The Constitutions of both Cuba and South Africa guarantee a “right to health” for all citizens and make it the responsibility of the government to deliver the right. The Cuban Constitution specifies that health services should be free to the consumer. The South African Constitution tempers the governmental obligation with terms like “reasonable” and within means. The countries are on very different paths to deliver these bold promises: Cuba through a State owned and operated delivery system that is free to the patient; South Africa through a National Health Insurance plan with comprehensive benefits purchased from public and private providers. Cuba has had fifty years to deliver on its promise while South Africa is just getting started. It would be unfair to declare a “winner” but it may be helpful for future policy choices to hypothesize about key drivers that set South Africa and Cuba on such different paths.

Cuba and South Africa are very different countries. South Africa has 53 million people; Cuba 11 million. Both had small ruling elites that expropriated great wealth from the forced labor of the majority of the populations. In both, the oppressed rose up and came to power: Cuba led by Fidel Castro; South Africa by Nelson Mandela. The foundational theme in Cuba is Revolution from the preceding order, while in South Africa it is Reconciliation with the past. This matters.

South Africa had major natural resources the world wanted. Cuba had few beyond sugar. International markets were open to South Africa but closed to Cuba. Some, but not all of the existing elites left South Africa. Cuba suffered huge capital and human resource outflows.

When Castro took over, more than half the doctors and other professionals fled. There was very little health infrastructure in the rural areas that were the core of the revolution. The country had to start almost from scratch in the face of US hostility that denied Cuba almost all international capital investment for decades. Castro relied on human capital and prevention as the basis for public health. Today the infant mortality rate is 2.4/1000. Life expectancy is 78. There is almost no difference between rural and urban health care access or outcomes. Cuba trains and has more doctors per capita than almost any other country in the world and regularly exports physici ans to other countries, including South Africa, for humanitarian and financial reasons. Specialists and family doctors are paid the same measly salaries, though many supplement their salaries with non medical work.

When Mandela took over, apartheid left two segregated systems; a weak public system providing minimal care to the vast majority of the residents and a private system in the White dominated cities serving the minority. The infant death rate was very high; life expectancy low and HIV/AIDS was rampant, infecting up to 20% of the adult population. Private hospitals and physicians took care of the whites in the cities, who usually paid out of pocket. About half of all health expenditures went to the private sector serving a small percentage of the population.

The theme of Reconciliation made it impossible for the ANC, the ruling party, to redistribute a significant percentage of health resource from urban whites to rural and township blacks and coloured. Redistribution had to be gradual. White clinic administrators could be replaced by Blacks over time. Capital investment in rural and township clinics could be made but in competition with other urgent public sector needs. Meanwhile private hospital operators found lucrative markets in the cities. Today there are two almost completely parallel systems, an improved but still low resourced public delivery system serving 85% of the people consuming 44% of all health expenditures and a private hospital, physician and health insurance system serving 15% of the people while consuming more than 40% of total health expenditures. The infant death rate is now significantly lower but still high. HIV/AIDs is now effectively treated throughout the country on a test and treat philosophy. Maternal transmission of HIV/AIDs has almost completely been eliminated. Waiting times at public hospitals are long.

National Health Insurance was seen, at least on paper, as a way to deliver universal health care by reconciling the differences between the public and private sectors and redistributing resources from the minority to the majority population without provoking the current users of the private system. A progressive national tax system and economic growth would finance subsidies for the poor. Access and quality would be improved by the national scheme contracting with both the existing public system and the private sector to provide comprehensive services to all. A 14 year timetable was laid out to enable the changes to be effected. Major issues of governance and finance remain unresolved. The national budget proposal for the coming year includes initial creation of a National Health Insurance Fund but the amount allocated is small and is likely to be used as supplementary funding to meet critical needs not for core financing.

There is lots of discussion among academics, career civil servants and opinion leaders about slowing things down. Conflicts between the National government that is mandated to implement the program and provincial governments that now control the delivery system are emerging, especially in areas where the dominant ANC party has lost control. Pilot projects are underway but the results have been mixed. There have been virtually no significant contracts between the public and private sectors. Few private sector doctors have agreed to public sector jobs. Some critics think the plan focuses too much on curative care rather than upstream promotion. The path to universal health care in South Africa has many potential footfalls, but the reason the country is on the path can be traced, I believe, to the founding theme of Reconciliation.

In 2004 Fidel Castro and Hugo Chavez made a deal to significantly expand eye surgery in Cuba and Venezuela to eliminate blindness from cataracts and other reversible eye conditions. Venezuela had oil cash so it provided the equipment. Cuba had the doctors so it rapidly expanded the number of ophthalmologists it trained. At first the patients came from Venezuela to Cuba by the thousands but over time the Cuban ophthalmologists went abroad to serve more people near their homes. By the time the formal program ended, more than 3 million people in Latin America and Africa benefited from it. Now, Cuba remains a center for eye related medical tourism.

It’s a question at the front of mind for an American visitor but seems strange to senior Cuban medical officials. Set aside the picture of the totem pole with family doctors at the bottom. Think instead of a strong foundation on which everything rests. When we asked the medical director of the largest teaching hospital in Cuba if the specialists felt superior to the family doctors he was genuinely puzzled by the question. He said: “How could we look down on them? They are basis of the entire system. We completely depend on them.”

