Cuban Health Care System 
By Talal Naeem 

"Cubans are people who r born in a third world economy and who sicken
and die of first world pathologies!"
Prof Theodore H. Macdonald, 1999 [1]

Today, Cuba claims to be a "world medical power" [2]. Cuban leaders
have the country's health indicators, particularly a low infant
mortality rate, high life expectancy and one of the highest doctor to
patient ratios, to support this claim. In fact, in some areas their
health standards even surpass those of developed countries. This
paper is divided into three sections. Section I explores how a small
developing country like Cuba could develop such a remarkable health
care system, unmatched in the third world. In Section II, keeping in
mind Cuba's successful strategies in their health sector, we analyzed
how a developing country like Pakistan could think beyond folklores
and implement similar strategies to improve the country's health
standards. Finally, Section III serves as an appendix giving details
regarding Pakistan's existing health structure.

Section I

Introduction to Cuba Cuba, with an area of 110,922 square kilometers
is the largest, and the most populous island-nation of the West
Indies. [3] Its current population is approximately 11.25 million
people, as reported by UNICEF in the 2004 Cuban demographic
statistics. [4] Fidel Castro, who came into power on 16th February
1959, by becoming a prime minister of the revolutionary government,
leads Cuba.3 From the very beginning Cuban leaders gave the country's
health care system one of their highest priorities.

Following the 1959 revolution, Cuban leaders considered superior
health statistics as adequate measures of a government's
effectiveness; which explains why providing top quality health care
to the masses has been one of their key policies. They aimed, for
Cuba to become a "world medical power", which meant 'socioeconomic
development, scientific achievement, a model health system and global
influence.'* This would ensure that Cubans enjoy a good standard of
living because of fulfillment of basic needs of life. Thus, Cuba has
managed to significantly develop its human resources, having an
impact world wide, in the form of Cuban doctors working all over the
world in times of need.

Cuban health care system

Before Fidel Castro came in power, Cuban Health Care Statistics
revealed a state similar to any other developing country. The
country's health care system was marked by "urban-rural
contradiction" with a majority of the doctors working in Cuba's urban
regions, and the privileged upper class enjoyed a better quality
medical treatment as compared to the rest of the public. [5] However,
today Cuban health indicators reveal an enormous improvement in the
infant mortality rates, and life expectancy at birth, since the
revolution. Today, Cuban health statistics reveal the country's
health care to be far more advanced than a developing country, in
fact, Cuban health care can be considered at par with those of the
industrialized world. According to the WHO, the patient to doctor
ratio in Cuba is 1 to 170, making Cuba ahead of the US where the
ratio is 1 to 188.[6] Cuba's life expectancy at birth is 75 years for
males and 79 years for females.6 The CIA World Fact book for 2005,
reports the infant mortality rate in Cuba as 6.33, being slightly
lower than that of the United States, which is 6.50. [7]

The main idea behind the revolution of the health system is evident
from Fidel Castro's mission of making Cuba a 'World Medical Power'.
He believes there can never be too many doctors and medical personnel
and envisions having, "A doctor on every fishing boat, on every
merchant ship, in every school, in every factory, on every block."
[8] In addition, Che Guevara, an Argentinean doctor, one of the key
revolutionary leaders of the 1956-59 Cuban revolution, also had a
similar vision of providing high quality free health care to all
citizens being the government's responsibility. These visions led to
the eventual success of Cuba's health care system.

We believe that Cuba's health care system was implemented using an
umbrella strategy. Henry Mitnzberg has defined an umbrella strategy
as, "senior management setting out broad guidelines and leaving the
specifics to others lower down in the organization. This strategy is
not only deliberate (in its guidelines) and emergent (in its
specifics) but it is also deliberately emergent in that the process
is consciously managed to allow strategies to emerge en route." 8
Cuban leaders and visionaries, specifically Fidel Castro and Che
Guevara, set these broad guidelines of providing high quality public
health care to all. The actual specifics were in the hands of the
Ministry of Public Health, which in turn set up an advisory
commission that aimed towards elaborating "the conceptualization of
community medicine." [9] Thus, Cuban leaders set out the deliberate
strategy for Cuba's health care system, whereas the Ministry of
Public Health and the appointed commission were involved in the
periodic evaluation and assessment of the implemented strategies.
This implies, that Cuba's health care strategy evolved through a
process of continuous criticism and evaluation, rather than following
hard guidelines.

