Health, health services, and health planning in Cuba

Citizen Participation in Health in the Republic of Cuba

Community participation in health was established as a guiding principle in the development of Cuban health services as early as 1961. This paper examines the nature and scope of popular participation in health utilizing Arnstein's “ladder of participation” as a theoretical framework for analysis. Attention is focused in particular on two of Cuba's mass organizations — the Committees for the Defense of the Revolution (CDR's) and the Cuban Women's Federation (FMC) — and on the broad-based People's Commissions on Health and Public Health Commissions which they help comprise.

Cuba's strong accent on consumer participation at all levels of society, and particularly at the broad institutional level, is seen as providing an important example to health professionals in other nations concerned with facilitating consumer involvement in the quest for healthier societies.

Cuba's response to the HIV epidemic

BACKGROUND

Cuba's response to the human immunodeficiency virus (HIV) epidemic has been to conduct mass testing of the population to ascertain seroprevalence, to enforce mandatory relative quarantine of persons testing positive, and to implement educational interventions using media and school-based programs.

METHODS

Interview with the Vice-Minister of Health and review of available data.

RESULTS

Reports to date show a very low seroprevalence rate without evidence of a widespread epidemic. Sexual contact with foreign-born persons is the primary risk factor. Possible advantages of Cuba's policy include rapid reduction in the risk of HIV transmission by infected blood products, an opportunity for focused education and secondary prevention, and limitation of new infections. Possible disadvantages include the restriction of individual freedom in those who are not guilty of any illegal act, quarantine of persons with false positive HIV tests, and ongoing transmission because of the incomplete nature of the quarantine. The policy is expensive and may displace other public health priorities. The content of the media-based educational interventions has emphasized rational medical information in unimaginative formats with a limited focus on prevention.

CONCLUSIONS

The issue of personal responsibility for behavioral change versus government imposed regulations is at the core of Cuba's HIV policy. The quarantine policy may paradoxically permit most Cubans to feel that they are personally invulnerable to the HIV epidemic.

The state, class and the allocation of health resources in southern Africa

In Africa the literature specifically linking the state, class and the allocation of health resources is sparse, and the evidential base for health research is inadequate and difficult to interpret. This paper looks at some of the ways in which state, class and health may be related in southern Africa. The region provides useful comparisons because of the starkness of the relationships between class and race and disease patterns and health care in much of the sub-continent; the different types of state and class structure within southern Africa; and the changes in ideology and to some extent health practice which came with the political independence of some of its component parts. Using both historical and contemporary data, it pinpoints the importance of analysing the specific and changing form of the state in the different countries of the region, in order to understand the social determinants of disease and the allocation of health resources, and looks at the significance of class, race, ethnicity and gender in the incidence of health and the state's response. It highlights the specific colonial legacies, continuing imperial linkages and location of countries in the international division of labour which inhibit changes in health care. Within the region, the migrant labour system and South Africa's aggressive policies of destabilisation create particular problems for weak states and for individuals within them attempting to implement more progressive health care programmes. The paper also argues that the ideological role played by health care has to be understood, and shows the diverse uses to which it is put across the region. The paper concludes that while the position of the state in the international and regional economy, its specific form and the nature of its class relations are predictors in some sense of health and health care, a variety of micro-level political and social decisions and mediations have also to be taken into account. While most of the countries of the region are in some sense part of the 'periphery', and a product of colonialism, these labels are insufficient to explain the differences between them in terms of disease patterns and health care systems. The specificities of internal social dynamics, local class ethnic and gender struggles and political conflicts are also crucial.

Health-care delivery in Cuba: nursing's role in achievement of the goal of 'Health for All'

The findings of a study of the delivery of nursing care in noninstitutionalized settings in Cuba are presented. The study investigated factors associated with change in health status and the role of nursing in the community to bring about that change since the time of the 1959 revolution. Recommendations of the World Health Organization's 'Goal of Health For All by the Year 2000' provided guidelines for the study. In the pursuit of Health for All, the World Health Organization specifically called for universal coverage with primary health care to include the following essential elements: education covering the prevention and control of major health problems; adequate food, safe water and nutrition; maternal and child health including family planning; immunization against infectious disease; prevention and control of endemic diseases; and treatment of diseases and injuries. Findings of the study suggest that nursing can play an important role in the delivery of health care that meets the World Health Organization's goal of Health for All through universal coverage of primary health care to the defined population.

