To the Editors:

As a supporter of MEDICC and an editorial board member of MEDICC Review, I write to express concerns about the Spanish translation of The Lancet‘s Series entitled Universal health coverage in Latin America. Although its meaning is often confusing, universal health coverage (UHC) generally refers to a financial reform extending insurance coverage in varying degrees to a larger part of a country’s population. UHC does not mean “health care for all” (HCA)—a health care delivery system that provides equal services for a population regardless of an individual’s or family’s financial resources.

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.[1] Only one article in The Lancet’s Series (by Heredia and colleagues, representing ALAMES) criticizes UHC and favors HCA.[2] ALAMES and other groups opposing UHC apparently were not invited to participate in launches of MEDICC Review’s UHC series.

In existing examples of UHC, private insurance corporations usually gain access to public trust funds for health and social security benefits, which the corporations receive for providing managed care services on a prepaid, capitated basis. As shown in prior research, the corporations tend to use much of the capitation payments for investment in the global financial marketplace.[3] Tiered benefits characterize most UHC proposals. UHC provides a minimum benefits package for the poor and uninsured, while the nonpoor or their employers can purchase additional benefits. As the ALAMES authors point out, UHC has become hegemonic in global health policy, without empirical substantiation.[2] A neoliberal ideology assumes the advantages of market processes, privatization, public sector cutbacks, and the diversion of public trust funds for health services to private corporations. International financial institutions, health organizations like WHO and PAHO that receive funding from the World Bank, and foundations like Rockefeller have promoted UHC and have funded the launches of MEDICC’S UHC series.

HCA sees heath care as a human right, provided in a national system where access does not differ according to people’s income, wealth, or other criteria. A single public system provides outpatient, inpatient and preventive services; that is the Cuban model. The launch of the UHC series in Havana therefore seems ominous. Questions arise:

• Does UHC figure in the future of Cuban health care?
• Is a subtext for the Havana launch a hope to privatize Cuba’s health system, or to open it up to private insurance corporations?
• Given MEDICC’s support for HCA, what happened to MEDICC’s vision in the fanfare for UHC?
• What role did funding agencies play and how were the funds used?
• What conflicts of interest, if any, have affected the authors and editors? Particularly troubling is the lack of clear disclosures in the translated articles of well known funding sources.
• Why was the editorial board not consulted before the decisions to translate the UHC series and to launch it in Havana?
• Do MEDICC and MEDICC Review support UHC or HCA?

I and many others look forward to the answers.[4]

Howard Waitzkin MD PhD FACP (waitzkin@newmex.com), distinguished professor emeritus, University of New Mexico, Albuquerque, USA. Adjunct professor of internal medicine, University of Illinois; adjunct professor of public health, University of Puerto Rico

1. Sengupta A. Universal health coverage: beyond rhetoric. Occasional Paper No. 20. Ottawa, Canada: International Development Research Centre; 2013 Nov [cited 2015 May 10]. Available from: http://www.municipalservicesproject.org/sites/municipalservicesproject.org/files/publications/OccasionalPaper20_Sengupta_Universal_Health_Coverage_Beyond_Rhetoric_Nov2013_0.pdf
2. Heredia N, Laurell AC, Feo O, Noronha J, González-Guzmán R, Torres-Tovar M. The right to health: what model for Latin America? Lancet. 2015 Apr 4;385(9975):e34–7. DOI: 10.1016/S0140-6736(14)61493–8. Epub 2014 Oct 15.
3. Waitzkin H. Medicine and Public Health at the End of Empire. Boulder (US): Paradigm Publishers; 2011.
4. Waitzkin H. The strange romance of MEDICC, The Lancet, Cuba, and universal health coverage. Soc Med/ Medicina Social. 2015, in press.

The Editors respond:

We thank Dr. Waitzkin for his comments on our journal’s recent publication in Spanish of The Lancet’s Series Universal health coverage in Latin America.

This journal and its publishers advocate extending health and quality health care to all worldwide. We agree with Dr Waitzkin that the term ‘universal health coverage’ is subject to multiple interpretations. These include publicly funded and provided universal, free or affordable services; mixed funding or mixed provision of services by the public and private sectors; others that would reduce its content to minimum-benefits packages or alternative systems of stratified health care delivery; and still others that would primarily identify it with market-based or private insurance-based decisionmaking.

We also agree that some of these definitions in practice are not the same as ‘health care for all,’ since their aim is not necessarily to continually expand coverage to reach ‘health care for all’, and in fact can present barriers to it.

In this sense, MEDICC Review finds useful WHO’s definition of UHC: “Universal health coverage is defined as ensuring that all people have access to needed promotive, preventive, curative and rehabilitative health services, of sufficient quality to be effective, while also ensuring that people do not suffer financial hardship when paying for these services.”[1]

One of the main reasons MEDICC Review came into existence was to make the Cuban experience in public health, medical research, population health strategies, outcomes and health sciences education more visible in the English medical literature. As with other Latin American countries’ health professionals, and arguably more so for Cubans, language and other obstacles often prevent broad global exposure. In the case of Cuba, which has attained the level of “high human development” according to UNDP, and has health outcomes similar to those of wealthier countries at a fraction of the cost, we find it important to share the lessons of the Cuban experience.