Therefore, it is evident that Cuba's health care strategy was
partially deliberate and partially unplanned; which also agrees with
J. Moncrieff's model of strategy dynamics. [10] The planned element
follows from the visions of Cuban leaders. However, the unplanned
element comes from "emergent strategies" that resulted from the
interaction of the implemented health care strategies with its
environment. For a reflective account of the human experiences
involved in Cuban medicine, the advisory commision sought for regular
feedback from patients regarding their interaction with doctor, to
recommend any positive changes in the prevalent strategies. This led
to the transition of the Cuban health care system, through three
periods namely: early transition (1959-1964), consolidation and the
policlinic phase (1965-1973) and the remaining years as the community
medicine and the family doctor phase.9 Early transition addressed
shortcomings of the medical-political imagination of the
pre-Revolutionary healthcare system, leading to a unified national
health system. Community medicine evolved in turn from the loopholes
identified in the polyclinic phase.

In the transition phase, within a short period of time, the Cuban
revolution almost ended private interest medical care and introduced
a new ideology of health. This ideology consisted primarily of
"social medicine". Social medicine can be defined as "the pursuit
integrated and implemented understanding of both health needs and
health services, giving attention to physical environment and human
biology, with primary focus on social equity in health." 9 Some of
the significant proposed changes included rural health programs,
regionalization of public health and hospitals, free medical care in
all public institutions, creation of preventive medical care
programs, free medical education etc.

As a result of this transition, almost half of Cuban physicians left
to the United States leaving only 3000 doctors and 16 professors in
the country's main medical college. [12] Their temporary replacements
were done through doctors from different Latin American countries. In
1961, as a permanent solution to this shortage of doctors, the
government planned to educate future doctors by converting a huge
nuns' convent into a teaching hospital. [13] According to WHO, today
there are 13 medical schools in Cuba. [14]

Following the transition phase came the polyclinic phase, during
which there was an integration of the changes proposed in the earlier
phase. This included the development of rural hospitals and health
centers, extension and regionalization of hospital system,
integration of the private and public health centers and the
development of national public health campaigns. The main focus of
this phase was on 'area polyclinics', [15] which catered to the
health needs of specific geographical areas.

Subsequently, came the community medicine phase which continues till
today and explains the success of Cuban health care. This phase
mainly consisted of an evaluation of the former phases through
patient feedback. This period mainly addressed the shortcomings of
the earlier phases, which included unsatisfactory appointments,
insufficient medical facilities, overworked physicians, long waiting
lists etc. Personalized health care was found to be the solution to
these shortcomings; every community block was assigned a physician
and a nursing team. This team was responsible for ensuring that all
people within their community receive the appropriate healthcare.
Moreover, it was the responsibility of the primary care physician to
act as third party in consultations between patients and specialists
and keep records of all patients' history.

The above-described phases through which the Cuban health system has
been through, explains how Cuba's health care strategies evolved over
time according to responses from the environment. Continuous changes
were made to remedy any inequities in the country's medical system so
as to ensure that a free and comprehensive health service is provided
to each and every member of Cuban society. This explains how the
health standards in Cuba have dramatically improved over the years,
eventually coming to par with those of developed countries.

International medical aid Frequently the Cuban leader, Fidel Castro
has said he wants his country to become a 'world medical power'. This
phrase refers to 'socioeconomic development, scientific achievement,
a model health system, and influence in the international arena. [16]
Cuba has managed to gain influence in the international arena by
impacting various countries through programs designed to provide
medical help beyond its borders; domestic success in the field of
medicine encouraged Cuban leaders to make health play a key role in
the country's foreign policy.

Despite its own economic difficulties, Cuba has provided assistance
to many third world countries over the past two decades. According to
the New York Times, Cuba sponsors possibly "the largest Peace Corps
style program of civilian aid in the world." Surprisingly, Cuba has
more doctors working abroad than does the World Health Organization.
[17] At the beginning of 2006, it was reported that 25,000 Cuban
doctors were involved in humanitarian missions in 68 different
countries. [18] As part of their aid effort, Cuban medical aid
workers have also been involved in training local workers, so as to
prepare their replacements. Cuba has helped build first of their
kind, medical schools in Yemen, Ethiopia and Guinea-Bissau, these
medical schools were also staffed with experienced Cuban professors
in their early years.

