revolution in health Cuba's experience in bringing health services to its people was observed for WH 0 by Eilif Liisberg and lraj"Tabibzadeh, interviewed here by Albert Ezban WORLD HEALTH : Dr Liisberg and Dr Tabibzadeh , you have viA'ited Cuba. Could you tell us what the purpose of your mission was ? EILIF LnSBERG : The purpose of the mission to Cuba was to study and describe the health services of Cuba as .part of a WHO/ UNICEF joint study on alternative approaches to meeting health needs of populations in devel- oping countries . We visited the Ministry of Health, at various levels of authority, and health institutions in Havana, in the pro- vinces and in rural areas. W.H.: What struck you most during your visit? KL. :What particularly impressed us was the intensive coverage achieved by the health ser- vices, practically 100 per cent. We went to quite remote areas and we found the same quality of health services there as in the capi- tal. [RAJ T ABIBZADEH: Probably as a result of this wide health service coverage, during the last ten years Cuba has been able to eradicate malaria and poliomyelitis and to reduce the threat of other diseases, so that communi- cable diseases no longer pose a major health problem in most parts of the country. Today the main causes of death in Cuba are heart disease, chronic respiratory diseases, malig- nant tumours, cerebrovascular diseases, acci- dents and other chronic diseases. W.H. : What are the reasons for these sue- . cesses? EL.: Several factors must have played a role. One of them, I think, must be the national will that has made social amenities and health services available to all the people. There is an extraordinary will to implement decisions, good organization of these ser- 14 vices, and excellent programming. One thing which impressed us was the feeling of partici- pation among all the health staff. That human side struck us very much in all the health institutions we visited. LT: We realized that the decision had been taken at the higher, political level that health and education are the primary objectives in Cuba's general social and economic develop- ment. As we understood it, more than 50 per cent of the government budget is allocated to health and education. These aspects, plus the CUBA IN FIGURES Popu lat ion (total) (urban) (ru ral ) Annual rate of popula - ti on increase Crude birth rate (per 1000) Crude death rate (per 1000) Life expectancy at birth Infant mortality per1000 live births Population under 15 yea rs %of deaths < 15 yea rs Number of hospital beds per 1000 popul at io n Sources : WHO. UN . 8657 160 (71) 60.5% (71) 39 .5% (71) 2.3% (72) 28.3 (72) 5.5 (72) 66.8 years (65-70) 27 (73) 36 .7% (7 1) 214% (71) 4. 26 (72) extensive training of manpower, have con- tributed to the successes in health matters. W.H.: In what way i$ community participation brought about? E.L. : Well, the whole country is organized according to different groups and levels of population . For instance, the Federation of Cuban Women, the trade unions, the Corn- mittees for the Defence of the Revolution, are all organized from the national level down to street level ; it is an intertwining system of organizations which coordinate be- tween each other to share responsibilities and actively participate in social and health work . There are regular meetings within the organizations, between the organizations and the administrative services, with the health services and with the Cuban Com- munist Party, and we really got the feeling people were interested. In fact, we joined in a street committee meeting and were told how interested they were in immunization and cleanliness. LT: You can measure community participa- tion by the fact that in most street or rural committees there are one or two persons who belong to the health department. As a result committee discussions tend to increase peo- ple's awareness of health matters. On the practical level , polio immunization, for example, is carried out by street volun- teers and in 1972 more than 900,000 children were immunized in less than three days. W.H.: How are preventive and curative health services integrated? LT: The Cuban health services very success- fully combine preventive, curative and pro- motional activities; there is no separation between these three main components of health activities. In the health centres, the same clinic usually serves for vaccination or A visiting nurse carrying out BCG vaccination . M ore than 90 per cent of the Cuban population is now protected by the tuberculosis programme which started in 1963. The TB mortality rate fell from 19.6 per 100,000 in 1962 to 4.1 in 1973. (Photo WHO/E. Rice)
other disease, prevention activities for chil- dren or infants, but it also administers cura- tive procedures and even promotional work about nutrition and so forth. It is all com- pletely integrated. W.H.: Is the health of the population a govern- ment responsibility? E.L.: Cuba's revolution in 1959 made big changes, one might say from the grass roots. We were told that the leader of the revolu- tion, Dr Fidel Castro, always explained how problems related together - health, educa- tion, nutrition, farm implements, fishing, communications and so on. Thus it was im- possible to make profound changes in the health of the population if there was a high percentage of illiteracy, or if some regions lacked communications. Roads have now been improved and illiteracy wiped out. All the people know how to read and write. Now they are able to educate the people in public health. Moreover it is the stated responsibili- ty of the government to provide health ser- vices for the people. I think this is one of the basic political decisions that have been taken. The leadership invariably describes health as the right of the people and one of the first priorities in Cuba's development, while the whole community is encouraged to participate actively in health work. W.H.: How has the