In 1978, the world was put on notice: health inequalities exacerbated by lack of access to essential services was a ticking time bomb threatening social and economic development everywhere. That year, over 100 countries signed on to the Declaration of Alma-Ata, which affirmed that “health . . . a state of complete physical, mental and social well-being, and not merely the absence of disease or infirmity, is a fundamental human right.” To guarantee this right, governments were urged to prioritize the provision of quality, continuous, comprehensive and affordable primary care for their entire populations by the year 2000.[1]
Forty years after Alma-Ata, many countries have failed unequivocally to attain that goal. In 2017, the World Bank and WHO released sobering data that nearly half the world’s population was still without essential health services. Meanwhile, the cost of those services—when accessible—had already pushed nearly 100 million people into extreme poverty.[2]
This dire state of affairs is not limited to developing countries. According to the Association of American Medical Colleges, the USA will be short 21,000–55,000 primary care physicians by 2032[3] and recent data are not encouraging: the percentage of fourth-year medical students filling primary care positions in the 2019 US National Residency Matching program was the lowest on record.[4] Furthermore, access to a primary care physician for US patients has remained flat—76.4% in 2015 compared to 76.8% in 1996—despite evidence that “access to primary care improves health outcomes and lowers health-care costs.”[5]
From astronomical medical school tuition to inconsistent political will, numerous factors contribute to this global human rights crisis. To forge a plan towards ‘building a healthier world,’ experts and governments were invited to share data, analysis and experiences at the 2019 UN General Assembly’s first High-Level Meeting on Universal Health Coverage (UHC). Among the countries presenting findings is Cuba, a small, developing nation whose health system aimed for universal care and coverage as early as 1960, when the rights to health and education were recognized. Through that decade’s Rural Medical Service, doctors fanned out nationwide to extend health services to all Cubans, reaching universal coverage well before the Alma-Ata Declaration was adopted.
It is now widely recognized that UHC contributes to overall social and economic development. Where health care services are not universal, the most vulnerable and poorest patients are either without care altogether, or often shunted to public facilities—making public health care essentially poor people’s health care. Cuba’s global cooperation policy has been to help staff and strengthen public health institutions and systems in coordination with host governments, primarily in developing countries, rather than “setting up shop” on their own. However, early experiences revealed a daunting challenge: many of these countries’ public systems were dysfunctional, poorly run and sometimes in danger of complete collapse, aggravated in cases of natural disasters or war. Often, the health systems where Cubans served were characterized by crumbling infrastructure, health worker shortages and spatial inequality, financial and material resource scarcity, ineffective or insufficient health surveillance mechanisms, and inconsistent national health protocols. This reality begged the question: could long-term improvements in patient outcomes be achieved in such contexts and might Cuba play a larger role?
