Pan American Health Organization

Cuba

  • Overall Context
  • Leading Health Challenges
  • Health Situation and Trends
  • Prospects
  • References
  • Full Article
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Overall Context

Flag of CubaThe Republic of Cuba is an archipelago in the Caribbean Sea with more than 1,600 islands, islets, and keys. The closest countries are Haiti, Bahamas, the United States of America, Jamaica, and Mexico. Its total area is 109,884.01 km2 and the capital is Havana. The 2011 political–administrative division established 15 provinces and 168 municipalities (including the special municipality of Isla de la Juventud) (). Cuba is a socialist State organized as a unitary democratic republic, and the official language is Spanish ().

Demographics

At the end of 2015, the population was 11,239,004—between 2010 and 2015 the population grew by 71,070—(3) and life expectancy at birth continued its upward trend, reaching 78.4 years (80.4 years for women and 76.5 for men) (). The most notable demographic change occurred in the age structure and in the aging of the population. The central provinces and the capital were home to the oldest populations in 2015: 20.4% of the over-85 population lived in Havana (). Figure 1 shows the changes in Cuba’s population structure between 1990 and 2015.

Figure 1. Population structure, by age and sex, Cuba, 1990 y 2015

The population increased 7.6% between 1990 and 2015, which was related to the country’s low birth rate. In 1990, the population structure had an expansive pyramidal shape for age groups older than 30 years, a relatively stationary pattern for groups under 15 years old , and a widening among groups between those ages; the latter is due to the 1960s demographic boom. By 2015, those three pattens had shifted toward older ages, while the population younger than 30 years took on a regressive form, spurred by a more marked decline in fertility and mortality in those groups, especially in the last three decades.

Source: Pan American Health Organization, based on data from the United Nations Department of Economic and Social Affairs. Population Division. New York; 2015.

The ratio of men to women was 993:1,000. The female population was more strongly represented in the older age groups, with women accounting for 53.2% of the population older than 60 years and living an average of four years longer than men. The decline in fertility occurred alongside an increase in the percentage of people aged 60 or older, which in 2015 represented 19.4% of all inhabitants ().

In 2015, the urban population was 8,641,760 and the rural population was 2,597,244, while the growth rate was 0.59 and –1.71 per 1,000 population for urban and rural areas, respectively. A total of 76.9% of the population lived in urban areas, slightly higher than the 75.4% recorded in 2010 ().

The Economy

The national economic model continues to have planning as its cornerstone. In 2010, drafting of the 2011–2015 Economic Outlook began, including the proposed Economic and Social Guidelines for updating the economic and social model (). This economic forecast includes planning the budget for all public health outlays the country will need to make during that five-year period ().

The National Bureau of Statistics and Information revealed that 2015 was a record year in terms of foreign visitors to the country, with 3,524,779 people. This represented a 17.4% increase in tourists compared to 2014, and constitutes the second largest source of revenue in Cuba ().

The Health System

Health has been a priority for Cuba since 1959, and efforts and resources have been devoted to the development and consolidation of the National Health System regulated by the Ministry of Public Health. In addition to Law 41 on Public Health, the Constitution of the Republic establishes the right to the protection of one’s health, and the State’s responsibility to guarantee that right (). The National Health Policy considers health to be an essential component of human well-being and a strategic objective of development. Consequently, all social sectors strive to ensure health coverage for all and share the objective of universal health to ensure that all inhabitants have equal opportunities to receive comprehensive, quality health services when they need them.

The National Health System is governed by the principles of universality, free services, access, regionalization and comprehensiveness, accessibility to all the citizens in the countryside and the city, and it follows an internationalist approach (). It is structured at three territorial levels (national, provincial, and municipal) and three levels of care, from a network of integrated and comprehensive, general and specialized, and regionalized services: primary care (represented by the family physician and nurse program, polyclinics, and other services); secondary care (represented by the hospitals); and tertiary care (comprising very specialized hospitals and the research institutes). Primary health care (PHC) is the main strategy and cornerstone of the National Health System.

The National Health System is currently immersed in a process of transformation which, among other objectives, seeks to continue making progress toward universal health, improve the health of the population, enhance the quality of services, and make its activities more efficient and sustainable ().