government undertaken the training and redeployment of health per- sonnel to implement its health policy? I.T.: Around the years 1959 and 1960, Cuba had about 6,000 physicians, more than half of them in Havana. In the first ten years of the revolution, about 2,800 of these doctors, for various reasons, left the country. The Cuban Ministry of Health in conjunction with the universities managed within the next ten years, from 1963 to 1973, to train about 5,000 doctors, so that in 1973 their numbers stood at around 8,000. The character of the training has also changed, and there is much emphasis on practical studies, close contact with the community, and an integrated preventive, curative and promotional ap- proach. The approach to the development of health services is pragmatic and gradual, in fact private practice still continues, with 350 physicians. But Cuba's fundamental concept of the physician today is of a man who heals by changing and improving the environment, the working conditions and food. All physicians have to work for two to three years after graduation in a rural health centre, and this is the starting point for career development. The government also trained a consider- able number of nursing staff and auxiliaries of all kinds. There has been total manpower planning in that the government doesn't only think of doctors and nurses but, for instance, of maintenance personnel in all the different specialities, like X-ray maintenance. What struck us was the mobility within the health services structure, how the assistant nurses or the nursing aides were given a general educa- tion by their colleagues in clinics to increase their general background so that they might later on join the nursing school. W.H.: Do the health services use traditional midwives and curanderos ( traditional doc- tors)? E.L.: No, the Cuban system is basically dependent on the physician and they have forbidden the activities of traditional mid- wives or other persons who previously prac- tised without licence. But they have trained them and brought them into the health ser- vice according to their capacity as different types of auxiliaries and under the supervision of the physicians. The curanderos were not allowed to practise. W.H.: In what ways has the government ap- proached rural health problems? LT.: First of all, top priority has been given to rural activities; for example, water supply and sewage disposal is immediately provided in new housing projects in the countryside. In such areas the rate of enteric diseases has usually dropped sharply. In addition , we un- derstood that health institutions now exist even in the most remote areas. After the government started sending out physicians to the rural areas and training auxiliaries, it began a series of pilot pro- grammes on a trial basis to find out how best to provide services for a community. It divided the programme into eight areas: inte- grated care for children, integrated care for women, integrated care for other adults, communicable diseases, environmental sani- tation, food hygiene, occupational health, and dentistry. In this study it was getting results within six months, and from then on it started implementing the results slowly all over the country, but again with emphasis on the remote areas. This is the interesting Opposite page : A teaching hospital in Santia- go de Cuba. Following a one-year internship in a teaching hospital, medical graduates spend two years in the peripheral services and may specialize afterwards. (Photo WHO/E. Rice) Below: A clinic 60 miles north of Santiago de Cuba. Health services have been regionalized in order to make primary care accessible to all. (Photo WHO/E. Rice) point: the Cubans did not start from the centre and work outwards, they started where there was nothing. Today, in most parts of the country, major health programme activities are concentrated along the lines of these eight programmes. W.H.: Could you describe the work being done in the field of maternal and child health? I.T.: Maternal and child health has been given the highest priority among other health activities, and today 93 per cent of all deliv- eries occur in hospital. Most pregnant women have pre-nat:;tl and post-natal care. The coverage is practically 100 per cent. There are often also child health clinics. Usually in each health centre there are three doctors, of whom one is a gynaecologist or obstetrician, one a paediatrician and the third an internist. Immunization of the children and their nutri- tion is arranged on the basis of a planned programme and auxiliaries call at the house at once if the mother has forgotten to bring her child for vaccination, because they keep a file on the family at the clinic. In fact, there are regular home visits on the basis of indi- vidual and family files for the purpose of different programmes. E.L.: Here too, the integrated approach en- sures that social legislation and labour legis- lation all fit in with health needs. Take for example the fact that women who breastfeed their children are given hours off to go home and feed them. A mother may stay home to look after her sick children and still be paid her salary. Pregnant women and women with children under one year old cannot lose their jobs; they have complete job security. There are also kindergartens to take care of chil- dren during working hours. W.H.: What are the main features of the health planning process in Cuba ? LT. : The Cubans' approach is essentially pragmatic; they plan on the basis of epide- miological findings, according to the priori- ties and real needs of the community, espe- cially in rural areas. They have these eight different programmes which have been men- tioned before. Thus each area is set a target not only annually but also monthly, which helps to evaluate their capacity to reach it. Such evaluation enables fresh targets to be set for each health centre, on a national , regional or local