GATS and Developing Countries
The health sector in Cuba
Sigrid Weitenberg Groningen, May 2003
GATS and Developing Countries
The health sector in Cuba
Recommendations to Cuba concerning objectives and positions in future GATS negotiations about the health sector
by
Sigrid Weitenberg
University of Groningen, The Netherlands
Science Shop of Economics, Management & Organisation
Mentors
Dr. M.A.G. van Offenbeek
Faculty of Management & Organisation University of Groningen
Dr. H.C. van der Blonk
Faculty of Management & Organisation University of Groningen
Pre-Face
In September 2002, the Science Shop of Economics, Management and Organisation of the University of Groningen started, by order of the Dutch Ministry of Foreign Affairs, a round table thesis project concerning the General Agreement on Trade in Services (GATS) and developing countries. For the last 8 months, within this project, I have conducted research to the opportunities and threats of liberalisation of trade in health services under the GATS for the health sector in Cuba. In connection with the research, I’ve stayed for two months in the city of Havana.
It was very valuable and interesting to experience Cuban life. It was a challenge to conduct research in a country where it is even difficult to get permission to visit a library and where people never seem to tell you what they really think. Although this sometimes frustrated me, the same Cuban people and culture also made it a fantastic period I never will forget.
I would like to thank everybody who supported me during the research: Manuel, Christina, Carlos, the family Carnota, Fara, Martijn and my family. Moreover, special thanks to my mentors Marjolein van Offenbeek and Heico van der Blonk, Elise Kamphuis from the Science Shop of Economics, Management and Organisation, Professor C. Jepma from the Faculty of Economics and the people from the Dutch Ministry of Foreign Affairs. Their feedback has been very constructive and useful for the research.
Sigrid Weitenberg
Groningen, May 2003
‘No hay honra mayor de la que ser combatientes por la salud humana’
(‘There is no greater honour than being a fighter for human health’)
Fidel Castro, Library of Public Health in Havana, December 2002
Abstract
The General Agreement on Trade Services (GATS) is established in 1995 and is the services part of the World Trade Organisation (WTO). The Agreement provides a legal framework for governing world trade in services. Each Member is allowed to make legally binding commitments concerning international trade within specific individual services sectors. The Agreement identifies 4 modes of supply, which refer to different forms of international trade:
‘cross-border supply’, ‘consumption abroad’, ‘commercial presence’ and ‘presence of natural persons’. Traditionally, especially the health services sector has been subject to serious impediments for trade between countries. Therefore, to date, less than 40% of WTO countries have made GATS commitments for the health sector. However, due to recent developments concerning trade in services, governments also have begun to reconsider their role in the provision of health services. Therefore, it was decided to make an assessment of the opportunities and threats of the GATS for the health sector. The research focused on Cuba, because this country has a comparative advantage in the health sector.
At this moment, the Cuban health sector is suffering from the difficult economic situation in Cuba. Due to the disappearance of trade with the former Soviet Union and East bloc countries in 1989, the U.S.-embargo became suddenly extremely effective and this caused a serious problem in the Cuban health system. In addition, the tightening of the embargo in 1992 strengthened this effect even more. These days, hardly any trade exists between medical companies and Cuba and medical goods have to be bought in relatively expensive markets.
Due to this and due to a lack of foreign currency, several important drugs are no longer available in Cuba. In addition, there are shortages in medical goods and equipment often needs to be replaced. In summary, at this moment, the equity, quality and efficiency of the Cuban health sector are being endangered.
In order to receive foreign currency, Cuba is trading health services via two modes of supply identified by the GATS: Consumption abroad’ (mode of supply 2) and ‘Presence of natural persons’ (mode of supply 4). Mode 2 occurs via special hospitals for foreign patients. The state-owned company Cubanacan Tourism and Health provides high quality health services at competitive prices only to foreigners. Part of the received incomes of the company is used for the public health system. Trade via mode 4 refers to the fact that Cuba sends health personnel abroad on short-term remunerated contracts to foreign countries, under government supervision. Although most health care provided by Cuban health professionals in foreign countries is for free, some countries pay the Cuban State. These incomes are also used for the public health sector.
Eventually, the main study was aimed at determining the opportunities and threats of liberalisation of trade in health services via modes of supply 2 and 4 under the GATS for the current problems within the health sector. In addition, the chance that Cuba will join future GATS negotiations about the health sector has been examined. The results of the study are based on primary research and secondary research in Cuba (the city of Havana) and secondary research in the Netherlands.
Opportunities of mode of supply 2 under the GATS refer to the fact that Cuba can request
other WTO countries to consider liberalisation of this mode and in addition, Cuba can request
other Members to consider liberalisation of health insurances, which may decrease an
important trade barrier. Because more countries may allow their citizens to receive health care
abroad and since treatment in foreign countries may be covered, the number of patients who
go abroad in order to receive health care may increase. Eventually, this may cause a rise in the
number of foreign patients coming to Cuba and this may increase the amount of money
generated by the company Cubanacan Tourism and Health. Since these incomes are (partly)
being used for the public health sector, its equity, quality and efficiency may improve.
In light of the current problems within the Cuban health sector, this will be a positive effect.
Liberalisation of health insurances also may have another effect on the quality of the Cuban health sector. If the control of quality is becoming more strict, this may have a positive impact on the quality of the health sector in Cuba since the country should pay attention to maintaining and upgrading the current level of quality of health services provided to foreign patients. Nevertheless, in case of insufficient capacity, an important threat of mode of supply 2 under the GATS for the current problems within the Cuban health sector is the (higher) chance of the effect of ‘crowding out’: the access of domestic patients to the health sector may decrease due to competition with foreigners. As ‘crowding out’ seriously endangers the equity of the health sector, it also may worsen the current problem in Cuba related with this aspect. Important is that Cuba takes into account the opportunity under the GATS to formulate domestic regulation in order to reduce the threat.
An opportunity of mode of supply 4 for the current problems is caused by the fact that the Cuban State may be able to send more health professionals abroad after requesting Member countries to consider liberalisation of trade in health services via this mode of supply. As the Cuban State receives part of the incomes generated through this mode of supply and uses them for the public health sector, the equity, quality and efficiency of the Cuban health sector may rise. However, the Cuban health sector may be threatened due to the possible increase in the effect of ‘brain drain’. The occurrence of this effect will depend on the facts whether there is a surplus of health professionals employed in the health sector and whether the movement abroad is permanent or temporary. A shortage in medical personnel may aggravate all current problems within the Cuban health sector. In order to decrease or even avoid the effect of
‘brain drain’ caused by permanent migration, Cuba and host countries should formulate domestic regulation.
