HEALTHCARE SYSTEMS IN LOW -RESOURCE COUNTRIES
- According to the W H O, 400 million people lack access to basic medical care, with the majority of these people coming from low-resource countries. This represents an enormous global health inequity.
- To move towards universal health coverage, healthcare systems in low-resource countries must make the most of what they have, incorporate innovation, and optimize human resources. In this section, you will focus on Cuba as a model of a well-functioning healthcare system in a low-resource country.
How can a high-resource country’s approach be applied to countries with a fraction of the S D G?
- All the countries previously discussed in this module spend a large amount of money on their healthcare systems. Low-resource countries simply do not have these resources to spend. Global health equity and U H C are noble goals, but they will be largely unrealized unless they can be afforded.
- Currently, most healthcare systems in low-resource settings follow the out-of-pocket model. This asserts that all healthcare is paid for by the individual, which creates inequitable access to healthcare, resulting in millions of people without healthcare.
HEALTH NEEDS OF LOW -RESOURCE POPULATIONS
In addition to funding, other considerations must be made to effectively compare healthcare systems in low-resource countries with high-resource countries. For example, people in low-resource countries have health needs that are significantly different from people in high-resource countries.
Compare health needs between high-resource and low-resource countries.
HIGH-RESOURCE COUNTRIES
- In high-resource countries, individuals commonly require care for chronic or lifestyle-based diseases.
- For example, cardiovascular disease and type II diabetes.
LOW-RESOURCE COUNTRIES
- In low-resource countries, health issues are often associated with:
1. Poor living conditions
2. Inability to access healthcare
3. Health illiteracy
4. Malnutrition
GEOGRAPHIC ACCESSIBILITY TO HEALTHCARE AS AN OBSTACLE
- Geographic accessibility to healthcare services are a major barrier to healthcare access in low-resource countries. Geographic accessibility is influenced by lack of infrastructure and communication in remote areas. It is also influenced by travel time to health services.
- It is important to note that geographic accessibility is a major barrier in rural communities in high-resource countries as well. As discussed in Module 04, many Indigenous communities have a lack of health infrastructures. Despite there being medical transportation benefits program in place to subsidize the travel expenses when accessing medical services, many Indigenous Peoples living in Canada report difficulty accessing healthcare services or receiving subpar healthcare services.
- Geographic accessibility in Indigenous communities is also influenced by low doctor retention rate and lack of Indigenous doctors
NEED FOR INDIGENOUS DOCTORS
- In 2016, it was reported that only 0.1% of all general practitioners and specialists in Canada identify as Indigenous, yet Indigenous Peoples makeup 4.5% of Canada’s population. Although medical schools in Canada encourage Indigenous students to apply and often hold spots specifically for Indigenous applicants each academic year, there are still barriers to accessing medical education. These barriers include the geographic and financial hurdles to taking the Medical College Admission Test (M C A T), funding travel for medical school interviews, the high cost of medical education, and the difficulty of being separated from their communities to access education.
- As a result of the low percentage of Indigenous practitioners, many Indigenous Peoples experience discrimination in healthcare; while others report receiving inadequate and culturally insensitive care. In Canada, there are Aboriginal Patient Navigators in place to help Indigenous Peoples feel safe with their experience at the hospital. However, some report that this role was unheard of, while others feel like they are too vulnerable to request for a patient navigator
Aboriginal Patient Navigators
People who work at the hospital as a liaison to assist Indigenous Peoples and refer them to the right healthcare resources
RETAINING TALENT AS AN OBSTACLE
- Retaining talent is a major problem in many low-resource countries. There is often not enough incentive to retain talent, leading to something called the brain drain; in which skilled workers leave their communities to pursue better opportunities.
- Large drains of medical professionals can be detrimental to a healthcare system, particularly in rural areas
HEALTHCARE IN CUBA
- Delivering effective care in low-resource settings requires a completely different approach.
- Cuba’s healthcare system is a model of successful low-resource healthcare provision. Cuba has been so successful that it has either surpassed or rivalled the United States in many health metrics despite having approximately 1/7th the S D G per capita.
- Cuba has spent 40 years making healthcare a priority despite a lack of money, medicines, and supplies. Despite these challenges, Cuba has never lacked healthcare professionals in the community
The Cuban Medical Model is based on three principles
- Insurance should cover all medical fees.