level, when next year's plan is being drawn up. E.L. : Remember, it is a total approach. The Cubans don't forget that you need drugs, transport and petrol. We didn't see any X- ray machines broken down or things that didn ' t work because of a Jack of spare parts. We found that the system worked quite smoothly because of this very weB-integrated planning activity. There seems to be very wide participation by a 11 the professional people in the plan- ning, and also a great sense of participation by a 11 kinds of specialists who are grouped into what they call task forces and who Jay down standards and norms which are then published as basic training manuals, for practical daily health work and for imple- mentation of the programmes. W.H.: Ho w have they dealt with the main health problems, for instance the communi- cable diseases ? What are the successes and what are the failures, if any ? E.L. :There has been a measurable success in the fight against the infectious diseases, and this can be seen in the mortality rates, as we11 as in the specific disease mortality rates and morbidity rates. Certain diseases have been, as we said, completely eradicated, like 18 malaria , tetanus, poliomyelitis. For tubercu- losis, to take one example, the morbidity rate in 1968 was 41 per 100,000, and in 1971 it was 17.8, which is a good measure of success. Gastroenteritis is one of the diseases they sti11 have and here they have an interesting ap- proach. They are very keen on early treat- ment of chi ldren with gastroenteritis and lay great emphasis on early case-finding. In fact they often send children with symptoms of gastroenteritis in very early stages to hospi- tal. The philosophy is that clean water and other environmental factors are very impor- tant, but that these cannot be changed over- night, so to attack the disease now they have to treat the cases as they appear, at the ear- liest possible stage. l.T.: The mortality rate from gastroenteritis has dropped from 42.5 in 1957 to 18.4 per I 00,000 in 1970 because of early case detec- tion and treatment in hospital, whi le the morbidity has not decreased so much because of inadequate rural sanitation in some areas. These pockets of poor sanitation in some rural areas wi11 di appear as recon- struction and new housing projects get under way. As reconstruction and housing projects based on the regrouping of scattered houses and vi11ages progress, rural water supply and sewage disposal schemes are simu ltaneously expanding. W.H.: What has been done in the field of nutrition? E. L. : In the field of nutrition the most strik- ing thing is the policy of equa l distribution of available food resources. A11 the population gets a minimum amount of animal proteins or calories and so on. I.T.: Pregnant women, chi ldren and elderly people receive more milk, eggs and some oth- er protein substances than the other groups. This improves a great deal the promotion of health of the population. E.L. : There is also a big programme of sup- plementary feeding in schools, in canteens Above: Clearing a river in the "10 October" region to control mosquito breeding. Malaria has now been eradicated in Cuba. ( Photo WHO/E. Rice) Opposite page : A day-care centre for children of working mothers. In many situations a dis- tinction between health and welfare is mean- ingless. ( Photo WHO/E. Rice) and so on . One daily meal is very often pro- vided free of charge or at a very nominal fee, so that also has had a considerable influence on the nutritional status. In addition, the overall agricultural policy has been geared to the needs of the population so that the fish- eries, the milk and meat production have been increased not for export but to improve the nutritional level of the population. Early detection of nutritional disease is an important part of the maternal and child health services and there is supplementary feeding for children who show signs of mal- nutrition. The authorities set up nutritional rehabilitation centres where difficult cases of mothers who need a lot of training are brought with their children to stay for maybe one or two months, to bring the child up to completely normal nutritional status. W. H.: To what extent can the Cuban example be followed by other countries? I.T.: The Cuban system as a whole can pro- bably not be transplanted to a developing country with a low socioeconomic level because at present the government, we were told, spends more than 50 per cent of the total budget on health and education. Also it has trained a lot of manpower and their basic approach in front-line health services relies on physicians, which could not be achieved for a long time in most developing countries. But there are lessons that one can learn and adapt to different situations in other deve- loping countries. One is the insistence on community participation in health activities and health education. There is the pragmatic planning based on priorities, epidemiological findings and the real needs of the communi- ty. Then the integrated approach to health, which is preventive, curative and promo- tional at grass-roots level , and not restricted to the curative aspect of health. Finally, the system of equal distribution of institutions, giving more attention to the most remote and rural areas rather than emphasizing health institutions for the capital or the big cities, could be profitably studied by other coun- tries. During the last ten years Cuba has devoted more effort to rural areas than to the cities. E.L.: In seeking reasons for Cuba's success I think we have to take into consideration the country's ability to implement political deci- sions and its political will to carry out a programme for the rural areas. This may not always be feasible under other socioeconom- ic systems, so we should consider that proba- bly the Cuban socioeconomic system is large- ly behind the success of what the country has been doing in the health field. • 19