On Universal Health Coverage

To the Editors:

Discussion of scientific topics among scholars, scientists and politicians is not always easy, since they each interpret and define them according to their ideology. This is also the case with universal health coverage (UHC), which has been defended by neoliberal currents of thought as the process of financial reforms that tend towards privatization, public sector funding cuts and the ever-increasing commodification of health services. We who support the right to comprehensive wellbeing of peoples, communities and individuals, without distinction of any kind and free from profit, believe that such a perspective is essential to guaranteeing elimination of geographic, economic and financial barriers to health as a basic human right. This is precisely the view of the multidisciplinary membership of the Association of Latin American Social Medicine (ALAMES)-Cuba.

MEDICC Review’s launch at Havana’s Cuba Salud 2015 convention last April of the Spanish translation of The Lancet’s Series Universal Health Coverage in Latin America[¹1 Cobertura universal de salud en Latinoamérica (Traducción al espanol de la Serie en The Lancet, Universal Health Coverage in Latin America). MEDICC Rev [Internet]. 2015;17(Suppl).- Available from: http://www.medicc.org/mediccreview/index.php?issue=33
http://www.medicc.org/me diccreview/inde... ] led ALAMES-Cuba several times to consider a Cuban position on universal health coverage (UHC). One such occasion was a meeting during the convention with participating ALAMES members visiting Cuba. We also responded a number of times through the ALAMES network to comments by Dr Waitzkin similar to those expressed in his letter to MEDICC Review.[²2 Letters [letters]. MEDICC Rev. 2015 Apr;17(3):5–6.]

After Cuba Salud, Dr Waitzkin visited Cuba and met with the ALAMES-Cuba executive committee where, once again, we explained our position on health as a fundamental right and the social project we are building in Cuba.

Here is the position of ALAMES-Cuba, also shared by the Cuban Society of Public Health, in response to Dr Waitzkin’s questions and expressed in the following principles:

• ALAMES supports the Cuban state policy that conceives health as a human right for all.

• We support the Cuban state policy of health care for all our population, which does not conceive of any privatization or other market mechanisms that convert health care into a product for sale or profit.

• We support and work for the social and economic transformations under way in Cuba, aimed at consolidating a prosperous and sustainable socialist system based on the individual, family and community.

• We support Cuban public health principles, based on ensuring population health through a single, universal and comprehensive system where every citizen has the right to receive free, quality health services (health promotion, disease prevention, treatment and rehabilitation) according to their needs; all of this achieved through community and intersectoral participation, strong solidarity and social commitment, and political will on the part of the state and government.

• We support Cuba’s UHC, as described here, conceived and developed over 50 years in Cuba, in which health and health care are state priorities and responsibilities, a UHC concept that has been and continues to be one of the principles of Cuba’s National Health System.

• ALAMES-Cuba understands UHC as that achieved in the revolutionary period from 1959 forward, when health care was consolidated as a human right and characterized as a state and social responsibility, strongly rooted in primary health care, the backbone of the Cuban health system.

• ALAMES-Cuba considers universal access as that which has been guaranteed by Cuba’s social and health systems, expressed in the full and real capacity of each person, group, community or population, without distinction, to use and receive comprehensive, timely and quality health services according their needs.

We reassure Dr Waitzkin—friend and collaborator of Cuba for so many years—of our certainty that no current of thinking will alter the humanistic foundations of Cuban public health and its health system, governed by principles of full rights and social justice upheld in the Constitution itself.

To the Editors:

As a member of MEDICC’s Academic Council and a participant—observer of the Cuban health systems before and after the 1959 revolution, I would like to comment on some concerns expressed in Dr Waitzkin’s letter in this column. My views are based on notions of the ideal versus the feasible, cost–benefit considerations, and the principles of justice and equity expressed in José Marti’s writings as well as in Fidel Castro’s 1953 defense, published as History Will Absolve Me.

I agree with the definition of universal health coverage (UHC) issued by the World Health Organization (WHO) and I quote it as an example of a solution to the conflict between the ideal and the feasible:

Globally, and thanks to their medical vocation, WHO leaders and the majority of health professionals would like the underlined phrase to be replaced by absolutely free of charge.

But is this globally or regionally feasible?

We know that exceptional countries with different social systems and organizational methods have achieved free, universal access to comprehensive medical services. In most countries, however, the only viable alternatives are those included in the spectrum of UHC as described by Dr Waitzkin or the WHO comprehensive definition and its underlined component.