The social security system includes two subsystems: social security and social welfare. Social Security guarantees adequate protection of all persons with disabilities due to old age, disability, or disease. In addition to pensions, it grants economic benefits through maternity leave for working women and subsidies needed for disease or accidents. Social Welfare offers care for the elderly and persons with disabilities in social institutions through programs geared to improve the quality of life and integration into society for those who need it ().

The most vulnerable sectors of the population are prioritized and efforts are encouraged to tailor work at the territorial and local level to better serve the needs of those requiring social welfare services ().

Leading Health Challenges

Critical Health Problems

Emerging Diseases

Active investigations of fever cases, border surveillance with strict international health monitoring, and environmental sanitation have been important factors in the strategy to control these diseases. The country reported, to the Pan American Health Organization (PAHO), 1,430 cases of laboratory-confirmed dengue in 2013; 2,522 cases in 2014; and 1,623 cases in 2015—serotypes 3 and 4 ()—in addition to 40 cases of chikungunya (). Furthermore, transmission of Vibrio cholerae O1 biotype El Tor was reported, primarily serotype Ogawa, and to a lesser degree Inaba, which caused a total of 65 cases of cholera ().

Maternal Mortality

The total maternal mortality rate was reduced from 43.1 per 100,000 live births in 2010 to 41.6 in 2015. The leading direct cause of maternal mortality in 2010 was complications related to the puerperium (ICD-10 codes O85–O92), at a rate of 8.6 per 100,000 live births, while in 2015 it was due to other complications (remaining O21–O23, O26, 029–O42, O47–O48, O95, A34, C58), with a rate of 8.0. The leading indirect cause in 2010 was respiratory diseases (O99.5), with a rate of 5.5 per 100,000 live births. In 2015 other indirect causes were responsible for the most deaths (remaining O10, O24–O25, O28, O99.1–O99.3, O99.6–O99.8, E23.0, M83.O, F53), with a rate of 8.8 ().

One of the main health challenges is to continue to apply an intersectoral approach to issues hindering greater reductions in maternal mortality. In 2015, the Ministry of Public Health concluded a national study on mortality in women of childbearing age in order to evaluate the quality of maternal death reporting (RAMOS method) (). This study standardized the country’s figures with those of the United Nations Maternal Mortality Estimation Inter-agency Group ().

Chronic Conditions

In 2015, noncommunicable diseases (NCDs) represented 80% of total of deaths (). Heart disease, malignant tumors, the cerebrovascular diseases, diabetes mellitus, chronic obstructive pulmonary disease, hypertension—as a common risk factor for NCDs—and mental health, are closely related to population aging and the growing need for comprehensive care due to the burden of disease, mortality, and associated disabilities.

Human Resources

In 2015 there were a total of 495,609 health workers, which represented 6.8% of the working age population, and 70.6% of them were women. There was one physician for every 127 inhabitants (7.84 per 1,000 population), one nursing professional for every 125 inhabitants (8.0 per 1,000 population), and one stomatologist for every 640 inhabitants (1.56 per 1,000population) (). The family physician and nurse program has universal coverage and is based on PHC.

In 2015, education of health personnel took place in 13 universities and 25 medical schools, 4 colleges of stomatology, one nursing school, one school of health technology, three schools of technology and nursing, 15 branches of medical sciences, the Latin American Medical School, the National School of Public Health, and the Havana Medical Sciences University Preparatory School in Cojímar ().

The medical science universities are part of the health sector and fall under the authority of the Ministry of Public Health. An education in the health sciences ensures that professionals and technical personnel have the skills needed to perform the four essential functions of the system (care, education, research, and administration) (), with emphasis on the PHC strategy. The updating of the family physician and nurse program and the enhancement of the plans, curricula, and teaching literature of the medical specialties has incorporated a gender perspective as well as subjects related to efficiency, solidarity, respect for differences, and shared responsibility in sexual and family matters. Between 2010 and 2015, 144,510 health professionals received degrees; of these, 47,145 were in medicine and 31,533 were in nursing ().

Health Knowledge, Technology, and Information

Automation and digital literacy must improve if Cuba is to achieve more complete and sustainable social development, especially in the health sector (). Infomed, the telematics information network of the National Health System, helps make information and communication technologies available in different venues such as libraries, laboratories, and points of presence at National Health System institutions connected to the network (). There are 707 libraries, of which 563 are connected to this network, which includes the 441 primary care polyclinics ().