In this report, the chance that Cuba will join GATS about the health sector in the future has been based on differences between Cuban cultural values and values of the GATS concerning health care. Since Cuban society is a socialist system, cultural values related to health care are based on socialist ideas that emphasize the importance of equality as a political principle. To the contrary, main values of the GATS are based on liberalism, which prioritises individual’s liberty and rights. Due to this, it may be unlikely that the Cuban State will make GATS commitments concerning liberalisation of trade in health services. However, Cuba should realise that it does not have to make GATS commitments for the health sector itself.
Moreover, if the right domestic regulation is developed, providing health care to foreigners and payment of Cuban health professionals abroad do not imply a threat to the basic idea of
‘free health services for the entire Cuban population’. Even more important, trade in health services under the GATS may contribute to maintaining the main Cuban cultural values concerning health care in the future.
Recommendations to Cuba
The recommendations are based on the presumption that Cuba is able to realise the opportunities of liberalisation of trade in health services via modes of supply 2 and 4 for the current problems in its health sector and to control the threats.
Mode of supply 2
•
Make requests to other WTO Members to consider liberalisation of health insurances.
•
Make requests to other WTO Members to consider liberalisation of mode of supply 2.
•
Formulate domestic regulation aimed at decreasing or preventing the effect of
‘crowding out’.
Mode of supply 4
•
Make requests to other WTO Members to consider liberalisation of trade in health services via mode of supply 4.
•
Formulate domestic regulation aimed at decreasing or preventing the effect of ‘brain drain’.
•
Stimulate host countries to take measures, which ensure that Cuban health professionals temporarily stay in the countries and return to Cuba.
• Consider existing domestic regulation of foreign (host) countries.
Table of Contents Abstract
ABSTRACT 5
CHAPTER 1: INTRODUCTION 10
§1.1: INTRODUCTION 10
§1.2: COUNTRY PROFILE 11
§1.3: EXPLORATORY STUDY 13 CHAPTER 2: THE HEALTH SECTOR IN CUBA 15
§2.1: HISTORY OF THE HEALTH SECTOR IN CUBA 15
§2.1.1: B
EFORE1959 15
§2.1.2: 1959- 1989 15
§2.1.3: 1989 -
NOW17
§2.2: THE CONTEMPORARY HEALTH SECTOR IN CUBA 17
§2.2.1: R
ECENT AND CURRENT REFORMS IN THE HEALTH SECTOR INC
UBA17
§2.2.2 C
URRENT QUALITY OF HEALTH CARE PROVIDED INC
UBA18
§2.2.3: C
ONTEMPORARY STRUCTURE OF THE HEALTH SECTOR INC
UBA19
§2.2.4 A
DMINISTRATIVE SYSTEM19
§2.2.5: H
EALTHI
NSTITUTIONS20
§2.2.6: F
INANCIALS
YSTEM22
§2.2.7: I
NSURANCE COMPANIES23
§2.2.8: D
OMESTIC REGULATIONS23
§2.2.9: P
ATIENTS23
§2.2.10: E
DUCATIONALS
YSTEM24
§2.2.11: P
ROFESSIONALS24
§2.3: CONCLUSIONS 25 CHAPTER 3: THE GENERAL AGREEMENT ON TRADE IN SERVICES (GATS) 26
§3.1: HISTORY AND OBJECTIVES 26
§3.2: OBLIGATIONS 26
§3.3: GATS NEGOTIATIONS 27
§3.4: GATS STRUCTURE 27
§3.5 THE GATS AND DEVELOPING COUNTRIES 29
§3.6 THE GATS AND THE HEALTH SECTOR 29
§3.7 THE GATS AND THE HEALTH SECTOR IN CUBA 32
§3.8: CONCLUSIONS OF THE EXPLORATORY STUDY 32 CHAPTER 4: MAIN STUDY 33
§4.1: PROBLEM STATEMENT 33
§4.2: RESEARCH APPROACH 33
§4.3: RESEARCH MODEL 35
§4.3.1 T
HEORY ONL
IBERALISM35
§4.3.2 T
HEORY ONC
ULTURE36
§4.3.3 D
EFINITION OF ELEMENTS37
§4.3.4 E
XPLANATION OF THE MODEL38
§4.4: SUB RESEARCH QUESTIONS 39
§4.5: RESEARCH METHOD 40
CHAPTER 5: THEORETICAL IMPLICATIONS OF LIBERALISATION UNDER
THE GATS 42
§5.1: THEORETICAL IMPLICATIONS OF LIBERALISATION VIA MODE OF SUPPLY 2 42
§5.1.1: M
ODE2
AND THE EQUITY OF THE HEALTH SECTOR42
§5.1.2: M
ODE2
AND THE QUALITY OF THE HEALTH SECTOR42
§5.1.3: M
ODE2
AND THE EFFICIENCY OF THE HEALTH SECTOR43
§5.1.4: R
ELATION WITH THEGATS 43
§5.1.5: C
ONCLUSIONS MODE2 45
§5.2: THEORETICAL IMPLICATIONS OF LIBERALISATION VIA MODE OF SUPPLY 4 46
§5.2.1: M
ODE4
AND THE EQUITY OF THE HEALTH SECTOR46
§5.2.2: M
ODE4
AND THE QUALITY OF THE HEALTH SECTOR47
§5.2.3: M
ODE4
AND THE EFFICIENCY OF THE HEALTH SECTOR47
§5.2.4: R
ELATION WITH THEGATS 48
§5.2.5: C
ONCLUSIONS MODE4 49
CHAPTER 6: CURRENT TRADE IN HEALTH SERVICES IN CUBA 51
§6.1: CURRENT TRADE IN HEALTH SERVICES VIA MODE OF SUPPLY 2 51
§6.2:CURRENT TRADE IN HEALTH SERVICES VIA MODE OF SUPPLY 4 54
CHAPTER 7: IMPLICATIONS OF LIBERALISATION UNDER THE GATS FOR THE CUBAN HEALTH SECTOR 56
§7.1: POSSIBILITIES OF MODE OF SUPPLY 2 56
§7.2: DESIRABILITY’S FOR THE CURRENT PROBLEMS 58
§7.3: POSSIBILITIES OF MODE OF SUPPLY 4 59
§7.4: DESIRABILITY’S FOR THE CURRENT PROBLEMS 60
§7.5: THE PROBABILITY OF GATS PARTICIPATION IN THE FUTURE 61 CHAPTER 8: CONCLUSIONS AND RECOMMENDATIONS 63
§8.1: CONCLUSIONS 63
§8.2: RECOMMENDATIONS 66
§8.3: REFLECTION AND RESEARCH SUGGESTIONS 67 REFERENCES 69
Chapter 1: Introduction
§1.1: Introduction
After eight years of negotiations, i.e. the Uruguay Round, the General Agreement on Trade in Services (GATS) is established in January 1995. The GATS is the services part of the World Trade Organisation (WTO). The Agreement provides a legal framework for governing world trade in services. In chapter 3 of this paper, the GATS will be described in more detail.
