Public Health (2004) 118, 599–601
STUDENT ELECTIVES IN PUBLIC HEALTH
An analysis of the Cuban health system
A. Aitsiselmi1
Addenbrooke’s Hospital, 41 Coton House, Long Road, Cambridge CB2 2SD, UK
Received 15 October 2003; accepted 17 December 2003
Available online 24 March 2004
I chose, Cuba as my elective destination for several
reasons. The fact that it is a Caribbean island with
some of the most beautiful beaches in the world did
not totally go amiss, but first and foremost, I
wanted to experience developing country health-
care, the Cuban way. Compared with other devel-
oping countries with more important economic
resources,1 Cuba has done remarkably well in
terms of health and development. It boasts health
indicators comparable with the world’s richest
nations including the USA and the UK (Table 1).
However, Cuba spends a fraction of what we do
on healthcare (Table 2). This is partly possible
because of the availability of other assets, such as a
large workforce paid in cheap local currency
(although some sectors of the economy operate in
US dollars). Cuba also employs low-technology,
high-impact preventive medicine as a health
strategy.
Cuba has made long-term investments in infra-
structure change, and given priority to previously
neglected rural areas.2 The latter accounted for the
bulk of the country’s mortality rate before the
revolution in 1959. The Cuban socialist revolution
has since brought massive healthcare and education
reforms that are the foundation in which Cuba
erected its social and healthcare achievements.
E-mail address: amina1@doctors.org.uk.
1
Current address: 6 Claygate, York, Y031 ONW, UK.
0033-3506/$ - see front matter Q 2004 Published by Elsevier Ltd on behalf of The Royal Institute of Public Health.
doi:10.1016/j.puhe.2003.12.008
The Cuban healthcare system
Cuba is a socialist country with a central form of
government. National health programmes are
devised at the Ministry of Health (MINSAP), and
implemented throughout the health system with
limited scope for deviation. This seems to have
worked fairly well for Cuba, with the national
programmes providing a unified and reproducible
standard of care.
The size of the Cuban workforce relative to its
population is several times larger than that in the
UK. The doctor:patient ratio is 1:172 in Cuba3
(1:480 in the UK). This affords the country a
substantial advantage in administering free and
universally accessible healthcare to its population.
This contrasts with some parts of Latin America
where only the wealthy are able to afford decent
healthcare.
Primary care
The structure of the primary care system is very
similar to that in the UK. All patients register with a
general practitioner (GP) in their community, who
is usually their first port of call when seeking
healthcare. The size of an individual GP’s patient
population in Cuba is kept to about 500 patients.
This allows the GP to devote enough time to each
patient. GPs divide their time between morning
surgery and afternoon home visits, when they can
see patients who are too ill to come to the surgery
600
Table 1 Basic health indicators.3
Under-5 mortality Life expectancy
rate/1000 (years)
UK 7 77.5
USA 9 77.0
Cuba 8 76.0
or ‘chase up’ those who have missed their
appointments.
GPs work together with a nurse. They also belong
to a multidisciplinary team integrating the GP and
nurse with community obstetrician, geriatrician,
psychiatrist and social worker. The team meets
regularly at the local polyclinic. There is generally
less emphasis on response to individual illness in
Cuba, and more emphasis on response to health
issues arising in the context of family and commu-
nity relationships.
Polyclinics are community health centres that
were originally set up to co-ordinate mass health-
care initiatives such as vaccinations. Their focus of
activity has changed to support GPs in the commu-
nity management of the growing burden of chronic
diseases. A wide range of services are provided,
including basic emergency services, specialist
clinics and alternative therapies.
Rural Cuba
Cuba’s healthcare reforms have aimed to eliminate
health differences between regions and population
groups. They have had their largest impact in rural
Cuba. Before the revolution, people lived in
appalling misery and died young of preventable
diseases. Today, even if living conditions continue
to be very basic in some areas, everyone has nearby
access to a full set of primary care services.
Facilities are purpose built where needed. Working
as a family doctor in a rural area is a compulsory
part of post-graduate medical training. As a result,
there is never a shortage of doctors for rural Cuba.
Table 2 Comparison of public health and economic indi-
cators.3,4
GDP spent Healthcare expenditure/
on healthcare (%) capita/year (£)
UK 10 1020
USA 13 2870
Cuba 7 7
A. Aitsiselmi
Some of the inhabitants felt that it was hard to keep
doctors away. The effectiveness of healthcare
delivery is also helped by Cuba’s impressive 97%
literacy rate.3
Cuba internationally
Cuba has a number of assets: cigars and sugar, but
also doctors and biotech products. It aims to share
its healthcare expertise with other low-income
countries, and formed a partnership with neighbour
Haiti to help set up Haiti’s immunization pro-
gramme. Cuba’s own immunization programme
received a PAHO award in 1999 for outstanding
achievement. After Hurricane Mitch in 1998, Cuba
sent 108 doctors to Honduras to provide humanitar-
ian assistance. Cuba is quoted to have more doctors
working abroad on humanitarian missions than the
World Health Organization.
The biotech sector is Cuba’s second most import-
ant growth industry after tourism. It has managed to
produce its own monoclonal antibody, interferon,
recombinant streptokinase5 and vaccines (including
the world’s only locally effective meningitis B
vaccine). These are produced cheaply, but trade
restrictions imposed by the USA hinder their export.
Finally, Cuba funds students to study at the Latin
American School of Medicine in Havana. This is the
first university campus in the world that is totally
dedicated to providing medical scholarships for the
developing world and poor students from wealthy
countries. Students are accepted from all over the
world including Latin America, the Middle East,
Europe and the USA.
Cuba and the HIV/AIDS epidemic
Havana’s AIDS sanatorium was set up in the late
1980s. In the wake of the epidemic, Cuba decided
to screen the entire population for the virus.
Anyone found to be HIV positive was quarantined
in the Havana sanatorium until they had been
educated adequately about the disease and were no
longer deemed to be a danger to society through
high-risk behaviour. This approach received much
international criticism because of the infringement
of civil liberties.
However, Cuba managed to avert the epidemic
and has a favourable situation compared with many
countries in Latin America or sub-Saharan Africa
where the epidemic is wreaking havoc.6 Its adult
incidence rate was estimated at 0.03% at the end of
1999.7 Compared with Brazil, for example, where
Healthcare in Cuba: large economic resources are not always indispensable
for successful development
a liberal approach was used and a tragic explosion
of HIV occurred, Cuba’s emphasis on social respon-
sibility over individual rights seems justified.8 In
terms of blood products, Cuba boldly ordered the
destruction of every unit of blood on the island soon
after discovering its first case of AIDS in 1985.
Conclusion
Spending my elective in Cuba showed me how a
great deal can be achieved from very little. With
political will, careful planning and long-term
investment, substantial healthcare and social
developments are possible. These achievements,
however, have sometimes come at the cost
of individual freedom in Cuba, and the country’s
political system continues to be the target of
criticism from the international community and
particular hostility from the USA. It is under
constant pressure to reform to a more democratic
form of government.
Cuba’s political philosophy—of social justice—is
at the heart of Cuba’s successes, but the strain on
the system is taking its toll. With the opening of
601
the island’s borders to tourism, prostitution and
illegal drug trafficking are beginning to rear their
ugly heads. Whether Cuba manages to integrate the
world market and international political system
while retaining its healthcare and social achieve-
ments will be the country’s most important
challenge yet.
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