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Correspondence: Dr Kate Robertshaw, Child Development Service, Hawke's Bay Hospital, Private Bag 9014, Hastings 4120, New Zealand. Fax: 00646 8781621; email: email@example.com; Dr Anthony Weldon, 173/461 St Kilda Road, Melbourne, Vic. 3004, Australia. Email: firstname.lastname@example.org
Despite being a poor country living with the US trade blockade for over 50 years, Cuba has achieved an infant mortality rate of 5.0 per 1000 live births and a life expectancy of 78 years, comparing very favourably with the statistics not only of Australasia, but also with other countries in Central and South America, and particularly with those of the United States. Following the Cuban revolution of 1959, the State prioritised health and education, and these priorities have been maintained ever since. Table 1 demonstrates these with the percentage of gross domestic product directed towards health compared with a range of other countries – both developed and developing – and outcomes.
Table 1. Comparison of markers of child health (infant mortality rate, maternal mortality rate and mortality rate under 5 years), life expectancy and health funding between Cuba, Jamaica (an island neighbour), the USA and Australasian countries†
Population (million) (2010)
Infant mortality (per 1000 live births) (2010)
Mortality rate in under 5 years (2010)
Maternal mortality (per 100 000 live births) (2010)
Life expectancy at birth (years) (2009)
Health expenditure % gross domestic product (2010)
How has this been achieved in a poor country, cut-off from access to the resources of its rich neighbour? A recent visit to Cuba focusing on Paediatrics and Child Health Care gave us the opportunity to try and learn some of the answers. During our visit, we had the opportunity to meet practitioners at various levels of the health-care system in different parts of the country and we will discuss the system as it is delivered at each of those levels.
The Rural Medical Service (RMS)
Prerevolution, health-care providers congregated in the major cities and charged for their services and there was marked health disparity between urban and rural populations. The infant mortality rate in rural areas was up to 100 per 1000 live births. In 1960, Cuban health care was remodelled to move away from the urban hospital and private practitioner pattern, and the RMS was established providing universal free health care. Filling posts in rural communities had been difficult when Cuba had 6300 doctors prerevolution. Almost half of these doctors left Cuba between 1959 and 1963, but the medical students at the time volunteered to work for a period in rural areas after graduation, committing a work force to these areas. The RMS focused on universal access to health care, prevention of disease and health promotion through health education.
By the 1970s, 53 rural hospitals had been established, and there was a measurable improvement in equity of access.
To sustain the supply of doctors in all areas, medical schools were established in all 13 provinces with graduates providing service in rural settings for the first 1 then 2 years after graduation. When selecting medical students, strong academic ability is required but personal attributes are also sought.
In the medical school of Camaguey province alone, we were told that some 600 doctors graduate each year. The 6-year course is standardised throughout the country. However, the course differs from Australasian training by including the use of natural medicines and its strong focus on the social determinants of health. Postgraduation and rural service, many Cuban doctors work overseas in countries where health care is lacking, particularly in Central and South America and Africa.
We visited the Latin American School of Medicine (abbreviated as ELAM in Spanish) in Havana, which was established after the hurricanes of 1998 devastated parts of the Caribbean and Central America. ELAM trains young people predominantly from those countries but also from other South American countries, Africa, the Middle East and even the USA.
The course is provided at no cost to the students who must have a high school diploma, be aged between 18 and 25 years, have good social standing and have no physical or mental limitations hindering their performance in the profession.
For non-Spanish speaking students, an intensive language course is provided prior to the premedical course. The first 2 years of the degree are given at the main campus in Havana and the following four years, training is provided at the medical universities throughout the rest of the country alongside Cuban students.
Primary Health Care
In 1978, the Cuban response to the Alma-Ata declaration relating to access to primary health care for all was to develop the Family Doctor Program, which came to fruition in 1984. Primary health care is the foundation of all health care in Cuba and is free.