In January 2000, the WTO Member Governments started a new round of negotiations about the liberalisation of trade in services. The purpose of the negotiations is to remove unnecessary regulations in order to stimulate domestic and foreign trade in services. The deadline of the negotiations is January 1, 2005. However, by June 30, 2002, members were able to submit their requests for market access. Furthermore, countries have submitted their initial offers concerning market access by March 31, 2003
1.
The concept of international trade in services is relatively new. Institutional, administrative and/or technical constraints, strict access regulations and controls and the need for direct physical contact between suppliers and consumers used to lead to a low level of trade in services
2. However, due to two recent developments, trade in services is increasing. First, various countries’ policies concerning services sectors are more market oriented these days.
Therefore, foreign and domestic private involvement within services sectors is increasing.
Second, due to technical developments services can be traded electronically between countries. This has helped to reduce distance-related barriers to trade in services
3.
Most developing countries seem to have little interest in the GATS negotiations. They think that through liberalising services sectors, developed countries will dominate their domestic markets. In some cases, developing countries are even afraid of loosing their sovereignty.
Furthermore, to date, little assessment of trade in services and developing countries has been made. Therefore, in September 2002, the Science Shop of Economics, Management and Organisation of the University of Groningen started, by order of the Dutch Ministry of Foreign Affairs, a round table thesis project concerning the GATS and developing countries.
The Dutch Ministry of Foreign Affairs has requested the Science Shop of Economics, Management and Organisation to select a group of students who would conduct research on the positions of developing countries within GATS negotiations. In order to find an answer to this question, the students have made assessments of the consequences of the GATS for different developing countries and different services sectors. At the end of the project, the students have informed the Ministry of Foreign Affairs about the recommendations, which can be made to the designated developing countries. The recommendations concern negotiating objectives and positions for future GATS negotiations rounds.
Within this project, I have conducted research on the health sector in Cuba. Due to the fact that few GATS commitments concerning the health sector have been made so far, it was very interesting to make an assessment of the opportunities and threats of the GATS for this sector.
The research focused on Cuba, because this country has a comparative advantage in the health sector.
Traditionally, especially the health services sector has been subject to serious impediments for trade between countries and government involvement has always been high within the sector.
Furthermore, trade-considerations have never been a relevant policy concern. In many countries there even used to exist and still exist a government monopoly offering health services free or significantly below costs. Finally, technical constraints always have hindered
1 Science Shop of Economics, Management and Organisation, University of Groningen (2002), Project Proposal, Round table thesis project: Gats and Developing Countries.
2 Adlung & Carzaniga (2001), ‘Health Services under the GATS’.
3 WTO (2001), Guide to the GATS, An Overview of Issues for Further Liberalisation of Trade in Services.
trade in health services between countries. Therefore, to date, less than 40% of WTO countries have made GATS schedules of commitments for the health sector. However, due to the recent developments concerning trade in services, governments also have begun to reconsider their role in the provision of health services. Although less rapidly than on, for example, financial and telecommunication services, more Members of the WTO are beginning to make some form of commitment on health services. This research has dealt with the question whether the GATS provides opportunities and threats for the health sector in Cuba.
The report starts in chapter 1 with a short profile of Cuba in order to provide information about the country. The next part of the report defines the preliminary goal and question of the research. In the beginning of this research, it was not clear to me what the final direction should be. Therefore, after formulating the preliminary research goal and question, exploratory research has been conducted first. The results of this study have determined the direction of the main study. Moreover, the results decided whether the main research goal and question needed to be adapted. Chapter 2 and 3 describe the results of the exploratory study.
The conclusions, which are drawn in these chapters, formed the basis for the main study. The final direction of the study and the final formulation of the main research goal and question are presented in chapter 4. In this chapter the theoretical framework, the sub questions and the research method are also introduced.
Furthermore, chapter 5 provides an analysis of the theoretical implications of liberalisation of trade in health services under the GATS for the health sector. In addition, current trade in health services in Cuba and its impact on the country’s health sector are discussed in chapter 6. Based on chapters 5 and 6, conclusions concerning the implications of liberalisation of trade in health services under the GATS for the Cuban health sector are drawn in chapter 7.
Moreover, this chapter describes the probability that Cuba will join GATS negotiations in the future.
Finally, chapter 8 presents the conclusions of the research and the final recommendations, which can be made to the Cuban State. In addition, this chapter consists of a reflection on the research and suggestions for further research. According to table 8.1, it appeared that the conclusions of this research could be compared with the outcome of a (partial) SWOT- analysis of the Cuban health sector and the GATS
4.
§1.2: Country Profile
Since the discovery of Cuba, the ‘Pearl of the Antilles’, by Columbus in 1492, the island has been a Spanish colony for more than two centuries. This period ended when, after two Wars of Independence, Cuba became an independent republic on May 20, 1902. The period following the independence has been dominated by corrupt governments, inefficiency and unemployment. In 1920, US companies owned more than two-third of Cuba’s farmland and most of its mines. Moreover, in 1958, when president Batista was in power after his second military coup, more than half of Cuba’s land, industry, and essential services were in foreign hands. It was in this period that a revolutionary circle, including Fidel Castro, was formed in Havana. Although the first attempt of the revolutionaries to seize power failed, in 1959 they succeeded and Batista fled to the Dominican Republic.
On January 1, 1959 a new period had begun for Cuba. Fidel Castro and companions turned Cuba into a socialist system. All major Cuban-owned firms and small private businesses were nationalized. Because also a lot of U.S. companies were nationalised by the Cuban State, the U.S. government imposed a partial embargo on the country in 1960. Moreover, the embargo became fully in 1961.
4 SWOT: S = Strengths, W = Weaknesses, O = Opportunities, T = Threats.
Within the first decade of the Cuban revolution, several economical problems existed throughout the country. Production fell, quality declined and bureaucracy increased. As inventories had been exhausted, Cuba intended to solve the problems by joining the Socialist bloc. For the next 30 years, Cuba had strong relationships with the Soviet Union. In this period, the country received military and economic assistance estimated at 5.6 billion USD annually. Due to this, Cuba was able to keep its economy afloat
5. However, in 1989, Eastern European communism collapsed. As Cuba was highly dependent on trade with the Soviet Union and the East bloc, this meant an economic disaster for the country. The Cuban economy suffered a decline of 35 % in gross domestic product between 1989 and 1993. To make it even worse for Cuba, the U.S.-embargo was tightened in 1992 with the Cuban Democracy Act, informally known as the Torricelli bill. This Act prohibited third country U.S. subsidiary transactions with Cuba. Furthermore, it also prohibited foreign ships that had entered Cuban ports for purposes of trade from (un) loading freight in the USA for 180 days
6. In order to survive the economic difficulties, the Cuban State had little choice but to take some significant reforms. Due to the shortage of hard currency, in 1993, the government made it legal for the Cuban population to use USD. Since this moment, Cubans who have access to dollars have been able to purchase (imported) goods in government run dollar- stores. People who only have access to the Cuban peso have to shop in under stocked peso stores. Therefore, jobs that make access to dollars easier (for example through dollar tips) have become highly desirable. Thus, these days it is not uncommon to see highly skilled Cuban professionals being employed as a taxi-driver or a waiter.
