A healthcare system, also referred to as a health system, are “all organizations, people and actions whose primary interest is to promote, restore or maintain health,” according to the World Health Organization. Access to a health system is an important concept to consider as informal settlements and urban slum continue to grow in cities of the global south. Health outcomes of urban populations are an important component of sustainable growth. A healthy population is more likely to be happy and motivated to participate in community engagement, urban politics and grassroots efforts that can improve the quality of life for the population.
The system of healthcare can be accessed through various types of networks, both formal and informal. In the formal sector healthcare is provided by organizations such as government, while the informal sector issues "unlicensed, unregulated" health providers. Informal healthcare provisions are highly popular in the global south, particularly in highly populated areas that lack sufficient public or affordable health systems. Havana, the capital city of Cuba, is a unique exception to healthcare systems of the global south. Cuba’s alternative health system combines aspects of healthcare from both the informal and formal sectors.
The U.S. embargo on Cuba blocked access to medical and health supplies, forcing Cuba’s government to provide healthcare accessible to its population. This resulted in Havana’s unique healthcare that is practiced by using both a formal top-down approach and an informal bottom-up approach. Havana practices community-based healthcare, natural traditional medicine, and organic farming, as a part of their unique health system. While Havana aims to provide accessible healthcare to all the population, discrimination against certain groups of people and the decreasing number of doctors in Havana has resulted in limitations similar to those found in other health systems of urban cities in the global north and south.
In cities of the geographic North, the delivery of services such as healthcare often follow a uniform and centralized framework that is integrated into the control of the formal Government or economy. This top-down approach, in theory, can provide a more uniform distribution of services that should ensure equal access for everyone because management and distribution is through a centrally planned and interconnected collection of networks. This can either manifest as a universal healthcare system that is funded by taxes and subsidized by the government- such as Canada- or provisioning can be provided by the private sector, such as in America. However, this neoliberal and commodity-based approach to the provisioning of health services assumes a more homogeneous landscape and institutional deficiencies can cause poor management and the under-investment of health services.
Contrary to this, Governments and economies of cities in the geographic south have often not yet established these types of formal networks. Instead, the provisioning of services such as healthcare can transpire through unregulated and informal networks with boundaries that shift to fill the demands of the rapidly growing and poverty-stricken populations of urban centers and mega-cities of the geographic south. This can manifest as a more bottom-up approach to the provisioning of services as small-scale operators and grassroots, collective initiatives work together to fill the gaps in services. This method is a ‘socio-technical dispositif’ which combines different methods- from the institutional and administrative level to the various physical and knowledge-based structures- to contribute to the administration of services; it considers how people interact with their built and natural environments at a local level and is described as an actor-network theory. However, the success of health services via this less formal, bottom-up network approach is largely reliant on community participation as well as sometimes the use of less regulated medicinal practices.
Limitations to accessing healthcare can occur whether health services are distributed via more formal, top-down networks or whether they are accessible through bottom-up networks and community initiatives. No single network type can ensure entirely equal, fair and high-quality health services. Theoretically, when networks are combined the varying networks can work together to ensure best practices. However, this may also lead to the inefficiencies of a system becoming more pronounced. For example, Havana, a city located in Cuba and situated in the geographic south, is unique in that it utilizes a more conventional framework in terms of healthcare provisioning and this appears as a combination of top-down and bottom-up network forms.
Access to Healthcare in Havana
History of Cuba
The country of Cuba is highly urbanized; 74% of the population lives in urban areas, with the largest urban center being the capital, Havana. The population in Havana is 2,135,498, making it the most densely populated city in Cuba. The history of Cuba forced its government to find alternative means to healthcare through the reallocation of funds and community engagement.
Following the collapse of the Soviet Union, Cuba experienced an economic crisis due to sanctions applied by the U.S. government and because of the loss of previously established trade agreements.  However, this attempt had little impact on the health system in Cuba. The government of Cuba maintained a free and universal healthcare system, even with heavy pressure to adopt a market-based economy. Diseases such as AIDS polio, tetanus, diphtheria and human rabies were successfully controlled.