As part of its medical diplomacy, Cuba also donates medical
equipment, supplies, and even complete facilities to countries in
need. These include, the donation to Bolivia of fully operational
pediatric intensive-care units in the 80s, and the donation of six
rural hospitals to Peru.17 The Cubans have also been involved in
providing significant medical aid to countries following major

Furthermore, just recently (September 2005), Cuba created a
1,586-strong international medical contingent that works against
disasters and serious epidemics. [19] This body is prepared to
cooperate in relief work needed by any nation of the world. The
international brigade is under the name of Henry Reeve, a US citizen
who gave up his life while fighting for Cuban independence.18 This
brigade is directly under the leadership of Cuba's revolutionary
leader Fidel Castro. Following Pakistan's devastating October 8th
2005 earthquake, an army of doctors from the Henry Reeve
International Contingent, arrived in Pakistan on October 14th to give
humanitarian aid to the victims of the catastrophe. By the end of
January 2006, over 2,000 Cuban medical staff was working in around 30
field hospitals in the earthquake-hit areas of Pakistan. 18 Up to
date, they have treated around 1,043,125 patients in various regions
of the country. 21

In addition to the medical assistance, free medical education is also
part of Cuba's international aid. The number of foreign students in
Cuban medical schools, at the end of 2005, totaled to 12,000 from 83
different countries. [21] Unlike other countries offering
scholarships to international students, it is interesting to note the
Cuban policy, which requires foreign students to return to their own
countries on the completion of their studies.

Furthermore, the development of the Cuban health sector is encouraged
by the government so as to enable Cuba to earn foreign currency by
exporting its health services. Initially Cuban aid was non-repayable,
however since 1977 Cuba has been charging countries based on their
ability to pay. [22] Poor countries receive aid for free, whereas
oil-rich countries like Libya and Iraq paid in hard currency but at
prices lower than those charged by other Western countries. According
to an advisor to the Cuban vice president, Cuba charges eleven
hundred dollars per month for a generalist medical doctor with eight
years' experience;22 these charges are significantly lower than the
amount charged by other international donors.

Moreover, the Cubans have also earned a significant amount of foreign
currency by providing medical care to individuals from various
Western countries. Cuba has heavily advertised "sun and surgery" and
"health tourism" to those people who find the price of medical
services at home unaffordable.23 Patients from various Latin American
countries, often come to Cuba for specialized treatment that is not
available in their home country. In addition, the Cuban government in
affiliation with the Venezuelan leader initiated a "free eye care
program" for all Caribbean who could not afford the prices charged by
private doctors in their region.24 The most symbolic example of
Cuba's international health aid is the free treatment given to an
eight-year-old British girl whose family could not afford paying for
her treatment in their home country.23

Obstacles to the existing health system One of the main obstacles to
the Cuban health system was the imposition of a United States
economic embargo in 1961, which continues till today. [23] The
effects of the embargo were heightened after the dissolution of the
Soviet Union, since the Cubans had hardly any support from the rest
of the world. Thus the Cuban model health care system has become
threatened by shortages of medical supplies, which are mainly
provided by the United States.

Section II To adequately understand the prevalent health system
crisis in Pakistan we need to analyze Pakistan's conditions at a
macro level. In our opinion, the deplorable condition of the health
care system in Pakistan cannot just be seen as the failure of
implementation or the lack of proper policy making by the government
but as the failure of the system, which over the years has evolved in
Pakistan. Moreover, the quality of public medical services seems to
be deteriorating over time, as an ever growing and over priced
private medical sector gains prominence in the country. We will
analyze each of these weaknesses and present our solutions to them,
in light of the lessons learnt from Cuba's health strategies. We are
going to analyze some of the most popular ones and compare them with
Cuba's healthcare strategies.