- Health providers should understand and live in the community they serve.
- Focusing on the community is more effective than focusing on the individual.
Note that the Cuban Medical Model is not based on the principle that health coverage is a universal right
THE CUBAN HEALTHCARE SYSTEM
- Salud! is a film about using new approaches and resources to advocate for healthcare globally. It documents the healthcare system of several under-developed countries, while highlighting the benefits of Cuba’s remarkable healthcare system
- This video highlights the stark disparities in global healthcare, focusing on Cuba’s approach to universal healthcare. It contrasts health outcomes in different regions, such as the one in 4000 maternal mortality rate in Europe versus one in 16 in Africa, and life expectancy differences between Canada and Haiti.
- The video shares personal testimonies from people in various countries like The Gambia, Honduras, Venezuela, and South Africa, revealing the challenges they face in accessing timely and adequate healthcare. For instance, in Honduras, a doctor’s part-time schedule leaves communities without consistent care. In Venezuela, a mother’s experience of being denied care for her son is described as a traumatizing violation of the right to life.
- Cuba’s healthcare system is presented as a model of access and equity. The country’s focus on primary care, rural healthcare services, and training a large workforce of doctors (over 60,000) has led to dramatic improvements in health outcomes. The Cuban government ensures healthcare is a human right for all citizens, regardless of their economic situation. Family doctors are deployed in communities to provide accessible, preventative care.
- Cuban doctors not only work domestically but also play a significant role in international health diplomacy, with over 100,000 health professionals sent to 101 countries since 1963. While Cuba’s health system faces challenges due to limited resources, including outdated medical equipment and economic constraints, its focus on primary care and prevention, along with a highly trained workforce, has made it successful.
- The video emphasizes that Cuba’s universal healthcare system, while not without challenges, showcases the potential for countries with low resources to provide quality care and achieve better health outcomes through solidarity, innovation, and a focus on primary healthcare.
Salud key takeaways
- Principles of Cuban healthcare: Universal access, primary care focus, health as a human right.
- Strengths: Accessible care, a large number of trained health professionals, strong preventative care, international health outreach.
- Challenges: Economic difficulties, outdated medical equipment, shortages of medicines.
- Advantages of universal coverage: It promotes equity, reduces health disparities, and leads to better public health outcomes despite resource limitations.
KEY FACTORS IN THE SUCCESS OF THE CUBAN HEALTHCARE SYSTEM
There are a number of key factors to Cuba’s healthcare success. Four of these factors could potentially be generalized into a model for successful healthcare in low-resource settings
- integration of public health
- doctor-patient ratio
- community health networks
- central government support
Integration of Public Health
There is equal emphasis on preventive/proactive healthcare services, and disease management/reactive healthcare services. This differs drastically from many other countries, where the main focus of healthcare is on disease management, not prevention. Cuba’s emphasis on prevention and early interventions saves a huge amount of money for the country, and is one of the main reasons why Cuba is able to spend so little on healthcare.
Doctor-Patient Ratio
One of the most noticeable differences between Cuba and other countries is its extremely high doctor- patient ratio (1 doctor per 175 in Cuba vs. 1 doctor per 500 in Canada). Unlike in Canada where doctors are more concentrated in cities and doctor shortages are a major problem in rural areas, in Cuba, doctors are more equally distributed throughout the population, allowing them to give quality, uniform health care to all citizens of the country.
Community Health Networks
In the 1970s, huge progress had been made towards building a U H C system, but Cuba still faced many common problems such as long wait times, short visits, and physician over-specialization. Recognizing that each community had its own social and physical determinants of health, policymakers created a system of primary care clinics that brought the doctors directly to the communities, providing them with housing and salaries. These doctors became integral members of underserved communities, providing early diagnosis and prevention tailored to the unique environmental factors influencing their assigned population.
Central Government Support
Many of the features identified would not have occurred had there not been an obvious commitment to health provision by the President Fidel Castro. During the “special period” following the collapse of the Cuban economy as a result of the breakup of the Soviet Union, the health and education budgets were protected from the general reduction in gross national product. This significant government commitment to health care ensures universal access to healthcare services and a true commitment to health as a human right
Name two health indicators in which Cuba surpasses the U S. What are possible reasons for this?
