014 was close to $18,000 and closer to $10,000 per year according to the Central Intelligence Agency (World Health Organization, 2019). Cuba GDP per capita is lower than the average for developing nations in the region and owing to a comparatively large tax base and low cost of care which is $1,828 per person per year Cuba’s working population is currently able to pay for the medical care for system dependents: full pension for those who are over the age of retirement, and for those under 20 (Johnson et al, 2018).

By spending roughly 8.8% of its GDP on health care, Cuba is able to provide preventive care, testing, and medications to hospitalized patients at no direct cost to the patient. Other health additions like hearing aids and glasses, drugs, and devices such as crutches and wheelchairs are available for purchase at government-subsidized stores for those who can afford to purchase them and are provided for free to low-income citizens (Johnson et al, 2018).

In Cuba, the access to universal health care, free education and the fact that the government is willing to implement policies to maximize equality for the citizens, have all been contributors to the positive health outcomes (Gorry, 2008). The approach of trying to remove both the economic and physical barriers to access to care all the while providing specific programs for vulnerable populations, has shown positive results in Cuba (Gorry, 2008). By implementing policies and developing programs has helped to provide for the health of these vulnerable populations. Some of these programs and populations include prioritizing the medications for their elderly, pregnant mothers and those who are chronically ill, a Maternal-Child Program that provides screening for cervical cancer, antenatal care, well-child visits, and immunization against  childhood illnesses, additional and specialized food for those who are ill, elderly, pregnant mothers, and children, primary care for communities in remote areas, social workers visiting households who are at-risk, job training/placement and in-home assistance for people who are disabled are a few of the many examples (Gorry, 2008).

The health outcomes in Cuba have been on an upward trajectory for the last half century and life expectancy has been increasing steadily over the past decade. Cuba was the first country in the world to eliminate polio and has also successfully eliminated measles, where many other developed nations have been unable to do this. What can contribute to these outcomes is the free or highly subsidized preventive and routine health maintenance services, such as prenatal care and childhood care. In 2015, roughly 95% of the women in Cuba who gave birth received prenatal care during their pregnancies (Johnson et al, 2018). The maternal mortality rate in Cuba was down to 38 per 100,000 births which was higher than many developed nations, it was still much lower than average for the Caribbean. In the United States, maternal mortality increased from 27 to 28 per 100,000 between 2010 and 2015(Johnson et al, 2018).

Cuba’s healthcare focuses on prevention and early detection and includes efforts to control chronic diseases such as diabetes and aggressively treat obtained diseases such as cancer. In the WHO’s most recent ranking of countries by healthcare performance, Cuba came in 36th in the world in terms of healthcare outcomes, and 39th in terms of system performance (Johnson et al, 2018).

Cuba emphasizes providing free preventive care directly to the population where they live and in their community. Giving their citizens treatment by a physician and making sure everyone receives at least one blood pressure screening annually. If patients do not show up for their appointments, the medical staff in Cuba then make house calls and these house calls are scheduled as part of normal practice procedures. This level of attention paid to each patient is only possible because, at 6.7 physicians per 1,000 people, Cuba has the highest doctor–patient ratio of the region and has more doctors per citizen than any other country in the world except for Monaco and Qatar (Johnson et al, 2018). Cuba’s doctors are able to make house calls to every person on their roster at least once per year.  In Cuba, doctors organize their patients into multiple health risk levels. Risk level 1 includes healthy people that do not have any risks, level 2 includes a person that smokes, level 3 is a person with chronic but stable diseases. Doctors plan their treatment and executed according to these risk levels and see patients with chronic diseases more often.

A potential health challenge is the aging of the Cuban population due to lower birth and infant mortality rates, longer life expectancies and migration. As of 2003, 15% of the Cuban population was 60 years or older. As this continues, existing health, education and cultural programs will need to be reevaluated and new initiatives will need to be implemented in order to cope with the effects this will have on Cuba, especially related to employment and productivity (Gorry, 2008).

