IN A NUTSHELL
Author's note
Can the progressive deprivation of essential conditions for life constitute a “genocide without weapons”? An analysis from the perspective of public health and Sustainable Health Equity
By Juan Garay[1]
SHEM[2] Co-Chair and Professor of Health Equity (Cuba, Mexico, Brazil, Spain)
By the same Author on PEAH: see HERE
Cuba Under Economic Siege
Evidence of the Humanitarian and Health Consequences of United States Coercive Measures and Arguments for an Equity-Based Response
I. Introduction
The purpose of this study is to contribute to a better understanding of recent trends and the current situation in Cuba in the social, political, economic, and health sectors, as well as to identify possible priorities for collaboration and cooperation.
This is the third article by the same author in the last three months addressing the health situation and challenges in Cuba. The previous articles analysed the humanitarian health crisis[3] and the risks of increasing inequity associated with neoliberal reforms of the private economy and their relationship with the selective United States economic siege.
The current analysis must be placed within a particularly complex context. The United States economic, commercial, and financial embargo and sanctions, intensified during 2026 and with increasing effects on third parties and, particularly, on access to fuel, are combined with internal factors that limit the country’s productive, financial, and administrative capacity. Declining domestic production, difficulties in importing essential goods, the energy crisis, the loss of capacity in public services, migration, and rapid population ageing are increasingly affecting living conditions and the capacity of the State to maintain basic services.
The latest available official data, corresponding to 2024, show a significant deterioration in some mortality indicators. The analysis conducted in this study estimates, in comparison with different historical and demographic references, an annual excess mortality of around 14,000 deaths and a loss of more than 100,000 years of life due to premature deaths associated with recent changes in mortality rates. These estimates should be interpreted as analytical calculations rather than official records of avoidable mortality.
Socioeconomic and migration trends, together with the deterioration of certain capacities within the social and health systems, suggest a possible worsening of this trend during 2025 and 2026. The available information on infant mortality, although still incomplete and showing important differences between territories, represents a warning signal. The national infant mortality rate may have increased to approximately 9.9 per 1,000 live births in 2025, compared with an average of around 4.4 per 1,000 during the previous fifteen years. Particularly high increases have also been observed in some municipalities analysed during the mission. These local data require confirmation through consolidated national statistics, but they justify priority monitoring.
The Cuban health system retains important structural strengths: universal coverage, an extensive primary health care network, historically high availability of health professionals, domestic training of human resources, and long experience in public health, prevention, and vaccination. However, these capacities are under increasing pressure. The reduction in the number of professionals, difficulties in importing raw materials, medicines, equipment and spare parts, problems in production and distribution, the energy crisis, and transport difficulties are progressively affecting the effective capacity of the system to provide timely and equitable care.
Access to medicines is one of the main critical areas. The irregular availability of essential medicines has contributed to the expansion of an informal market in which the prices of some treatments represent a very high proportion of the income of public-sector workers and pensioners. This situation may transform chronic diseases that are normally manageable into additional sources of inequity and mortality, particularly among older people and households without stable access to foreign currency or remittances.
The analysis of the burden of health inequity developed in this study, using historical, territorial, and international references, makes it possible to estimate part of the mortality and potential years of life that could be avoided through improvements in social, economic, environmental, and health conditions. The results suggest that recent deterioration affects not only national averages but may also be widening differences between age groups, sexes, and territories.
At the same time, growing economic inequality can be observed between people with access to income in foreign currencies, remittances, or private economic activities and those who depend mainly on public salaries or pensions. The development of micro, small, and medium-sized enterprises has created new opportunities for employment and income, but it has not compensated for the loss of capacity of the public sector to guarantee universal services. In addition, an important proportion of private activity is concentrated in trade and the importation of consumer goods, while national productive capacity for essential goods remains limited.
In this context, it is particularly important to protect effective and equitable access to essential medicines, primary health care, adequate food, water, energy, transport, and other fundamental determinants of health. International cooperation can play an important role if it is directed towards preserving public capacities, strengthening national production and distribution, and reducing inequalities in access.
Based on the analysis conducted, possible priority areas for collaboration include support for primary health care professionals and services, strengthening equitable access to essential medicines, improving storage and distribution systems, supporting academic and health institutions, restoring national pharmaceutical production capacities, and promoting sustainable solutions in energy, water, and food.
