First published in ITIJ 107, December 2009
Cuba’s faded and decaying grandeur, with its iconic 1950s American cars and Caribbean beaches, is as much of a pull to tourists as its turbulent political history and revolutionary icons. Tatum Anderson evaluates what facilities are on offer to tourists who need medical help
With an indigenous population of over 11 million, Cuba receives a further boost of around two million international visitors a year. Canadians form the largest proportion of its tourists, but Europeans from the UK, Spain, Italy, Germany and France largely make up the rest. More recently, however, Cuba has begun to market its tourist industry to Argentina, Brazil, Spain, Portugal, Bulgaria and Russia and is also understood to be working on China, a large potential market.
The largest of the Caribbean islands, Cuba is actually an archipelago that sits between the Gulf of Mexico and the Caribbean Sea. Many tourists head for the resort areas along the north and south coast at Pinar del Río, Varadero, Trinidad, Cayo Coco and Playa, Santa Lucía and Santiago de Cuba. Concurrently, however, Cuba is establishing another type of tourism industry – health tourism. Patients from over 90 countries worldwide – including famous personalities such as Diego Maradona – have reportedly visited Cuba for treatments.
Health tourism generates an income of approximately US$50 million each year, according to experts, and almost 10,000 people have already visited Cuba to receive a range of services from plastic surgery or drug rehabilitation to orthopaedic surgery and treatments for vitiligo, psoriasis and alopecia. Most patients come from Europe and Canada, but some health tourists will travel from the US, despite legal restrictions. The island offers not only health services, but luxury hotels and beaches where patients can recuperate from treatments. It even offers sightseeing tours for recovering patients. Thus, there is a great incentive for Cuba to provide world-class health services if it is to attract patients from the rest of the world. That’s good news tourists and assistance companies alike.
Cuba is essentially capitalising on a reputation it has built in healthcare. It is a poor country, one of the poorest in the Caribbean, but it has still pursued the principal of free universal access to healthcare for all inhabitants. As such, public health experts see its system as a model, particularly for other developing countries.
Cubans enjoy an integrated, free system of care led by the Ministry of Public Health or Ministerio de Salud Pública, which is composed of a family doctor system, municipal health centres or polyclinics, public hospitals and pharmaceutical and research institutions. By 2005, its primary healthcare (PHC) comprised some 31,000 physicians and nurses, organised in a network that encompassed 442 polyclinics, 64 rural hospitals and some 22,000 GP clinics, according to Pan-American Health Organisation (PAHO), a division of WHO.
The healthcare system has grown up amidst a revolution, which saw half of the country’s doctors flee a decades-old US government trade embargo and the dramatic collapse of the island’s economy when the Soviet bloc disintegrated. Cuba lost over 80 per cent of its foreign trade in the 1990s and the loss of income took its toll on the health of the population. The country’s most significant health reforms took place during the 1970s and 1980s.
Other countries have made similar changes more recently, in the 1990s, say public health experts. For instance, the 1980s saw the introduction of the family doctor system, which embedded a small doctor-and-nurse team within communities, sometimes in nearby flats or houses. Although not necessarily well-equipped, these teams were able to promote family health and disease prevention amongst a few hundred families in their areas, link to other services and maintain good health monitoring records.
"Patients from over 90 countries worldwide – including famous personalities such as Diego Maradona – have reportedly visited Cuba for treatments"
The country has also placed great importance on training new doctors and now has an enormous workforce too. Cuba had 70,594 physicians (62.7 per 10,000 people) in 2007. Indeed, there are so many medical graduates, that Cuba has been exporting thousands to Africa and Latin America since the 1970s, who provide free medical services to these communities in what is seen as an exercise in soft diplomacy. Over 28,000 Cuban health professionals were serving abroad in 2006, says Medical Education Cooperation with Cuba (MEDICC), a non-profit organisation promoting US, Cuban and global health collaboration.
Therefore, with an enormous healthcare workforce, good health surveillance systems and a burgeoning domestic drug and vaccine manufacturing industry, Cuba can claim to have eliminated some infectious diseases that typically blight poor countries. Indeed, declining mortality and fertility rates on the island means that its population’s entire demographic has shifted. Citizens are increasingly facing health problems seen in rich countries instead – chronic disease and old age. As a result, its healthcare system has been forced to alter health priorities to try and keep pace.
Chronic health problems are treated at the appropriate level of care according to PAHO. Cuba’s National Cardiology and Cardiovascular Surgery Network tracks surgical procedures performed nationwide and provides follow-up care. Indeed its Hemodynamics and Interventional Cardiology Section had performed 5,008 diagnostic procedures and 1,354 major surgeries with a medium to high level of sophistication by 2005, it says. Some of those treatments included highly complex repairs of congenital malformations and heart transplants. But, while malaria and other poverty-related diseases may have been effectively eliminated, some infectious diseases such as diarrheal illness persist. This exposes large health inequalities among the provinces in Cuba and probably reflects the differences in sewage, water supply and general living conditions, say academics.
As with many parts of life on this Caribbean island, tourists are generally kept at arms length from most residents, often visiting different hotels, restaurants and even shops. This is primarily the result of a dual currency system. Cubans are paid, and can buy staples and non-luxury items, in Cuban pesos (CUP) while tourists use a currency called the Convertible Peso (CUC$). Goods and services priced in CUC$ are usually more expensive, so many ordinary Cubans cannot use them. This segregation has extended to healthcare too. Tourists are serviced by a separate system that is largely managed by the Ministry of Tourism. Here, patients are expected to pay for treatment although, just like Cuba’s licensed hotels and restaurants, the tourist health system is run by the government. The health system is managed by Cubanacan Turismo y Salud (CTS), a subsidiary of the Cubanacan Group, which oversees Cuba's finest hotels, luxury resorts and restaurants.