In 1993 the U.S. sanctions imposed upon Cuba resulted in a complete block of medical supplies, foods, fossil fuels and chemicals for agriculture. The embargo also limited access to water treatment chemicals for its water storage system. The restricted water supply followed an increase in diseases. Doctors were unable to treat simple diseases successfully. The lack of medicines and even basic medical supplies, such as gloves, gauze, and antibacterial soap were extremely limited. The U.S blockade had detrimental effects on local levels. Havana experienced an epidemic of optic and peripheral neuropathy while malnutrition became rampant. The daily caloric intake of Cubans became 30% lower than in the 1980s. Because raw materials were limited, Cuba was unavailable to produce their own medicine. In addition, patients in the health system in Havana had to bring their own sanitary supplies such as soap, toilet paper, and sheets. Absenteeism among medical staff and theft of supplies were major problems.
In response to the undergoing crisis urban populations developed grassroots initiatives, which included urban agriculture and community healthcare, which were both supported by the government. Moreover the government reallocated existing funds in support of healthcare practices, such as Natural Traditional Medicine (NTM) and other preventive health care approaches. Thus, the success of Cuban healthcare was based on both top-down and bottom-up initiatives.
Government-supported and Grassroot Initiatives
Preventive medical care consisted of alternative technologies such as a network of family doctors. Havana adopted these methods in which doctors are assigned a neighborhood to serve families. This was an initiative by the doctors in Havana, which was supported by the government, due to its success. The objective is to get “intimate knowledge of the individual, familial and risk profile." This is able to do in Havana and all Cuba with an estimate of 68 155 total doctors in Cuba in 2004 with 99.1% of the population being covered by a family doctor service. The neighborhoods in Havana are “equipped with a community clinic that addresses the needs of its residents. In addition, an expansion of networks links the extension of benefits from local clinics for minor ailments to regional hospitals for the chronically ill while providing the required service and medicines whenever available." Therefore, the social network in Havana is crucial as it is their only social capital that fulfills healthcare service more efficiently.
Natural Traditional Medicine
Natural Traditional Medicine (NTM) is known as an alternative medicine to the US, but has been applied within the healthcare system in Cuba for a long time; NTM originally arose in Cuba as a result of the collapse of the socialist block. It was a cheap and effective solution initiated by the government to ensure a healthy population. Over time, due to its success, it became permanently integrated into the the larger healthcare system. Additionally, these practices were adopted by the network of family doctors and bottom-up initiatives, such as organic farming, as more farms began growing medicinal plants, which reinforced NTM practices. Some successful NTM practices include, the use of acupuncture to treat menopausal symptoms in women and hypnotherapy for irritable bowel syndrome. Moreover, Dr. Bosch an anesthetist in one of Havana's pain clinic's stated that of the 75,063 NTM patients from 1986 to 2007, 96.2 % reported symptomatic relief within an average of 8.1 sessions. This compares with only a 92% effectiveness rate reported from patients treated with an allopathic nerve block during the same time. Although NTM is very successful, not many scientific studies are able to validate these practices due to poor methodology and sample size. However, Doctors believe that experiential and anecdotal evidence (like in Dr. Bosch's case) is enough to validate NTM practices and to continue them in Cuban cities like Havana. This shows that Havana's healthcare success is rooted in the top-down and bottom-up networks working in collaboration, as physicians have government support to continue practicing NTM, even without significant empirical evidence. Thus, it is evident that the government trusts and supports community efforts.
Food security became a major issue after the fall of USSR, thus citizens of Cuban cities like Havana began practicing urban agriculture and organic farming, which was supported by the government. Practicing organic farming not only produces food security but it also imposes less pressure on the environment due to the lack of pollution by pesticides and herbicides and the elimination of large scale monoculture. Moreover, it is healthier for the human body. Furthermore, small farmers are supported, through their Organopónicos, which are small organic urban farms, which are naturally fertilized through compost and worms, such as the California Red Worms in Havana. . Such farms are situated in the suburbs of Havana and not only grow food, but also grow herbal medicines like eucalyptus and chamomile . These are distributed by the government to doctors all over Cuba to practice NTM. Thus, although organic farming and urban agriculture was a bottom-up initiative, which started out as small-scale, with top-down (government) support, it was created into a large-scale strategy to ensure food security.
Problems to Accessing Healthcare
Inequality within the System
Although Cuban cities like Havana take pride in their equity of public health services, there are certain problems with the system. Same-sex couples are sometimes denied healthcare check-ups due to the homophobia of some healthcare professionals. Exclusion from the health system has resulted in many consequences for LGBTQ members. For example, individuals who are unaware of certain health risks and are denied check-ups can have permanent negative impacts on their overall health if treatment is delayed.