II. Health in Cuba before 2020
The demographic, political, economic, and psychosocial complexity of Cuba, together with existing limitations in certain areas of economic and social information, makes it difficult to produce a precise picture of the current situation and, particularly, to develop short- and medium-term scenarios. For this reason, the present analysis combines official Cuban statistics, international sources, and estimates specifically developed for this study.
Until approximately 2015, Cuba showed an unusual combination of relatively high health and wellbeing indicators with levels of ecological resource consumption lower than those of high-income countries. According to the Sustainable Health Equity Atlas developed by J. Garay and the Sustainable Health Equity Movement (SHEM), Cuba was above the global average for certain health and wellbeing indicators while maintaining a relatively low ecological footprint.
Table 1. Comparative analysis of economic, ecological, and health indicators for Cuba, the global average, and the Sustainable Equity reference
The comparison with the Dominican Republic is particularly illustrative. Both countries share certain historical, geographical, and demographic characteristics, although they have followed different economic and political trajectories. Until approximately 2020, Cuba had a life expectancy nearly five years higher than that of the Dominican Republic, with a difference of more than six years among men. This health advantage was achieved with significantly lower levels of economic resources and ecological consumption than those of high-income countries.
Table 2. Comparative analysis of economic, ecological, and health indicators for Cuba, the United States, and the Dominican Republic
Source: Sustainable Health Equity Atlas, J. Garay, SHEM[4]
The comparison with the United States is also significant. Despite the United States having a per capita biocapacity several times higher and a GDP per capita far above that of Cuba, Cuba’s life expectancy until approximately 2020 was comparable and, in some groups, slightly higher, particularly among men. This difference is one of the factors supporting an analysis of the Cuban experience from the perspective of social efficiency and equity, without ignoring its important economic and political limitations.
Since 2020, however, health indicators have shown significant deterioration. The pandemic caused a substantial increase in mortality and a decline in life expectancy to levels not observed for previous decades. In 2021, life expectancy fell to approximately 73.2 years. This was followed by a partial recovery during 2022 and 2023, but data for 2024 show a further deterioration.
Analysis of data from the Statistical Yearbook of Health indicates that in 2024 life expectancy declined by approximately 1.1 years compared with 2023, according to the calculation used in this study, accompanied by an increase in mortality adjusted for demographic structure. Estimated excess mortality compared with 2023 was around 13,800 deaths.
The absence of consolidated statistics for 2025 and 2026 requires subsequent trends to be interpreted with caution. Nevertheless, the increase in infant mortality reported in 2025 and data obtained in some municipalities during 2026 are warning signals that support the hypothesis of a possible worsening of health conditions. This hypothesis should be tested when complete national statistics become available.
III. Demography
Demographic change is one of the main structural factors shaping the current situation. Cuba increased from approximately seven million inhabitants in 1959 to nearly ten million by the mid-1980s. Since then, population growth has stopped and, since approximately 2019, the population has entered a period of decline.
Current estimates place the resident population at around 9.5 million people, although the effective figure may be lower if people who have recently emigrated but remain administratively registered as residents are taken into account.
Historically, Cuban migration has been directed mainly towards the United States, followed by Spain and Mexico. In recent years, new migration routes towards Latin America, including Brazil, have developed. For part of the low-income population, migration involves the sale of family assets, particularly homes, in order to finance documentation, transport, visas, and initial settlement costs.
Migration has also begun to modify the sex structure of the population. Until approximately 2012, more men than women lived in Cuba, whereas this relationship subsequently reversed and there is now a slight female majority. This phenomenon may be related both to migration, which affects particular age and sex groups differently, and to the greater proportion of women at older ages.
Population ageing is another major challenge. Approximately one quarter of the population is currently aged 60 years or over. The birth rate has declined steadily over previous decades, and fertility is clearly below replacement level, at around 1.3 children per woman.
The combination of low fertility, migration, and increased survival during previous decades is producing rapid population ageing and a decline in the working-age population. This increases the dependency ratio and places additional pressure on pension systems, health care, and long-term care.