Furthermore, although highly restricted, the Cuban State permitted self-employment by individual Cubans and allowed the creation of free farmers’ markets in 1994. Finally, the government encouraged foreign investment, especially in tourism. However, in its desire for capital without capitalism, foreign companies are not allowed to directly hire Cuban employees. They have to pay the wages to the Cuban State. The government will pay the salaries in pesos to the workers, keeping the biggest part of the hard currency for itself. Since 1994, foreign investment has been allowed in all sectors, except in education and health. Due to these limited economic reforms Cuba succeeded in increasing its access to a part of the hard currency required to keep the economy functioning, however, at a low level. The fact that foreign investment is prohibited in the health sector may have a substantial influence on the possible occurrence of trade in the Cuban health sector and, therefore, it should be taken into account when examining the opportunities and threats of the GATS for this sector during the research.
Nowadays, Cuba still is a socialist state controlled by President Fidel Castro. The country has 11 million inhabitants of which 2 million live in the capital Havana. Due to the fact that Castro is Chief of State, First Secretary of the Communist Party and commander in chief of the armed forces, Castro exercises control over all parts of Cuban life
7. Moreover, as the Cuban economy is based on Marxist – Leninist precepts, his government owns and runs most means of its production. Finally, about 75 % of the labour force is directly employed by the Cuban State.
Main sectors of Cuban economy are tourism, nickel mining, agriculture and especially sugar and tobacco. Since the late 90’s, instead of sugar, tourism is the main source of foreign exchange. Moreover, remittances from Cuban people living abroad are important sources of income for many families. The value of total remittances is estimated at 500 – 800 million USD annually. Some of Cuba’s key economic indicators are summarised in table 1.1.
5 URL: http://www.countrywatch.com/cw_country.asp?vCOUNTRY=45.
6 Kaufman & Rothkopf (2000), Cuba, the contours of change.
7 URL:http://lib.lmu.edu/ref/ejournlc5.htm.
Preliminary research goal: To inform the Dutch Ministry of Foreign Affairs about the
recommendations, which can be made to the government of Cuba in order to help the country identify negotiating objectives and positions for future GATS negotiations about the health sector.
Table 1.1: Key Economic Indicators of Cuba 8.
Economic Indicators
GDP (2002 est.) 25.9 billion USD (PPP)
GDP- real growth rate 0 %
GDP- per capita 2,300 USD
GDP- composition by sector
• Agriculture
• Industry
• Services (incl. Tourism)
8 % 35 % 53 %
Labour force 4.3 million (state sector 78 %, non state sector 22 %,
1999)
Unemployment rate 4 %
Industries Sugar, petroleum, tobacco, chemicals, construction,
services, nickel, steel, cement, agricultural machinery, biotechnology
§1.3: Exploratory Study
Preliminary research question: What are the opportunities and threats of liberalisation of
trade in health services under the GATS for the health sector in Cuba?
In order to find an answer to the preliminary research question, I started with conducting exploratory research. The results of this research have determined the direction of the main study. Moreover, based on the results it could be decided whether the preliminary research goal and question needed to be adapted.
Exploratory research goal: To make a profile of the health sector in Cuba and a profile of the
GATS in order to determine in which areas the GATS could be relevant for Cuba. These areas are the focus of the main study.
Exploratory research questions:
1. What is the current structure and context of the health sector in Cuba?
2. What is the GATS?
3. According to the answers to questions 1 and 2, which areas of the GATS could be relevant for the health sector in Cuba?
8 URL:http://www.odci.gov/cia/publications/factbook/geos/cu.html#Econ.
Exploratory research method
The first research question has been answered by reviewing the literature on the health sector in Cuba. Information has been gathered from the Internet, relevant books and written documents, the World Health Organisation (WHO) and the Ministry of Public Health in Cuba.
Furthermore, the part of the main study conducted in Cuba also provided additional primary data, which has been used for further answering the first exploratory question. Conversations with people working in the Cuban health sector and observations of the country and its health sector contributed to finding an answer to this question. The fact that both primary and secondary research has been conducted has led to a more valid profile of the Cuban health sector and therefore increased the quality of the exploratory research.
Finally, a review on literature concerning the GATS has provided the answer on question two.
As an enormous amount of information can be found about the GATS, only the basic and
essential parts of the Agreement have been included. In addition, parts, which are relevant for
the research, also have been covered. Chapter 2 and 3 deal with the first two exploratory
questions. The results presented here provide an answer to these questions. In section 3.8,
question 3 will be answered.
Chapter 2: The health sector in Cuba
This chapter will provide an answer to exploratory research question 1. Based on an analysis of the historical and the contemporary Cuban health sector, the current structure and context of this sector will be described.
§2.1: History of the health sector in Cuba
§2.1.1: Before 1959
Before the Cuban Revolution in 1959, the quality of health care in Cuba was low. The government spent only a small amount of money on the public health sector. Due to corrupt politicians and government employee’s part of this budget was not even used for the health sector. Patients who needed to stay in the hospital only secured a bed by gaining the recommendation of a politician. The only way to get such a recommendation was through bribing various government employees
9.
The absence of real government health care led to a health sector in pre-revolutionary Cuba that was almost entirely private. Therefore, health care was concentrated in the two big cities Havana and Santiago, as doctors could not make a living practising in rural areas. However, even in the cities not everybody had access to health services due to the high prices. Health care was only provided to wealthy people who could pay for it. Poor people and people living in rural areas far away from the cities were not able to use these services.
Besides wealthy Cuban people, the private clinics focused on treating foreigners, mostly Americans. Clinics provided health services for much lower prices than those offered in the USA. For this reason, a large number of Americans was attracted to Cuba for medical care. In addition, in Cuba did not exist an organisation like the American Medical Association (AMA). The AMA provided rules concerning ethical and safety issues. Due to the fact that such rules did not apply to health services in Cuba, medical care provided here could be more innovative. For example, radical cosmetic surgeries, which were not allowed in the USA, could be obtained in Cuba for a relatively low price.
In pre-revolutionary Cuba, a lot of people died because of the low quality of health care.
Diseases, which could have been cured, caused the death of thousands of people a year, especially children. Life expectancy has always been low due to the absence of public medical care and due to the fact people were not aware of their unhealthy way of living. Campaigns about hygiene or health food did not exist. The revolution in Cuba in 1959, however, caused a tremendous change in the health sector.