The Environment and Human Security

Rising sea levels will continue to be the principal danger posed by climate change to the Cuban archipelago, due to the effects of coastal flooding and salinization of the groundwater and soil, as well as the destruction of the natural and built coastal environment. With regard to human settlements, it is estimated that partial damage will be caused to 78 settlements by 2050, and 107 by 2100, while 15 settlements are expected to be completely destroyed by 2050, and 6 more by 2100 ().

The main environmental problems facing the Cuban archipelago are the downgrading of soils, damages to forest coverage, atmospheric emissions, noise pollution, the dumping of chemicals and hazardous waste, the loss of biodiversity, problems with the availability and quality of water, and the impact of climate change, which is gradually becoming a hindrance to sustainable development in the country ().

In 2014, the percentage of population with access to drinking water was 95.2% (98.1% in urban areas and 85.4% in rural ones), while the percentage of inhabitants with access to basic sanitation reached 96.7% (98.2% in urban areas and 91.7% in rural ones) ().

From 2001 to 2015, eight intense hurricanes damaged Cuba, an unprecedented frequency in the island’s history (). In the 2010–2015 period there were few tropical cyclones that impacted the country. However, on 25 October 2012, Hurricane Sandy, Category 2 on the Saffir–Simpson Hurricane Wind Scale, crossed the eastern region from south to north, killing 11 people and injuring more than 100, with serious flooding and material damages (). Improvements continue to be made to the capacity to respond to disaster risks. Cuba has a catastrophe response plan that consists of an organized early warning system, an effective evacuation system, and a social safety net for protection of the general population. The latter devotes special attention to the most vulnerable groups: pregnant women, the elderly, persons with disabilities, children, coastal residents, and populations residing near at-risk sites ().

Aging

In 2015, more than half (57%) of people 60 to 74 years old had intermediate and university-level education (). Family doctors provide comprehensive in-home and institutional care to older persons, with the support of multidisciplinary geriatric service teams. In 2014 two new geriatric services were added, for a total of 36, and including 769 beds. With the reorganization of hospital-based services in the context of the health sector transformation process begun in 2010, 57 beds were added to the existing services, and the opening of 12 new care centers for older persons, with a total of 128 beds, was proposed. This would yield 954 spaces by 2016, which is one bed for every 2,000 older persons ().

The specialty of geriatrics and gerontology was strengthened in the country: in 2015 there were 477 geriatricians and 152 residents were trained; furthermore, 135,219 consultations () were offered in this specialty. The Comprehensive Older Adult Program, a priority in the National Health System, includes the formation of human capital among its strategies. In 2015 there were 147 nursing homes and 265 “grandparent homes” (Casas del Abuelo, senior day care homes), as well as grandparent circles in the community and other institutions to serve older persons who needed them due to their socioeconomic status or disability (). The grandparent homes fulfill an essential role: help family caregivers remain in the workforce, with an inclusive approach and a gender perspective vis-à-vis the family and society.

Migration

In 2015 there was internal migration of 80,581 inhabitants (41,524 men and 39,057 women). Havana was the preferred destination, receiving 23,136 people (11,395 men and 11,741 women) ().

That same year, the adverse impact of the U.S. “wet foot, dry foot” policy was revealed when some 7,802 Cubans were stranded for four months in Central America before receiving transit visas in Costa Rica to enter the United States (). As part of the normalization of diplomatic relations between Cuba and the United States, in 2016 an agreement was signed to ensure regular, safe, and orderly migration, which put an end to the “wet foot, dry foot” policy and to the Cuban Medical Professional Parole Program, which favored illegal immigration and the brain drain ().

Monitoring of the Health System’s Organization, Provision of Care, and Performance

In 2015, gross domestic product (GDP) was 54.45 billion pesos (1 peso ($) = 1 US$) in 1997 constant prices, with health and social welfare expenditures of 8.997 billion pesos. Execution of the public health budget was $7.179 billion in 2015, which represented an increase of 49.8% in current currency between 2010 and 2015 (). Expenditure on health per inhabitant was $639.58, one-third more in current currency than the $426.49 recorded in 2010 (). In constant 1997 prices, expenditure on health and social welfare per inhabitant was $800.56, the second-largest category of GDP ().

