This highly structured, prevention-oriented system has produced positive results. Vaccination rates in Cuba are among the highest in the world. The life expectancy of 78 years from birth is virtually identical to that in the United States. The infant mortality rate in Cuba has fallen from more than 80 per 1000 live births in the 1950s to less than 5 per 1000 — lower than the U.S. rate, although the maternal mortality rate remains well above those in developed countries and is in the middle of the range for Caribbean countries.
Without doubt, the improved health outcomes are largely the result of improvements in nutrition and education, which address the social determinants of health. Cuba's literacy rate is 99%, and health education is part of the mandatory school curriculum.
A recent national program to promote acceptance of men who have sex with men was designed in part to reduce rates of sexually transmitted disease and improve acceptance of and adherence to treatment. Cigarettes can no longer be obtained with monthly ration cards, and smoking rates have decreased, though local health teams say it remains difficult to get smokers to quit. Contraception is free and strongly encouraged. Abortion is legal but is seen as a failure of prevention.
But one should not romanticize Cuban health care. The system is not designed for consumer choice or individual initiatives. There is no alternative, private-payer health system. Physicians get government benefits such as housing and food subsidies, but they are paid only about $20 per month. Their education is free, and they are respected, but they are unlikely to attain personal wealth.
Cuba is a country where 80% of the citizens work for the government, and the government manages the budgets. In a community health clinic, signs tell patients how much their free care is actually costing the system, but no market forces compel efficiency.
Resources are limited, as we learned in meeting with Cuban medical and public health professionals as part of a group of editors from the United States. A nephrologist in Cienfuegos, 160 miles south of Havana, lists 77 patients on dialysis in the province, which on a population basis is about 40% of the current U.S. rate — similar to what the U.S. rate was in 1985. A neurologist reports that his hospital got a CT scanner only 12 years ago.
U.S. students who are enrolled in a Cuban medical school say that operating rooms run quickly and efficiently but with very little technology. Access to information through the Internet is minimal. One medical student reports being limited to 30 minutes per week of dial-up access. This limitation, like many of the resource constraints that affect progress, is blamed on the long-standing U.S. economic embargo, but there may be other forces in the central government working against rapid, easy communication among Cubans and with the United States.