Cuba has sent more than 2,000 health workers to other countries to treat patients with COVID-19, and the government says the island is a "medical powerhouse."
But in recent years, the government slashed the budget for public health, closed hospitals in rural areas and sent thousands of community doctors to "missions" abroad, through a program that became the country's primary source of foreign exchange.
The cuts in health care during the last decade have affected the quality and access to medical services and could hinder the response to the coronavirus pandemic, despite government figures suggesting the country has flattened the curve of new cases, a group of experts warned in a report published by the independent organization Centro de Estudios Convivencia.
Between 2008 and 2018, while the total number of doctors grew by 28% to a record 95,487, the number of nurses fell by 20% and the number of health technicians by 58. In total, health workers decreased by 22 percent, according to official figures published by the National Office of Statistics and Information.
According to the report, between 2009 and 2018, "state budget expenditures in public health decreased from 19% to 17.1 percent." As a proportion of the gross domestic product, spending shrank from 12.8 to 10.5 percent, during years in which the economy barely grew or contracted.
The report, authored by economists, sociologists, doctors, and other experts, also relied on an unpublished study carried out by the economist and emeritus professor at the University of Pittsburgh, Carmelo Mesa-Lago, and demographer Sergio Diaz-Brisquet.
Cutting social spending was one of the strategies implemented under the government of Raul Castro, who tried to promote a partial reform of the island's socialist economy. The economic problems of the government in recent years, hit by the crisis in Venezuela and the strengthening of the U.S. embargo under the Donald Trump administration, have meant that even fewer resources reach the health system.
The cuts caused a "general decline in all hospital facilities" and the deterioration of some health indicators, such as maternal mortality, which grew by 41% between 2007 and 2018. In those years, the government closed a third of the country's hospitals, including all located in isolated rural areas.
Those "patients are referred to regional hospitals, but the time and cost of transportation increases as well as and the risk for emergency cases," the authors of the report said.
The deterioration of hospital facilities and equipment, and the lack of medical supplies, "suggest a severe impact of COVID-19 on the island, as well as difficulties in the management of the crisis by the government," even if official figures suggest the outbreak is under control.
As of Monday, the Ministry of Health reported 1,947 confirmed cases of people with COVID-19 and 82 deaths. Last Thursday, Cuban leader Miguel Diaz-Canel said his government's response to the pandemic was "worthy, especially in the conditions in which the country has done so."
Diaz-Canel said that the low mortality in critically ill patients with COVID-19 was due to the use of two drugs produced in the country, "the anti-cd6 antibody", and "the cigb 258 peptide," according to a report in the Communist Party daily Granma.
But the only statistics available on coronavirus cases on the island come from the government. Official data on acute respiratory diseases in March and April suggest the outbreak was probably bigger than reported by health authorities.
Although public health remains free, budget and staff cuts already had "a negative impact in terms of access and quality of health services. It seems impossible that it would not have an effect in relation to the coronavirus," Mesa-Lago told the Herald.
Official data also suggests that the export of medical services grew at the expense of "family doctors" working in the local communities. In a decade, between 2008 and 2018, the number of those doctors decreased by 60 percent.
Although Cuba has nine doctors for every thousand people, according to the public health minister, Jose Angel Portal, tens of thousands do not treat Cuban patients.
More than 2,300 doctors, nurses and technicians have been sent to 24 nations to treat patients with COVID-19. That's on top of the 28,000 Cuban health professionals that work in 59 countries as part of official "brigades."
That number was higher _ around 10,000 more _ a couple of years ago, but Cuba withdrew from the agreement with Brazil when President Jair Bolsonaro questioned why the doctors were not paid their salaries in full. The governments of Ecuador and Bolivia also canceled the hiring of Cuban doctors in 2019.
Doctors who have abandoned these missions and documents published in Brazil indicate that the island's government usually keeps most of the money destined for the doctors' salaries. The Cuban government says the brigades are an example of "solidarity" and international cooperation but has not publicly disclosed the conditions in the contracts.
The export of medical services brought $6.3 billion in revenue to the island's government in 2018.
Cuban authorities have not given a detailed account of how the money earned through these medical brigades is spent. Many hospitals in the country are deteriorated and have problems with the water service; there are few MRI or CAT-scan machines, and there is a chronic shortage of medicines.
The independent newspaper 14ymedio reported last week that in Camaguey, in the center of the country, aspirin has been hard to find in pharmacies in the past year. Another independent media outlet, Cubanet, has published videos documenting the poor hygiene and even the presence of roaches in some Havana hospitals.
A recent outbreak of coronavirus at the Faustino Perez hospital in Matanzas, to the east of the capital, revealed that the building has had trouble with the water service for a year. The government blamed hospital staff for failing to follow protocol and spreading the disease. Still, several doctors in that province said local authorities failed in providing adequate means of protection.
The government has not said how many health workers have been infected with the virus, but there are reports of staff contagion in at least two other hospitals.
The Convivencia report recommended measures that the Cuban authorities could take to better address the coronavirus crisis, from providing protective equipment to doctors and increasing their wages, to strategies to protect the most vulnerable populations and allow independent monitoring of data.
The Cuban Minister of Finance and Prices, Meisi Bolanos, recently said that the state "would reinforce" the budget assigned to public health but did not say by how much.