§2.1.2: 1959- 1989
On January 1, 1959, president Batista of Cuba escaped to the Dominican Republic because of increasing pressure and violence caused by several rebel movements. A week later, on January 8, 1959, the revolutionaries came from Santiago to Havana to celebrate their triumph.
Hundreds of thousands of people welcomed the leader of the rebels, named Fidel Castro, a young Cuban lawyer born in the Cuban province of Holguín
10.
Followed by his brother Raul and followed by close friends who also contributed to the revolution Fidel Castro became Cuba’s new first man. The government of Fidel Castro made some radical changes in policy. In only twenty-two months of revolutionary government, they turned Cuba into a socialist system. This was accomplished without a revolution communist
9 MacDonald (1999), A Developmental Analysis of Cuba’s Health System Since 1959.
10 Hatchwell & Calder (1998), Cuba: Mensen-Politiek-Economie-Cultuur.
party leading the changes. Only in 1965, one integrated party, the present Cuban Communist Party (PCC), was formed
11.
The revolution’s social and economic policies were aimed at transforming the banking, industrial, and housing and trade systems. Furthermore, their main priority was to improve the educational and health system throughout the country
12. In this section, the developments within the health sector in this period will be discussed.
After the revolution, the health sector in Cuba changed from a privatised into a socialised system. Medical care no longer was a private business occupation; it now belonged to the state. In 1960, the Cuban Health System, co-ordinated by the Ministry of Public Health, was created. According to the law pursued by the Ministry of Public Health, every Cuban citizen had the right to obtain free health services. Furthermore, the quality of health services in Cuba should be improved radically.
The Ministry defined several principles for the national health system, which were based on socialist public health. The main principles were focused on:
•
Providing medical care and prevention to the entire population of Cuba.
•
Developing activities aimed at the protection of the social environment.
•
Giving attention to the elderly and physically and mentally disabled people.
•
Providing medical information to health workers in order to sustain and improve their knowledge.
•
Realising biomedical research and improving scientific activities.
•
Importing, producing and distributing drugs and medical equipment.
•
Keeping up with statistical information concerning the health sector.
•
Appropriate planning of all health activities
13.
In the first half year after the revolution, a lot of doctors left Cuba because they did not want to work as public servants for a much lower salary than before the revolution. Moreover, the idea of being sent to all possible places within Cuba and therefore also the rural ones, made a lot of doctors leave the country. In 1959, 3000 doctors left Cuba, which decreased the number of remaining doctors to only 3000. A strange situation had occurred; new legislation made medical care available for anyone, however, the number of doctors became half of what it had been when serving 10 % of the population
14. The government had to come up with several new ideas and strategies in order to achieve the goal of improved quality of health care for everybody.
To meet with the shortage of doctors, the Ministry of Public Health decided to use doctors volunteering from other countries and medical students in their last two years of training.
Furthermore, a new generation of well-trained medical workers was sent throughout Cuba to places were no doctor had ever been. These doctors practised medicines in community polyclinics, which were created all over the country. In the beginning, doctors could not do much in rural areas due to the bad circumstances. However, the revolution also improved sanitary systems, roads, schools and medical posts. Together with the Family Doctor Plan, which will be explained in section 1.2.5, these efforts created a decentralised health system, which reached every single person within Cuba
15.
The health sector also became more internationalised with foreign medical staff travelling to Cuba for education, Cuban staff travelling to other countries to provide health services and tourists having access to Cuban health services in special clinics. The result was that the
11Azicri (1988), Cuba: Politics, Economics and Society.
12 Azicri (1988), Cuba: Politics, Economics and Society.
13 Cuban Ministry of Public Health (MINSAP, 1990), Manual de Enfermeria General I y II.
14 MacDonald (1999), A Developmental Analysis of Cuba’s Health System Since 1959.
15 Ibid.
health sector in Cuba could be compared with health systems in developed countries in Europe and in North America.
§2.1.3: 1989 - now
Since its creation by the government of president Eisenhouwer in 1960, the US-embargo has had a negative influence on the economy of Cuba. The prohibitions within the embargo included a ban on U.S. exports to Cuba and also a ban on Cuban imports into the U.S.A.
16For this reason, trade between Cuba and the U.S.A. in drugs and medical equipment did not exist. Until the late 80’s this problem was compensated with the relationship between Cuba and the Soviet bloc. The inability to import drugs and medical equipment from the U.S.A was largely offset by trade with the Soviet bloc and Western Europe. However, as the socialist bloc crumbled in 1989, the U.S.-embargo became suddenly extremely effective. Its negative influence on the entire economy and also on the health sector increased radically. In two years time the Cuban economy contracted by 35 %.
So, after 1989, Cuba did not any longer have access to the East bloc medical market.
Furthermore, it was hard to purchase medical products from the market of Western Europe, due to shortages of hard currency. To make things worse for the health sector in Cuba, the embargo was tightened in 1992. The Cuban Democracy Act, informally known as the Torricelli bill, prohibited third country U.S. subsidiary transactions with Cuba. Furthermore, it also prohibited foreign ships that had entered Cuban ports for purposes of trade from (un) loading freight in the U.S.A for 180 days
17.
In this period several third-country medical companies were taken over by U.S. companies.
These companies used to be prime suppliers to the health sector in Cuba. However, now being third-country U.S. subsidiaries, they became subject to the embargo. Therefore, they were no longer allowed to deliver drugs or medical equipment to Cuba. Due to these developments, Cuba suddenly had to deal with cut-offs of key medicines, medical equipment, medical texts, inputs for diagnostics, vaccinations and pharmaceutical and biotechnology research and development
18. The health sector severely weakened.
§2.2: The contemporary health sector in Cuba
§2.2.1: Recent and current reforms in the health sector in Cuba
Since the revolution, the main principles of Ministry of Public Health have not changed.
Moreover, the right of every Cuban citizen to obtain free health services is still the most important law concerning the health sector. In 1991, the Ministry drafted a document,
‘Objectives, Aims, and Guidelines for Improving the Health of the Cuban Population 1992- 2000’. The document defined several health goals and objectives to be achieved by the year 2000. In 1996, four strategies and four priority programmes were identified
19. The strategies include reorientation towards the family doctor plan and primary care; revitalisation of hospital care, high-technology programs and research institutions; development of a program on natural and traditional medicine and remedies; and care with an emphasis on dentistry, optical services and health transport. Priority programmes include maternal and child health care, chronic non-communicable diseases, communicable diseases and care of the elderly.
However, the Cuban State also needed to pursue new strategies in order to cope with the developments within the health sector in the 90’s. Despite the economic crisis, the Ministry of
16 American Association for World Health (AAWH, 1997), Denial of Food and Medicine: the impact of the U.S.
Embargo on Health and Nutrition in Cuba..
