Cuba has for a long time boasted the lowest child mortality rate in the Caribbean and Latin America. Given the post-revolutionary regime’s implementation of universal healthcare and unrelenting commitment to improving health outcomes, this may be considered unremarkable. What is certainly remarkable however, is that Cuba, the 78th richest country in the world, also has a lower child mortality rate than the second richest – the United States1 .
The infant mortality rate in Cuba currently stands at 5.4 per 1000 live births2. This compares to 6.6 per 1000 live births in the United States3. This is an astonishing statistic when one considers the extreme material disparities between the two nations. Cuba’s GDP per capita is one eighth of that of the United States. The average monthly wage in Cuba is under $30, compared to $3428 in the United States4.
Cuba did not get to this point overnight. In 1960, immediately following the revolution, Cuba had an infant mortality rate of 39 in 10005. At this same time, the United States’ stood at 26 in 10006. Part of the reason for the reduction in the mortality rate has been the post-revolutionary regime’s training of thousands of primary care physicians every year. The explosion in the number of physicians and clinics has ensured that almost all deliveries take place in a hospital or a clinic7.
For these feats, Cuba is near-universally recognised as the paragon of improving health outcomes in limited-resource countries. The World Health Organization Commission on Social Determinants of Health has identified her as an example of “good health at low cost”8.
In order to best leverage the learnings from Cuba’s experience, one must consider how Cuba arrived at this point. According to a study published in the Canadian Medical Association Journal, Cuba has achieved this extraordinary change in fortunes by focusing on 3 major initiatives; primary care through polyclinics, science with direct feedback to the community, and a population health approach9.
Polyclinics are clinics operating independently of hospitals that provide both general and specialist treatments to outpatients. Although polyclinics existed in Cuba as outpatient facilities for decades before the revolution, following the revolution they took on a new form. Instead of being purely outpatient facilities, these new polyclinics seek to unify curative and preventative medicine. Polyclinics combine primary care programs with public health programs. This means that a single polyclinic will be engaged in maternal health, dentistry, vaccination outreach programs and much more. Staff extend services to home visits, workplaces, schools and communities. The average polyclinic offers 22 different services in total, ensuring that there exists a single point of entry into the healthcare systems for Cubans. There are currently around 500 of these polyclinics operating in Cuba. These ensure that there is 1 physician per 159 people and 1 nurse per 79.5 people. This is significantly superior to the 1 physician per 339 people currently operating in the United States10.
The Cuban healthcare system places science uses science as a key piece of their preventative program as well as a crucial tool for evaluation. Maternal supervision begins even before conception, with women subject to a risk-assessment of their pregnancy risk factors. Polyclinic staff can plan with women using this data the optimal time for conception. At-risk women receive a partogram highlighting the steps that will be taken if complications arise. If a complication does arise during pregnancy, the expectant mother can be referred to a maternal home, which she can either stay at following the birth, or be admitted as an outpatient.
Medical genetics is a field that is also central to Cuban maternal health. All pregnant women and newborns are subject to a genetic risk assessment at their local polyclinic. This can help identify whether the newborn is at increased risk of disease or disorder, in order to improve early detection and treatment.
Population Health Approach
Cuba does not view maternal health obligations as ending at delivery. The majority of children take part in the Educa a Tu Hijo (Educate Your Child) program, which empowers parents to stimulate their children’s integrated development. As well as providing information and training, families with children under the age of two receive at least weekly home visits. Children between two and four years then attend weekly group events at parks, cultural facilities and sports centres with child development counsellors. Data is collected on all mothers and children using the program and this is used for evaluations to inform future programs.
Global and Public Health Lessons
Cuba’s achievements cannot be considered a panacea that can be applied to all global health challenges in all locations. However, there is much that we can learn from its achievements.
National governments can see meaningful change in health outcomes if they are sufficiently committed to change – even with limited resources at their disposal. Public health efforts must be centered in and focused on the community first and foremost. Curative and preventative healthcare must not be siloed into their respective ‘correct places’ and instead a truly integrated healthcare system must be pursued. This can be achieved with the help of data-based decision making.
Cuba has designed a blueprint that could be used to tackle all manner of global health challenges, not only in similar limited-resource countries, but even in some of the world’s most prosperous nations, including the United States.
1. Central Intelligence Agency World Factbook https://www.cia.gov/library/publications/the-world-factbook/rankorder/2001rank.html
2. UNICEF Data https://data.unicef.org/country/cub/
3. UNICEF Data https://data.unicef.org/country/usa/
4. Cuba Average Monthly Salary. Trading Economics https://tradingeconomics.com/cuba/wages
5. Mortality Decline in Cuba, 1900-1959: Patterns, Comparisons, And Causes. James W. McGuire and Laura B. Frankel. http://lasa.international.pitt.edu/Lasa2003/McGuireJames.pdf
6. Trends in Infant Mortality by Cause of Death and Other Characteristics, 1960-88. US Department Of Health & Human Services https://www.cdc.gov/nchs/data/series/sr_20/sr20_020acc.pdf
7. Inter-American Commission on Human Rights https://www.cidh.oas.org/annualrep/2001eng/chap.4b.htm#_ftn38
8. Action On The Social Determinants Of Health: Learning From Previous Experiences. World Health Organisation. https://www.who.int/social_determinants/resources/action_sd.pdf?ua=1
9. Cuba’s System Of Maternal Health and Early Childhood Development: Lessons For Canada https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2630353/
10. A Census of Actively Licensed Physicians in the United States, 2016. Federation Of State Medical Boards https://www.fsmb.org/siteassets/advocacy/publications/2016census.pdf