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.
It’s noteworthy that remote geographical location, teenage pregnancy, and unstable living conditions are also considered criteria for admission.
“Early detection of at-risk pregnancies is especially important; transferring to a maternity home means a mother is close to the services she and her baby need,” says Dr Myrna Ortega, co-author of the maternal-child health programme’s uniform practice guidelines for maternity homes.
Each maternity home is staffed by a multidisciplinary team comprising an obstetrician, psychologist, clinical nutritionist, dietitian, internist, dentist and fitness trainer. In addition to daily checks of vital signs, weight and abdominal circumference, women receive nutritional analysis and education, individualised diets tailored to their needs, exercise classes and counselling.
Within 72 hours of birth, the mother and baby have their first intake exam, complemented by monthly follow-up exams through the first year of life, including vaccination against 13 childhood diseases; the majority of these vaccines are manufactured in Cuba.
It’s worth pointing out that all of these services, plus secondary and tertiary care and vaccinations, are provided free of charge.
Medicines, including antiretrovirals for people with HIV, meanwhile, are heavily subsidised negating barriers to access; this is possible, in part, because 67 per cent of all essential medicines registered for domestic use are manufactured on the island.
Yet, the availability of medicine at affordable prices is a double-edged sword since it feeds the tendency to self-medicate and forgo the doctor’s visit altogether.
Low-risk perception of HIV (Cuba has one of the lowest prevalence rates in the Americas) has resulted in a drop in condom use – another issue health authorities are facing. Such problems related to patient responsibility are among the greatest challenges to Cuban health today.
SHOESTRING SUSTAINABILITY: AN OXYMORON?
Taken together, Cuba’s approach gives “the world a model for transforming health systems towards the noble ideals of equity and social justice . . . illustrating well that societies that have the least inequality have the best health outcomes, regardless of the levels of spending on health”, said director of the World Health Organisation Margaret Chan on a recent visit to Cuba.
Levelling the playing field in an effort to provide “health for all” is effective and noble, as Chan observed, but is it a sustainable strategy for a universal system?
Cuba weathered the dramatic economic crash of the 1990s following the collapse of the Soviet bloc (known on the island as the Special Period in Time of Peace) with few lasting effects on physical health. Furthermore, Cuba’s health system has held the line despite a total economic, financial and commercial embargo of the island by the United States for 50 years.
However, the global economic recession combined with a trio of hurricanes in 2008 causing an estimated $10 billion (€8.14 billion) in damages and mismanagement of health system resources forced policy-makers to retool health financing and spending.
In late 2010, two documents were released guiding the reorganisation of the health system – Necessary Transformations in the Public Health System and Public Health Work Objectives and Indicators 2011.
The first proposed “reorganising, downsizing and regionalising health services by maximising the efficient, rational use of scarce resources, while guaranteeing quality access and providing sustainability to the health system”.
The second established an action plan for achieving those goals; the changes are currently being implemented. Spending cuts are being realised by closing or reorganising under-utilised facilities; consolidating epidemiological surveillance and reporting; strengthening health promotion; prioritising clinical and diagnostic methodologies; addressing patient complaints and satisfaction; and forging stronger intersectoral collaboration.
On the revenue side, Cuba is focusing on aggressive marketing of biopharmaceutical products and adjustments to international co-operation in health agreements.
Both represent a shift from a solidarity-based approach whereby Cuba posted health professionals and provided generic medications to public health systems around the world at little or no cost to host countries (excepting resource exchange agreements with Venezuela under which Cuba receives oil at preferential rates in exchange for professional support and expertise).
The programme of Cuban health professionals serving in resource-scarce settings abroad is particularly ambitious and represents the world’s largest, long-term response to the crisis in human resources for health: there are currently more than 15,000 Cuban doctors working in 66 countries – more than all G8 countries combined.
While no figures are publicly available for this programme, Cuba is seeking new partnerships in more developed nations – notably in the Middle East and wealthy African countries such as Angola – where Cuban doctors are contracted under bilateral agreements to offset costs.
Similar adjustments are being considered for Havana’s Latin American Medical School (Elam), which until now has extended full scholarships to needy students from resource-scarce settings; since 1999, more than 12,000 doctors have graduated from the Elam and another 20,000 are currently matriculated, with Cuba assuming all costs.
While Cuba’s commitment to international co-operation in underserved areas remains solid according to authorities, seeking financial support for both of these programmes from recipient countries will likely take on more prominence in the future.
But it is Cuba’s biotech sector which is providing the greatest stimulus for health system sustainability. Based at Havana’s “Scientific Pole” comprising 24 research institutions and 58 manufacturing facilities, Cuba’s biopharmaceutical industry produces vaccines, generic drugs and unique, innovative therapies. These include a synthetic antigen vaccine against Haemophilus influenzae b (Hib); a vaccine against type-B bacterial meningococcal disease, the only commercially available vaccine of its kind; and Nimotuzumab, an anti-tumour epidermal growth factor receptor.
Joint ventures whereby Cuba provides the know-how and technology transfer while partner countries – particularly Brazil and China – provide financing for in-country clinical trials, approval and manufacturing, are beginning to pay off. Between 1995 and 2010, Cuba’s biotech revenues increased five-fold; in 2011 these revenues totalled $711 million. Biopharmaceutical products now represent the second-largest export earner after nickel, with revenues expected to surpass $1 billion by 2016.
LESSONS FROM THE FIELD
While Cuba’s strategy for providing universal care cannot be lifted wholesale to other countries, 50 years of experience can provide guidance for other public health systems aiming to improve outcomes. Clearly, implementing a system which recognises health and wellbeing as basic human rights is impossible without the corresponding political will.
As a first step, governments must be willing and able to appropriate the necessary funds to train, place and pay the health professionals required to provide equitable access to quality care.
This necessitates prioritising vulnerable populations, whether that vulnerability is health-related or more broadly linked to social determinants, such as gender, geographical location, or access to potable water, safe housing and education.
Once the linkage between these factors and health are defined, it is also incumbent upon governing bodies to attempt to address those inequities as well.
Cuba’s experience has also shown that accurate epidemiological surveillance is essential for understanding the health picture of a population and designing relevant responses. This includes health promotion and disease- prevention programmes targeting specific health problems facing the community. A strong, neighbourhood-based primary care system is one of the most efficient and cost-effective mechanisms for achieving these goals.
However, Cuba’s experience has also shown that a health system only works as well as the professionals working within it, coupled with how patients use that system.
Perhaps the best lesson from Cuba’s more than 50 years of providing universal care is that the system must constantly be evaluated, updated and changed – as the health picture evolves, so too must the system.
Conner Gorry is a journalist based in Havana where she reports for MEDICC Review, a peer-reviewed journal in English dedicated to Cuban health and medicine. She blogs at hereishavana.wordpress.com.