One of the most famous folklore championed by the liberal school of
thought is the inefficiency of public institutions. These inefficient
institutions in their opinion should therefore be replaced by the
more efficient and competitive private sector in order for
development to take place. Pakistan's economy heavily relies on loans
from international intuitions. These institutions grant loans to
Pakistan on the condition that Pakistan would in turn abide by the
policies drafted by these intuitions. The largest of these donors are
World Bank and the IMF. The World Banks in its "recommendations"4 has
directed the government of Pakistan to encourage the private sector
to play a more active part in the health care system. It has advised
the government to further decrease its stake in the health care
system and to merely restrict its role to that of a regulator in the
health care sector. USA is often cited as a successful example of
such policy implementations. Various regimes over the past therefore
have hailed the slogan of privatization in an unsuccessful attempt to
imitate their masters.

The human development report published by the Mahbub-ul-Haq human
development center (HDC) in 2005 ranked all the countries of the
world according to their health index. Only one (USA) out of the top
ten countries in this list had a health system that relied primarily
on the private sector. Cuba's fully nationalized health care system
with its limited resources and heavy embargos was ranked at number
seven ahead of developed countries like USA, UK, France, Japan,
Italy, and Switzerland etc [24]. Health system in Cuba is fully
nationalized. In our opinion, the reasons for this overwhelming
dominance at the top positions of countries that rely heavily on the
public health sector, over countries where private sector dominates
the health care system is because of the inherent characteristics of
the private sector. The private sector is always driven by the profit
motive. Its services therefore, would be directed towards those
activities and individuals who could maximize its profits. Recently,
Hurricane Katrina's survivors suffered from a severe shortage of
doctors, the reason being that most of them had private practices.
Due to this, the doctors of New Orleans fled to neighboring states
leaving behind victims of the Hurricane, as there was no profit
motive for them to stay back and treat the survivors. [25] The
government on the other hand is responsible for its citizens and
would cater to their health needs irrespective of the profits they
would make. Secondly governments usually have more resources at their
disposal compared to private individuals. It can therefore spend more
and in a much planned way on the health care system. Thirdly, income
disparities in developing countries like Pakistan are enormous. With
32% of its population under the poverty line5, dependence on the
private health care would deprive more than a third of the population
from access to health services. Pakistan's first priority therefore
should be spending more on the public health care sector and raising
its standard at par with the private health sector. It should then
further strive to improve its services in order to provide quality
health care to the vast majority of the population who cannot afford
private health services.

Moreover, money perceived as the only motivator is another folklore
common amongst policy makers. One of the most commonly cited reasons
for doctors not joining the public sector is that private hospitals
pay more compared to government hospitals. Money is the only criteria
given for people joining the profession of a doctor. The Cuban
doctors on the other hand have demonstrated that this is entirely
untrue. In addition, Cuban doctors are not highly paid, and a number
of times they have to put in long hours to cater to the needs of
their patients. In addition, the Cuban doctors are sometimes also
referred to as 'doctors of the world.' This is because they are
willing to serve in any part of the world they are needed in and that
too, free of charge. Currently Cuba has over 25,000 health
professionals providing aid in 68 countries, including Latin
American, African and Asian nations.6

So what is it that motivates the Cuban doctors to work selflessly for
humanity? As indicated above the Cuban doctors are not very highly
paid so money is out of the question. In our opinion it is the human
nature itself, which motivates them to work this way. It is also the
system prevalent in Cuba that has helped the Cubans to bring forth
this aspect of human nature. If a country guarantees its people food,
clothing, shelter, employment, education and entertainment, people of
that country do not have to worry about the basic necessities of life
anymore. It is then that they truly experience the feeling of being
human and exploring what human beings are truly capable of. Moreover,
the system run in Cuba is not based on the excessive profits and
larger market shares, as is the case in capitalist societies. As a
result, the post-revolution generations have been brought up in a
society that strives to work selflessly for the welfare of the
collective rather than individuals. This is the ideology with which
the Cubans believe in and look up to. They truly want to live the
revolution and carry it forward. They believe that selfless help of
the humanity would only make them true socialists.