Discrepancies of mortality rates in Havana have been reported based on one’s skin color. The non-white population has a higher mortality rate compared to the white population in Havana. Also, lower standards of healthcare have been reported by the non-white population. However, there is little evidence of discrimination in Havana to access medical services because all ethnic groups have equal access to free education and in theory, the health system operates in the same way. Therefore, healthcare inequality among people of different color is not because of ethnicity, but rather due to social status. Moreover, Havana faces challenges to provide healthcare for all population and the elderly is associated to be the most impacted. There is no evidence that suggests unequal access to healthcare based on gender, socioeconomic and racial differences. However, due to the Cuban history of political and economic struggle, children and pregnant women were often prioritized to access essential goods such as food and medicines, resulting in a situation that has left older adults more vulnerable. Indeed, the elderly population in Havana demonstrate a deficit in nutrition based on a constant weight issue. A higher percentage of the elderly population in Havana consider their health condition as deficient in contrast as in Matanzas City, Cuba. This suggests the complex nature of delivering equal healthcare in a city with a large population density. The increase of diseases such as dementia, cardiovascular and chronic vascular demonstrates a miscue in equal access to a healthcare system.
Limitations of Health Networks
Healthcare in Havana is treated as a right rather than a commodity, thus becoming a doctor in this city is about helping the community rather than earning a lot of money, as doctors do not earn very high wages. Although this ensures that people become doctors to help the community, there can be a lack of incentive to stay in Cuba. The family doctor system in Havana is experiencing a few changes as many neighborhood clinics have closed down due to a deficit of doctors and nurses since 2006. Due to a shortage of doctors in Venezuela and Brazil, many doctors are sent to these countries from Cuba in exchange for oil. Doctors in Havana are paid between $20 and $25 per month, but are paid around $150 and $375 a month in these other countries, which makes migrating to them very appealing. Even though health indices have not been impacted by this change, people are unsatisfied as they do not have access to immediate medical service anymore.
The health system of Havana adopted both top-down and bottom-up approaches that Cuba claims to have created a free, equally accessible, universal healthcare system. However, this theoretical approach to healthcare has proven impractical when applied to Havana. This is because the top-down approach does not take into account social aspects that affect healthcare professionals’ decisions. The government’s interference in the bottom-up approach to healthcare diverges from the actor-network theory that allowed people to create networks of health systems, resulting in gaps being created and not addressed by the government and subsequently the government-provide health system.
These gaps appear in the forms of discrimination against the LGBTQ+ community, racialized bodies and the elderly population. This demonstrates the need for a pragmatic health system to be formed by actors of the population in order to address the limitations specific to the city that would otherwise go unnoticed or ignored by the larger systems of governments or formal organizations. Furthermore, the formal network of health in Havana promises doctors for every family and individual, however the socioeconomic factors that cause Cuban doctors to leave the country for better pay and discrimination, to a certain degree, against the elderly, people of colour and the LGBTQ, demonstrate the need to analyze factors surrounding a system in order for it to benefit the entire population.
The successful aspects of Havana’s healthcare system are revealed through the self-sustainable approaches implemented as a result of Cuba’s isolation from the globalization of cities in the global north and south. From this, Havana was able to tailor their health system specifically to the context of the city’s unique lifestyle. This ideology is applicable to all cities of the global south that attempt and fail to implement health systems found in cities of the global north. More effective is the grassroot bottom-up approach that tailors the system to the city’s people, taking into account their specific needs, which has proven overall to be a successful approach to healthcare in Havana.
- Rehfuess, Eva A., Bruce, Nigel & Bartram, Jamie K. (2009). Bulletin of the World Health Organization. More health for your buck: health sector functions to secure environmental health. Rertieved from https://www.who.int/bulletin/volumes/87/11/08-059865/en/
- United Nations International Institute for Global Health. (2018). People, planet and participation: The Kuching statement on healthy, just and sustainable urban development. Health Promotion International, 33(1), 149-151. doi:10.1093/heapro/daw046
- Basu, S., Andrews, J., Kishore, S., Panjabi, R., & Stuckler, D. (2012). Comparative performance of private and public healthcare systems in low- and middle-income countries: a systematic review. PLoS medicine, 9(6), e1001244. Retrieved from doi:10.1371/journal.pmed.1001244
- Roberg, J., & Kuttruff, A. (2007). Cuba: Ideological Success or Ideological Failure? Human Rights Quarterly, 29(3), 779-795. Retrieved from http://www.jstor.org.ezproxy.library.ubc.ca/stable/20072822
- McPhee, S. (2019) Lecture week 9: Infrastructure and public services in cities of the global south [PowerPoint slides]. Retrieved from UBC GEOG 352 Canvas site.
