Cuba is, today, the country with the most doctors per thousand inhabitants. There are, however, fewer and fewer health professionals on the island providing primary care. An analysis of the Public Health Statistical Yearbooks corroborates this contradiction, and Cubans' perception that they are dealing with a health system that does not correspond to that portrayed in the official propaganda.
In 2010 the number of doctors assigned to Family Clinics was 36,478, while in 2017 there were only 13,131; that is, a 64% drop in less than a decade.
Thus, we are witness to a scenario in which Cuba, with more doctors per thousand inhabitants (7.5) than countries like Sweden (4.2), Germany (4.1), the USA (2.6) and Japan (2.4) -according to 2014 data from the World Bank-, has decided to drastically cut primary care for the population.
Health and voluntarism
1984 was the year in which, on the initiative of Fidel Castro, and with the aim of taking health care to the entire country, the Cuban Government created the Family Doctor and Nurse Program. In 1987, the first specialists in Comprehensive General Medicine graduated, and ten years later, 18,090 practices, built in communities, towns and neighborhoods, had transformed the public health scenario at the national level.
According to the official version, thereafter hospital admissions were reduced thanks to preventive care. Likewise, the quality of prenatal care was increased, and vaccination coverage exceeded 98% ... these and other health indicators made the program an international benchmark. However, it lacked a sustainability plan.
In 1991, the collapse of the USSR and the socialist block, and the end of subsidies to the Cuban Government, triggered an economic implosion that plunged the island into an unprecedented crisis and revealed the structural vulnerability of the government's plans.
Health, petrodollars and corporations
The rise of Hugo Chávez to power in Venezuela in 1999 completely transformed this situation. The ideological affinity between Caracas and Havana led to an economic relationship based on the exchange of oil for professional services. While more than 100,000 barrels of crude arrived daily in Cuba, under preferential conditions, tens of thousands of health workers, teachers and Cuban sports coaches landed at the Maiquetía Airport.
Caracas replaced Moscow as Havana’s economic lifeline. On October 31, in an act marking 18 years since the signing of the Cuba-Venezuela Cooperation Agreement, Venezuelan President Nicolás Maduro said that thanks to Barrio Adentro –the program in which health professionals from the Island participate– there had been 872 million consultations and more than 50 million administrations of care at high-technology centers staffed by Cuban doctors.
This shot in the arm, provided by Venezuela, revealed a new scenario in Havana: it had a medical care system that was unsustainable within the country, but a veritable army of professionals, and the possibility of capitalizing on the international sale of its services.
Given this situation, following the 6th Congress of the Communist Party, the Government initiated a strategy called the Updating of the Economic Model. New commercial entities, under the guise of shell corporations, performed functions previously covered by the ministries, especially in the most lucrative activities, as the company Comercializadora de Servicios Médicos Cubanos (CSMC S.A.) took over the business of exporting health personnel.
By the end of 2017 there were Cuban health workers in 64 countries, with Brazil and Venezuela as the main destinations.
Business is business
The new arrangement has radically altered the public health situation in Cuba, to the detriment of both professionals and the population.
"On the one hand, there is the problem of medical personnel's pay. According to the National Office of Statistics and Information (ONEI), the average salary in the Health sector in the country in 2017 was 833 pesos per month, equivalent to some 34 dollars. In 2014, after a salary increase, doctors with two specialties went on to earn 1,600 pesos per month, equivalent to about 64 dollars, while colleagues with a single specialty had a salary of less than 60 dollars (1,460 pesos).
These miserable salaries are the main reason why Cuban doctors are willing to be sent by the Government to any country in the world, including some with high rates of violence, or racked by armed conflicts, in order to access resources impossible to obtain on the island.
The situation of Cuban doctors is so critical that they agree to the Cuban State retaining more than 70% of the amount they are actually paid by their destination countries, and the imposition of stringent limits on their freedom.
In an article published by the Pan American Journal of Public Health in 2016, a group of authors, including the Cuban Minister of Public Health at the time, Roberto Morales Ojeda, stated that the "medical cooperation program [in which Havana includes the sale of professional services] produced an annual revenue growth rate of more than 200%."
