It is widely recognised that healthcare in Cuba is at a high level and that child health, in particular, is excellent.1 This is illustrated by data from the World Health Organization (WHO) in its report World Health Statistics 20072 and UNICEF in its report The State of the World’s Children 2008.3 Table 1 shows mortality rates for neonates, infants and children under the age of 5 (U5MR) for Cuba and three of its nearest neighbours, who all have a higher standard of living, as well as showing the United Kingdom and the United States. The U5MR is considered by UNICEF as the single most important indicator of the state of a nation’s children.3 It is used as a marker of whether countries are successfully reducing child mortality.

Cuba has both the lowest U5MR and the greatest reduction in U5MR (between 1990 and 2003) in Latin America and the Caribbean.4 The U5MR in Cuba is considerably lower than that of wealthier neighbouring countries and in between that of the U5MR of the United Kingdom and the United States. The United Kingdom and the United States are in the top 10 richest countries in the world, whereas Cuba is ranked as the 120th wealthiest country. At a time when many countries are following the American model of privatising health care, it is useful to look at how Cuba has managed to reduce its mortality rates for children with a free publically funded healthcare system.

PRIMARY HEALTHCARE

One of the strengths of the Cuban health system is its primary healthcare. This is based on the family doctor.5 Almost half of Cuban doctors are family doctors and they are based in a small primary care centre (consultorio). Attached to each consultorio is a nurse and both the family doctor and nurse live either next to the consultorio or very close to it. There are currently 15 150 consultorios in Cuba. The family doctor and nurse provide medical care for between 120 and 160 families.

The populations covered by each family doctor are usually the same each year, that is, there is little migration between cities and rural areas. This provides an excellent opportunity for each family physician to get to know individual families. The family doctor and nurse have a good understanding of each patient and their families both medically and socially. Patients with social problems that may affect their health are identified early. Each patient is seen at least twice each year for a routine check up. One check up occurs within the primary care clinic and the other occurs in the patient’s home. Newborn infants are seen fortnightly for the first 6 months and subsequently monthly until the age of 12 months.

Breast feeding is important in relation to both reducing infant morbidity and mortality. The WHO recommends exclusive breast feeding for the first 6 months of life. A recent UNICEF multiple indicator cluster survey6 showed that 26% of Cuban infants at the age of 6 months were still exclusively breast fed and 47% of Cuban infants between the ages of 6 and 9 months were still being breast fed. These high breastfeeding rates are due to a combination of education and the intensive input of the primary healthcare team, both antenatally and to young women.

The family doctor and nurse theoretically provide a 24-h service for their patients. Family doctors are usually present in the clinic each morning but in the afternoons will often see patients at home or meet with other health professionals.

Immunisations

There is a comprehensive immunisation programme that starts at birth with BCG and Hepatitis B vaccination.7 In the first year of life, three doses of DPT are given alongside polio, MMR, Hib and Men B (table 2). The vaccine for meningococcus types B and C was developed in Cuba.8 9 Oral polio vaccine is given only during national mass campaigns (usually during February and April).10 Immunisations are provided in the polyclinics as vaccines need to be stored in fridges and Cuba does not have the resources to provide a fridge for each family doctor. Despite this the immunisation uptake (88–99%) is similar to that in the UK (81–96%). Immunisation has resulted in the elimination of several diseases throughout Cuba: polio 1962, neonatal tetanus 1972, diphtheria 1979, measles 1993, whooping cough 1994 and rubella 1995.11 Additionally, there have been no reported cases of acute hepatitis B in children under the age of 5 years since 2000.11

SECONDARY CARE

There are currently 444 polyclinics in Cuba and family doctors often refer patients to the polyclinic for a more specialised second opinion. A typical polyclinic covers 30–40 family doctors and a population of about 30 000. Polyclinics offer a variety of specialist opinions. These include paediatrics, dentistry, social work, physiotherapy and clinical psychology and larger polyclinics may offer a variety of other specialities. Cuba has an excellent education system and has trained a wide variety of health professionals (table 3).7 Specialty services may be provided on a weekly basis rather than every single day. A child who needs to see a specialist, eg, a clinical psychologist, will have to wait up to 1 week for an opinion. Polyclinics also offer emergency medical assessment and treatment. Parents of young children, however, often prefer to go directly to the Emergency Department within a Children’s Hospital.

Tertiary care is provided in hospitals and research institutes. There are currently 24 children’s hospitals throughout Cuba. Specialised services such as paediatric cardiology and paediatric oncology are provided in regional centres or Havana.

PUBLIC HEALTH

The Ministry of Public Health of Cuba provides extensive information in relation to the health of the Cuban people and the health personnel involved in providing healthcare.7 They provide annual statistics and include an annual health statistics report in English. The major causes of mortality in Cuban infants in the first year of life are congenital malformations, septicaemia and intracranial haemorrhage. The major causes of mortality between the ages of 1 and 14 years are trauma, malignancy and congenital malformations.

Child health does not relate solely to the healthcare system. The provision of clean water, adequate diet and housing as well as education, are all crucial in relation to health. The United Nations, in September 2000, adopted the Millennium Declaration, which consisted of eight goals with a view to reducing poverty and hunger and, in particular, improving health and education.12 Millennium Development Goal (MDG) Four (MDG 4) is to reduce the U5MR by two thirds between the years 1990 and 2015.12 Cuba is on track to achieve MDG 4 and has attained the two MDGs that relate to education. MDG 2 ensures that all boys and girls complete a full course of primary schooling and MDG 3 eliminates gender disparity in primary and secondary education.11 Education is free and universal for all children between the ages of 6 and 16 years. Nursery education from the age of 3 years is available but has to be paid for.