Obviously, while some UHC approaches may prove considerably more effective than others, it is also clear that each country and culture must find its own path to accessible, affordable health care for all: it goes without saying that Latin America and the Caribbean is a region of diverse political, economic, social and cultural contexts. For example, the development of a single, integrated health system in Cuba took place in a context vastly different from those faced by health authorities and social movements in nations such as Chile, Colombia or even Brazil.

This begins to explain why MEDICC Review cooperated with The Lancet on the project: Two of our journal’s main objectives are, first, to heighten the visibility of Cuba’s real-world experiences in health and medicine, as well as those of the rest of Latin America and the Caribbean; and second, to contribute to the analysis, discussion and debate of the most pressing health issues of our time.

Translation and distribution of The Lancet‘s Series provided the opportunity to make available in Spanish substantive work published in English concerning various UHC strategies employed in Latin America. We believe this publication is particularly relevant for Spanish-speaking policymakers, frontline health workers and social movements struggling to improve access to quality health care in the region. Sharing such data and perspectives can encourage and even empower them to enter the debate, contributing their own vital evidence.

In response to Dr. Waitzkin’s specific questions:

• According to the Cuban Constitution (Article 50) and most recent statements by Cuba’s Minister of Public Health, the Cuban state is obligated to guarantee every Cuban “the right to health protection and care….[including] free medical and hospital care…[and] free dental care.”[2] In April 2015, the Minister reaffirmed that Cuba’s National Health System “is based on the principles of public health, state responsibility and social medicine; as well as provision of free and accessible services, preventive orientation, application of scientific advances, community participation, intersectoral approaches, regional organization and a profound commitment to international solidarity.”[3] While health system decisions are the prerogative of Cuban authorities, we know of no plans to introduce private insurance schemes in Cuba.
• Our participation in the Series does not reflect a “hope” or wish to “privatize Cuba’s health system.” Rather, we suspect that careful reading of the papers translated would confirm the value of the system designed by Cuban policymakers.
  MEDICC and MEDICC Review consider the WHO definition of UHC appropriate. We understand, however, that many different UHC approaches are being tried and believe that information and various perspectives on their successes and failures should be made widely available.
• As indicated in our Spanish Prologue, MEDICC Review received funding from the UN Economic Commission for Latin America and the Caribbean (which in turn received a grant for the entire project from The Rockefeller Foundation) and from PAHO for translation and publication of the Series. Neither agency nor the foundation was involved in our translation or editorial processes.
• The authors disclosed potential conflicts of interest in the original Lancet English papers. MEDICC Review editors have no conflicts of interest.
  Our policy is to consult our Editorial Board on general themes, but not on decisions about the publication of individual articles or groups of articles. In a 2013 newsletter, the Editorial Board was in fact informed of the journal’s intention to cooperate in this project.

We encourage our readers to compare and contrast approaches used to provide health for all, contributing to this critical debate.

1. World Health Organization [Internet]. Geneva: World Health Organization; c2015. Programmes. Health systems. Universal Health Coverage. [cited 2015 Jul 20]. Available from: http://www.who.int/healthsystems/universal_health
   _coverage/en/
2. National Assembly of People’s Power (CU). Constitution of the Republic of Cuba. Havana: National Assembly of People’s Power (CU); 1992 Aug 1. Article 50. p. 24. Spanish, English.
3. Ministry of Public Health (CU). Keynote address by Dr Roberto Morales Ojeda, Minister of Public Health at the opening of CUBASALUD 2015. International Conference Center. April 20, 2015, Havana, Cuba. Havana: Ministry of Public Health (CU). Spanish, English.

To the Editors:

I would like to comment on Gail Reed’s January 2015 article (Meet Cuban Ebola Fighters: Interview with Felix Báez and Jorge Pérez), describing the efforts of Drs Báez and Pérez, and many other Cuban health care workers, to combat Ebola in West Africa.

From mid-December 2014 until the end of January 2015, I worked as a physician with Partners in Health in the current Ebola outbreak, and was deployed to the Maforki Ebola Treatment Unit in Port Loko, Sierra Leone. In addition to partnering with a strong and talented group of Sierra Leonean health care workers, I had the good fortune of working alongside many of the Cuban doctors and nurses that Dr. Pérez helped train at the Pedro Kourí Tropical Medicine Institute.

The Cubans’ attention to safety was exemplary. Not only did they look out for one another, they also looked out for everyone on the team—including those of us from the US and from Sierra Leone. They were a fun and animated group to work with, always keeping morale up.

The Cuban medical brigade made a big difference in the Maforki unit, and the magnitude of Cuba’s contribution to the fight against Ebola in West Africa as a whole is inspiring. I would like to thank Drs Báez and Pérez and the Cuban medical brigades for their dedication and hard work in fighting this outbreak.

As the number of Ebola cases in West Africa falls, attention is turning toward strengthening the health care systems that gave way to this unprecedented outbreak. I am hopeful that many countries, including Cuba and the USA, are able to work together again in support of the Sierra Leonean, Liberian and Guinean governments through this process.

Dana Clutter MD (dclutter@stanford.edu), infectious diseases fellow, Division of Infectious Diseases, Stanford University School of Medicine, Stanford, USA