The foregoing confirms the high priority assigned to the health sector despite the difficult economic situation. Cuba is hampered by the United States’ economic, trade, and financial blockade, which remains in full force and prevents the completion of international trade transactions (), even though diplomatic relations have been reestablished.

The biotechnology industry produces 525 generic drugs (of 849 in the country’s Basic Schedule of Essential Drugs) and 8 vaccines (of 11 on the national vaccination schedule to protect against 13 diseases). Additionally, it contributes foreign exchange to help finance the National Health System by exporting innovative products (). Something similar occurs with Cuban medical services abroad, which constitutes an important source of financing. Both sectors contribute to the sustainability of the National Health System.

Social welfare provided support for the people who needed it. The number and quality of grandparent homes and nursing homes increased, in accordance with the policy adopted to serve the aging population. Furthermore, protection was provided to 1.6 million retirees and expenditures increased on social security, maternity leave payments, and protections for partial disability. In 2015 the public health and education budget accounted for 54% of the total budget, an expression of the commitment to human development found in Cuban public policies ().

Health services are differentiated to meet the needs of each territory, community, population group, family, and individual, in order to guarantee equity and efficiency based on an assessment of the health situation at each level of the system. This is conducted through a system organized into PHC-based Integrated Health Services Networks (Redes Integradas de Servicios de Salud(RISS) /Atención Primaria en Salud (APS)). At the end of 2015 there were a total of 11,958 medical care units, comprising 451 polyclinics, which have 10,782 family physician and nurse offices, 112 intensive care units (32 of which are pediatric), 120 municipal intensive vital support areas, 110 stomatology clinics, and 136 maternity homes. The country had 151 hospitals and 12 research institutes that represent the highest level of specialization in the National Health System. The total number of medical beds was 45,892 and the social welfare units totaled 442 with 14,168 beds (). There were comprehensive rehabilitation services at all levels, with 420 primary care wards.

Starting in October 2015, Cuba decided to strengthen the monitoring and evaluation of its universal health strategy. Cuba’s significant progress towards that goal is largely due to the fact that ever since the National Health System was founded in 1959, it always endeavored to instill the values, objectives, principles, and guidelines of universal health into the institution. Cuba not only has one of the lowest out-of-pocket expenditures in the region (which reflects the degree of financial protection), it also has a people- and community-centered health system, which is organized according to RISS/APS, with a strong intersectoral component, whose fundamental values are the right to health, solidarity, and equity.

The transformation of the National Health System took place between 2010 and 2015. Its program document lays out three main objectives: continue to improve the health of the population, increase the quality of and satisfaction with services, and make the system efficient and sustainable. Hence, the health services have been reorganized, streamlined, and regionalized to produce the most efficient and rational use of resources, especially technology, and to guarantee access (). Since their launching in November 2010, these transformations have made it possible to progressively achieve the proposed objectives (). The changes have been implemented through a process of information-sharing and dialogue with the community and health workers in different institutions and territories throughout the country, in which the special features and complexity of each service are taken into account.

Health promotion and disease prevention are fundamental activities that benefit from the broad, active, and organized participation of the community and of multiple sectors. These are essential components of Cuban society and the National Health System, and they decisively help improve the population’s health indicators, particularly for women and children. An intersectoral approach is the tool used to manage health from the grassroots up to the highest levels of management of the government and the State ().

In 2014 Cuba chaired the 67th World Health Assembly, the first time it held that honor. That same year 256 Cuban physicians went to West Africa to help manage Ebola virus disease. In 2015 medical cooperation was provided through the sending of 67,707 health workers to 65 countries on five continents, including 24 in the Americas; 43,631 (64%) of these workers were women ().

Prospects

Cuba is currently facing several challenges. Resisting climate change is a high priority. The impacts felt today, along with the increase in extreme weather events and the country’s vulnerability, portend major economic and social burdens. Cuba must improve the resilience of the health sector, based on better knowledge and understanding of the relationships between climate variability, climate change, and human health. This key action should revolve around two essential linchpins: infectious diseases and the health sector’s Surveillance and Early Warning System (). Enhanced resilience should also benefit the fight against NCDs. Box 1 highlights Cuba’s main achievements and challenges in health.