Another important issue is the lack of medical equipment that is available in Cuba. This takes a large toll on medical care. Although, medical professionals are widely available, this can not make up for the dire condition of Cuba’s healthcare facilities (InterNations, n.d).

Systems thinking analysis of domains

The health care system in Cuba has been integrated with their social and economic development in order to benefits its citizens. Their health care policies prioritize prevention, primary care, community services, and active participation of all its citizens which has led to an increased and higher ranking on many major health indicators, despite their economic challenges (Johnson et al, 2018). The economic disadvantage and political isolation that Cuba has faced has in turn worked somewhat to their advantage when it comes to health and health care. The current success in the health care system in Cuba is based on shifting variables which include a large working-age population and very high doctor–patient ratio, which may not always be available in the future and may change the structure of the system (Johnson et al, 2018). Health systems in Cuba are a direct effect of the influence of policy-making in health care and it challenges the beliefs that high-quality care for everyone requires a large financial investment. The system consists of 6 hierarchical and interconnecting levels. These levels consist of national health institutes and hospital centers, the provincial hospitals, municipal hospitals, and the area health centers or community care. Minipolyclinics are served by a family physician team which consists of a family physician, nurse, and social worker. The strategy behind the family physician team has led to strengthened disease surveillance and completed information about health status and characteristics of neighborhoods. Neighborhood residents are able to determine their own health care and protection. Volunteers build minipolyclinics and housing for family physicians and nurses in the community.

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Cuba’s healthcare system is well organized, and well attuned to the needs of their current population. By providing universal primary care, a high doctor–patient ratio, and excellent education of both doctors and lay people have reduced chronic diseases and increased compliance, lowering costs, and expanding access without investing heavily in technology (Johnson et al, 2018).  Many outcomes have been achieved by recruiting medical students from Latin America and Africa.  Students are dawn to the free education and many newly trained doctors choose to remain in Cuba which in turn improves the doctor-patient ratio. The downfall of this is that it drains other countries of their physician populations, and so to compensate for this in 2015, Cuba placed 34,000 doctors in 52 poorer countries (Cooper et al, 2006).

There is another issue that Cuba is facing which is the population drain. Cuba’s population is the fastest aging in the Caribbean and the bulk of the working population in will reach retirement age by 2020. Due to this, Cuba has already begun closing hospitals and cutting some services. Cuba may be able to begin to make up for the shrinking tax base with profit from U.S. medical tourism due to the end of the U.S. embargo and reopening of the political relations. With a percentage of the United States’ GDP, Cuba has one of the most efficient and effective healthcare systems in the world, but this trend may or may not be sustainable in the face of a growing economy, expanding industry, and shifting population dynamics (Johnson et al, 2018).

Strategic policy recommendations

Although the health care strategy and policies have for the most part led to success, there are some policies and changes that can be made for improvement. Health authorities in Cuba agree that additional attention is needed to implement aggressive, systematic approaches that will improve problem areas like maternal mortality, availability of nutritious food and important medications. Instruments have been proposed for measuring health outcomes and to define a more equitable and efficient health policy (Gorry, 2008). In addition, modifications to primary health care in Cuba aiming at tailoring services to local health care, improving access, and increasing technological and physical capacities of polyclinics and hospitals, indicates continued commitment to equity-driven policy making (Gorry, 2008).

Another policy recommendation that could improve health care in Cuba is the implementation of technology. Cuba has not achieved excellent overall health and health care by means of increasing technology. In Cuba, pencil and paper charting is common, CT scanners are uncommon, and the medical students have limited, dialup Internet access (Johnson et al, 2018).

Summary of lessons for U.S. health system

The health care system in Cuba has had some repercussions on the United States health care system because it has suggested that the reasonable distribution of health care services in the United States should require a national health insurance and service delivery system. Even though the US health system is the largest industry in the US and it has achieved impressive technological advances, the health of millions of US citizens deteriorates. Life expectancy in Cuba is 72.5 which is higher than in the United States which is 71.9 (Latridis, 1990). The U.S. needs a system that provides equitable, and quality health care to all (Johnson et al, 2018).