We visited a family doctor, who was working in a community called Las Terrazas, some 120 km from Havana. Las Terrazas was established after the revolution in one of the many areas that had suffered widespread deforestation, leaving ecological and social ruin in its wake. Peasants living in extremely poor conditions in surrounding villages were offered work to create ‘terraces’ where thousands of trees were then planted to create what is now a beautiful forested region and has become a nature reserve. The doctor we met and the two nurses who work alongside him live and work in this community and provide basic medical services for the population of some 1000–1300 people. This model is reproduced throughout Cuba in both rural and urban regions. Their role is to provide basic medical services but, in contrast to our general practitioner model, they are obliged to visit every patient on their books at least once a year in their own home. The practitioner is expected to not only provide health checks and medical care but also to observe and be aware of the psychosocial situation of his patients and intervene as required.
Traditional medicines are used extensively as well as familiar pharmaceuticals. Practice was strongly influenced by guidelines that all family practitioners follow. This ensures there is consistency of practice, but the family doctor we met also acknowledged that it constrained his practice in some respects.
Polyclinics provide secondary level health care but are fully integrated with primary care. There are around 444 polyclinics across Cuba. We visited such a clinic in Santa Clara.
They provide multidisciplinary outpatient clinics across a range of specialities including paediatrics, obstetrics and gynaecology, emergency medicine, and internal medicine. Services including dentistry, social work, physiotherapy and clinical psychology are available as well as radiology and laboratory services.
We were told that patients would be seen within a week or so of referral and the family doctor remains closely involved. An appointment to see a psychologist for children with behavioural issues would be available usually within about 3–4 weeks.
Doctors often work where they were born and train local medical students at the polyclinic to maintain the focus on community-based care.
Our observations were that the human resource was skilful and committed, but infrastructure was poorly maintained including sanitation and hand washing facilities. Difficulties with maintenance relate in part to the US trade blockade, creating problems with the supplies of building materials and perhaps prioritisation of other needs where resources are limited.
The Cuban health system reflects a political acknowledgement of the importance of the health of its mothers and children. Good child health is reflected in the low infant mortality rate (5.0 per 1000 live births) and the low rates of low birthweight (LBW) babies (6%).The LBW rate has been falling in Cuba since 1990 compared with wealthier countries like the USA and UK, where the rate has been rising. Many factors influence LBW including poor socio-economic conditions, maternal education, quality of antenatal care and nutrition. These areas are targeted in Cuba by structured antenatal care provided through primary care integrating maternal education, for example, about breastfeeding, with assessment of medical and social well-being. Family doctor health checks occur 12 times in a low-risk pregnancy.
We visited a 15-bed maternity home (Hogar Materno) in Vinales. Hogar Materno provided a homely environment for women with higher risk pregnancies due to medical complications such as pregnancy-induced hypertension, threatened premature labour, twins, etc. as well as for women with significant psychosocial issues, including distance from maternity services and teen pregnancy. The centre was staffed by nurses and, most importantly, a cook who provided a well-balanced diet for these women. Good food and the opportunity to rest from household chores are strong incentives for the women to stay. There is also a sorority and camaraderie for those sharing their pregnancies together. The local family practitioner visited daily to monitor the women's progress, but deliveries were conducted at a nearby hospital with full obstetric facilities.
Rules were strict – no smoking was allowed. Those with alcohol or drug-related problems were treated by their family doctor and psychologist and could only access the maternity home if they were not using. Families could visit but not stay.
Within each of the 13 regions of Cuba, there are tertiary paediatric services. The William Soler Paediatric Hospital in Havana is the main paediatric surgical hospital for Havana. We visited the intensive care unit, though this had more the appearance of a high dependency unit as none of the patients there at that time were on ventilators. A young adolescent was recovering from a liver transplant – some 15–20 are performed there each year. Other patients there were recovering from Staph. Pneumonia and two patients had caustic ingestion.