IV. Political context
Cuba maintains a political structure centred around the Communist Party of Cuba (PCC), constitutionally recognised as the leading force of society and the State. The PCC provides political direction to the main structures of government, including the Council of State, the Council of Ministers, and the country’s institutional system.
The National Assembly of People’s Power is the main representative and legislative body. Its members are elected through the constitutionally established electoral system, although the composition of national institutions remains closely linked to the political and social structures of the Cuban system. In addition to the PCC, social and mass organisations participate in institutional representation, including organisations representing women, students, farmers, and other social groups.
The process for approving major socioeconomic transformations reflects this hierarchical structure of decision-making. Strategic measures are discussed and approved within political structures before being submitted to the corresponding legislative bodies.
The main traditional media—television, radio, and the press—remain under State control. At the same time, social networks and digital platforms have become an increasingly important source of alternative information, debate, and circulation of opinions, although they are also exposed to misinformation and political polarisation.
In foreign policy, relations with the United States remain particularly tense, although some spaces for dialogue exist. Cuba continues to participate actively in the G77 and maintains political and economic relations with Venezuela, Russia, China, Vietnam, Mexico, Brazil, and other countries. The international situation and the tightening of United States sanctions have progressively altered opportunities for cooperation and trade.
V. The embargo, sanctions, and the international context
Specific consideration should be given to the evolution of the United States economic, commercial, and financial embargo. For decades, a system of bilateral restrictions has been maintained, accompanied by measures with extraterritorial effects, particularly following the Helms-Burton legislation.
During 2026, according to the information analysed during the mission, these restrictions have acquired new dimensions, particularly regarding access to fuel and the behaviour of third-party economic and financial operators. Secondary sanctions and concerns about regulatory risks may generate effects extending beyond the companies formally subject to sanctions.
This phenomenon is particularly relevant for humanitarian cooperation. International organisations, United Nations agencies, and NGOs may face difficulties in transporting or financing certain donations when shipping companies, banks, or suppliers adopt policies of sanctions over-compliance.
The practical consequence is that medicines, food, agricultural equipment, and other goods intended for social programmes may be delayed or temporarily immobilised. These difficulties should be considered in any cooperation strategy intended to operate in Cuba, as they may affect both the cost and logistical feasibility of interventions.
At the same time, greater openness can be observed towards certain commercial flows linked to the Cuban private sector. This process may contribute to economic diversification, but it may also generate new inequalities if access to foreign currency, fuel, and imported goods becomes concentrated among groups with greater economic capacity.
From a public health perspective, the central question should not be limited to determining which actor is responsible for each restriction, but rather to analysing their concrete consequences for the availability of medicines, food, energy, water, transport, and health services, and to establishing cooperation mechanisms that reduce their effects on the most vulnerable populations.
VI. Economy
Limitations of information
The Cuban macroeconomic situation is particularly difficult to quantify. Official statistics do not always allow the full range of transactions carried out in foreign currencies or in informal markets to be reconstructed. This is compounded by multiple exchange rates, restrictions on banking liquidity, and difficulties in recording economic activities carried out outside official channels.
GDP per capita estimates produced by international organisations may be useful for international comparisons, but they do not necessarily reflect the effective purchasing power of the population. The existence of different exchange rates and the significant depreciation of the Cuban peso in informal markets mean that direct conversion of GDP and official salaries can produce very different results depending on the exchange rate used.
A significant proportion of economic transactions currently takes place through informal or semi-formal mechanisms. This particularly affects trade in consumer goods, medicines, foreign currencies, and certain services.
State sector
The State sector continues to play a fundamental role in the provision of social services, particularly health, education, social security, water, sanitation, justice, and other public services.
However, the loss of productive capacity, financial restrictions, infrastructure deterioration, and fuel shortages are reducing the effective capacity of these structures. In some services, informal payments or alternative mechanisms may emerge to compensate for the loss of workers’ purchasing power, with potentially negative consequences for access and equity.
The creation and expansion of micro, small, and medium-sized enterprises has introduced an important transformation. The establishment of an MSME can now take place relatively quickly, and thousands of formally registered private entities already exist.