Rural development and primary health care in less developed countries

The traditional approach has been to regard health activities as a small component of rural development programmes. Under the Primary Health Care approach health is seen as the lever for rural development. But there are tendencies in the implementation of Primary Health Care in less developed countries towards limiting the range of activities to preventive and curative personal health services and of denuding it of its community development orientation. This paper highlights some of the issues that seem to militate against the establishment of Primary Health Care with its full complement of rural development activities. These activities together with the preventive and curative personal health services undertaken in the framework of community development promise to lead to the achievement of the hitherto elusive goal of improving the socioeconomic and health status of the rural population of less developed countries.

Health education in Cuba: a preface

Critics of health education policy in the United States fault it for ignoring the unequal ability of Americans to adopt more healthy behavior and for underestimating the social, economic, and political causes of disease. Many critics hypothesize that health education in a less bourgeois society would be more equitable and less individualistic. This article tests that hypothesis by analyzing the current Cuban health education program aimed at the reduction of chronic diseases. It argues that while the Cuban program appears to be every bit as individualistic as the North American program, theirs may not be comparable to ours because Cubans are less likely than Americans to reify the state. At least among supporters of the revolution, Cubans do not automatically make a conceptual distinction between the individual and the society. Discussions about responsibility for disease prevention take on new meaning in this light.

U.S. Marxist scholarship in the analysis of health and medicine

This article makes a review of 1.) dominant analyses of health and medicine in the social sciences of the U.S. and 2.) Marxist critiques of these analyses. It presents the roots of Marxist scholarship in the study of health and medicine and discusses the main Marxist critiques of the hegemonic pluralist and power elite interpretations of the institutions of medicine and of their corporatization. It also reviews Marxist studies of 1.) the crisis of medicine; 2.) the relationship between production, work, and health; and 3.) imperialism, health, and medicine. It concludes with a discussion of the operational meaning of Marxism in health and medicine, with presentation of current Marxist debates on socialist medicine and their consequences for political praxis.

Community medicine in Cuba

The 25 years of revolution in Cuba have brought about great changes in the health care system. The health status of the population has been transformed from that of a developing country to one approximating the developed countries. The delivery of primary care at the community level has evolved over the past 15 years as a result of critical evaluations of the new implementations. The community polyclinic has been the basis for all health planning since 1975. This model has the health of the community as its main concern and the mechanism for involving the community in healthcare decisions has been established. The history of the community polyclinic and the evolution of the guidelines by which it functions are reviewed. In practice, many problems persist and the strategy for resolution of current conflicts will provide for interesting developments in the near future.

The Puerto Rican and Cuban public health systems: a comparison

This article compares the Puerto Rican and Cuban public health and mental health systems and the respective health profiles, emphasizing the role of psychosocial stressors. The Cuban health system was found to be better organized and more capable of providing equitable health care and encouraging community participation in health care delivery. However, the Puerto Rican public health system is in crisis and in the process of turning over the administration of its facilities to the private medical sector. Although both countries share health profiles similar to those of developed nations, differences in morbidity and mortality patterns, and the seemingly epidemic incidence of mental disorders in Puerto Rico suggest dissimilarities between their respective psychosocial stressors. Differences in the quality of public health care and in the health profiles seem mostly attributable to the divergent political and economic organization and priorities of both countries.

Biomedical and ethnomedical practice in rural Zaire: contrasts and complements

Some health care planners and scholars who work in developing countries have advocated the promotion of some form of cooperation, or even integration of the medical services of biomedical practitioners with the services of local healers. This paper discusses issues that mus be addressed in the consideration of such possibility in a rural community in Zaire where the "dual use' of medical resources is evident. After briefly outlining the characteristics of the biomedical and ethnomedical systems that now exist, the strengths and weaknesses of each system are evaluated and compared. In promoting cooperation between different types of practitioners, project planners, it is argued, should consider the strengths and weaknesses of each type of medical practice and should seek to improve the use of existing medical resources. The paper concludes by outlining a series of progressive stages of contact among practitioners that could lead to a system of mutual referral.