17 Kaufman & Rothkopf (2000), Cuba, the contours of change.
18 American Association for World health (1997), op. cit.
19 URL:http://www.paho.org/English?HIA1998/Cuba.pdf.
Public Health decided to focus at maintaining the sustainability of the sector in financial terms and increasing the quality and effectiveness of health services
20. The contents of the reforms of the health sector are recorded in the Methodological File, which contains the main objectives of the Ministry of Public Health. The objectives are:
•
To improve the efficiency and quality of the National Health System, while respecting the basic strategies and principles.
•
To achieve greater decentralisation and inter-sectoral action within the health system.
•
To achieve greater efficiency of and participation by the international community.
•
To promote other basic areas of specialised care
21.
After the design of the Methodological File by several experts from the Ministry of Public Health, a plan of action was developed to implement the File. To achieve this, the plan of action defined the necessary actions, responsibilities, timetables and evaluation criteria.
Evaluations are made periodically at every level in the health system. Twice a year, the Ministry of Public Health evaluates the progress made, in order to control and coordinate the implementation of the new strategies.
Primary care is at the core of the strategies pursued by the Ministry of Public Health. In order to achieve the goal of efficiency, the need for more expensive hospital care has to be reduced.
Therefore, the Ministry focuses at increasing the utilization of primary care provided by Family Doctors and Polyclinics. Patients can obtain all regular health services at this level.
Only in emergencies or when specialised services are required, they will go to a hospital and receive more expensive secondary care. Furthermore, the emphasis on prevention, health promotion, early diagnosis and early intervention will save costs due to a decrease in utilisation of expensive secondary health care in hospitals
22.
§2.2.2 Current quality of health care provided in Cuba
Due to the efforts to sustain and improve the quality of the health sector and due to the emphasis on prevention and early diagnosis, the government succeeded, despite the embargo and the disappearance of trade with the East bloc, in maintaining the high standard of the health sector in Cuba. Table 2.1 shows Cuba’s main health indicators and the indicators of 4 other countries. Based on these marks, it can be concluded that the standard of the Cuban health sector can be compared with the standard of an industrialised nation like the UK.
Table 2.1: Comparative health indicators23.
20 URL:http://www.paho.org/English?HIA1998/Cuba.pdf.
21 Ibid.
22 Comisión Económica para América Latina y el Caribe (2000), La Economía Cubana: Reformas Estructurales y Desempeňo en los Noventa.
23 United Nations Development Program (UNDP, 2002), Human Development Report.
Country
Health Indicator Cuba UK Chile Haiti Guatemala
Life expectancy (years; 2000) 76 78 75 53 65
Infant mortality (per 1,000; 2000) 7 6 10 81 44
Maternal mortality (per 100,000;
1985-1999)
33 7 23 520 190
Doctors (per 100,000; 1990-1999) 530 164 110 8 93
However, Cuba still has a shortage of all kinds of medical goods. Although this cannot be seen in the current health indicators of Cuba presented in table 1.2, this may endanger the quality of the health sector in the (near) future.
For example, the repair of equipment has slowed down through the lack of spare parts
24. Therefore, a lot of medical equipment is out of commission.
When I visited the hospital ‘Docente Comandante Manuel Fajardo’ in the city of Havana, a medical student told me that at that moment only 3 of the 8 operating rooms were being used.
The other 5 already had been out of order for a long period of time. Moreover, the Ministry of Public Health reports that 13% of Cuba’s X-ray machines do not function anymore.
Finally, today, only 889 of the 1,297 medicines available in Cuba in 1991 can be obtained.
Some 60% of drugs are produced by Cuban research institutes throughout the country.
Nevertheless, the more sophisticated drugs have to be bought in Europe, which is very expensive. Due to shortages of hard currency it is difficult for Cuba to obtain all medicines, therefore, the availability of medicines changes through time
25.
§2.2.3: Contemporary structure of the health sector in Cuba
In order to describe the health structure in Cuba in more detail the following model will be used.
Figure 2.1: Descriptive model of elements in the health sector 26.
Figure 2.1 contains several elements, which form together the structure of the health sector.
To describe the structure of the Cuban health sector each element will be treated in the following sections.
§2.2.4 Administrative system
In Cuba, health is considered the key ingredient for quality of life and is seen as a strategic objective in society’s development process
27. The Cuban Health System, created in 1960, is
24 American Association for World Health (1997), Denial of Food and Medicine: The impact of the U.S.
embargo on health and nutrition in Cuba.
25 According to an interview with a doctor from the Cuban Ministry of Public Health, December 2002.
26 Adapted from M. van Offenbeek et al. (2002), University of Groningen, The Netherlands.
27 URL:http://www.paho.org/English?HIA1998/Cuba.pdf.
Patients
Health Institutions Professionals
Insurance companies
Domestic Regulations
Financial System
Educational System Administrative System
the only health system within Cuba. This decentralised system provides health services at three different levels: the national level, the provincial level and the municipal level
28.
The central organ on the national level is the Ministry of Public Health. The Ministry controls, co-ordinates and directs all the health services and activities within the country. Also operating on the national level, directly under the Ministry, are university centres, specialised medical research and care institutions, the Union of the Medical-Pharmaceutical Industry and several firms, which distribute, import and/or export drugs and medical equipment. On the provincial level, the provincial assemblies have direct financial and administrative control over the provincial public health offices. These offices are, for example, provincial hospitals, inter-municipal hospitals, education centres, blood banks and health and epidemiological centres.
Finally, the municipal level exists of several municipal public health offices. Municipal assemblies control the offices both financially and administratively. Examples of municipal public health offices are polyclinics, municipal hospitals, oral health clinics, maternity homes and old people’s homes. These offices provide health care to so-called ‘areas of health’, which exist of 7,000 till 35,000 inhabitants. Within these areas, Family Doctors, Pharmacies and other medical posts focus on different ‘sectors of health’. Municipal assemblies also coordinate the latter.
Within the Municipal assemblies, the People’s Councils are the nuclei at the municipal level.
The Councils act as an organ for coordination, thus expressing the administrative decentralisation within the health system of Cuba
29.
Finally, as a result of the new strategy of the government, nowadays, the assemblies on each level are made up of representatives of the various social sectors and civic organisations and are headed by a government representative. This has increased the collaboration between different sectors and, therefore, also the social participation in the identification and the solution of problems concerning the health sector
30.
§2.2.5: Health Institutions
Family Doctor offices
Until 1984, polyclinics and hospitals were the only health institutions, which provided primary medical care to the community. In 1984, the Program of Integral Community Attention, better known as the Family Doctor Plan, was initiated. This plan added an extra level of community care to the health system
31. At the municipal level, Family Doctors provide primary and preventive health services to 120 families in a certain neighbourhood.
According to the definition of the Ministry of Health in Cuba, primary care refers to the first contact between the population and the national health system.
