Revolutionary Medicine: Can Less Sometimes Be More?

Cuba is probably not the place most think of when looking for insights on how to address shortcomings of the high-cost, complex, and fragmented U.S. healthcare system. Healthcare delivery in the communist island nation is tightly controlled. It is characterized by long lines for specialty care, a frustrating absence of most technological advances of recent decades, and, owing to a meager hard currency balance and the stifling U.S. embargo, little to no access to the most current drugs and medical equipment. Cuba’s paltry GDP per capita, a fifth of that of the United States, also makes it difficult to make a meaningful comparison of the two countries’ fundamentally different healthcare models.

Remarkably, however, Cuba’s public health outcomes are impressive relative to those of its far richer northern neighbor. According to the World Health Organization, infant mortality rates, neonatal mortality rates, and mortality rates for children under five years are lower than the same rates in the United States. Vaccination rates in Cuba are higher. Life expectancy at birth in 2015 was virtually tied, at 79.1 years for Cuba versus 79.3 for the United States. 

Not every major health outcome is better in Cuba, of course. Incidence rates for chronic conditions such as cardiovascular diseases and cancer are lower but rising, and death rates from these diseases remain high. Respiratory disease burden remains low, but unless air pollution is better managed, this burden is likely to grow. The annual maternal mortality rate per 100,000 live births in Cuba, at 39, is impressive for a low-income country but higher than the rate of 14 in the United States (although the latter has been trending up). Still, despite extensive shortcomings in specialty care, Cuba appears to do a better job in preventive care at a fraction of the cost.

How Cuba Does It

As observed during a recent visit, the healthcare system in Cuba is designed around community-based primary care and not around the hospital system. This focus on preventive care is attained by three connected levels of healthcare delivery: polyclinics, which are mostly outpatient facilities based in the community; general hospitals, which are facilities for general acute care; and specialized inpatient institutions focused on specialty or tertiary care. Perhaps the most critical element of this system is the coordinating and surveilling role played by family physicians and nurses who live in the community. Each provider is responsible for a group of families living within a few blocks. As the designated provider, the physician or nurse carries out detailed surveillance activities, actively monitoring the environment and health of the members of the community. These providers also act as advocates and navigators of patients through the three tiers of the healthcare delivery system, which gives these family providers a good understanding of the health of their communities at any given time. 

Cuba is an extremely poor country, and life is hard for most residents. The resource-constrained and rationed healthcare system presents challenges that most Americans clearly would not accept, such as long lines and waiting times, extremely limited provider choice, substandard specialty care, and no access to the latest drugs or equipment. Nonetheless, the respectable public health outcomes that Cuba is able to achieve underscore the value of an unrelenting focus on primary care, which has helped the island nation achieve results far beyond what might be expected based on the average income level.

What We Can Learn

So what, if anything, can the United States learn from Cuba? Americans are unlikely to take extreme bureaucratic measures to control high prices (which, more than healthcare usage or demographics, are the root cause of the high costs of American health care. Neither is it likely that the incentive structure for costly drug development—ill-designed to address the growing healthcare crisis stemming from complex, chronic diseases that last over long periods of time—will change any time soon. 

The United States can, however, take a lesson from Cuba that is arguably more feasible: We can work harder to meet the need for a bottoms-up, community-based primary care system. Some initiatives already have begun toward this purpose. The University of Illinois at Chicago and the Kellogg Foundation are working with Cuban public health authorities to combat high infant mortality in a struggling neighborhood in South Chicago. The rising cost and complexity of healthcare delivery in the United States may require nothing less than the continuation and expansion of such cross-border learning ventures. Although the healthcare system in Cuba is far from perfect, its focus on community-based primary care is worth consideration as U.S. hospitals and health systems continue seeking effective strategies for improvement.

Aamer Mumtaz, MBA, MPH, is an independent healthcare consultant based out of the Los Angeles area.