The private sector offers salaries substantially higher than those available in the public sector and is becoming an increasingly important source of income for part of the population. However, a significant proportion of these activities is concentrated in trade, imports, and services, with still limited capacity to replace the State in the universal provision of social services.
Income and inequality
Public salaries and pensions have lost a substantial part of their purchasing power due to inflation and the depreciation of the Cuban peso. The figures used in this study place the average salary of workers in the budget-funded sector at around 7,000 CUP per month, while the incomes of many private-sector workers are several times higher.
Remittances from abroad are another fundamental component of household economies. Some studies have estimated flows close to US$2 billion annually. However, their distribution is highly unequal and depends mainly on the existence of relatives living abroad.
As a consequence, an economically differentiated society is emerging between those with access to foreign currency, remittances, or private economic activities and those who depend mainly on public salaries or pensions.
This transformation has important health consequences. When public services lose their capacity to provide services free of charge or at subsidised prices, the loss of purchasing power particularly affects households without access to foreign currency, increasing differences in nutrition, medicines, transport, and other determinants of health.
Informal economy
A growing proportion of economic activity takes place through social networks, digital platforms, and informal markets. These mechanisms make it possible to meet needs that cannot be adequately covered through official channels, but they often lack economic, fiscal, health, or consumer protection regulations.
The informal market for medicines is a particularly relevant example from a public health perspective. The availability of certain drugs may depend on travellers, intermediaries, and private networks, often at high prices and without sufficient guarantees regarding storage, authenticity, or quality.
Public assets
The State retains a very substantial proportion of the country’s land and productive and residential assets, as well as almost all State-owned hotel infrastructure. These assets represent considerable potential economic capacity, although their real value and capacity to generate liquid resources are difficult to estimate.
Any strategy for the use of these assets should be assessed not only from a financial perspective but also in terms of its distributive, environmental, and social consequences.
VIII. Ecology and sustainability
Cuba has high biodiversity and a natural heritage of considerable importance. Since the beginning of comparable international series, the country has maintained a relatively low ecological footprint per capita compared with high-income countries.
Cuban biocapacity per capita is approximately 50% below the global average. For long periods, the ecological footprint per capita has remained relatively close to the available biocapacity.
Figure 1. Evolution of per capita biocapacity in Cuba compared with the global average, 1960–2020
The carbon footprint has followed a different trajectory. Per capita emissions increased during certain decades, subsequently declined, and later returned to levels above those considered compatible with certain sustainability criteria.
The estimates used in this study place average emissions during 2015–2020 at approximately 2.5 tonnes of CO₂ per inhabitant, above a sustainability threshold estimated at around 1.8 tonnes.
Figures 2 and 3. Evolution of the ecological footprint and carbon footprint per capita in Cuba, 1960–2020, with reference to the ethical threshold of the planetary boundary
These emissions are nevertheless considerably lower than those of the United States and the European Union. The main issue for Cuba is not simply to reduce emissions, but to avoid a future economic recovery based on a model of consumption intensive in fossil fuels and imported goods.
The energy crisis has temporarily reduced some emissions, but the increasing dependence on imported goods may shift an important part of the environmental footprint abroad. The increase in waste from packaging and processed products is also becoming a growing problem in a context of weakening public collection and recycling systems.
IX. Society and living conditions
The energy crisis is currently one of the main determinants of living conditions. Insufficient fuel for thermoelectric power plants, together with breakdowns and deteriorating infrastructure, has produced significant deficits in electricity generation.
Irregular electricity supply directly affects other essential services. Water pumps depend on electricity, meaning that power cuts may result in interruptions to water supply. Internet access and communications are also affected.
Prolonged periods without electricity, water, or communication have cumulative effects on health. They make personal and household hygiene more difficult and affect food preservation, meal preparation, hydration, night-time rest, and the use of fans or other cooling systems during periods of extreme heat.
These problems disproportionately affect older people, households with chronic illnesses, persons with disabilities, and those without the resources to acquire generators, fuel, or private supply systems.