Besides direct medical care, Family Doctors are also responsible for maintaining health records, vaccinating patients in time and providing health instructions
32. Cuban people first see their Family Doctor for primary care and, when necessary, the doctor will send them to the hospital. Moreover, patients will go directly to a hospital when they need services that cannot be provided by a Family Doctor.
In order to create an intensive and personal relationship between doctor and patient, the Family Doctor lives in the same neighbourhood in which he or she serves. During the day, the doctor practices medicine in the Family Doctor office, the so-called ‘consultario’. Family
28 URL:http://www.paho.org/English?HIA1998/Cuba.pdf.
29 Ibid.
30 Ibid.
31 S. Bernal (2000), Cuba’s Health Care and Educational Systems.
32 Ibid.
Doctors also rotate shifts in polyclinics and visit patients at home. House calls are made after receiving a request from a patient. Furthermore, also spontaneous house calls are made to see whether people are doing all right.
In 2001, there were over 30,000 Family Doctors in Cuba. The Family Doctor Plan has contributed to a health system in which every citizen is able to obtain health services.
Nowadays, the doctors serve 100% of the Cuban population. Part of the new strategy formulated by the government focused on the improvement of primary care provided by Family Doctors through giving priority to health promotion and disease prevention. It is the responsibility of the doctor to maintain and improve the health of the people in the neighbourhood of the ‘consultario’.
Polyclinics
Polyclinics, which are situated in cities and rural areas, are the basic units of the health sector in Cuba. Together with the Family Doctors offices, they provide primary medical care at the municipal level to the main part of the Cuban population. Health services provided by polyclinics include general medicines, paediatrics, gynaecology, dental care, psychiatry and control of communicable diseases and health education. In 2001, the number of polyclinics in Cuba was 440. People can visit the specialists in the polyclinics from 8 a.m. until 12 a.m. and from 8 a.m. until 4 p.m. for emergencies. At night, two Family Doctors are available.
Hospitals
In 2001, a total of 270 hospitals existed throughout Cuba. The hospitals provide secondary and tertiary medical care at different levels of the health system. According to the Ministry of Public Health a hospital is ‘an institution which has, according to its function in the health system, all necessary human, material and financial resources in order to provide qualified and specialised medical attention to people with all kinds of diseases, to pregnant women and also to healthy people. Moreover, these institutions realise activities concerning research and education’
33. The Ministry defines secondary and tertiary care as ‘more specialised and complex medical care offered to a higher number of patients’. In addition, it states that tertiary care also includes research activities.
There are 7 different kinds of hospitals in Cuba: rural, local, municipal, inter-municipal, provincial, inter-provincial and national hospitals. Differences between hospitals concern the amount of beds they have and the number of inhabitants to which they provide medical care.
The rural hospital is the smallest with an amount of beds between 25 and 75 and health care provided to 5,000 up to 20,000 people. Furthermore, with an amount of beds between 800 and 1,000 beds and health care for more than 1 million inhabitants, the national hospital is the biggest one.
Due to the fact that a lot of general medical care takes place at the primary level, several hospitals in Cuba are specialised in a certain area. For example, in Havana, there are hospitals specialised in oncology, surgery, cardiology and paediatrics. Moreover, some of these hospitals have research centres besides the facilitations for hospitalisation and treatment of patients. These centres are aimed at developing and improving knowledge concerning a certain specialisation.
Finally, throughout the country, there also exist special clinics and departments of hospitals focused at providing health care to foreigners.
33 Cuban Ministry of Public Health (MINSAP, 1990), Manual de Enfermeria General I y II.
Research Institutes
In Cuba, research is conducted under the control and supervision of the Faculties of Medical Sciences. In every Cuban province one Faculty is located. In total, there are 12 research institutes throughout the country. As there is few trade in drugs, medical equipment and medical information, research institutions are important health units in Cuba. Therefore, Cuba is highly dependent on research for obtaining substitutes for certain drugs and on the development of new medicines. Nowadays, the institutes produce some 60 % of all drugs used in Cuba. The more sophisticated drugs have to be bought in Europe or Asia
34.
Cubanacan Tourism and Health
Cubanacan Tourism and Health, its first name was Servimed, is a state-owned enterprise focused at offering health services to foreigners and tourists in three main areas: assistance, prevention and quality of life
35. The company will be further described in chapter 6 of this report.
Other health institutions
In addition to the already mentioned health institutions, Cuba also contains 164 health posts, 258 maternal homes and 25 blood banks. In 168 dental clinics oral health services are provided and social welfare services include 269 old people’s homes and 33 homes for disabled people.
§2.2.6: Financial System
The National Health System in Cuba is completely financed by state resources
36. Financing is highly decentralised, as more than 90 % is financed from municipal budgets. In the process of defining the height of budgets, at the provincial and municipal level, health institutions send their budgets to local administration councils. These provisional budgets are discussed and approved by the People’s Assemblies. At the national level, the Ministry of Public Health and the Ministry of Finance and Pricing pursue an analysis of joint interests and options on which the national budgetary policy is based. In this way, information concerning budgets is exchanged among all levels of the health sector.
The goal of the Ministry of Public Health to maintain the quality of health care in Cuba is reflected in the steady increase in the total amount of money spent by the entire health sector despite the economic crisis. In 1989, the amount totalled 1,016 million pesos (some 37.6 million USD) and this number increased with 77%, till 1,796 million pesos (some 66.5 million USD) in 2001. Moreover, as a percentage of the entire state budget, the budget for the health sector rose from 6.6% in 1990 till 11.4% in 2001
37. However, from another point of view, figures are less positive.
The decisive factor for ensuring the sustainability of the National Health System is foreign currency financing for the sector. Since 1993, all imports of supplies by the Ministry of Public Health must be financed out of the foreign currency budget that the State allocates for this purpose
38. In 1989, before the crisis, the amount of money spent on imports of medicines, equipment and instruments was 237 million USD. By 1994 this figure had dropped to only 90 million USD. Although the amount increased to 138 million in 1998, this was not enough to cover all necessities. The severe reduction in foreign currency seriously affected supply. For example, the availability of medical supplies used in health units decreased and the
34 According to an interview with a doctor from the MINSAP, December 2002.
35 Cubanacan Tourism and Health (December 2000), Catalogue, Havana, December 2002.
36 URL:http://www.paho.org/English?HIA1998/Cuba.pdf.
37 Oficina Nacional de Estadisticas (ONE, 2002), Annuario Estadistico 2001.
38 URL:http://www.paho.org/English?HIA1998/Cuba.pdf.
production of drugs by the domestic industry dropped by more than one-third between 1990 and 1993.