The high health care costs seen in the United States do not necessarily produce high health outcomes. Equally, Cuba spends less than a tenth of what the U.S. does but has attained comparable outcomes on many health indicators, specifically like life expectancy and infant mortality rates (O’Hanlon and Harvey, 2017). Although health care providers in Cuba have less access to health care supplies and to technology, the health care system is government run and the coverage is universal. The health care system in the United States has many resources but is not widely universal and consists of a mix of private and public providers and payers (O’Hanlon and Harvey, 2017).  Some of the features of the health care system in Cuba could provide useful lessons to the United States. The United States could address lessons from Cuba on prioritizing primary care, prevention, and especially social determinants of health (O’Hanlon and Harvey, 2017). Cuba puts an emphasis on providing primary care and prevention which is a key differentiation between the two health care systems. Medical schools in Cuba are run by the  government and have free tuition, but they emphasize primary care, global public health, and social determinants of health into their courses when schools in the U.S. are just now starting to do (O’Hanlon and Harvey, 2017).

In Cuba, the consultorio is made up of a doctor and nurse team that provides primary care services for many patients in the office and in patients’ homes (O’Hanlon and Harvey, 2017). Doctors not only conduct screenings and educate patients, but they also understand their family and social backgrounds within communities. For other complex services, physicians refer patients to local polyclinics made of integrated doctor-nurse teams that provide a wide range of services which can include pediatric, dental, eye, and behavioral health care. These clinics also often communicate directly with the patient’s family doctor to ensure appropriate follow-up. (O’Hanlon and Harvey, 2017).

The ability to care for the needs of all the citizens within a polyclinic relies on the knowledge and efforts of the staff, which starts by prioritizing these ideals in the medical education system in Cuba. All medical students enter a six-year training which starts right from high school and are educated as primary care providers. After this, the students who want to specialize go on to get a graduate degree. While some U.S. medical students typically acquire some basic epidemiological knowledge during their education, the health care and education systems in Cuba both stress that it is the doctors’ role to promote public health and that it is their obligation to address these health care disparities and inequalities that they often see (O’Hanlon and Harvey, 2017).

The United States still only has a small amount of medical schools that are looking to expand the doctors’ role in the understanding and addressing social determinants of health (O’Hanlon and Harvey, 2017). It will require the US medical system to integrate this perspective into the teaching of primary care in order to achieve affordable, high-quality health care that improves population health. Lessons from the approach in Cuba would help the United States achieve better results with less (O’Hanlon and Harvey, 2017).

References

• Cooper RS, Kennelly JF. Orduñez-Garcia P. Health in Cuba. International Journal of Epidemiology. 35(4):818. doi:10.1093/ije/dyl175. Published 2006.
• Gorry, C. (2008, July). MDGs & Health Equity in Cuba. Medicc Review. Retrieved from http://www.medicc.org/publications/medicc_review/0905/spotlight.html
• InterNations. (n.d). Healthcare and Education in Cuba. Retrieved from https://www.internations.org/cuba-expats/guide/life-in-cuba-15677/healthcare-and-education-in-cuba-2
• Johnson, J., Stoskopf, C., Leius, S. (2018). Comparative health systems. Burlington, MA: Jones & Bartlett Learning.
•   Latridis, D.S. (1990). Cuba’s health care policy: prevention and active community participation. Retrieved from  https://www.ncbi.nlm.nih.gov/pubmed/2315760
• O’Hanlon, C.E., and Harvey, M. (2017, October 6). Doing More with Less: Lessons from Cuba’s Health Care System.  Retrieved from https://www.rand.org/blog/2017/10/doing-more-with-less-lessons-from-cubas-health-care.html
• World Health Organization. (2019). Cuba. Retrieved from https://www.who.int/countries/cub/en/