Cuban Healthcare System: A Primary Care Model
The United States could learn from the Cuban healthcare system.
Last December, President Barrack Obama announced that it was time — after 50 years of complex policy and politics — to restore diplomatic and economic ties with Cuba. Whatever the pros and cons of this decision, I believe the two countries have a lot to learn from one another.
In December 2011, I had the pleasure to be part of a team of healthcare administrators who toured Cuba to learn how the Cuban government has established an effective public healthcare system. Based on my observations, the Cuban healthcare system works well for them.
While the United States struggles to provide universal, affordable healthcare for its citizens, our Cuban neighbors have made healthcare a constitutional right. The Cuban healthcare system is not only free for all Cuban citizens, the quality of primary care is equal to or better than the United States and other industrial nations, at a fraction of the cost. For example, Cuba has the same 78-year life expectancy as our country, while spending only 4 percent of the amount the United States spends on healthcare per person, annually.
Fundamentals of Cuban Healthcare
According to “Primary Health Care in Cuba, The Other Revolution,” the development of the Cuban healthcare system is based on three central assumptions:
Health is the responsibility of the state;
Health is a social issue, as well as a biological one; and
Health is a national priority, requiring participation from all sectors of the government and civil society.
The basis for the entire Cuban healthcare system is preventive care and the primary healthcare (PHC) model. Although Cuba has achieved success with its current model, it was not the starting point. Shortly after the 1959 revolution, the government established municipal “polyclinics,” which continue to function as multi-specialty clinics. In the early 1960s, the emphasis was on health screenings, vector control, and other measures to bring infectious disease under control. The PHC model of the community family doctor was introduced in 1984.
The healthcare system is now structured on two levels: level 1 is PHC, and level 2 is secondary healthcare (hospitals).
Primary Healthcare Level 1:
- Family doctor unit
- Polyclinics (includes dental care)
- Specialty institutions
- Mothers’ homes
- Grandparent homes (not a nursing home setting, but senior day care)
- Community mental health clinics
Secondary Healthcare Level 2:
- Inpatient hospital
- Inpatient nursing home care (This is minimal, as the culture focuses on family members remaining in the home.)
With the limited time available to our tour group, we did not have the opportunity to visit any secondary healthcare facilities; however, we did visit all of the PHC Level 1 care units. We found the medical directors, physicians, nurses, and everyone we came in contact with to be welcoming and informative.
We learned that the “family doctor unit” is a single physician with a team of nurses, statisticians, and technical assistants who care for a set number of individuals within their community. Eighty percent of Cuba’s physicians are primary care doctors, with only 20 percent trained as specialists. In the United States, these proportions are reversed.
Better Family Healthcare
and Minimizing Hospital Visits
Most primary care offices are on the first floor of a building, and the physician resides on the upper level with his or her family. Physicians and their teams know their patients well, and often tend to three or four generations of the same family in a single home visit. The average number of patients is approximately 1,000 per physician, compared to approximately 2,500 patients per primary care physician in the United States. The physician in each unit has been trained to care for the entire group assigned to him. This includes home visits, specialty care after consulting with specialists in the polyclinic, office visits, acute illnesses, long term care in the home, and — ultimately — keeping his or her patient population out of the secondary level of care (hospitalization). In short, all care is coordinated through the family doctor unit.
Other Cuban Level 1 Healthcare System Components
Polyclinics are larger, more regional clinics that include multiple specialties, dental, rehab, diagnostic lab, radiology, urgent care, and 24 hour emergency services accessible by everyone in the community. Generally, this is done by consultation request of the family unit doctor. But per Cuban health officials, anyone may enter the polyclinic on his or her own. After consultation, the specialist recommends treatment options to the family unit physician. The family doctor then resumes care, consulting with the specialist to meet the continued needs of the patient.
Specialty institutions are available if further specialty care is needed. For example, if a cardiac patient needs further testing, such as a stress test, the patient is referred to the Cardiovascular Institute for further care. Some testing, due to limited resources within the PHC, must be done at the hospital. This varies from procedure to procedure, and resource availability at the time of need. As we would expect, there are fewer magnetic resonance imaging and computed tomography scanners in all of Cuba than exist in my rural Western Pennsylvania hometown marketplace.