The neonatal intensive care unit (see Fig. 1) nearby looked quiet compared with similar units in Australasia and well staffed. The unit looked adequately equipped albeit with older models of equipment.
In Camaguey, we visited the Children's Hospital and also participated in a 1-day workshop where doctors from that hospital and the region made presentations on a variety of paediatric topics at a standard entirely comparable with meetings in Australasia.
From the outside, the Camaguey Hospital building was in a state of disrepair with parts supported by wooden beams. This section of the building was in fact the administration section; the wards behind had been renovated or rebuilt. We visited the Haematology/Oncology Unit and met families who described good supportive care over time and who were happy with the treatment their children had received.
We also were taken to the emergency department (ED), which looked like any other ED of a paediatric hospital with many people waiting to be seen. We asked why this was so, given that there was apparently such ease of access to family practitioners, and we were told that, like elsewhere, parents believe that they will receive the best care for their children at a dedicated children's hospital. Many doctors were on duty and waiting times were less than an hour.
Paediatric Disability & Rehabilitation Centre
This centre in Camaguey provides a range of services for children with disabilities. Parents bring their children here for a variable number of sessions each week, some being willing to travel great distances to access the centre. Given the temperate climate year round, this facility does not have any grand buildings and many of the treatments are delivered outdoors. Hippotherapy is provided next to occupational and physiotherapy. On a concreted space, we saw a young boy in a walker being encouraged to kick a soccer ball, and in another area, on a rug and in the sunlight, two babies were being given physiotherapy to music. We were treated to a skilful dance presentation by an adolescent couple with Down syndrome. Music and dance are central to Cuban culture and are included at the centre both as a therapy and a model for inclusion.
In Cuba, when it is recognised that a child has a significant disability, then one of the parents is able to stay at home full time with the infant or child without loss of income.
We felt privileged to meet Aleida Guevera, Che's daughter, herself a paediatrician. She holds no official government position, but it seems that she acts as an ambassador-at-large and has travelled widely throughout the world, including at least one trip to Australia. She was a strong advocate for learning from the traditional medications used in Cuban society over generations.
We discussed the impact of the US trade blockade. We had observed, while travelling around, the influence on medical infrastructure from poorly maintained buildings, a shortage of paper to write on (or wipe with) and limited supplies of up-to-date equipment and computers. However, despite these challenges, we met caring doctors and patients who felt well cared for. The family doctor we had met in Terrazas had told us ‘We treat with heart’, and this appeared to be true.
It was interesting to discuss with Aleida, the future direction of Cuba. In recent months, since the coming to power of Raul Castro, there has been an easing of many of the strict socialist principles that have been followed since the revolution. Thus, for example, in recent months it has become possible for people to take bank loans to start their own small businesses. This is referred to as the ‘new’ socialism. Aleida Guevara expressed some reservations about these changes but was adamant that in whatever way the Cuban society and political system change in the future, the emphasis and priority given to health and education would remain.
While obviously being an articulate and experienced advocate of the Cuban political system, she showed her true colours as a paediatrican, and once these more formal discussions had finished, she gravitated to the two children who were with us and immediately engaged in play with them. A true paediatrician.
Cuba is a poor country operating a socialist society since the revolution of 1959. From the outset, health and education have been prioritised with radical reform of their health-care system. Medical education is targeted to providing doctors both academically and motivationally committed to serving the common good, with the workforce being tailored to meet the health needs of the people. Doctors are exported to provide Cuba's contribution to improving world health. Primary health care, in the spirit of Alma Ata, is universally available, accessible and free at point of access. Secondary care and tertiary care are well integrated with primary care. Cuban health has improved since these reforms, particularly with respect to children. The Cuban model has much to teach us on how to improve health with a limited budget.
It will be interesting to observe changes that occur to health care in Cuba in the coming years in the era of the ‘new’ socialism and if the trade blockade is lifted.
We would like to thank Professor Imti Choonara for advising on our paper.