The government of Pakistan therefore needs to motivate the people of
our country and provide them with material condition similar to those
in which the Cuban doctors were brought up not only to get a better
health care system but also to build a better country. They need to
emancipate the masses from their suffering and distress by providing
them with all the basic necessities of life like the Cuban government
does. It is only then that we would be able to produce doctors like
those of Cuba. These changes would take a long time to come into
effect, as they require the entire system of Pakistan to be replaced.
To make the health system better in the shot term the government
needs to provide the doctors serving in the public sector with
non-monetary benefits. A few of the proposed benefits are listed

It should first of all make medical education free for all students
aspiring to become doctors in the public health sector. These doctors
should then be required by law to work for public hospitals; failing
to do so should result in severe legal action. The government could
also draft policies, which would make working in rural areas for a
certain period during their service tenure, mandatory. In our opinion
besides free education if doctors working in public hospitals were
given all the facilities given to doctors of the armed forces of
Pakistan like free housing, no electric or telecom charges, quality
education for children at discounted rates, access to cheap
entertainment (club memberships), a chance to get a specialization at
no cost etc there would be a significant increase in the number of
people opting to join public hospitals. The immediate argument that
one might be confronted with on the proposition of these changes
might be that how could a developing country finance these reforms? A
simple answer could be if Cuba with all its embargos and limited
resources could do it, so can we. All we have to do is free some of
our resources from the defense budget and allocate them towards
social welfare. To move even further we can follow Castro's footsteps
and convert some of our state mansions into public universities, for
the benefit of the public.

Ricardo Semler in his article 'managing without managers' says: "As
we have seen, a key assumption in planning is that of detachment,
particularly of strategy from operations, and, as a result, of what
is called strategic management from operating management"7. He refers
to it as the 'fallacy of detachment'. This is in our opinion is
another folklore which strategy formulators strongly believe in.
Semler in his article points out that it is usually the corporations
which are victims of this folklore. In our opinion his analysis can
be extended to governments, and the government of Pakistan is one of
the victims of this folklore. To further aggravate the situation
Pakistan's political environment is plagued with extreme political
stability. Frequent military coups and rapid over throw of civilian
governments has resulted in the Pakistani population witnessing
different rulers every now and then with totally contrasting agendas.
Therefore, instead of learning from past mistakes and building on the
past, as in Cuba's case, we have seen new governments to totally
dissolve the plans of preceding governments and engage in a "heroic"
effort to start from the scratch.

The policy makers of our country should be people, who interact with
the common man in public hospitals on daily basis, rather than
ministers or bureaucrats who in their whole live have never seen what
a public hospital looks like. These people should ask patients to
give recommendations regarding ways in which they could improve
current public medical sector. In addition these people should
themselves observe the conditions of the medicals sector and come up
with innovative ideas and suggestion to improve or adapt with time.
New policies for public health care sector should be formulated in
accordance with these observations and feedback. The observers should
be the ones who should formulate these policies in order to avoid the
fallacy of detachment. This body of policy makers should be
democratically elected. It should be autonomous and all decisions
regarding policy making or changing should be subjected to their
approval. Another obstacle which hampers effective policy formulation
is the colonial bureaucratic culture in our society. Because of this
culture, the lower staff in public hospitals is subjected to
treatment similar to what the blacks experienced in the apartheid.
They have to adhere to orders strictly and little deviations or
innovation on their part could lead to punishments varying from
verbal and physical abuse to job termination. As a result of this
attitude people have stopped thinking out side the box. They just
adhere to the directions given by their superiors. These are the
people who interact most with the common man and they themselves are
part of the common people of Pakistan. Their input and innovative
ideas could play a pivotal role in the evolution of a better health
strategy. These people should therefore be brought into the lime
light and they should be encouraged to adapt to the situation.
Instead of imposing sever penalties important lessons and significant
insights should be drawn from their mistakes.

The fact that Pakistan spends only 0.8% of its GDP on health
services8 is heartening. With an ever-increasing population and such
statistics, one should not expect to see improvement in the health
sector. In Cuba every community block has a 'family doctor.' This
means that there is one doctor for approximately 170 patients9. The
doctors know their patients personally and frequently provide
services at their doorstep. If such arrangement could be made in
Pakistan i.e. we could have a family doctor for every community block
and that doctor would know the people of the locality personally
people would be able to get quality health care irrespective of their
geographic location or their social status.