Cuba has identified and developed various means to acquire foreign currency in order to decrease the shortage. Foreign currency is obtained through exporting medicines to other countries (47 million USD in 1997), offering health services to foreigners, donations of employees working in the Cuban tourism sector (they gave 20% of all tips to a special cancer project in 1996, this generated more than 1 million USD) and Cuban medical professionals working abroad (an estimated amount of 6 million a year). Moreover, Cuba also acquires currency through medical education provided to foreign students and the export of software with medical applications to other countries. Finally, the Ministry of Public Health depends on donations of several NGO’s
39.
§2.2.7: Insurance companies
The Ministry of Public health provides a single health insurance program. This program guarantees free health services for 100 % of the Cuban population
40. The right of every Cuban citizen to have access to all kinds of health services is included in the Constitution of the Republic of Cuba. Health services refer to diagnosis, treatment, rehabilitation, therapeutic and high-tech resources and health promotion and education activities. All health services are provided to the entire Cuban population, without any discrimination.
The insurance program does not cover expenditures by families on hearing, dental, and orthopaedic prosthesis; wheelchairs and crutches; drugs prescribed on an outpatient basis and eyeglasses. People have to pay for these health services and products themselves. However, due to government subsidisation, the costs are relatively low.
§2.2.8: Domestic regulations
In 1983, the Cuban Parliament adopted the Public Health Law. This law includes the activities, which the State has to carry out in order to provide free health services to every Cuban citizen. Furthermore, the law provides rules for the organisation of the health sector and its services. The Public Health Law is complemented by other legislation, including environmental laws, regulations concerning basic sanitation, a decree-law on international health regulations and regulations on occupational health and protection of workers
41.
Due to the recent reforms within the health sector, the Public Health Law now needs to be adapted to the new circumstances. In 1995, the Health Commission of the Cuban Parliament and the Ministry of Public Health together started with the revision of the existing law
42.
§2.2.9: Patients
The entire Cuban population has access to all kinds of health services. Since the initiation in 1984 of the Family Doctor Plan, even in the rural areas, medical care is provided to all.
Furthermore, in 1996, more than 25,000 foreign patients came to Cuba for all kinds of treatment. The country mainly attracts foreign patients from Latin America, Europe and Russia. Special hospitals and clinics in Cuba provide high-quality health services for relative low prices
43.
39 Comisión Económica para América Latina y el Caribe (2000), La Economía Cubana: Reformas Estructurales y Desempeňo en los Noventa.
40 Ibid.
41 Ibid.
42 URL: http://www.paho.org/English/SHA/prflcub.htm.
43 Chanda (2001), ‘Trade in Health Services’.
§2.2.10: Educational System
An important aspect of education in primary and secondary school is Socialist Labour. In Cuba children learn to do community work at a very young age. When a child is around the age of 8, he or she will probably be working a couple of hours a week on activities like reading to blind people, weeding gardens or visiting an old people’s home.
Secondary school covers two cycles. The first cycle, lower secondary school, includes the compulsory education which students need to continue general secondary education or to start technical and teacher studies. The second cycle of secondary school, pre-university education, provides a complete polytechnic secondary education. When students have completed the second cycle, they are able to continue education at technical institutes or at the university
44. In Grade 11, the second grade of pre-university education, students who want to become a doctor have to write an essay on their reasons for wanting this. The final selection of candidates is partly based on this essay. Other selection criteria are the student’s score on the final year’s examinations and its performance in front of an interview panel. The interview panel wants to see two letters of reference, one from the school head and one from the Committee for the Defence of the Revolution (CDR). The latter of the CDR is very important.
The more a student has joined volunteering activities in, for example, Socialist Labour, the more chance he or she has to be accepted
45. Thus, selection is not only based on academic performances, but social attitudes are also important aspects.
Nowadays, in Cuba, there are 22 medical schools throughout the country. The basic medical degree course takes six years. After this education, students obtain the title ‘Doctor en Medicina’ (Doctor of Medicine). All new ‘Doctors en Medicina’ are obliged to work in social services (for example schools) for one year. Furthermore, they have to work as a Family Doctor for three years
46. When they have finished these four years, a specialisation can be chosen. The length of education differs between the specialisations.
In Cuba, both the opportunities for becoming a ‘Doctor en Medicina’ and for becoming a specialist depend on the number of doctor and specialist needed. For example, when few new doctors or specific specialists are needed throughout the country, the selection of new candidates will be stricter.
Cuba also provides education and training to students and health professionals from selected foreign countries. Bilateral agreements coordinate the process of teaching and learning
47. Poor students from less developed countries where education facilities are of low quality or do not exist, receive a scholarship. The Cuban Ministry of Public Health will pay all the expenditures they have to make. The main reason of the Cuban State to provide these facilities is, that when the students return to their own country they will be able to contribute to and improve the standard of the health sector
48.
§2.2.11: Professionals
In 2001, Cuba had 67,128 doctors, 80,719 nurses, 10,150 dentists, and 67,128 technical professionals
49. In total 223,958 workers were employed in all areas of the health sector.
Nowadays, an adequate number of doctors have been reached. However, there still is a shortage in the number of nurses. Therefore, people are encouraged to participate in the education for both mid- and high-level nursing personnel.
44 MacDonald (1999), A Developmental Analysis of Cuba’s Health System Since 1959.
45 Ibid.
46 URL:http://whqlibdoc.who.int/publications/WDMS/PRELIM.pdf.
47 Chanda (2001), ‘Trade in Health Services’.
48 According to an interview with a doctor from the Ministry of Public Health, December 2002.
49 According to an interview with a doctor from the Ministry of Public Health, December 2002.
Besides medical employees working within the country boarders, Cuba also has agreements with other countries about health professionals working abroad. In 2001, there were 3,418 Cuban medical professionals working in 57 foreign countries
50.
§2.3: Conclusions
Based on the analysis of the health sector in Cuba, it can be concluded that the loss of trade with the East bloc and the influence of the U.S.- embargo have caused a serious problem in the country’s health system. Trade with the former Soviet Union and East bloc countries used to offset the negative influence, which the embargo had on the economy of Cuba. However, after the disappearance of the trade, the embargo became extremely effective. Moreover, the tightening of the embargo in 1992 strengthened this effect even more.
The U.S.– embargo covers a lot of medical companies throughout the world. Therefore, hardly any trade exists between these companies and Cuba and medical goods have to be bought in more expensive markets. Due to this and due to the lack of foreign currency, several important drugs are no longer available. In addition, there are shortages in medical goods and equipment often needs to be replaced. In order to cope with the decrease and to prevent a possible loss of quality of health services in the future, the Cuban State has formulated new strategies, which improved the situation a little these days. However, since the problems have not been solved yet, the health sector still has to deal with them. This research will deal with the question whether the General Agreement of Trade in Services (GATS) could contribute to solving the current problems. In order to determine which areas of the GATS could be relevant for the health sector in Cuba, the Agreement will be discussed in the next chapter.
50 Juventud Rebelde (Cuban newspaper, April 2002)
