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Cuba: Health
Country Study > Chapter 2 > The Society and Its Environment > Health

HEALTH


Revolutionary Cuba is proud of and constantly proclaims its achievements in the health sector. These claims are validated by the government's release of copious volumes of statistical data with some regularity (such as the Anuario Estadistico of the Ministry of Public Health) and by its calling attention to the success of domestic programs designed to reduce infectious diseases, promote maternal and child health, and develop a modern biotechnology industry. Cuba is also proud of the "internationalist" public health assistance programs that it launched in Africa and other developing regions (often in support of Soviet-assisted internationalist ventures, as in Angola and Nicaragua), the many foreign physicians it has trained at home, and the medical services it offers in Havana hospitals to fee-paying foreign patients. In 2000 the latter service was expanded when Cuba began to offer medical services to selected patients from Venezuela in exchange for oil under an agreement negotiated between President Fidel Castro and President Hugo Chavez Frias. These achievements are partially rooted in the relatively advanced medical system inherited by the socialist government and in the priority accorded by the authorities to the health sector since the earliest days of the Revolution. In fact, since 1978 President Castro has often boasted about his intent to make Cuba a world "medical power" capable of challenging the United States in many public health areas.

In prerevolutionary Cuba, public hospitals, private physicians, and mutualist welfare associations provided medical services. The latter, the equivalent of modern-day prepaid medical plans, were established in Cuba by Spanish immigrants, although the mutualist model was later adopted by labor unions, professional groups, and private medical practitioners. By 1958 mutualist associations served about half of Havana's population, as well as 350,000 members in other cities of the country. Although relatively extensive by developing country standards of the 1950s, the national health network was primarily urban-based. It consisted of thirty hospitals and dispensaries administered by the Ministry of Health and Social Assistance plus fourteen other hospitals and sixty dispensaries managed by autonomous public entities, such as the National Tuberculosis Council (Consejo Nacional de Tuberculosis). The primacy of the country's capital was reflected in the national distribution of hospital beds: 62 percent of all hospital beds were in La Habana Province in 1958. Access to health care for the poorest segments of the population, particularly in the countryside, and for blacks and mulattos was mostly limited to public facilities.

Redressing these inequities in health care access was at the heart of the populist agenda of the Revolution. The early public health reforms were based on four pillars: increasing emphasis on preventive medicine, improving overall sanitary standards, addressing the nutritional needs of disadvantaged social groups, and increasing reliance on public health education. Another important component was expanding the national health and hospital infrastructure and equalizing access to health care facilities throughout the country, most of all in rural areas. Rural medical facilities, capable of providing only the most essential services, began to be built in the early 1960s. Fifty-six rural hospitals and numerous rural medical posts were operating by 1975. At the same time, the government aggressively began to expand training programs for physicians and other health personnel needed to staff these facilities. Physician training became a priority inasmuch as approximately half of the prerevolutionary stock of medical doctors, dissatisfied with the radicalization of the Revolution, emigrated. By the late 1960s, the private practice of medicine had largely been banned; only a few older physicians were still being allowed to see private patients.

The Ministry of Public Health administers a hierarchical and regional system of public health facilities and hospitals, whereby the most routine needs of patients are attended to at the local level; referrals are made to increasingly specialized facilities as the need arises. Each province has a hierarchical structure of medical facilities capable of providing all types of care, except for the most specialized and costly. The latter are available only in selected Havana hospitals. Municipalities within each province are divided into basic health units, or health areas, which act as service areas for polyclinics (policlinicos) or the traditional basic primary health care facilities. These units provide preventive and curative services in internal medicine, pediatrics, obstetrics and gynecology, and dentistry, as well as elementary sanitary and psychological services. The next three levels-municipal, provincial, and national-are responsible for increasingly specialized hospital and other services.

The polyclinics began to be supplemented by "family doctors" in 1984. The intent of the Family Doctor Program is to monitor the health of all Cubans by assigning physician-nurse teams to groups of 120 to 150 families. These teams playa frontline preventive-medicine role and intervene the moment an incipient medical condition is identified. Each family group, ranging in size from 600 to 700 individuals, is provided with locally based medical dispensaries equipped to provide essential preventive services. To be familiar with the communities they serve, physician-nurse teams and their families must reside there, often in apartments built at or in close proximity to the dispensaries. The health teams must also provide health and nutrition education, as well as organize adult exercise classes. Family Doctor teams must be available at all times, pay home calls to patients unable to visit dispensaries, and provide services to the elderly and chronically ill. Family doctors must also monitor patient treatment and serve as patients' advocates when hospitalizations are required. In 1993 about half of the Family Doctor teams were deployed in urban areas.

In 1997 Cuba had 339,943 health personnel, including 62,624 physicians and dentists, of which 28,855, or 46 percent, were family doctors. The total also included 81,333 nurses and more than 56,342 mid-level technicians. The ratio of population to physicians in 1997 was 214, one of the lowest in the world, down from 1,393 in 1970. In a May 1998 speech, Fidel Castro noted that Cuba has a doctor for every 176 inhabitants.

As a point of comparison, Cuba has physician-to-population ratios 2.5 and two times higher than Canada and the United States, respectively, two of the countries that spend the most in health care costs. In contrast, the Cuban nurses to physicians ratio of 1.3 is about two-thirds lower than in these two countries.