Cost of food and basic goods
Current prices of basic food products represent a very high proportion of public-sector salaries. The family food basket calculated for this study amounts to approximately 85,000 CUP per month.
| Basic good / kg-l |
Price CUP |
Proportion of two average salaries |
Equivalent in Spain (€) |
| FOOD |
|
|
|
| Sweet potato |
200 |
2.9% |
60 |
| Cassava |
160 |
2.3% |
48 |
| Taro |
400 |
5.7% |
120 |
| Rice |
700 |
10.0% |
210 |
| Beans |
800 |
11.4% |
240 |
| Lentils |
1,000 |
14.3% |
300 |
| Eggs, one dozen |
2,010 |
28.7% |
603 |
| Cooking oil |
4,000 |
57.1% |
1,200 |
| Chicken (imported from the United States) |
1,500 |
21.4% |
450 |
| Minced meat (imported from Brazil) |
1,120 |
16.0% |
336 |
| Powdered milk |
4,000 |
57.1% |
1,200 |
| Flour |
1,000 |
14.3% |
300 |
| Salt |
800 |
11.4% |
240 |
| Sugar |
1,100 |
15.7% |
330 |
| Coffee |
7,000 |
100.0% |
2,100 |
| Seasonal fruit |
200 |
2.9% |
60 |
| Onion |
1,200 |
17.1% |
360 |
| Garlic, one unit |
40 |
0.6% |
12 |
| Bread roll |
250 |
3.6% |
75 |
| White Cuban cheese |
2,000 |
28.6% |
600 |
| Monthly family basket |
85,130 |
608.1% |
12,769.5 |
| HYGIENE |
|
|
|
| Bar soap |
350 |
5.0% |
105 |
| Detergent, 1 kg |
1,500 |
21.4% |
450 |
| Toilet paper, one roll |
200 |
2.9% |
60 |
| TRANSPORT |
|
|
|
| Journey of 2–3 km by tricycle |
200 |
2.9% |
60 |
| Journey of 2–3 km by car |
1,000 |
14.3% |
300 |
| OTHER EXPENSES |
|
|
|
| Restaurant meal |
3,000 |
42.9% |
900 |
| One night in a hotel |
21,000 |
300.0% |
6,300 |
| Bicycle |
140,000 |
2,000.0% |
42,000 |
| Mobile telephone |
91,000 |
1,300.0% |
27,300 |
| Rice cooker |
95,000 |
1,357.1% |
28,500 |
| Washing machine |
110,000 |
1,571.4% |
33,000 |
| Computer |
350,000 |
5,000.0% |
105,000 |
| Electric tricycle |
3,500,000 |
50,000.0% |
1,050,000 |
| Car |
28,000,000 |
400,000.0% |
8,400,000 |
Table 3. Prices of basic products in relation to the average State salary and equivalent costs in Spain
When this amount is compared with the average public-sector salary used as a reference, basic food for a family of four requires several monthly salaries. Housing, electricity, water, gas, transport, medicines, hygiene, and other essential goods must be added to these expenses.
The calculation used in this study places the minimum cost of a dignified life at around 210,000 CUP per month, although this figure should be considered an analytical estimate rather than an official poverty threshold.
The discrepancy between the official exchange rate and the effective exchange rate is one of the main factors required to understand this situation. Converting official salaries using the State exchange rate may provide a very different picture from the population’s actual purchasing power.
X. Psychosocial conditions
The material conditions described above also have psychosocial consequences. Economic insecurity, the migration of family members, separation from support networks, difficulties in accessing essential goods, and prolonged interruptions in electricity and water supplies may increase stress and social isolation.
Official information available on mental health is limited. Among the available indicators is the suicide rate, estimated at approximately 13.8 per 100,000 inhabitants, with a marked difference between men and women.
Dementia is also becoming an increasing cause of mortality in the context of rapid population ageing. The growing number of older people living alone or with reduced family networks creates an increasing need for community support services, care, and mental health services.
XI. Health
Life expectancy
Life expectancy is one of the most sensitive indicators for assessing overall changes in living and health conditions.
In 1959, Cuban life expectancy was around 63 years. It subsequently increased steadily, reaching approximately 77.4 years at the beginning of the 2000s.
After a period of stagnation, the pandemic caused an exceptional decline. In 2021, life expectancy fell to approximately 73.2 years. The subsequent recovery was partial, and the 2024 data again show deterioration.
