What do Kerala and Cuba have in common? To start with, they are both small places—Kerala has a population of only 33 million and Cuba is one-third of that. Both have a high female literacy rate, with Kerala at 97.9% and Cuba at 99%. Both have achieved a stage of zero population growth. And, if you believe it makes a difference (I don’t), both have embraced a socialist-communist ideology for a long time.
The most important similarity is that they are both winners in public health delivery, especially maternal and child health. Their health outcomes compare with those of the world’s developed countries. In an earlier article I had looked at Kerala’s health performance and called out some amazing indicators, one of which is that neonatal (under 28 days) deaths per 1,000 live births is six, which falls in the same bracket as the US at four and the UK at three.
Cuba’s infant (one year) deaths per 1,000 live births is four, which is less than the US at six and on a par with the UK at four. Life expectancy at birth in Cuba is 80—like that of the Netherlands, the UK and the US. Immunization coverage is as high as 99%. Cuba’s health outcomes can be attributed to three main reasons: political will, innovations in front-line delivery and community involvement.
In terms of political will, Cuba’s healthcare is enshrined as a fundamental right in its constitution. Cuban leaders pledged to provide world-class healthcare services during the revolutionary struggle in 1958. The communist ideology led to reorganization of the healthcare system to assure less disparity among people. This was done through equitable universal access to healthcare for all.
Their healthcare system functions through six hierarchical interlocking levels. These are national health institutes, provincial hospital centres, municipal hospital centres, polyclinics, sector polyclinics and satellite polyclinics. Sector polyclinics provide primary healthcare and serve a population of 4,000-5,000, who are closely supported by satellite polyclinics, each staffed with a doctor, a nurse and a social worker.
The Cuban healthcare model focuses on mitigating health issues at a nascent stage, instead of incurring huge expenditure in treating diseases as they arise. This is attained through innovation in service delivery. Front-line health delivery is highly focused, emphasizing smart data use. Each residential area has a family physician, who is responsible for around 120 families. Along with the nurse, the doctor pays a home visit to each family at least once a year. They conduct a health check-up for everyone and enquire about social conditions.
Using this information, patients are categorized under various “risk categories" and their health is monitored based on this mapping. Patients categorized as “high risk" are given regular medical attention and their cases are referred to polyclinics. The health data is generated from the grassroots and used to treat patients as well as provide inputs in policymaking. To overcome the shortage in supply of essential medicines, use of traditional cures based on indigenous knowledge is promoted. Children are taught the basics of health.
Community involvement is a key part of the Cuban model. The Cuban constitution itself underscores participation of the people in developing and maintaining the healthcare system. Community plays an active role in supporting the local government’s efforts to provide healthcare access. Mass organizations such as the Federation of Cuban Women, with membership of women above the age of 14, are critical in providing support to the local government. They do this by drawing up an annual health plan, being involved in its implementation with the help of the community volunteers; monitoring the health profile of people, managing the healthcare centres, organizing immunization camps and mobilizing the community to avail the services provided. These organizations are like watchdogs for the community.
The experiences of different regions including Bangladesh, Kerala, Tamil Nadu and, now, Cuba, enumerate a simple yet compelling mantra—accessible, good healthcare services can be provided through innovation in front-line service delivery and involvement of the community within the overarching umbrella of political will.
Ashok Alexander is founder-director of Antara Foundation. His Twitter handle is @alexander_ashok.