While these are the problems that medical personnel face, those of the population stem from the export of medical services, which has rendered the entire national health system feeble and exposed.
In 2017, for example, in which the Government earned over 11.37 billion from the export of professional services, only the equivalent of 428 million dollars was allocated to public health and social welfare expenses.
The result of this imbalance is a sharp decrease in health personnel in Cuba, the closure of infrastructures, a reduction in the number of hospital beds, shortages at pharmacies, and an increase in diseases related to deficient health conditions, a phenomenon that the DIARIO DE CUBA will address during upcoming issues of this investigation, starting today.
Statistics and primary care
The solution that the government has found to reconcile the unsustainability of an extensive health care model with the demands of a prosperous business dedicated to exporting medical services is what has been called "reorganization" of the Health sector, which began in 2010, the year before CSMC S.A. emerged
In the aforementioned article in the Pan American Journal of Public Health, dedicated to the health system's "transformations" and "sustainability" strategies between 2011 and 2016, the authors attribute the need to "reorganize" to the US embargo and the aggravation of the economic crisis in the 90s. They also blame these causes for the physical deterioration of health units, the lack of supplies, and the decrease in the quality of the services given the population.
Specifically, the strategy has resulted in a major cut in personnel, and a reduction in infrastructures, clearly reflected in the level of primary care, with some contrasts that official statistics fail to explain: although the number of doctors dedicated to Family Consultations has dropped 23,347 since 2010 (from 36,478 to 13,131), graduations of specialists in Comprehensive General Medicine –the professionals that the Government assigns to Primary Care– has steadily risen. There were 47,638 last year.
The official figures also fail to specify the number of general practitioners and specialists who are abroad.
Only the 2012 Public Health Yearbook contains any figure in this respect, in its introduction: "more than 39,000 (Health) employees" in 66 countries.
In most cases sector officials, in their statements on the subject, mention the total number of professionals in other countries, without specifying how many of them are doctors.
However, in 2015 the Deputy Minister of Public Health, Marcia Cobas, told the regime's press that there were more than 50,000 "collaborators" in 67 countries, and that more than 25,000 of them were doctors.
The "reorganization" also results in a loss of infrastructure. Thus, the number of medical offices at which family doctors provide services has fallen, from 14,671 in 2001 to 10,869 in 2017; that is, 3,802 fewer.
This is compounded by the disappearance of other primary care centers, such as "polyclinics," which have dropped from 499 in 2008 to 450 in 2017.
The government describes this reduction as a "compaction". It argues that it has been implemented in, among other areas, towns of less than 5,000 inhabitants, redistributed to nearby health facilities.
These small towns are often in problematic, inaccessible places, in a country whose transportation deficiencies are chronic. And, although the official statistical yearbooks do not include the number of ambulances and mobile units available, there are more and more complaints from Cubans who must travel miles on their own to receive medical assistance, even when it is urgent.
According to official statistics, since 2007 438 Family Doctor Offices were eliminated in Pinar del Río, 325 in Sancti Spíritus, 257 in Villa Clara, 236 in Camagüey, and 224 in Holguín, all provinces with vast rural areas.
Two-fold benefits
"Cuba has the largest number of doctors relative to its population in the world, but its people are still suffering from increasing problems with regards to medical care. When publishing its figures on doctors per thousand inhabitants, the government does not subtract those professionals who are no longer serving in the country's communities. Nor does it subtract (or even mention a number) those who care for foreign patients in Cuba, as part of the business of the obscure Comercializadora de Servicios Medicos S.A.
This lack of transparency, and attempts to cover it up, are hardly surprising from a government accustomed to controlling access to information and infringing upon its people's liberties. Along the way it also denies doctors' fundamental rights, and undermines Cubans' health care.
In order to project itself as an "international medical powerhouse", the Government of Cuba is fighting to camouflage the obvious decline in public health in the country. It needs to do so, not only to obtain revenue, but also to benefit politically, by bolstering its cache. These dual assets, however, do nothing to improve Cubans' health and quality of life.