The paradigm of health care for all (HCA) is enshrined in the Cuban constitution, and has been reaffirmed by our Minister of Public Health. Its roots are mythological (Asclepius), historical (Hippocratic oath), biblical (“Rise up and walk, Lazarus”—Jesus of Nazareth), socialist (health care is a constitutional right and a government responsibility), ethical (the Golden Rule), humanistic (symbolized by Mother Teresa of Calcutta and Florence Nightingale, founder of nursing), and steeped in the thinking of José Martí (that the fundamental law of the republic be devotion to the full dignity of all).[²2 Constitución de la República de Cuba [Internet]. Havana: Government of the Republic of Cuba; 1976 Feb 24 [cited 2015 Oct 5]; [about 25 screens]. Available from: http://www.cuba.cu/gobierno/cuba.htm. Spanish.
http://www.cuba.cu/gobierno/cuba.htm... ]

Possibly the most pertinent humanistic merit of our single health system is that we have managed to achieve and maintain it under the worst economic conditions. Amidst such severe resource scarcity, the system has nevertheless offered full scholarships to train foreign health professionals; its health professionals have freely collaborated with other countries to offer prevention, medical care and teaching; and it has reached out to aid poor countries in response to disasters and health emergencies. This is how we fulfill the principles of justice and equity. The moral value of domestic and international solidarity is not expressed solely by donating what we can spare—which is very little—but by sharing the little we have.

Dr Waitzkin respects and understands the Cuban model. I hope he also understands that—as in the case of The Lancet’s Series—the message is meant for the full range of health care providers, practitioners and policymakers worldwide. When they design a model, their options depend on multiple factors; even when humanistic goals are similar, they confront profound differences in the real possibilities for their expression in an ever more restricted cost–benefit context, especially in neoliberal environments.

When defining the spectrum of UHC, the authors of the Series emphasized that absolutely free universal access seems unlikely to be completely attainable. WHO’s meta-message is that, due to current global complexities, it would not be good tactics to insist that all health systems be absolutely free of charge, since this would leave most countries out of the running.

Nor would it help reduce inequities for the poor for a progressive journal such as MEDIC Review to publish entirely on HCA’s goals, experiences and results, while neglecting to share lessons from experiences with UHC.

To the Editors:

I write concerning Dr Waitzkin’s comments on the Spanish translation of The Lancet’s Series Universal Health Coverage in Latin America. In October 2014, the National School of Public Health (ENSAP) in Havana organized a scientific forum on universal health coverage (UHC). I moderated a roundtable discussion on UHC, where participants unanimously decided to focus on the existence (or not) of UHC in Cuba from the beginnings of the National Health System to date.

Interesting and valuable perspectives on UHC arose: questions, criticisms and partial acceptance of this global strategy. My own opinion is that all guidance, rules, programs and strategies coming from world and regional health organizations should be adapted according to each country’s specific context, policies and public health approaches. I therefore insisted on not concentrating exclusively on the financial basis of the UHC strategy (avoiding an economicist discussion), but on recognizing the extent to which the principle of accessibility to quality health care for all Cubans had been fulfilled—and whether it is still being fulfilled— as a contribution to this global strategic effort.

The political, economic and social changes now taking place in Cuba require renewal and adjustment in all sectors and institutions with social roles. That is why the Ministry of Public Health has proposed substantial changes in the National Health System’s policies and strategies (the so-called transformations), in order to maintain the health indicators Cuba has achieved and especially to adjust the policies to the different, current context.

As a member of the Editorial Board of the journal Revista Cubana de Salud Pública, I am aware that several articles have been published on UHC. One of them, recently included as an editorial, outlines the Cuban position on this strategy in response to the recent questions about it.[¹1 López Puig P. Cobertura Universal en Salud y el caso cubano. Rev Cubana Salud Pública [Internet]. 2015 JanߝMar [cited 2015 Oct 5];41(1):1–3. Available from: http://scielo.sld.cu/pdf/rcsp/v41n1/spu01115.pdf. Spanish.
http://scielo.sld.cu/pdf/rcsp/v41n1/spu0... ] There is also an upcoming special issue on UHC, for which I was invited to contribute a manuscript I consider a critique of this strategy and its relation to the epidemiologic work of Cuban health services.

Stepping into the debate to directly address Dr Waitzkin’s comments about Cuba’s position on UHC, I will comment on those I consider to be most pertinent to my role as a professor.

Dr Waitzkin writes: UHC has received wide criticism from progressive organizations and individuals such as the Association of Latin American Social Medicine (ALAMES), the worldwide People’s Health Movement, Global Health Watch and various academically based researchers including myself. Correct, and in the interests of debate, I welcome Dr Waitzkin’s honest and courageous position, although it reflects an extreme rejection I believe is derived from his primarily economic–financial lens. ALAMES’ rejection of UHC seems to be based on general ideological principles rather than a measured analysis of the strategy’s substance; that is, its advantages and disadvantages, implicit and explicit elements, and good or bad intentions.

