Cuba has a successful healthcare model with quality, access and outcomes better than the majority of counties around the world. In fact Cuba considers healthcare one of their major exports; Cuba exports approximately $8B of professional services carried out by its physicians and nurses each year, with 37,000 professionals working in 77 countries.
Now that Cuba is opening to Americans, a recent trip offered an exciting opportunity to better understand how they've created such a successful model. This week review of their healthcare system was eye-opening and demonstrated some ways in which Cuba has developed this model of care.
What is interesting is that Cuba's success in healthcare seems less about them creating a better delivery model for care but more about developing a model that creates better adherence to basic standards of care. The delivery model is efficient but the adherence is more impressive. Here are some examples:
1. Segmentation of assets and labor. The structure of the health system builds upon the base level of primary care, with primary care physicians or family doctors distributed within the neighborhoods. The next level is the polyclinic, which coordinates the majority of outpatient specialty activity. The third level is single specialty tertiary hospital locations, which are distributed in the major cities.
This segmentation model may promote more customized care for the population but doesn't seem to take advantage of scale economies, particularly in the tertiary hospitals, which is important for clinical and financial performance. Organizing the population by acuity and disease outweighs the clinical and financial benefits of consolidation. This balance is likely the opposite in most US markets.
2. Access. With over 67 physicians per 100,000 population, Cuba has the best access to physicians. The physicians, particularly family doctors, are located in neighborhoods, living within a mile or less of their patient base. The physicians know the families, friends, behaviors and risk factors for their neighborhoods.
While access to physicians is impressive, there were accounts of family doctors entering homes unannounced to observe health and environmental factors of their "patients". These unannounced visits, while common in Cuba, may not be as welcome in the US given privacy requirements of our population.
3. Behavioral adherence. Because of communism, Cuba has complete control over the behavioral and health standards it places on its populations. Cuba unequivocally follows basic clinical care guidelines for prevention, diagnosis and treatment. For example, Cuba's immunization coverage for measles is 99%, compared to the US average of 91% and the world average of 84%. When there's an outbreak, the system quickly moves into homes and the work place to tend to health, behavior and environmental needs (e.g. water, sanitation, cleanliness).
It is unlikely the US can move toward more direct control over its population's behaviors given our democratic republic heritage. That said, there is precedence in the US for regulating health precursors, such as pollution, smoking and car safety. Is it unrealistic to assume that one day calorie, exercise and gun violence will fall under similar regulations?
4. Government control. The Cuban government controls the supply of healthcare services by organizing the medical training and deployment of physicians and providers across the country and the demand for services through paying for the access to and use of services for the population. This model allows an orchestrated balance of supply and demand. When there are shortages or surpluses on either side of the supply/demand equation, the government can use its power to affect a more optimal balance.
Given the complexity of the US health system, it is unlikely we achieve this orchestrated balance. It is more likely as the trade restraints are lessened, Cuba moves more toward the US model of consumerism and choice for both supply and demand of services.
These and other attributes have helped Cuba develop an impressive model of healthcare, in which a small country, isolated from much of the world. As Cuba opens its doors, it will be interesting to see how the healthcare system remains strong, given other opportunities for trade. Perhaps Cuba becomes a healthcare destination, perhaps Cuba builds upon its professional services export model, perhaps Cuba accelerates its investments in research and innovation. Regardless of the approach, I am hopeful that Cuba continues its journey developing the best care model for adherence and outcomes known throughout the world and we can continue to learn from them.
1 Frist, B. Cuba's Most Valuable Export: Its Healthcare Expertise. Forbes. June 8, 2015.
2 Source: World Health Statistics 2015, World Health Organization
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