Lessons from the Cuban health system
Key findings from a British Academy funded project (Rob Baggott and George Lambie).
1. Our research confirmed that the potential lessons from the Cuban case are
overwhelmingly positive. Despite substantial cultural and political differences, and
given its level of economic development, the Cuban health systems had a number of strengths
which could be emulated by other countries, including richer nations. These positive lessons included:
- a focus on prevention and the social, economic and environmental determinants of health and health inequalities
- a holistic approach to health, including an emphasis on the gathering of information about patient and family circumstances (eg: social and economic conditions) to enable health workers to make informed decisions about prevention and treatment
- equitable access to universal health services;
- a focus on primary care and community-based care,
- an emphasis on child and maternity health,
- intersectorality, collaboration and integration between different agencies on health and related matters and the incorporation of health considerations in all policies
- the overall cost effectiveness of the Cuban system,
- investment in medical training
- Cuba’s efforts to provide medical aid and support to countries in great need
As the literature review showed, these features have been long recognised. Our primaryresearch confirmed the acknowledgement of these positive attributes. However, italso revealed others which appear less overtly in the literature. These included:
- Cuba’s growing pharmaceutical and biotechnology industries,
- the community-oriented nature of medical education and training
- mechanisms of public and community involvement in health
- Cuba’s role in South-South support and co-operation
- its policies on elderly people’s health and welfare
2. Set against this positive picture are weaknesses, most of which were identified in the literature andconfirmed by informants. These included shortages of supplies, equipmentand medicines, to a large extent the result of the embargo, and the low pay ofhealth workers. In addition, it was indicated that shortages were associated with other problems, including black markets, special treatment for elites, inducements,and private top up payments. Our research identified other problems, including shortages of staff due to overseas missions, the predominance of a top down approach to policy making, bureaucracy and related inefficiencies, overuse and misuse of services, and some lack of appreciation among citizens of free health services.
3. Despite the broadly positive lessons of the Cuban system for Western industrialised countries, especially at a time of austerity and budgetary restraint, our research found that there was a great reluctance to acknowledge them. This was due to a range of factors: ignorance of Cuban achievements, a belief that Cuban policies were not supported by sufficient evidence (and indeed might be mere ‘propaganda’), ideological barriers (neo-liberal bias leading to a dismissal of any policies pursued by a socialist regime), and political, practical or cultural barriers (which were believed to render Cuban policies unworkable in a Western capitalist host country). This research has made a major contribution by clarifying and challenging these various arguments against learning from Cuban health policies and experiences.
4. Even so, policy makers and practitioners were willing to consider potential lessons from Cuba, even in the USA where significant hostility to Cuba remains. Some within the US, particularly those based in poorer states, see Cuban policies as a means of addressing the inequities of the US health care system. Moreover, the Latin American Medical School based in Cuba has recruited students from underprivileged backgrounds in the USA, Who have subsequently returned to work in deprived areas after graduation. Examples of a desire in the UK to learn from the Cuban system include: a visit by the Health Select Committee in 2000 to explore the Cuban’s approach to public health, a more recent visit by Northern Ireland Assembly members exploring Cuba’s approach to reducing health inequalities, and a new research project supported by the National Institute for Clinical Excellence and the Department for International Development to investigate the Cuban system of medical education. We also learned that other countries, notably Holland and Belgium have taken an interest in the Cuban health system and have sought to generate domestic policy developments as a result. Meanwhile, countries in ‘the South’ have been very keen to work with the Cubans and learn from them, including Venezuela, South Africa, Brazil, Bangladesh and many others (notably including many countries which have received Cubanmedical aid in times of crisis, such as Haiti for example). On top of this, international bodies such as WHO (and its regional presence, PAHO) and UNICEF, have increasingly acknowledged the Cuban contribution both indirectly (by acknowledging the importance of primary care, prevention, addressing social health determinants, universal health coverage and other policies pursued by Cubans) and by directly and openly praising Cuba’s health system. However, our research did indicate a disjunction between the leadership of some international organisations and their bureaucracies, the latter being less keen to praise Cuba.
5. The research also found that there were various mechanisms which couldsupport and promote policy learning from the Cuban case. These included international conferences, including those hosted by Cubans themselves; visits from overseas professionals and exchange schemes; the activities of MEDICC (a US based body which aims to publicise the achievements of the Cuban health system), and the dissemination of research findings (eg: MEDICC established its own journal and undertook a deliberate strategy of disseminating findings via this route). The research also enabled us to reflect on the processes of policy learning in health (which may have wider application to other policy arenas). First, it appears that policy learning is much more complex than portrayed by conventional models. In particular we found evidence of an interactive process, where lessons are learned and transmitted between different jursidictions. For example, the Cubans deliberately sought to emulate features of the original NHS and the Soviet health care system. Subsequently other countries have learned from the Cuban adaptation of these systems. Moreover, our research confirms that policy learning is rarely from a single source. Lessons are often drawn simultaneously from more than one country or model. Another finding was that the principles of a particular policy or system can be spread between countries, without overt acknowledgement. Hence the Cuban system is seen as a useful lesson to others seeking to reform their system, but there is a political reluctance to fully acknowledge this. Instead of seeking to learn from the Cuban experience in the round (ie: the impact of its whole system on health), its component parts (eg; primary care, prevention, universal coverage) are seen as worthy of emulation, and in most cases this is not explicitly related to the Cuban experience itself. Although the WHO leadership has more recently acknowledged the strengths of the Cuban health system, there has been a general reluctance to acknowledge its lessons. This has been fuelled by bias against socialised systems and in favour of markets, and buttressed by the dominance of neo-liberal ideas and states. It is ironic that most recent policy ideas shaping health policy and the NHS in England, from which the Cubans learned, have come from the US, which is the polar opposite of the Cuban health system. However, a further finding suggested that the dominance of neo-liberal policy ideas is not complete and that this may be a result of learning mechanisms and pathways that are less easy for governments to control. Practitioners and local community decision-makers, influenced by the Cuban experience, have sought to shape agendas and make changes. We detected some evidence of this happening in Belgium and Holland, where local agencies and practitioners tried to make health services more community oriented and prevention-focused. In the UK, some GPs working in deprived areas adopted similar ideas and practices in an effort to meet the needs of their populations.