Cooperation for Health: The Cuban Experience Gail A. Reed International Director, MEDICC April 25, 2007.

Cooperation for Health: The Cuban Experience

Gail A. ReedInternational Director, MEDICC

April 25, 2007

““An evaluation of 25 countries in An evaluation of 25 countries in

the Americas measuring relative the Americas measuring relative

inequalities in health revealed that inequalities in health revealed that

CubaCuba is the country with the best is the country with the best

health situation in Latin America health situation in Latin America

and the Caribbean. It is also the and the Caribbean. It is also the

country which has achieved the country which has achieved the

most effective impact with most effective impact with

resources, though scarce, invested resources, though scarce, invested

in the health sector”in the health sector”

(Study on Human Development and (Study on Human Development and Equity in Cuba, UNDP, 1999)Equity in Cuba, UNDP, 1999)

““An evaluation of 25 countries in An evaluation of 25 countries in

the Americas measuring relative the Americas measuring relative

inequalities in health revealed that inequalities in health revealed that

CubaCuba is the country with the best is the country with the best

health situation in Latin America health situation in Latin America

and the Caribbean. It is also the and the Caribbean. It is also the

country which has achieved the country which has achieved the

most effective impact with most effective impact with

resources, though scarce, invested resources, though scarce, invested

in the health sector”in the health sector”

(Study on Human Development and (Study on Human Development and Equity in Cuba, UNDP, 1999)Equity in Cuba, UNDP, 1999)

CUBACUBA

Cuba: Key Health Indicators - 2003Cuba: Key Health Indicators - 2003

Region Infant Mortality* Under 5 Mortality*

World 56 81

Most developed 8 10

Developing 61 89

Least developed 97 161

Latin America & Caribbean 32 41

Cuba 5.8 7.7Source: United Nations, 2003 and Anuario Estadístico de Salud*per 1,000 live birthsSource: United Nations, 2003 and Anuario Estadístico de Salud*per 1,000 live births

Human Resources for HealthHuman Resources for Health

Fortify the system’s scientific and ethical vitality among new leaders

• Outstanding Graduates program

Train more health care professionals (2005)

• Total health workers: 447 023• Total physicians: 70 594 (1x159 inh.)• Nurses x 10.000 inh.: 79.5

2006 – 2007 (January 2007)

• Medical school enrollment: 24 682• University nurse enrollment: 45 319• Allied health enrollment: 73 620• Clinical Psychology: 1445

Share lessons and expertise with other developing countries

Global Cooperation: Scaling Up to Meet the Crisis

• Research Applied to Prevention• Treating Low-Income Patients in Cuba• Disaster Risk Reduction & Relief• Cuban Medical Teams Abroad• Training Doctors for Global Health

Global Cooperation: Scaling Up to Meet the Crisis

• Research Applied to Prevention• Treating Low-Income Patients in Cuba• Disaster Risk Reduction & Relief• Cuban Medical Teams Abroad• Training Doctors for Global Health

Treating Low-Income Patients in Cuba

• >500,000 eye surgeries in Cuba (2004-2006) (including >70,000 Cubans)

• Patients from 29 countries

• Vision restoration projected for 6 million in the next decade

Treating Low-Income Patients in Cuba

• >500,000 eye surgeries in Cuba (2004-2006) (including >70,000 Cubans)

• Patients from 29 countries

• Vision restoration projected for 6 million in the next decade

Cuban International Disaster Relief1960-2000Cuban International Disaster Relief1960-2000

1960 Chile Earthquake, 5,000 dead Medical team

1970 Peru Earthquake, 60,000 dead Medical team, 6 rural hospitals,106,000 blood donations

1972 Nicaragua Earthquake, 5,000 dead Medical team, food, medicines

1974 Honduras Hurricane Fifi, 2,000 dead Medical team

1990 Soviet Union Chernobyl disaster program 17,733 children treated in Cubathrough October, 2004

1996 Brazil Radiation poisoning 52 patients treated in Cuba

1998 Central America

Hurricane Mitch, 30,000 dead and disappeared

Medical teams

1998 Haiti Hurricane Georges Medical team

1999 Venezuela Torrential rains, mudslides, 9,000 dead

Medical team

2000 El Salvador Dengue epidemic, 10,000 cases over 16 wks.

Medical team, advisors and equipment

Disaster Risk Reduction & Relief

• Katrina sparks Henry Reeve Contingent: 5,000 specially trained medical personnel

• UN Designates Cuba as Regional Disaster Preparedness Hub

Disaster Risk Reduction & Relief

• Katrina sparks Henry Reeve Contingent: 5,000 specially trained medical personnel

• UN Designates Cuba as Regional Disaster Preparedness Hub

The Henry Reeve Contingent2005-2006The Henry Reeve Contingent2005-2006

October 2005 Pakistan Earthquake, 75,000dead. 3.3 millionhomeless.

