CUBA'S HEALTH CARE: LESSONS TO BE LEARNT

Despite suffering US embargoes for 47 years, Cuba's healthcare indicators are on par with the most developed countries

MAHVISH JADOON
Sep 24 - 30, 2007

The ratio of doctors to population in Pakistan is 1 to 1254. Dentist to population ratio is 1 to 20839. It is thus no wonder that the health indicators of Pakistan are dismal. It is estimated that 80% of all deaths and 90% of all illnesses in Pakistan result from diseases which are preventable. All this and many more indicators such as high population growth rates, high infant mortality rates, high maternal mortality ratio, and a high prevalence of communicable and non-communicable diseases cry foul the government's commitment to the Millennium Development Goals and other such social development promises.

Pakistan's health sector portrays an array of public and highly unregulated private services. About 80% of total healthcare expenditure is private expenses, and the majority of this is out-of-pocket payments. In a poor country such as ours, the prevalence of private practices and their incumbent costs helps to discourage people to get treatment for conditions that may become complicated and thus even more costly to cure.

Over the years there have been certain improvements in the health sector with an increase in the number of health facilities. Immunization of children aged 12-23 months has increased appreciatively in the last 5 years. Total fertility rates have also declined from 4.5 in 1998-99 to 3.8 in 2005-06. The decline in fertility rates is mainly attributed to the Lady Health Workers program in the rural areas which has helped to increase the knowledge of contraception.

Despite these improvements the scope of the government's initiatives for increasing health coverage has been limited. A comprehensive strategy is required that should target the grass roots level working up. At the moment public sector spending on health is only $4 per capita and as a percentage of GDP it is 2.7%. Such a low allocation to health shows that it is far from one of the top priorities of the government which is still pinning its hopes on a 'trickle-down effect' to improve the lot of its people.

Over the past there has not been much support by policy makers and health specialists towards increasing the social security net. A national health plan which envisages free healthcare for all is seen by the majority is unattainable and utopian. More attention and stress is given to improving the regulation of the private sector which may be affordable to all. Such thinking seems to have rubbed off on our policy makers from those of the US, the champion of all that is related to private enterprises and free market processes. With a per capita spending of $6,543 on health (55.2% of which is private expenditure), it spends the most in the world and is still ranked 37th by the WHO on its healthcare.

Other countries which spend far less than the US on health have succeeded in ranking higher by the WHO mostly because they do not depend on the private sector to impart healthcare. It is usually argued in Pakistan that such a national health system is only possible in developed countries with a broad tax base. This 'precondition' for a working and successful national health system is proved wrong by the case of Cuba. Cuba's health system works; and it is completely run by the government which assumes fiscal and administrative responsibility. It has the most impressive doctor to patient ratio of 1 to 175. All this and more while facing more than 40 years of US trade and financial embargoes.

The US imposed embargoes on Cuba in early 1960's; three years after Fidel Castro took power in 1959. At that time there was a mass exodus of Cuban doctors to the United States leaving the country with only 3000 physicians and 16 medical professors. A program of nationalization and regionalization of medical services was started in 1960 to deal with this shortage. Cuba now has 66,600 physicians, 83,880 nurses, and 9,841 dentists. It's density of physicians per 1000 population is 5.91, much better than the US at 2.3 and the UK at 2.56. Its life expectancies are at par with the most developed countries and its infant mortality rate is also the lowest.

The success of Cuba's healthcare system, despite the economic difficulties that it faces and its status as a third world country, is recognized widely. Former UN secretary general Kofi Annan has lauded Cuban healthcare; along with other western diplomats. "Health and education are the revolution's pillars of legitimacy so the government has to make them work," says a senior western diplomat in Havana. "If they don't it loses all its moral authority. My sense is that the health system is quite good," reports UK's Guardian newspaper.

The Cuban government also operates possibly the largest medical school in the world, the Latin American School of Medicine (LASM) which is a major part of the Cuban healthcare system. The majority of students are foreign and all study there for free. The only condition is that they have to go back to their countries and help their impoverished communities. Cuba has also given an offer of 1000 medical scholarships for Pakistani students.

These measures are part of Cuba's foreign policy which were also demonstrated after the October 2005 earthquake. The largest contingent of aid workers to arrive in Pakistan was from Cuba. Around 2,600 medical personnel from Cuba, which included 1,430 doctors, treated the earthquake-affected people. The also donated 30 mobile hospitals and a large quantity of medicines and equipment to Pakistan. The Cubans not only lived with the affected people in the same surroundings but stayed on longer than other medical professionals from different countries.

The success of the Cuban healthcare system is mainly due to the commitment to 'preventive' rather than 'curative' medicine. Economically starved Cuba cannot afford expensive medicines and even basics such as Aspirin are sometimes not available. Therefore the system promotes exercise, hygiene, and regular check ups to identify and cure diseases before they become advanced and costly. Policy makers from UK's National Health Service (NHS) have visited Cuba to learn from their success and to try to move from a system that focuses on keeping people alive to one that keeps them healthy.

If such a country as Cuba suffering from 47 years of economic embargoes can have such a successful health system, then Pakistan with all its foreign aid from the 'War against Terrorism' surely does not have an excuse. If more resources were directed towards the welfare of our population rather than paying off huge foreign debts and sustaining our defense expenditure then there can be no impediment towards achieving a healthy nation.

CORE HEALTH INDICATORS

 

TOTAL EXPENDITURE SPENDING ON HEALTH AS PERCENTAGE OF GDP

PRIVATE EXPENDITURE AS PERCENTAGE OF TOTAL EXPENDITURE ON HEALTH

PER CAPITA SPENDING TOTAL (PRIVATE+ GOVERNMENT) EXPENDITURE ON HEALTH AT AVERAGE RATE(US$)

GROSS NATIONAL INCOME PER CAPITA PPP (US$)

FEMALE LIFE EXPECTANCY AT BIRTH, YEARS

INFANT MORTALITY PER 1,000 LIVE BIRTHS

MATERNAL MORTALITY PER 100,000 LIVE BIRTHS

PHYSICIANS DENSITY PER 1000 POPULATION

Pakistan

2.7

80.4

18

770

62

80

500

0.74

Cuba

6.4

12.2

260

1,170

79

5

33

5.91

United States

15.7

55.3

6,543

44,970

80

7

14

2.56

United Kingdom

8.3

13.7

3,065

40,180

81

5

11

2.30

Source: WHO Statistical Information System: World Health Statistics, Pakistan Economic Survey 2006-07, World Bank Data and Statistics