Cuba: A Role Model for Health System Strengthening?
A doctor treating a patient in a Cuban hospital. Cuba ranks highly amongst countries that train the most doctors per head of population.
Courtesy of Creative Commons.
James Barclay and Laura Halley are medical students undertaking a project on the global health worker crisis. In the first of what will be a four-part series exploring the issue of health workers and their maldistribution around the world, they begin by examining the problem at hand and how Cuba may have some lessons for the world in terms of training physicians.
Of all developing nations, Cuba stands out both for its doctor-patient ratio and for its unique system of universal health coverage.
In the wake of Hurricane Katrina, Fidel Castro offered to send 1,500 Cuban doctors to the United States in an extraordinary offer of humanitarian assistance. It was never accepted. Whilst the world suffers a staggering health worker shortage, how does a country with a developing world economy manage to achieve the largest number of doctors per population in any country?
The global shortage of health workers is one of the biggest challenges to global health in the twenty first century. It underlies many pressing issues such as HIV/AIDS and poor maternal health. The shortfall is most crippling in low and middle income countries, notably Sub-Saharan Africa and Asia, where urgent needs simply cannot be met without a skilled and adequate workforce. The WHO estimates the global gap to be in excess of four million, a deficit that is by no means exclusive to low income countries. Western nations now require ever increasing numbers of health workers to provide health care for ageing populations, providing employment opportunities to health professionals in developing countries. The NHS, the largest employer in Europe, has long had a history of active recruitment from developing nations to boost health worker numbers. Thankfully, following the adoption of an ethical international recruitment code by the UK Department of Health in 2001, active recruitment is no longer permitted. However, applicants from low and middle income countries are not prohibited from applying.
Of all developing nations, Cuba stands out both for its doctor-patient ratio and for its unique system of universal health coverage. The country consistently achieves health statistics on a par with Western nations despite being poorly equipped: Cuba has a GDP one tenth of the UK’s and has suffered a United States embargo now for almost five decades. It is precisely this low budget that has forced Cuba to change its attitude towards disease. Whereas a British or American doctor may be tempted to rely on the expensive gadgetry fixed into any modern medical system, a Cuban doctor must take preventative action before a more costly intervention is required. In an admirable display of community medicine, a Cuban can expect an annual unprompted visit from their GP who will give advice on their wider lifestyle and environment.
One of the most remarkable aspects of the Cuban health system is the Escuela Latinoamericana de Medicina (ELAM). This is a medical school like no other: established in 1998 as part of a humanitarian aid effort following the devastation caused by Hurricane Mitch, it offers free medical training to students from underdeveloped areas in 29 overseas countries, including the United States. The irony is that while the USA continues its embargo due to the countries’ conflicting ideologies, cash-strapped Cuba has opened its doors to US students from deprived communities. Students must display a commitment to serve in impoverished areas of their home countries, and are contracted to return after graduation. The programme focuses on public health, instilling the idea of community orientated primary care (COPC) from the outset. The ELAM programme is unique in its ability to recruit doctors from vulnerable communities and for its emphasis on preventative medicine.
It is not hard to see why Castro has poured such efforts into health care- the excellent health of the population plays strongly in his political favour. After all, the revolutionary Che Guevara, now a clichéd icon of many a t-shirt and poster, was himself a doctor. As Castro’s health continues to deteriorate it seems the same cannot be said of the legacy of his health system, which has become, in the words of the ex Secretary-General of the UN Kofi Annan, ‘the envy of many other nations.’ Just maybe, developed countries that perversely rely on doctors from abroad could learn to take a more responsible view of the global health worker shortage. Surely we would take a greater pride in our role in the global community if, like Cuba, we were to actively fund doctors to help in impoverished, often forgotten corners of our world.
James and Laura are two students studying Medicine at the University of Edinburgh, UK. They are currently undertaking a project on the global health workforce crisis and will be considering numerous aspects to the quandary including evidence, education and the impact of the UK on global health policy.
Find out more
Visit the World Health Organisation website for more information on the global health workforce crisis: http://www.who.int/topics/health_workforce/en/
For a paper giving an insight into ELAM:
Huish R. Going where no doctor has gone before: The role of Cuba’s Latin American School of Medicine in meeting the needs of some of the world’s most vulnerable populations. Public Health 2008; 122: 552-7 doi: 10.1016/j.puhe.2008.03.001 pmid: 18466937.
November 5th, 2009 at 4:19 am
When you use the phrase “labor shortage” or “skills shortage” you’re speaking in a sentence fragment. What you actually mean to say is: “There is a labor shortage at the salary level I’m willing to pay.” That statement is the correct phrase; the complete sentence and the intellectually honest statement.
Employers speak about shortages as though they represent some absolute, readily identifiable lack of desirable services. Price is rarely accorded its proper importance in their discussion.
If you start raising wages and improving working conditions, and continue doing so, you’ll solve your shortage and will have people lining up around the block to work for you even if you need to have huge piles of steaming manure hand-scooped on a blazing summer afternoon.
Re: Shortage caused by employees retiring out of the workforce: With the majority of retirement accounts down about 50% or more, most people entering retirement age are working well into their sunset years. So, you won’t be getting a worker shortage anytime soon due to retirees exiting the workforce.
Okay, fine. Some specialized jobs require training and/or certification, again, the solution is higher wages and improved benefits. People will self-fund their re-education so that they can enter the industry in a work-ready state. The attractive wages, working conditions and career prospects of technology during the 1980’s and 1990’s was a prime example of people’s willingness to self-fund their own career re-education.
There is never enough of any good or service to satisfy all wants or desires. A buyer, or employer, must give up something to get something. They must pay the market price and forego whatever else he could have for the same price. The forces of supply and demand determine these prices — and the price of a skilled workman is no exception. The buyer can take it or leave it. However, those who choose to leave it (because of lack of funds or personal preference) must not cry shortage. The good is available at the market price. All goods and services are scarce, but scarcity and shortages are by no means synonymous. Scarcity is a regrettable and unavoidable fact.
Shortages are purely a function of price. The only way in which a shortage has existed, or ever will exist, is in cases where the “going price” has been held below the market-clearing price.