Physicians are trained in twenty-three medical schools, ten of which are located in Havana, and four dentistry schools. The 1993 graduating class consisted of 4,780 doctors, with an additional 20,801 students enrolled that year in medical school. Interestingly, the 4,781 students in the sixth (and last) year of medical training was nearly double the number (2,608) enrolled in the first year. The dramatic enrollment decline indicates that the educational authorities are concerned about a physician surplus created by medical school admission policies (which became more selective in the 1990s), declining population growth, and lessened demand for Cuban "internationalist" physicians since the end of the Cold War. The number of medical graduates drastically declined in 1996, when they totaled only 3,418, a decline of 28.5 percent in relation to 1993.

The health infrastructure in 1997 included 283 hospitals, 440 Polyclinics, 161 medical posts, 220 maternity homes, 168 dental clinics, and other facilities. Forty-eight hospitals are in Havana, and sixty-four are in rural areas. Other facilities included 196 nursing homes for the elderly (sixty-three of which provide only day services) and twenty-seven homes for the disabled. The total number of hospital beds in 1997, including military hospitals, reached 66,195, up from 51,244 in 1975. The number of social assistance beds has been doubled since 1975 to at least 14,20l.

Cuba's contemporary health profile resembles that of developed nations. Most causes of death are degenerative in nature, for example, cancer and diseases of the heart and cardiovascular system. Infectious diseases account for only a small share of all deaths. The general outlines of this mortality pattern preceded the Revolution, however; by the 1950s, cardiovascular diseases and cancer already were the leading causes of death.

In 1996 the five leading causes of death were diseases of the heart (with a death rate of206 deaths per 100,000 population), malignant tumors (137 deaths per 100,000 population), cerebrovascular disease (72 deaths per 100,000 population), accidents (51 deaths per 100,000 population), and influenza and pneumonia (40 deaths per 100,000 population). Deaths from these five causes accounted for 70.1 percent of all deaths in 1996. The death rate from infectious and parasitic diseases was low (53 deaths per 100,000 population), representing only 7.4 percent of all deaths.

The first individuals identified as human immunodeficiency virus (HIV)-positive were found in Cuba in 1986. Through an aggressive prevention program that has included close monitoring of cases, large-scale screening, and extensive education programs as well as the controversial practice of isolating infected patients by forcibly interning them in sanatoriums, the health authorities succeeded in minimizing the number of cases. By 1999 only 2,155 cases had been diagnosed as HIV positive, 811 of which were known to have developed full-blown acquired immunodeficiency syndrome (AIDS). Some of the most controversial practices of the National AIDS Program have been somewhat relaxed; for example, patients considered to pose low risks of infecting others are being allowed to receive treatment on an outpatient basis. At the close of 1995, about a fourth of HIV-positive cases were enrolled in the outpatient program. Vigilance continues to be strict because there is concern that, with the combination of a rising tide of foreign tourists and the reappearance of prostitution, the disease is becoming more widespread.

As part of its overall health development strategy, and in keeping with Fidel Castro's wishes of making Cuba a world medical power, major investments have been made since the early 1980s to develop a national biotechnology industry. In addition to acquiring foreign technology, the government has devoted much attention to training abroad the Cuban scientists currently staffing the Center for Genetic Engineering and Biotechnology (Centro de Ingenieria Genetica y Biotecnologia-CIGB) and other research facilities. Cuba has produced some biotechnology health products for domestic use and exported small quantities to developing countries and the former socialist world. Inadequate marketing capabilities and quality-control problems hamper Cuba's ability to sell biotechnology products abroad, but attempts along these lines continue to be made through joint-venture agreements with firms from Canada and other countries. Some observers have voiced concerns that the major biotechnology investments are also related to a desire to develop the capacity to produce biological weapons.

Despite the country's emphasis on preventive medicine, Cuba's public health approach was and continues to be hospital-and physician-intensive. This public-health approach places a heavy financial burden on the nation not only by being physician-intensive but also by emphasizing other costly medical inputs. These include obtaining the latest medical equipment and consistently exceeding internationally recommended medical norms as regards, for example, the number of recommended prenatal visits and the constant monitoring of healthy people by family doctors. Cuba was able to bear these excessive costs as long as its economy was cushioned by Soviet subsidies. Without subsidies, the unsustainable character of the national public health approach became apparent: equipment and medicine shortages currently hamper the effectiveness of the Cuban health system (see Social Consequences of the Special Period, this ch.). These high costs explain why many other developing countries were unwilling to emulate Cuba's public health model, despite its many well-publicized achievements during the 1970s and 1980s. In the late 1990s, the provision of quality health care services deteriorated to such an extent that commonly prescribed medications were often not available and patients, when hospitalized, were often asked to bring their own bed sheets, towels, and other personal supplies. The government has even been forced to accept medical donations from abroad that are distributed through the Roman Catholic Church and other charities. In addition, Cubans residing abroad provide an unknown, but very substantial, number of the medications consumed.




Last Updated: April 2001


Editor's Note: Country Studies included here were published between 1988 and 1998. The Country study for Cuba was first published in 2001. Where available, the data has been updated through 2008. The date at the bottom of each section will indicate the time period of the data. Information on some countries may no longer be up to date. See the "Research Completed" date at the beginning of each study on the Title Page or the "Data as of" date at the end of each section of text. This information is included due to its comprehensiveness and for historical purposes.

Note that current information from the CIA World Factbook, U.S. Department of State Background Notes, Australia's Department of Foreign Affairs and Trade Country Briefs, the UK's Foreign and Commonwealth Office's Country Profiles, and the World Bank can be found on Factba.se.

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