There is a strong ideological and pedagogical emphasis on family medicine. I was told that all medical students spend significant time in a family doctor’s office from the start of their training. At the end of the revolution in 1959 about half the doctors in the country left for the US, leaving fewer than 3000 doctors for the entire population. What had been one of the most sophisticated medical care systems in Latin America suddenly had to start over again almost from scratch.  Several core political decisions shaped the new system: the divide between rural and urban access to care would be closed; medical care would be free to all; the focus would be on prevention of disease; decisions would be based on the best science available; human personnel development would be favored over technology. (Cuba had people but not much hard capital for investment.) Building the system around a large base of family doctors was the logical result of these principles, and entirely consistent with the communal political structure emerging from the revolution.

Still, there had to be more to the matter. There is.

All physicians receive the same paltry salary from the State, regardless of specialty. Family doctors, however, are provided with a free house, often above their clinic.

The chance to work abroad is also a very strong attraction to being a family physician. Doctors are a major export industry in Cuba and a principal element in Cuba’s international political influence.  Cuban doctors staff many of the field stations during crises like Ebola and the hospitals in Haiti, Venezuela, Angola and other developing and oil rich nations. More than 37,000 Cuban doctors are working outside the country in a typical year.  The Cuban government is often paid handsomely for these services. Last year Forbes magazine reported that Cuba may receive as much as $8 billion a year from the oil rich countries where their doctors practice.  The doctors also earn much more working abroad than at home. They are able to accumulate resources and material goods to bring home—to the house the government has already given them. Cuban doctors returning home after a number of years abroad have the right to buy a car at deep discount—and the cash to do so.

For most doctors family medicine is their only choice. The Ministry of Health tightly controls access to specialty training. Each year it estimates the number of specialists the country will need at the time the incoming class will graduate and that is the number of admissions for the year.

Some of the experts we met expressed doubts and fears about the future of the family doctor based system. While doctors never made much money, they had a nice home and enjoyed the respect of their neighbors. Nobody else was making more.

Going into medicine was always at the top of the choices listed by high school students who wanted to go university. That may no longer be true. Cuba has opened about 100 job categories to “private” enterprise. People in these jobs can set up their own businesses and earn more money. As a result, Cuba’s best and brightest are increasingly selecting university training for careers in tourism, the arts and music. We were told repeatedly that engineers and doctors are driving taxis because they could not earn a living in their chosen careers. The government has raised doctors’ salaries but there is concern that it won’t be able to keep up with rising incomes in the new private sector. One of the specialists I interviewed said flatly that if doctors’ salaries did not increase, they would leave. She, for example, can open a practice in Ecuador and significantly increase her income immediately.

Cuba has a lower infant mortality rate than the US. 4.2/1000  versus 6.1/1000. The rate does not vary all that much around the country, suggesting that good maternal and infant care are available wherever a woman lives.

Here are some of the reasons.  Medical care is free; guaranteed in the Constitution as a responsibility of the government.  Everyone in Cuba has a family doctor who usually lives above the clinic in the neighborhood and makes regular house calls. Really. He/she is required by the maternity protocol to do a full early pregnancy examination before the ninth week of pregnancy during which the potential complications are identified.  A plan for the pregnancy is developed and reviewed with the consulting obstetrician. Both clinical and social risks are considered, for example twins, gestational diabetes or hypertension, inadequate nutrition and family environment. The family physician and nurse follow women in the low risk category.  The national protocol includes 12 visits and timely screenings for developmental problems. Ultrasound exams are routine. Women get paid time off for their prenatal visits.

If there are any concerns about possible risks to delivering a healthy baby, the pregnant woman lives in a “maternity home” under medical, nutrition and social worker supervision. Saying no to this special treatment does not seem to be option. When the baby is about to be born the woman is transferred to a hospital that knows the individual treatment plan and is prepared for the mother and baby.  There is extensive neonatal screening for all babies to identify both common and rare genetic, metabolic or hormonal abnormalities. All newborns are tested for hearing. Within three days after discharge the family doctor and nurse make a house call to assess baby, mother and the environment. Supplemental nutrition is provided for both.  Babies and mothers see the family doctor regularly in the first year of life and all babies are immunized against 13 childhood diseases. All complications are reviewed with the consulting pediatrician who can see the baby and mother at the regional polyclinic (multi-specialty ambulatory center).

Without respect to the high level of care mothers and children receive, Cuba has a very low birth rate; currently 1.42 per woman, way below the population replacement rate of 2.1. In fact, the government announced new financial incentives just this week to encourage women to have more children. There is considerable skepticism they will do much good. People we talked with gave us powerful reasons there are so few babies. The education level for women has risen sharply, increasing their opportunities in the workplace. Housing is crowded and expensive. Young couples often have to delay living together and getting married until they can afford to buy even a tiny apartment. Salaries remain low, making many people afraid they cannot afford to raise a child, yet. Contraception is widely available at very low cost. Abortion is legal, free and not stigmatized.

There will be many lessons about healthcare from Cuba. Here is one I came across today as we were passing a home for women with high risk pregnancies. They stay there getting support until they are ready to deliver. Our guide, a very well informed young lady, said these homes are important because the birth rate is so low, 1.2/1000. She said that a couple of years ago the government stopped selling condoms, claiming they were in short supply. The real reason, she said, was to try to drive up the birth rate. The actual result was a sudden increase in abortions. Condoms went back on sale in a couple of months. Seems to be a pretty clear natural experiment.

The rapid aging of the population is clearly an emerging problem that I will address in another post.