2.465 medical team32 field hospitals(7 months)

October 2005 Guatemala Hurricane Stan, 670dead. 300.000homeless.

600 medical team andmedicines(3 months)

February 2006 Bolivia Flooding 140 medical team20 field hospitals and medicines

June 2006 Indonesia Earthquake, 6000dead.

135 medical team2 field hospitals

Continuous Care Medical TeamsContinuous Care Medical Teams

Began with newly independent Algeria,1963

100,000 Cuban health professionals in 101 countries

February, 2007: 29,809 Cuban healthprofessionals in 69 countries

Cuban International Medical Cooperation1963-2006Cuban International Medical Cooperation1963-2006

Source: International Cooperation Unit, Ministry of Public Health, Havana

Region Countries

Africa 38

Americas 37

Europe 8

Asia/Mideast 18

TOTAL 101

Cuban Medical Teams Abroad

“We were particularly attracted to the Cuban doctors because we knew of the type of health system that they’d built in Cuba with limited resources; and the underlying philosophy of primary health care was the same we’re aspiring to introduce for our own health system. The Cubans became in fact very good role models.”

Ayanda Ntsaluba, MD, MPH, Director General Foreign Affairs, South Africa

Cuban Medical Teams Abroad

“We were particularly attracted to the Cuban doctors because we knew of the type of health system that they’d built in Cuba with limited resources; and the underlying philosophy of primary health care was the same we’re aspiring to introduce for our own health system. The Cubans became in fact very good role models.”

Ayanda Ntsaluba, MD, MPH, Director General Foreign Affairs, South Africa

Turning the Corner:Cuba’s Family Doctor ProgramTurning the Corner:Cuba’s Family Doctor Program

Family medicine put to the test: Healthy people in a resource-scarce environment

Evolution of community-based models:Maximizing lessons for other developing countries

Turning the Corner:From Cooperation to Sustainable AssistanceTurning the Corner:From Cooperation to Sustainable Assistance

Hundreds of health professionals sent to Central America and Haiti in the wake of Hurricanes Georges and Mitch.

1998:

Cuba’s Comprehensive Health Program:Confronting the Real DisasterCuba’s Comprehensive Health Program:Confronting the Real Disaster

• Direct long-term medical care

• Applying lessons from Cuban experience

• On-the-ground training of local personnel

• Development and sharing of research

• Academic training for Cubans at international sites

• Trilateral cooperation

• Scholarships for medical education

• 29 countries involved (21 in Africa)

• Direct long-term medical care

• Applying lessons from Cuban experience

• On-the-ground training of local personnel

• Development and sharing of research

• Academic training for Cubans at international sites

• Trilateral cooperation

• Scholarships for medical education

• 29 countries involved (21 in Africa)

Direct Medical Services: Strengthening Health SystemsDirect Medical Services: Strengthening Health Systems

• Bilateral government accords, identify needs

• Bolster public health infrastructure, capabilities

• Shared financial responsibility

• Mainly remote, rural postings

• Individual commitment/institutional commitment

• Numbers of professionals enough to make a difference

• Bilateral government accords, identify needs

• Bolster public health infrastructure, capabilities

• Shared financial responsibility

• Mainly remote, rural postings

• Individual commitment/institutional commitment

• Numbers of professionals enough to make a difference

Challenges and Opportunities:Bolstering Local Public Health SystemsChallenges and Opportunities:Bolstering Local Public Health Systems

Opportunities Challenges____________________________________________________________________

Sustainability Frustration with local infrastructure

Increase understanding locally Bend to local opinions

Long-range perspective, understanding Vulnerable to govt changes, political will

Horizontal model, broad presence Integrate vertical programs

Increase staffing for health system Create felt need in population

Broad skill set Mismatched, narrow skill set

Direct Medical Services: Professionals OnlyDirect Medical Services: Professionals Only

• Mainly family doctors at primary care level

• Other specialists at primary, secondary levels

• Other disciplines: biostatistics, epidemiology, electromedicine

Lessons from the Cuban Health Care Experience:Patient-Based and Population-BasedLessons from the Cuban Health Care Experience:Patient-Based and Population-Based

• “Guardians of health” in geographic area

• Marrying clinical medicine and public health practice

• Risk factor diagnosis/health situation diagnosis

• Measure outcomes

Training Local Health System PersonnelTraining Local Health System Personnel

• Midwives

• Continuing medical education for nurses, others

• Biomedical Engineering

• Health statisticians and systems managers

• Health promoters

Research:Development and SharingResearch:Development and Sharing

• Disease-specific: cholera, malaria, genetically-based

• General epidemiological

• Scientific forums

• Advice in specific fields

Cuban Academic Training at

International Sites:

