It was a September morning of 1958 and the place Harvard Medical School. A group of geniuses, mostly boys, were at the first day of their medical school and were in rapt attention of the college dean’s welcome address. After a short adrenaline pumping spiel, the dean pauses, turns around to the black board, and writes the number twenty-six. And as the buzz settled down, he utters the following words, “Gentlemen, I urge you to engrave this on the template of your memories; there are thousands of diseases in this world, but medical science has empirical cure for only twenty-six of them. The rest is guesswork”. This is how Erich Segal opened his bestselling novel ‘Doctors’, a compelling story set in the context of medical profession in the US. Six decades down the lane, medical science has become much advanced. Fiction and novels aside, the World Health Organization (WHO) currently lists about fourteen thousand diseases and disorders, each of which requires different protocols for treatment. And tackling these complexities need collaboration of systems, process and technology along with human intelligence.
Amidst all the advancements, India with its innovative and cost-effective manufacturing, deservingly earned the recognition as the ‘pharmacy of the world’. However, as per WHO’s ranking of the Health Systems, India is positioned way below at 112 amongst the member countries. As per recent Government of India data, 34 out of every 1000 newborns in India would not survive till their first birthday (also called Infant Mortality Rate or IMR). In countries like the US, IMR is as low as 6 and in the UK it is even better at 4. But wait on. While comparing development and setting benchmarks, we are often clouded by an obsession to the developed world. How about learning from elsewhere? In this context, it may be worthwhile to focus on the health indicators of a Caribbean island nation, which otherwise is more famous for Cigars. It’s quite likely that we may imbibe more from the land of Castro than that of Kennedy.
Tracing the Success Story
It was the Cuban missile crisis of 1962 that gave a platform for President Kennedy to demonstrate to the world a few lessons on leadership. With it, started a turbulent political relationship between Cuba and the US that lasted for six decades. The American flag was unfurled again at the embassy in the capital city of Havana ever since the easing of trade and travel restrictions by President Obama. The two countries have had divergent paths to progress during all these years but there is something that even the developed world aspires for, which Cuba has achieved.
According to the Human Development Index, Cuba is ranked the eighth highest in entire North America. It also ranks highly in metrics of national performance, especially health care. As per the ranking by WHO, Cuba is placed in the top tier with a rank of thirty nine. This nation of about 11 million people has also achieved a stage of zero population growth. Earlier in this article, we had glanced at the IMRs of different countries; for Cuba this figure is an enviable 4, at par with the UK. Life expectancy at birth in Cuba is 80, similar to that of the US, and Immunization coverage is as high as 99%. In 2015, Cuba also became the first country to eradicate mother-to-child transmission of HIV, a milestone hailed by WHO as "one of the greatest public health achievements possible".
The Ps of Success
That leads to the critical question as to how Cuba achieved these positive outcomes. From what various research publications suggest, it may be best to capture the critical success factors as a ‘bunch’ of Ps, which includes Primary Care, People, Preventive care and Peso.
The Primary Care level is assigned with the role of providing health promotion and protection, along with the resolution of minor health issues that account for an estimated 80% of total health concerns. The remaining 15% of health issues that may result in hospitalization is managed at the secondary care level, and tertiary care caters to last 5% where illness has resulted in severe complications. The back-bone of this system is the nationwide polyclinics that focus on all residents of defined geographic areas. Since physicians focus on pre-defined residential area rather than self-selecting patients, they are more likely to reach out to those who typically avoid interaction with the health care system.
People support through community outreach is one of the greatest strengths of the Cuban primary care system. Participation through organizations like the Federation of Cuban Women (FMC) is critical in providing support to the local government. Almost 90% of Cuban women over 14 years of age are members of the FMC, thereby providing mass connect.
Cuba’s focus on Preventive care, starting with the medical education and curriculum, is cited as a game changer, which even the US is trying to emulate. Their healthcare is modeled in such a way that the focus is more on mitigating health issues at a nascent stage, rather than incurring huge expenditure in treating diseases. Both the allocated physician and nurse visit each family at least once every year to conduct health check-ups and capture their social conditions. The data collected at the ground level is used for risk profiling and thereby adopt appropriate interventions.
Peso is the local currency of Cuba. Despite the long standing economic embargo that stifled the country, Cuba’s spending of more than 11% of its GDP on health demonstrates their priorities. Compare that with India’s current budgetary allocation of only about 1% of GDP on health, which is one of the lowest in the world.
The Last P
Healthcare is complex and Cuba's health system may have much more to achieve. It may also be difficult to transfer many Cuban lessons outside of its unique social context. However, beyond the White beaches and Tobacco fields, beneath the Caribbean soul and European architecture, despite the Economic hardships and Political alienation, Cuba has demonstrated to the world how to be one of the healthiest countries on the planet. In a recent article, the founder director of Antara foundation, Ashok Alexander, has drawn some parallels between Cuba and the Indian state of Kerala. He has pointed out that along with high female literacy, the most important similarity between Cuba and Kerala is that both are winners in public health delivery, especially maternal and child health. Some may argue that probably another ’P’ may be of relevance here; Political will and ideology. Has it made a difference in health of these states is certainly a matter of debate, and may be best reserved for another day.
The author is Co-founder & Director @ BioQuest Solutions Pvt. Ltd, a Bangalore based MNC that has been partnering with clients across the life-sciences knowledge value chain since 2005.