Three of the major causes of death in young children worldwide are pneumonia, diarrhoeal diseases and neonatal infections.3 These are all treatable conditions but are dependent upon access to healthcare, both for pregnant women and young children, alongside access to clean drinking water and sanitation. Access to healthcare in Cuba is universal with 99.9% of live births occurring in hospital.7 11 99.7% of the population have access to a family doctor.7

Undernutrition is a key factor in up to half of all deaths in children under five worldwide.3 The percentage of low birthweight babies born in Cuba (5%) is considerably lower than neighbouring countries: Costa Rica (7%), Dominican Republic (11%) and Jamaica (12%) (data for 1999–2006 from UNICEF3). This is thought to be due to the excellent primary healthcare alongside targeted nutrition and education of women of child-bearing age. An additional factor is the recognition that the health of women and children is a priority in relation to public health.11

The number of children under the age of 5 years dying due to diarrhoeal diseases (both absolute and as a percentage) is considerably lower in Cuba than in neighbouring countries2 (table 4). This is probably due to a combination of factors including education and awareness of both parents and siblings of young children of the importance of hygiene, alongside the availability of an adequate water supply and adequate levels of sanitation.3 Surveillance for intestinal parasitosis in young children is carried out each May and October.11 This is done by collecting a single stool sample from all asymptomatic children attending selected day care centres where 15% of young children between the ages of 1 and 4 years attend.

POLITICAL ISSUES

It is impossible to discuss healthcare in Cuba without considering the political situation on the island. Prior to the Cuban Revolution in 1959, healthcare was centred in the major cities.13 Healthcare in the rural areas was non existent. In the first few years following the revolution almost half the 6000 doctors in Cuba emigrated to the United States. The Cuban political viewpoint on healthcare has always been that all Cubans are entitled to free and comprehensive healthcare and that this should be provided by the government and not left to private corporations.14

Improvements in healthcare were seen in the 1960s and 70s. In 1962 a widespread immunisation programme was introduced for diphtheria, tetanus, whooping cough and poliomyelitis. In 1984 a new model of providing health was established based on the family doctor. This model was introduced following the 1978 Alma Ata declaration.3 It was recognised that basing health round family doctors would strengthen primary healthcare and this has been confirmed by the continual decline in mortality rates of infants and children as documented by UNICEF (table 5).15

These achievements are even more remarkable if one considers the effects of the economic blockade on Cuba imposed by the United States. This economic blockade makes it more difficult for Cuba to purchase food, medicines and equipment that have a direct effect on health.11 16 An additional feature of the US blockade is the political and scientific isolation of Cuban health professionals. The US government actively discourages its citizens from visiting Cuba, and American health professionals need permission from their government to visit or attend scientific meetings in Cuba. It also considerably raises the prices of non-medical items such as construction materials. Many of Cuba’s hospitals and other government buildings are in a poor physical state.

The dissolution of the Soviet Union in the 1990s resulted in Cuba suddenly losing its trading partners (75% fall) and sources of investment.17 From 1989 to 1993 Cuba’s gross domestic product (GDP) and individual per capita income dropped by approximately 40%.17 The United Nations stated that the loss of trading partners for Cuba constituted a loss of markets more severe than that brought about by the Great Depression.17 Despite the effects of the blockade and the loss of its trading partners, healthcare services have been maintained and mortality rates for infants and children have continued to fall.

Tourism is now the biggest source of income, accounting for 8% Cuban GDP.17 Increased tourism in Cuba has, however, resulted in greater inequality with people working in the tourist industry seeing significant rises in their income.18 Inequalities in society are often associated with inequalities in health.19 In many societies black people are the poorest sections of the community and have shorter life expectancy. By 1981 Cuba had achieved equal life expectancy for black and white adults.18 In contrast, black adults in the United States and Brazil had a life expectancy 6–7 years shorter than white Americans and Brazilians in the same time period. Increased tourism has benefited white communities more than black communities within Cuba. It is to be hoped that inequalities in Cuban society can be reduced, while at the same time maintaining tourism, which is essential economically for Cuba to survive.

Many European countries are adopting an American model of healthcare with an increased role for private corporations who provide healthcare in order to make a profit.20 21 Cuba provides an alternative model of healthcare which, according to both the WHO and UNICEF, provides excellent healthcare at a lower price. It would be difficult to replicate Cuba’s healthcare systems in other countries. There are, however, important lessons that one can learn from a healthcare model that is universal, free of charge and based on a local accessible family doctor and nurse.

UNICEF, in its annual report, highlights that two thirds of deaths in children U5MR are preventable.3 Key services highlighted as essential to reduce death rates in young children include access to healthcare at birth, especially for low birthweight babies; adequate nutrition, especially exclusive breast feeding in the first six months and continued breast feeding for at least two more years; immunisation; oral rehydration therapy and zinc; antibiotics for pneumonia and antimalarial treatment. The presence of a free, locally accessible healthcare system alongside a free adequately funded secondary healthcare system in Cuba reinforces UNICEF’s position that the majority of child deaths worldwide are preventable. Universal education (particularly women’s education) and access to water and sanitation alongside a political commitment to reduce inequalities in society are all key aspects of improving child health both in developing and developed countries.

SUMMARY

Cuba provides excellent healthcare for its children and this is reflected in low mortality rates. The basis of its healthcare is an extensive primary healthcare system that is focused on prevention. This healthcare system is free of charge and publicly funded and has achieved excellent healthcare at a low price.