An early emphasis on community-based primary care in medical education could help address the social determinants of health that may negatively impact outcomes in the United States.
The United States’ high healthcare costs do not yield corresponding health outcomes for its citizens. Conversely, Cuba, with less than a tenth of U.S. expenditures, has attained comparable outcomes on many indicators, particularly life expectancy and infant mortality.
This contrast raises the obvious question of how Cuba achieves these outcomes, a problematic question because multiple factors could contribute to the system’s success. Regardless, the differences between the two countries’ healthcare systems remain stark. Although Cuban healthcare providers have less access to technology and supplies, coverage is universal and the system is largely government-run, with the exception of the black market and medical tourism. Conversely, healthcare in the United States is not universal and consists of a disjointed, yet well-resourced mix of private and public providers and payers. Health system differences between Cuba and the United States likely account for much of Cuba’s ability to do more with less.
It is unlikely that the United States will adopt socialized healthcare any time soon, but some of the Cuban system’s distinguishing features might still provide useful lessons. In particular, the United States could do well to import lessons on prioritizing primary care and prevention as well as addressing social determinants of health.
In fact, Cuba’s emphasis on primary care and prevention is a key differentiating feature of the two systems. Cuban medical schools, which are government-run and tuition-free, incorporate primary care, public health, and social determinants in their curricula in ways that U.S. schools are just beginning to do. Furthermore, the nationwide system of consultorios (family medical offices) and polyclinics play a central role in providing community-based medical and mental health services for all residents of defined geographic areas.
The Cuban consultorio comprises a doctor and nurse team who provides basic primary care services for 600-900 patients in both the office and patients’ homes. Mornings are typically devoted to on-site care and afternoons to public health promotion, by collecting health statistics or visiting individual homes to address prevention, health education, and environmental factors affecting patients’ health. Physicians are expected not only to conduct screenings and educate patients, but also to understand their family and social backgrounds. Since physicians focus on a residential area rather than on self-selecting patients, they are more likely to reach out to those who typically avoid interaction with the healthcare system—an initiative much less common in the United States.
For more complex services, physicians refer patients to local polyclinics, each serving a single geographic area of approximately 25,000–35,000 people. The polyclinic staff is typically integrated doctor-nurse teams that provide a wide range of services including pediatric, dental, eye, and behavioral health care. They also communicate directly with the patient’s family doctor to ensure appropriate follow-up.
The set-up and structure of this geographic-based healthcare system ensures “‘that people [are] understood in all their dimensions: biological, psychological and social [and] as individuals, within families, and within their communities.’” In surveying the environment or visiting patients’ homes, physicians are able to assess the elements that constitute social determinants of health and thus tailor services to the specific needs of each community. They consider factors such as education, housing, environmental elements (e.g. sanitation and clean air), food and nutrition, and employment.
A polyclinic’s ability to care for and respond to the needs of its citizens relies on the staff’s knowledge and efforts in carrying out these responsibilities, which is grounded in the Cuban medical education system. All physicians enter this six-year training directly from high school, and are first educated as primary care practitioners. Later, those who wish to specialize must obtain a post-graduate degree. This policy resulted from a 1984 governmental shift that prioritized health promotion over sickness control. This change led schools to broaden providers’ role as solely family physicians to “comprehensive general physicians.” While U.S. medical students typically acquire some basic epidemiological knowledge during their education, the Cuban healthcare system stresses the physicians’ role to promote public health and their moral obligation to address healthcare disparities and inequalities.
Cuba’s health system is far from perfect. Facilities often lack basic supplies or equipment, physicians receive poor compensation, and many providers defect when serving in foreign medical missions. Furthermore, some of the consultorio and polyclinic successes could be due to low residential mobility for both patients and physicians, resulting in sustained doctor-patient relationships. Additionally, many of the lessons from Cuba are difficult to transfer outside of its unique social context. Certain social determinants of health in the United States, such as economic stability, are less influential in Cuba because the government provides some food and other necessities.
However, the imperative for a stronger emphasis on social determinants of health in primary care in the United States has grown increasingly urgent. Undergraduate medical education has started to promote this focus, with the American Medical Association's adoption of a 2014 policy to integrate more training on this subject. Some of the adopted approaches provide additional training and research to understand health disparities or address diversity in the medical education pipeline so that physicians more closely resemble the communities they serve. Furthermore, a few places also have adopted elements of community-based medicine and employ interdisciplinary teams to help address barriers to a healthy life.
The Morehouse School of Medicine in Atlanta implemented a required service-learning community health course in 1998. Students partner with an organization to conduct a health-needs assessment, identify a pressing community health issue, and then design and implement an intervention to address it. The needs identified often center on social determinants of health, such as housing conditions, available nutrition, and educational attainment.
More recently, the Green Family Foundation Neighborhood Health Education and Learning Program (NeighborhoodHELP™) at Florida International University started to send integrated teams of medical, nursing, education, law, and social work students to underserved neighborhoods to address similar concerns. Over a period of three years, students cultivate relationships with household members to identify areas of need and develop plans to address health and quality of life issues.
Still, the United States has a relatively small number of medical schools actively seeking to expand the physician’s role in understanding and addressing social determinants of health. Achieving the "triple aim" of affordable, high-quality healthcare that improves population health will require the medical field to better integrate this perspective into primary care provision. Lessons from the Cuban approach might help the United States achieve more with less.
Claire E. O’Hanlon is an assistant policy researcher at the nonprofit, nonpartisan RAND Corporation and a doctoral candidate at the Pardee RAND Graduate School. Her research focuses on the intersection of health systems, economics, and technology. Her dissertation is on the impacts of U.S. healthcare industry consolidation. She is Cuban-American.
Melody Harvey is an assistant policy researcher at the nonprofit, nonpartisan RAND Corporation and a doctoral candidate at the Pardee RAND Graduate School. Harvey’s research focuses on the impacts of social and consumer policies on financially vulnerable Americans. She is currently analyzing the impact of a housing program on health service utilization and county departments' net cost expenditures to inform homelessness policy