The capitalist world-system and international health

A number of world health problems which have been discretely considered in the past are viewed in this paper as interwoven with each other and with the functioning of the capitalist political-economic world-system. Thus, climactic explanations ("tropical medicine"), and even poverty when conceived in cultural terms or as a structural problem resident entirely within a single nation, are seen as inadequate for understanding any or all of the problems discussed briefly here: poor general health levels in peripheral and semi-peripheral nations, especially rising infant mortality rates in countries such as Brazil; comerciogenic malnutrition; dumping and exploitative sale of drugs, pesticides and other products banned or restricted in core nations; genocidal and other threatening approaches to population control; export of hazardous and polluting industry to peripheral and semi-peripheral nations; similar export of human experimentation; the sale of irrelevant, high medical technology to countries lacking basic public health measures, the "brain drain", and medical imperialism. Also discounted are moralistic inveighing, complaints about inadequate information and its transfer, discussions of bureaucratic bumbling or inter-agency politics and professional rivalries, various forms of victim-blaming, and other explanations and corrective approaches which ignore class structure and the control, distribution, and expropriation of resources in nations and the world-system. The framework suggests the importance of a worldwide cultural hegemony, including a medical cultural hegemony, established by and in the service of the ruling classes. Socialist-oriented nations which are quasi-independent of the capitalist world-system are seen as suffering less from its effects. This suggests that we should conceive of world socialist health and world capitalist health, rather than any kind of unified phenomenon called "international health".

The distribution and supply of Cuban medical personnel in Third World countries

More than 2,000 Cuban health care personnel are presently providing care in Third World nations; less than five years ago this number was fewer than 100. Some 1,500 of these are physicians, representing nearly 13% of Cuba's 12,000 health service physicians. Cuba dominates the health care delivery system of four small African nations and South Yemen, and Cubans are a major presence in a number of larger countries, such as Iraq.

The international transfer of medical technology--an analysis and a proposal for effective monitoring

The international transfer of medical technology to the developing countries occurs at four levels--medical education, research, and missions; multinational corporate transactions; technical assistance projects sponsored by the World Health Organization; and bilateral foreign aid programs. In this article, a proposal is made for effective monitoring of international medical technology transfer through political and legal means, including a specific code of conduct for corporations engaged in medical technology transfer. The development of "intermediate health technologies" along the lines suggested by E. F. Schumacher, and the advantages of such an innovation in terms of population issues and economic development are also discussed.

Notes on health care planning in Latin America and the Caribbean

Attention is called to the fact that the efforts to improve health of populations in Latin America have generally failed. The inequality in the distribution of ill-health is great. The authors accept the fact that the lack of resources available to the health sector may be a restriction towards the improvement of the situation, but they argue that a much more important issue is the misuse of such resources and their maldistribution within the health sector. The lack of integration and coordination between the health services, the conflict of public and private health systems, the under-utilization of existing services and the gap between planning and real implementation are discussed.

The Cuban health system: a trial of a comprehensive service in a poor country

This article reviews Cuban health programs in terms of six goals that seem to have been adopted, explicitly or implicitly, by the administration. Postrevolutionary Cuba has placed a high priority on health, and aims to create a health service that is comprehensive in scope and content, in population covered, and in organizational forms and levels of specialization. Within this service, the Cuban health administration has attempted to apply, with every appearance of success, what is known about the major diseases that affect their society. This health program has also focused on human needs, has tried to measure the effects of its activities, and has responded to evaluation. Some trends in Cuban health patterns are described from available data. With preventable diseases under control, Cuba now faces problems similar to those of developed countries. The new phase will require new approaches, with emphasis on the research techniques of epidemiology and the social sciences to develop and evaluate possible preventive approaches to chronic disease.