These were some of the folklores, which the government believes in
and all of which have been proven wrong by the revolutionary country
of Cuba. If the Pakistan's government wants to raise the level of its
health standard at par with that of Cuba it too like Cuba, has to
think out of the box. The long term solution in our opinion, as
pointed out earlier, for these problems is the replacement of the
decadent system currently prevalent in Pakistan. People would only be
able to think outside the box and truly act as human beings once they
are emancipated from the struggle of procuring the basic necessities
of life. This long term solution can only be provided by a
revolutionary government like that of Cuba. Observing the material
conditions of Pakistan no such revolutionary party is strong enough
to challenge the state. This solution would therefore take a long
time. To provide temporary relief to the masses the government should
at least think beyond the common folklores and try implementing the
reforms pointed above. While these reforms, in our opinion, might not
be successful in healing the wounds inflicted by the system but they
may help pacify the pain.


[1] Farag, Essam. "Cuban Healthcare:An analysis of a Community-based
model." The Ambassadors 7 July 2000. 15 Feb. 2006.

[2] Feinsilver, Julie M. "Cuba as a "World Medical Power": The
Politics of Symbolism." Latin American Research Review (1989). 15
Feb. 2006.

[3] Azicri, Max. Cuba: Politics, Economics & Society. 1st ed. Vol.
1.Great Britain: Pinter, 1988. 1-35.

[4], 16th
Feb, 2006.

* Feinsilver, Julie M. "Cuba as a "World Medical Power": The Politics
of Symbolism." Latin American Research Review (1989). 15 Feb. 2006.

[5] Farag, Essam. "Cuban Healthcare:An analysis of a Community-based
model." The Ambassadors 7 July 2000. 15 Feb. 2006.

[6], 2nd Feb, 2006

2nd Feb 2006

[8] Feinsilver, Julie M. "Cuba as a "World Medical Power": The
Politics of Symbolism." Latin American Research Review (1989). 15
Feb. 2006.

8 Mintzberg, Henry. "Crafting Strategy." Harvard Business Review

[9] Halebsky, Sandor, and John M. Kirk, eds. Cuba: Twenty Five years
of Revolution 1959-1984. 1st ed. Vol. 1. New York: Praeger, 1985.

[10] Moncrieff, J. (1999). Is Strategy making a difference? Long
Range Planning Review, Vol 32, no 2, pp 273-276.

9 Halebsky, Sandor, and John M. Kirk, eds. Cuba: Twenty Five years of
Revolution 1959-1984. 1st ed. Vol. 1. New York: Praeger, 1985. 45-62.

[12] Farag, Essam. "Cuban Healthcare:An analysis of a Community-based
model." The Ambassadors 7 July 2000. 15 Feb. 2006.

[13] Bernal, Stephanie. "Women's Healthcare in Cuba:Observation of
Medical Facilities in Cerro, Havana." 1 Feb. 2006

[14], 20th Feb, 2006

[15] Halebsky, Sandor, and John M. Kirk, eds. Cuba:Twenty Five years
of Revolution 1959-1984. 1st ed. Vol. 1. New York: Praeger, 1985.

[16] Feinsilver, Julie M. "Cuba as a "World Medical Power": The
Politics of Symbolism." Latin American Research Review (1989). 15
Feb. 2006.

[17] Feinsilver, Julie M. "Cuba as a "World Medical Power": The
Politics of Symbolism." Latin American Research Review (1989). 15
Feb. 2006.

[18], 22nd Feb,

[19], 22nd Feb,

18 , 22nd Feb,

[21], 10th
Feb, 2006

[22] Feinsilver, Julie M. "Cuba as a "World Medical Power": The
Politics of Symbolism." Latin American Research Review (1989). 15
Feb. 2006.

[23] Schwab, Peter. "Cuban Healthcare and the US embargo." An
Independent Socialist Magazine 30 Nov. 1997. 20 Feb. 2006.

[24] Human Development in South Asia 2004. Mahbub ul Haq Human
Development Center. New York: Oxford UP, 2005.

[25] Darce, Kieth. "The Doctor is Out." The Times Picayune 8 Feb.
2006. 1 Mar. 2006

s. e. anderson (author of "The Black Holocaust for Beginners" - Writers + Readers) +