Mothers’ homes are maternity homes for at-risk, pregnant mothers or fetuses, based on limited criteria. Mothers can be admitted at any point during their gestation. This would include the need for bed rest due to possible early labor or hypertensive diabetic status or nutritional deficiencies. Ninety-nine percent of babies are born in the hospital; thus, if the expectant mother is in a rural location, she may reside at the mothers’ home late in her trimester. Evidence of Cuba’s success with this model shows up in its infant mortality rate — at 4.6 percent, one of the lowest in the world, and lower than the U.S. rate of 6.4 percent.
A Grandparent home is not equivalent to a U.S. nursing home. They are adult day care centers where working families can bring the elderly during the day. The senior adults are cared for and fed, and have a chance to mingle with other senior adults from the community.
Elderly care is promoted at the home as part of the Cuban culture. Families are encouraged to care for the grandparents with supervision of the family unit physician team. This team also includes
Community mental health centers care for mentally ill patients and support their families in centers located in the community. The director stressed that, optimally, the whole family is involved in the patient’s care and in supporting their own needs as caretakers. Group sessions with patients and families are held daily at the center. For example, mothers of children with attention deficit disorder (ADD) are able to network and lean on each other for support. Each center is staffed with psychologists, psychiatrists, nurses, technicians, and social workers.
Prevention, Not Profit, Is the Primary Focus
The Cuban healthcare system stresses preventive health. Despite limited resources, Cuba has a record unmatched by any economically disadvantaged nation of dealing with chronic and infectious diseases. These include polio (eradicated 1962), malaria (eradicated 1967), neonatal tetanus (eradicated 1972), diphtheria (eradicated 1979), congenital rubella syndrome (eradicated 1989), post-mumps meningitis (eradicated 1989), measles (eradicated 1993), rubella (eradicated 1995), and tuberculous meningitis (eradicated 1997).
You could argue that it’s easy to accomplish such goals when various elements are implemented or mandated within the community. For example, in Cuba education is free from preschool through graduate level degrees, and they integrate the education and healthcare systems. Children are vaccinated and receive periodic checkups at schools. School lessons include proper hygiene, such as brushing teeth, all the way to learning about contraceptive use. Adults are “required” to check in for a yearly physical.
Cuban physicians have learned to work effectively without the heavy emphasis on technology and pharmaceuticals, commonly relied on in the United States. Although they are proud of their ability to diagnosis and treat underlying problems without automatically reaching for a prescription pad, most Cuban physicians acknowledge the benefit of access to cancer-treating technologies and drugs that are not available, today (even though U.S. law exempted medicine and healthcare supplies from the U.S. embargo of Cuba in 1992).
Because the Cuban system is nonprofit and not reimbursement-based, there is no need to spend resources on coding and billing claims for services rendered. The office “statistician” focus is on quality indicators. Despite the lack of ICD-9 and ICD-10, electronic health records, and other end-user systems, they manage to capture data throughout the entire healthcare system. Because Cubans seldom move more than a few houses or blocks from where they were born, the same physician may treat an individual from the cradle to the grave, and has knowledge and records of all family members. This allows office visits to be interactive discussions, rather than focused on meeting evaluation and management documentation guidelines.
Although the embargo has blocked U.S. products from entering Cuba, it has not stopped the Cuban government from giving humanitarian help to other countries. Cuban doctors were some of the first in the world to step up during the 2014 Ebola breakout in Africa. We learned that Cuba has sent more than 125,000 healthcare professionals to provide care in 154 countries. In fact, Cuba — which is approximately the size of Pennsylvania — has more physicians than all of Africa.
The members of my tour group and I received an open invitation to return to learn more about Cuba’s healthcare success and struggles, along with its culture and people. It was a wonderful learning opportunity, and one that I am happy to share with others. If you have any questions, or would like to learn more, please contact me at
Joette Derricks, MPA, CMPE, CPC, CHC, CSSGB, has 35 years of healthcare finance, operations, and compliance experience. A national speaker and author, her unique style is to bridge the regulatory requirements with the practical realities of day-to-day operations. Derricks has provided numerous expert reports and testimony regarding Medicare, Medicaid, and third-party payer regulations with an emphasis on coding, billing, and reimbursement rules. She serves as the vice president, regulatory affairs at Anesthesia Business Consultants, and is a member of the Ann Arbor, Mich., local chapter.
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