- AlSayyad, N. (2004). Urban informality as a “new” way of life. Urban Informality: Transnational Perspectives from the Middle East, Latin America, and South Asia, 7-30.
- Ebanks, E.G. (1998). Urbanization in Cuba. Paper presented at the Canadian Population Society meetings. Retrieved from https://ir.lib.uwo.ca/cgi/viewcontent.cgi?article=1123&context=pscpapers
- Thomas, J. G. (2016). Historical reflections on the post-soviet Cuban health-care system, 1992–2009. Cuban Studies, 44(1), 189-213. doi:10.1353/cub.2016.0023
- Nayeri, K., & López-Pardo, C. M. (2005). Economic crisis and access to care: Cuba's health care system since the collapse of the soviet union. International Journal of Health Services, 35(4), 797-816. doi:10.2190/C1QG-6Y0X-CJJA-863H
- Funes, Fernando (2002). Sustainable Agriculture and Resistance: Transforming Food production in Cuba. (14-19). University of Texas
- Andaya, E., & Elise Andaya. (2009). Cuba: Health care as social justice NACLA.
- Binns, L. A. (2013). Cuba: healthcare and the revolution. The West Indian Medical Journal, 62(3), 244–249. Retrieved from http://ezproxy.library.ubc.ca/login?url=http://search.ebscohost.com/login.aspx?direct=true&db=mnh&AN=24564047&site=ehost-live&scope=site
- Wright, S. (2012). Natural and Traditional Medicine in Cuba: Outmoded Quackery or a legitimate tributary to sustainable healthcare?, International Journal of Cuban Studies, 4(1), 88-99. Retrieved from http://www.jstor.org/stable/41926673
- Atwood, R. (2017). Organic or starve: Can Cuba's new farming model provide food security? Retrieved March 4, 2019, from https://www.theguardian.com/environment/2017/oct/28/organic-or-starve-can-cubas-new-farming-model-provide-food-security
- Ewing, E. (2008, April 04). Cuba's organic revolution. Retrieved March 21, 2019, from https://www.theguardian.com/environment/2008/apr/04/organics.food
- Cuban Green Revolution - Natural Medicine Advances. (n.d.). Retrieved from http://www.positivehealth.com/article/herbal-medicine/cuba-s-green-revolution-natural-medicine-advances
- González, I. (n.d.). Lesbians Receiving Unequal Treatment from Cuban Health Services. Retrieved April, 2015, from http://www.ipsnews.net/2015/04/lesbians-receiving-unequal-treatment-from-cuban-health-services/
- Perera, C., Cabrera, F., Albizu-Campos, J. C., & Brønnum-Hansen, H. (2019). Health expectancies among non-white and white populations living in Havana, 2000–2004. European Journal of Ageing, 16(1), 17-24. doi:10.1007/s10433-018-0472-5
- Da Silva Coqueiro, R., Rodrigues Barbosa, A., & Ferreti Borgatto, A. (2010). Nutritional status, health conditions and socio-demographic factors in the elderly of Havana, Cuba: Data from SABE survey. The Journal of Nutrition, Health & Aging, 14(10), 803-808. doi:10.1007/s12603-010-0126-6
- De Jesús Llibre, J., Valhuerdi, A., Fernández, O., Llibre, J. C., Porto, R., López, A. M., Moreno, C. (2010). Prevalence of stroke and associated risk factors in older adults in havana city and matanzas provinces, cuba (10/66 population-based study). MEDICC Review, 12(3), 20.
- Warner. (2018, September 17). Is the Cuban healthcare system really as great as people claim? Retrieved March 21, 2019, from https://theconversation.com/is-the-cuban-healthcare-system-really-as-great-as-people-claim-69526
|This urbanization resource was created by Will Engle. It is shared under a CC-BY 4.0 International License.|