Outstanding Graduates

Program

Cuban Academic Training at

International Sites:

Outstanding Graduates

Program

Trilateral CooperationTrilateral Cooperation

• Haiti

• Honduras

• South Africa

• HIV/AIDS offer

Scaling up: The Latin American Medical School (1998)

• 29 countries

• 10,000 students, 3,000 first graduates (05-06)

• 100 indigenous populations

• 51% women

• Low-income students

• Commitment to serve

• Sustainability

Scaling up: The Latin American Medical School (1998)

• 29 countries

• 10,000 students, 3,000 first graduates (05-06)

• 100 indigenous populations

• 51% women

• Low-income students

• Commitment to serve

• Sustainability

Different from Previous Scholarships:Aiming for SustainabilityDifferent from Previous Scholarships:Aiming for Sustainability

• Student selection: poor, indigenous, marginalized

• Bridging program

• Training geared to country of origin

• Looking for commitment to underserved

• Eventually replace Cuban doctors in-country

Training Doctors for Global Health

“I think the Cuban system of training could serve as an example to the rest of the world if we wish to have functioning health systems in the future. The Cuban system trains doctors for communities, willing to sacrifice for the welfare of others. I think there is a need for such a paradigm shift.”

Nestor Shivute, MD, WHO Country Representative, Gambia

Training Doctors for Global Health

“I think the Cuban system of training could serve as an example to the rest of the world if we wish to have functioning health systems in the future. The Cuban system trains doctors for communities, willing to sacrifice for the welfare of others. I think there is a need for such a paradigm shift.”

Nestor Shivute, MD, WHO Country Representative, Gambia

Training Professionals for Global HealthTraining Professionals for Global Health

Profession International Enrollment 2006-2007

Medicine 23,567*

Dentistry 80

Nursing 128

Allied Health 383

Residencies 704

TOTAL 24,862

Source: Minsap, March 2007Source: Minsap, March 2007* Includes 12,600 medical and pre-med in new program.* Includes 12,600 medical and pre-med in new program.

Training Professionals for Global Health

• At least 100,000 new doctors by 2015

• Second Latin American Medical School

• Cuba has founded 11 medical schools and 2 nursing schools abroad

• Cuban professors teach in a dozen others

Training Professionals for Global Health

• At least 100,000 new doctors by 2015

• Second Latin American Medical School

• Cuba has founded 11 medical schools and 2 nursing schools abroad

• Cuban professors teach in a dozen others

Human Resources for Health:The Africa ProgramHuman Resources for Health:The Africa Program

• Medical Schools in Africa • The South Africa model

Scaling up:Esmeralda, University in the AmazonScaling up:Esmeralda, University in the Amazon

Health Equity & Cooperation:Challenges We FaceHealth Equity & Cooperation:Challenges We Face

$$ Resources$$ Resources LackingLacking Wise use (still lacking…)Wise use (still lacking…)

GoalsGoals Disease drivenDisease driven Healthy people drivenHealthy people driven

ProgramsPrograms SilosSilos BlanketsBlankets

ModelsModels Stand-aloneStand-alone Building health systemsBuilding health systems

PrioritiesPriorities Donor drivenDonor driven Effective local leadershipEffective local leadership

InvestmentsInvestments In buildingsIn buildings In peopleIn people

ReachReach Pilot programsPilot programs Scaling UpScaling Up

WayWay IndependentIndependent Real cooperationReal cooperation

MovementMovement Band aidsBand aids ChangeChange

“We are still challenged to be dissatisfied.

Let us be dissatisfied until every man can have food and material necessities for his body, culture and education for his mind, freedom and human dignity for his spirit.…

Let us be dissatisfied until the empty stomachs of Mississippi are filled, and the idol industries of Appalachia are revitalized.

Let us be dissatisfied until our brother of the Third World—Asia, Africa, Latin America—(is) lifted from the long night of poverty, illiteracy and disease.

Let us be dissatisfied until brotherhood is no longer a meaningless word at the end of a prayer, but the first order of business on every legislative agenda.”

Dr. Martin Luther King, JrFebruary 23, 1968

“We are still challenged to be dissatisfied.

Let us be dissatisfied until every man can have food and material necessities for his body, culture and education for his mind, freedom and human dignity for his spirit.…

Let us be dissatisfied until the empty stomachs of Mississippi are filled, and the idol industries of Appalachia are revitalized.

Let us be dissatisfied until our brother of the Third World—Asia, Africa, Latin America—(is) lifted from the long night of poverty, illiteracy and disease.

Let us be dissatisfied until brotherhood is no longer a meaningless word at the end of a prayer, but the first order of business on every legislative agenda.”

Dr. Martin Luther King, JrFebruary 23, 1968