In many ways, Cuba is an exemplar of how to achieve the Triple Aim.
Cuba spends just under $2,000 per person on health, and yet life expectancies are comparable to the United States (which spends about $9,000 per capita on health). The system is also far more equitable than ours in the US because everyone is guaranteed access to the same quality health care.
I recently traveled there with a group of 14 health care executives who wanted to know what Cuba’s both positive and negative examples could teach us. I wanted to share a few of the things we learned.
A different way to train doctors
Cuba’s Latin American School of Medicine (known by its Spanish acronym, ELAM) is the largest medical school in the world, with 4,000 students attending from 98 countries. Cuba trains doctors at no charge, and provides room and board, medical care, and even a small monthly stipend. As part of Cuba’s medical diplomacy, it accepts students from countries facing the worst health outcomes and natural disasters, including Haiti and Honduras.
The school also has American medical students. I spent the afternoon with 15 such students, who came from all over the United States to learn a different way to practice medicine that focuses on a population, not just individual patients. What I heard about their education was fascinating.
Students spend their first year “learning how to learn,” developing curiosity, academic rigor, focused learning skills, and empathy. Also in their first year of study, the system assigns them a bed. Rather than rotating from one department to another, they work with a team that cares for any patient admitted to their assigned bed. This system trains them to be experienced generalists, prepared for whatever comes their way.
Unlike the US, their training doesn’t rely on expensive technology and testing. Instead, they learn to diagnose illness with a thorough physical exam and conversation with the patient — they catch 90 percent of health problems this way. They also learn to include shamans and traditional healers in the care of the patient.
Health care starts in the communityEvery person in Cuba is assigned a health number and has an annual care plan developed for them, based on their level of risk:
The health care system starts in the community, where each neighborhood has a clinic with a doctor and a nurse. The doctor-nurse teams spend each morning in their neighborhood office seeing patients and each afternoon out visiting their neighbors based on need.
Each town has a polyclinic, which serves roughly 37,000 people with all kinds of specialists. The staff in the polyclinic see about 40 emergency visits a day, rehab visits, dental and mental health visits, and 300 specialist visits. These polyclinics also have inpatients, so that people don’t have to leave the community to be admitted. There are no electronic records, just paper, but the providers described frequent communication between them.
District hospitals, maternity hospitals, and academic medical centers provide specialty services and link all information about the patient back to the other clinicians in the neighborhood and the polyclinic.
People have many opportunities to interact with the health care system. Once you find out you are pregnant, you go to the dentist, and the dentist talks to your doctor. We visited an obstetrics hospital that reported going 12 years with no maternal deaths, and two neonatal deaths. They say that “breast feeding is the first immunization” — and 83 percent of women breastfeed. After a baby is born, providers visit every day for the first month, making sure breastfeeding is going well, the mother is picking up her food rations, and to address domestic violence or other clinical or social challenges.
Health education is a big part of Cuba’s health care system. Children learn about dental care, nutrition, and fitness. Diabetes is a growing problem, and so students are learning about health and nutrition in school and in summer camps. As soon as a child is diagnosed with diabetes, they go to a week-long camp with their parents and grandparents, where they learn about the condition, how to cook, and what to eat. At the end of the week, they go to a party where they try out their skills in a real-world situation.
All school children spend four hours each day in academic learning, spend two hours each day in physical activity, and have time every day to develop intellectual skills in an area of interest, including theater, painting, and music. We met with a group interested in health care, and they demonstrated what they’ve learned about CPR, setting broken bones, and other first aid care.
Treating the whole person
Each community has a neighborhood center. The unemployment rate is horrible, but instead of letting people sit at home, they can come together at a neighborhood center every day. We met a man who is out of work, and could easily be isolated, but like others in his community, he goes to a neighborhood center focused on art, and created an instrument from old bike handles, bells from a cow, and other parts. He’s the most amazing musician, and seemed to take great satisfaction in being part of the artistic life of his neighborhood center.
We also saw a bench at the neighborhood center that the community dedicated to an elderly lady named Elena. Every day, even at 100 years of age, Elena would walk to a street corner, and sit on the bench there. When people asked her what she was waiting for, she said, “I’m waiting for my love.” When Elena died, community members built that bench to remember her.
We also visited a senior home. Many of the middle aged people are working and not at home to care for their elderly relatives. Social isolation contributes to poor health, so seniors can go to a senior home to spend their days engaging in social activities, creating artwork, and eating three meals. The joy there was infectious!
Lessons for the United States
We would not want to replicate everything we saw in Cuba. Eating sugar, because the country is a huge sugar producer, is part of the culture, and this has led to problems with diabetes. There’s very little protein available in the food rations. We’ve made so much progress in the US with decreasing tobacco use, but it is still rampant in Cuba. Alcohol and drugs also contribute to big health and social problems there.
We were told that end-of-life care conversations don’t happen. The patients and families, we heard, have no voice in end-of-life decisions. There are no “do not resuscitate” orders.
But on the whole, Cuba’s health system is well designed to provide care for individuals and populations at much less cost than our health system.
As we work toward ACOs in the US, Cuba’s health system is worth study. Our schools can begin with including health and self-care in the earliest grades. We can identify and build local health teams who truly know and understand the people in their populations, and not just when they are ill and need health care. We can push for interoperability of electronic records to achieve the kinds of connectedness that the providers in Cuba have through phones and faxes. We can reach out to support all the social determinants to create and sustain better health for all.
Leave your thoughts about Cuba’s health system in the comments section below, and learn more about IHI’s initiatives to improve population health, such as the 100 Million Healthier Lives initiative and the Triple Aim for Populations.
Maureen Bisognano is IHI President Emerita and Senior Fellow. She recently paid a visit to Cuba.