"Cuba is essentially capitalising on a reputation it has built in healthcare"
Cubanacan Group is a state-run corporation of tourism and international trade, which markets and operates Cuban hotels at home and abroad. It boasts 70 hotels and 15,000 rooms, and even runs partnerships with international hotel chains. CTS runs different types of health services for tourists. It operates international clinics that offer primary healthcare services to tourists, organises health tourism services at specialist centres and runs health spas and a network of drugstores and opticians too.
Major resort areas run international clinics that handle more complex medical conditions with permanent teams of doctors and nurses. These clinics are equipped to offer emergency medical attention too, according to CTS. There are such CTS clinics in Pinar del Rio, Havana, Varadero, Cienfuegos, Trinidad, Cayo Coco in Ciego de Avila, Playa Santa Lucia in Camaguey, Santiago de Cuba and in Baracoa, plus CTS-linked doctors in 100 hotels across the islands. There are also stand-alone CTS clinics that are not in the major resort areas, but are, instead, within hospitals.
Tourists can be referred to specialist public hospitals if more serious conditions cannot be treated at CTS clinics or in the medical emergency rooms located at some hotels. CTS says it has a network of specialised vehicles to transport patients to Cuba’s national health service, although the state also runs a road ambulance service.
With at least one public hospital in each of Cuba’s 14 provinces and several facilities in Havana, the nation’s capital, the island is home to around 270 hospitals. They provide general, clinical, surgical, paediatric, and gynaecological and obstetric care. Over 60 hospitals aimed at the rural population, also offer basic care. That said, medical facilities in Havana are generally better than those available elsewhere in the country, says the UK government.
However, even at public hospitals, travellers are often treated in dedicated tourist wards. The Frank Pais Orthopedic and Scientific Compound, a specialist orthopaedic centre, says it offers 677 beds for Cuban patients plus a special section exclusively reserved for treating foreigners. In Havana, however, many travellers are sent to Cira Garcia Central Clinic, which is owned by CTS. The hospital has 39 private rooms – including suites – that offer surgical, intensive and intermediate care, as well as scanning and laboratory facilities.
In emergencies, tourists can be treated at other types of Cuban institutions, such as the polyclinics used by ordinary Cubans. Typically, these have no in-patient facilities, although there are up to eight beds, and a maximum stay of eight hours is allowed. The polyclinics often boast maternity staff, dentists, ambulances and laboratories too. In fact, experts say that around 80 per cent of specialist services in Cuba are provided by polyclinics.
Asistur, an official Cuban assistance firm, provides services to over 200 foreign assistance and insurance companies worldwide, says Cira Garcia is well-equipped to deal with tourists. Emilio Guevara, managing director of Asistur says that, like other CTS clinics, it is more likely to have multilingual staff, can process invoices and deliver medical reports required by assistance firms. “Cira Garcia is used, not only because of the good services it provides, but because of the very good administrative performance,” he says.
In contrast, there is little administrative infrastructure dedicated to invoicing at polyclinics. That said, in an emergency, tourists are treated regardless of their ability to pay or whether they are insured, say experts. However, foreign governments warn visitors that healthcare can be expensive – a, basic hospital stay can cost as much as £200 per day plus medical expenses, says the UK Foreign and Commonwealth Office (FCO). Patients requiring medical treatment will often be expected to pay in hard currency.
"The country has also placed great importance on training new doctors and now has an enormous work force … there are so many medical graduates that Cuba has been exporting thousands to Africa and Latin America since the 1970s"
Asistur agrees that medical assistance at CTS clinics and in provincial hospitals is usually invoiced directly to tourists, but invoices can also be sent to assistance companies if visitors are covered by a policy it recognises. Repatriation is usually organised via the airlines that regularly fly to Cuba, such as Iberia, Air France or Air Canada. However, there are no air ambulance companies in Cuba, so critically ill patients must be transported using firms from Canada, Puerto Rico, Mexico and, occasionally, the US and Europe. Special arrangements are essential before such transport is permitted to land in Cuba, however. “We arrange landing clearance for air ambulances and co-ordinate immigration and transport arrangements for the arriving crew,” says Asistur’s Guevara. European foreign affairs departments advise their nationals that medical evacuation can be expensive too.
Reports on the state of the nation’s hospitals vary, however. Reports describe some facilities as well-equipped; others state that in many parts of Cuba, doctors are badly paid, poor facilities are rife, with many buildings in a poor state of repair, that equipment can be out-dated, there is poor choice and essential drugs (especially those priced in Cuban pesos) are frequently non-existent. The FCO, for instance, advises its citizens to bring adequate quantities of their own prescription drugs because of frequent shortages.
The US embargo and Cuban rules that restrict imports both contribute to the shortage, says MEDICC. Asistur insists, however, that for tourists, drugs and supplies are guaranteed in clinics and hospitals, and are invoiced directly to tourists or through the assistance firm if recognised by Asistur. Some drugs can be also bought in pharmacies located at some hotels and in Cuba’s largest cities, says Guevara. Indeed, CTS boasts a network of outlets in major locations across the country selling Cuban-made drugs and cosmetic preparations.
MEDICC agrees that Cuba’s resources are stretched – especially with so many of its doctors working abroad – and that it faces serious challenges and will have to refurbish and re-equip its hospitals. In 2004, around 444 community polyclinics and 52 hospitals and tertiary institutes were earmarked for an upgrade. A few have been completed, such as Hermanos Ameijeiras Hospital, Pando Ferrer Ophthalmological Institute and the Enrique Cabrera Clinical-Surgical Hospital in Havana, it says. The success of the national refurbishment project is key to Cuba’s continuing reputation as a public health model and, ultimately, as a health tourism centre.