The “target” of the UHC message is financing, with the goal of achieving universal coverage in countries with fragmented or segmented systems and limited access to health care for their populations. Quoting Dr Waitzkin: A single public system provides outpatient, inpatient and preventive services; that is the Cuban model. That is so; it is the Cuban model, and the UHC financing-centered proposal does not enter into it. What does enter, is the following imperative—also included in the UHC strategy: that all people have access to needed promotive, preventive, curative and rehabilitative health services, of sufficient quality to be effective.[²2 World Health Organization [Internet]. Geneva: World Health Organization; c2015. Programmes. Health systems. Universal Health Coverage; [cited 2015 Sep 20]. Available from: http://www.who.int/healthsystems/universal_health_coverage/en/
http://www.who.int/healthsystems/univers... ] Yes, we must closely examine the current state of universal access and guarantee it with quality. This is why I think it pertinent to adapt this essential aspect of the UHC strategy in the process of transformation our National Health System is undergoing, with particular relevance to local health services.

Two of Dr Waitzkin’s questions explicitly referred to Cuba’s health system:

Dr Waitzkin writes: The launch of the UHC Series in Havana therefore seems ominous. I have no grounds to pronounce on a supposed future “privatization” of the National Health System, which I worked in for 42 years, but I am sure that whoever is charged with that decision will know how to assess the possible consequences so as to preserve the health of Cuba’s population.

I appreciated reading Dr Waitzkin’s comments, the clarifying replies from MEDICC Review’s editors, and the opportunity to express my own opinions. I hope other Cuban colleagues will join in and enrich the debate.

To the Editors:

It is worthwhile to look at the term, universal health coverage (UHC) in the context of how its use has changed over time. Fifteen years ago, when neoliberal processes were on the rise, the concept was distorted depending on the interests of both the funded and the funders. But the concept is clear, and if we examine the outcomes of the Cuban health system in its light, there is no doubt that Cuba fully complies with it:

This is guaranteed in our Constitution and in Cuba’s National Health System. It was reconfirmed in the keynote address by our Minister of Public Health at the Cuba Salud 2015 conference. Today we don’t talk about ’universal coverage’ but ’universal health,’ a term I think is even more appropriate than health care for all, the one commonly used years ago in response to patent distortions of UHC in countries where neoliberal trends predominated.

The reply from MEDICC Review’s editors is clear. What is important in Latin American countries is to achieve health for all— meaning universal health. We should not fear debate: Cuba has much to bring to the discussion, since the very principles and programmatic bases of its health system guarantee universal health to all Cubans (and many citizens around the world) through a single national health system that exemplifies both the state and social character of Cuban medicine. Cuba’s is a system that is accessible, free and prevention-oriented; that applies scientific and technical advances to the health of all peoples it serves; and that maintains a strong commitment to community and intersectoral participation, as well as internationalism.

If that is not UHC—according to the WHO—or better yet, universal health, what is?

On Medical Education for Health Equity

To the Editors:

In September 2015, I had the opportunity to attend an international conference of health educators in Gauteng Province, South Africa. Hosted by the South African Association for Health Educationalists and The Network: Towards Unity for Health, the conference was attended by more than 400 delegates from around the world, inspired by its theme: Bambanani (working together). Numerous examples of students’ interventions improving health in communities colored the conference, with highlights from medical students in Sierra Leone who joined national and international health workers to fight Ebola in their country.

Representatives of some schools in The Training for Health Equity Network (THEnet) attended the conference, and papers presented were a testimony to their commitment to improve the health of the disadvantaged populations they serve. In 2008, Medicc Review introduced its readers to the recently born THEnet and its 8 founding schools (now 12), all socially responsive to the needs of their respective communities.[¹1 Neusy AJ, Palsdottir B. A round table of innovative leaders in medical education. MEDICC Rev [Internet]. 2008 [cited 2015 Sep 13];10(4):20–24. Available from: http://medicc.org/mediccreview/index.php?issue1
http://medicc.org/mediccreview/index.php... ] In different continents and cultures, these schools recruit students from disadvantaged communities and their teaching–learning scenarios are community based. THEnet schools have placed public health needs at the core of curriculum design, with a view to training capable professionals who can work in teams leading to change. Many of the posters and oral presentations in the above-mentioned conference showed the concern and determination of health professionals in some parts of the world to respond to the call for “transformative health education” for the 21st century.[²2 Frenk J, Chen L, Bhutta ZA, Cohen J, Crisp N, Evans T, et al. Health professionals for a new century: transforming education to strengthen health systems in an independent world. Lancet. 2010 Dec 4;376(9756):1923–58.] The design and implementation of socially responsive curricula is not an easy task, but health educators have opted to offer modules and electives as a step closer to that goal.

MEDICC Review through its published papers has shown its commitment to present socially responsive health sciences curricula. Why not also broaden the spectrum to open a space for individual modules that respond to the need for transformative health sciences education? These attempts may be small in size, but could motivate educators in different latitudes to design and implement community-based modules, projects or experiences that could be transformative for their students.

The Editors respond:

MEDICC Review welcomes submissions such as those described by Dr Gari. The Lessons from the Field section may be an appropriate space for sharing such experiences with others working to transform health professional education towards greater health equity globally. Instructions for authors can be found online at www.medico.org/mediccreview/index.php?issue=&id=57&a=vp

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