Among the highest priority issues that the health sector and other sectors should tackle jointly are the NCDs, the very low fertility of the population and its impact on health, loss of the replacement rate, and population aging (). These trends imply an enormous burden for the National Health System—in its preventive dimensions, in terms of health workers and disease care, rehabilitation, and care throughout life, and in terms of its organization, financing, and efficiency. The most important principle of the Cuban public health system is and will continue to be the primacy of prevention over cure, within a primary health care approach. The solid and rapid implementation of the PHC strategy, imbued in the family physician and nurse program, has fueled the health system’s progress toward universal health. The strengthening of the preventive approach and health promotion is necessary not only from a health standpoint but also because of the economic imperative to keep the National Health System sustainable. These principles must adapt to the new challenges.

In addition to their high mortality, NCDs bring the burden of recurrent flare-ups and increasing disability, place significant pressure on the health services, and require the allocation of additional human, material, and financial resources to satisfy the demand for care.

The National Health System is bracing itself for the progressive aging of the population. At the end of 2015, the country was better positioned to provide health services to the elderly population than in previous years. Measures related to the care of older persons include: the validation of protocols to address geriatric problems; the performance of annual health assessments on more than 95% of older persons; the enhancement of gerontological care at the primary level; and an increase in the number, repair, and support for grandparent homes and existing nursing homes ().

In a country forecasted to have around 30% of its population over 60 years old by 2030, it is vital to increase the geriatric competencies of all health professionals and step up training in geriatrics and gerontology, as well as adapt the National Health System to respond to the multiple needs of this group ().

The great task that Cuba must accomplish in health in the coming years is to ensure the sustainability and consolidation of its achievements within a framework suited to a new demographic, epidemiological, economic, social, and political reality. Only more efficient operation of the National Health System will make it possible to continue to guarantee the right to health and sustain progress toward universal health.

Box 1. Achievements and Challenges in Health

In 2015 Cuba achieved the Millennium Development Goals. This demonstrates not only the government’s determination to continue to facilitate the achievement of better standards of living and welfare for its population (by continuously fighting poverty and hunger, reducing and mitigating environmental degradation, improving levels of education and health, and promoting gender equity and international cooperation), but also its political will to channel the country’s limited resources toward the achievement of the greatest possible financial and social good ().

One of the biggest successes the Cuban public health system ever had occurred on 30 June 2015 when the country obtained certification of the elimination of mother-to-child transmission of HIV and congenital syphilis. To do so, the country underwent a rigorous World Health Organization review process and had to submit a report describing the demographic and socioeconomic context, the epidemiological situation of HIV and syphilis, respect for human rights, the health system, the programmatic aspects linked to the epidemic and impact indicators, etc., that documented the work done to achieve and sustain this milestone ().

The country stands by its decision to comply with all international agreements it has adopted on women’s rights and aims to achieve gender equity. The Beijing agreements should be mainstreamed into an effective program to support achievement of the Sustainable Development Goals. While all of this was happening, in 2015 Cuba obtained a high human development index, placing it 67th among the 188 countries of the world, while Cuba is among the top 10 countries of Latin America and the Caribbean ().

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Reference/Note:

1. International Statistical Classification of Diseases and Related Health Problems, 10th revision.

2. Reproductive Age Mortality Studies.

3. Studies indicate that by 2050 2.45% of the land area will be permanently submerged due to sea levels rising by 27 cm, and the situation would be worse by 2100. These estimates do not include the keys ().

4. Grandparent circles are associations to promote health, recreation, and daily physical activity. They are present in all localities throughout the country and revolve around educational activities and health promotion for older persons ().

5. This is a process that includes an assessment and planned interventions. It is led by the basic health team and addresses the health situation of individuals and families. It is implemented through a series of actions. The assessment will confirm or modify the categorization of individuals into one of the four established “dispensary” groups: healthy people, those at risk, sick people, and persons with disabilities ().

6. Operación Milagro: This is a health plan started jointly by the governments of Cuba and Venezuela that seeks to address certain eye diseases in the population. The plan also operates in 31 countries of Latin America, the Caribbean, Asia, and Africa.

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