Dr. Carpenter’s Response:
There are many health indicators in which Cuba surpasses the U S. For example, Cuba demonstrates much lower rates of H I V prevalence, which may be explained by travel restrictions placed on Cuban citizens. Cuba also has higher rates of immunization, which reflect the greater flexibility in choice that American’s have for immunizing their children. Also, Cuban health indicators show almost equal rates of infant mortality, perhaps correlated to the higher rates of immunization, or to the community-based approach/healthcare model
WEAKNESSES OF THE CUBAN HEALTHCARE SYSTEM
Despite the strengths of the Cuban healthcare system, there are two main limitations.
- drug and equipment storage
- lack of freedman for doctors and patients
DRUG & EQUIPMENT STORAGE
One limitation is that even common and essential medicines and equipment are often conspicuously absent in Cuba, according to interviews of Cubans conducted by the National Post. Because of this, there is a substantial black market for drugs or medical services that aren’t otherwise accessible.
LACK OF FREEDOM FOR DOCTORS AND PATIENTS
A second limitation of Cuba’s healthcare system is the lack of freedom that Cuban doctors and patients experience. According to some, there are weaknesses in the following spheres: right to privacy in physician-patient relationship, informed consent, right to refuse treatment, and right to protest or sue for malpractice. In addition, doctors do not have as much freedom to choose where they will practice and as such, they are sometimes placed in locations that are not ideal for their life and families.
SOUTH-SOUTH COOPERATION
- As you can imagine, one can generalize the factors that brought success to Cuba to guide policy decisions in other countries with limited resources.
- Using a model of successful programs in one low-resource country to model in another low-resource country has been called “South-South Cooperation”.
- It is probably becoming clear to you that it would be very difficult to improve a system in a low- resource country by attempting to use guidance from the systems of countries that are resource-rich.
HEALTHCARE IN GAMBIA
- Successful South-South cooperation has occurred between Cuba and Gambia. In the mid 1990s, the Gambian president recognized the link between poor health and low productivity, and decided to make health a major priority as part of a national development strategy. Instead of modelling the Gambian healthcare system on that of a developed nation, the president decided to ask Cuba for help.
- What followed was a remarkable transformation in which Cubans helped develop a new health system, increasing access to clean water, reducing the burden of malaria, and making improvements to nutrition
VIDEO: APPLYING THE CUBAN MODEL IN GAMBIA
- This video focuses on Cuba’s healthcare system, its influence on the Gambia’s public health sector, and the successes and challenges faced by Cuban doctors working in Africa.
The Cuban healthcare system, especially its primary care approach, has been a model for countries with limited resources, such as the Gambia. Cuban doctors were sent to the Gambia in 1996 to help establish the country’s first public health system. At the time, the Gambia had only two hospitals and minimal access to healthcare. With Cuba’s support, the Gambia built new hospitals, health centers, and clinics, and Cuban medical professionals became an integral part of the healthcare system, serving even in the most isolated areas. - Cuban doctors brought a family doctor system, emphasizing accessibility and affordability for the common people. They lived in the communities they served, which helped foster trust and improved patient care. Many of these doctors worked in the most remote villages, treating diseases such as malaria, respiratory infections, anemia, and skin diseases.
- Cultural difficulties were significant, especially given the scarcity of resources and the harsh living conditions in the Gambia. Cuban doctors faced challenges adjusting to the local environment, including poor hygiene and inadequate infrastructure. However, they learned to adapt by integrating into the communities, embracing the local culture, and adjusting their medical practices to the realities of their new environment. One doctor shared how her young daughter wrote a letter expressing understanding of her mother’s mission and how she learned to give the same affection to the children she treated as she would to her own.
- The arrival of Cuban doctors has led to tangible improvements in the Gambia’s healthcare system. Malaria cases significantly dropped, with a reduction in incidence from 600,000 in 2002 to 200,000 in 2004. The country also saw a decrease in infant mortality rates, and the widespread use of mosquito nets helped prevent malaria transmission. The Cuban health program was deemed one of the best malaria control programs in Africa.
- Despite some resistance from local health professionals, who initially feared the Cuban presence might overshadow their own work, the Cuban doctors’ humanitarian mission was widely praised by the local population. The Cuban doctors worked in rural and underserved areas, where Honduran doctors refused to go, helping to fill critical gaps in healthcare delivery.
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Module 4 Section 110
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