Figure 4. Evolution of average life expectancy at birth and life expectancy disaggregated by sex in Cuba, 1950–2024
According to the analysis conducted using available statistics, life expectancy in 2024 was around 75.4 years, with differences between men and women. These figures indicate a recovery from the 2021 low but do not yet demonstrate a sustained recovery to pre-pandemic levels.
Territorial differences are relatively moderate compared with those in other countries, although relevant variations exist. Guantánamo has one of the highest values, while the Isle of Youth has one of the lowest.
XII. Burden of health inequity
The calculation of mortality rates by age and sex and their comparison with different references makes it possible to estimate the potential burden of mortality associated with avoidable inequalities.
When Cuba in 2024 is compared with the average of the two decades preceding the pandemic, estimated excess mortality is approximately 11,349 deaths, of which around 65% occurred among men.
Compared with mortality rates in 2023, estimated excess mortality reaches approximately 13,783 deaths, with around 62% occurring among men.
Comparison with Guantánamo, used as an internal territorial reference, produces a higher estimate, close to 21,033 deaths. Comparison with an international Sustainable Health Equity reference, represented in this analysis by Sri Lanka, produces a different estimate of approximately 6,600 deaths.
Comparisons with Costa Rica and Spain generate substantially higher potential burdens, exceeding 44,000 and 53,000 deaths, respectively. These figures should not be interpreted as the actual number of deaths that could be prevented through a specific intervention, but rather as counterfactual estimates dependent on the reference used.
Analysis of the relative burden of inequity (RBI) makes it possible to express these differences as a proportion of observed mortality. In relation to the Cuban period 2000–2019, the estimated RBI for 2024 is around 9.6%. Compared with 2023, it rises to approximately 10.4%. The comparison with Guantánamo reaches 16.4%, while international references generate different values according to the social, economic, and environmental characteristics of each country.
Analysis by age shows that inequity is not distributed evenly. Children and certain younger age groups show particularly sensitive burdens when international references with higher survival are used.
Figure 5. Relative burden of inequity by age and according to different Sustainable Health Equity references
The results suggest that Cuba could benefit from a specific analysis of the factors that allow countries with limited economic resources to maintain better health outcomes. Sri Lanka represents a particularly interesting reference from this perspective, while Guantánamo provides a useful internal reference for identifying potentially replicable territorial practices.
XIII. Years of life lost
Including age in the calculation makes it possible to estimate not only the number of potentially avoidable deaths but also the number of years of life lost.
For 2024, the estimated number of years of life lost associated with the burden of inequity is approximately:
60,000 compared with the Cuban average for 2000–2019.
110,000 compared with Cuba in 2023.
118,000 compared with Guantánamo.
120,000 compared with the Sri Lanka reference.
343,000 compared with Costa Rica.
574,000 compared with Spain.
The differences between these figures demonstrate the importance of carefully selecting the references used. The higher the survival of the population used for comparison, the greater the potential number of years of life lost identified.
This indicator is particularly useful for guiding public policies because it makes it possible to identify where the potential loss of health is concentrated: not only in the number of deaths, but also in deaths occurring at relatively early ages.
XIV. Main patterns of morbidity and mortality
Cardiovascular diseases are the leading cause of death, followed by tumours and respiratory diseases. Cerebrovascular diseases and accidents also account for a significant proportion of mortality.
Infectious diseases have considerably reduced their relative importance compared with previous decades. However, some communicable diseases show worrying trends, including syphilis and certain respiratory infections, hepatitis, and tuberculosis.
From the perspective of years of life lost, tumours are among the main causes, particularly lung, colon, prostate, and breast cancer.
Infant mortality is one of the most sensitive indicators of the current situation. Mortality among children under five may have increased from approximately 6.2 per 1,000 in 2020 to 9.7 per 1,000 in 2024. Two thirds of these deaths occur during the first year of life, and an important proportion are related to perinatal conditions.
Maternal mortality also shows signs of deterioration. In 2024, it was around 33 per 100,000 live births according to the data used in this study, representing an increase compared with the previous year.
Low birth weight has increased from approximately 5% during the two decades preceding the pandemic to around 7–8% in recent years.
Regarding chronic diseases, hypertension, asthma, diabetes, and cerebrovascular disease represent an important burden for the health system, particularly in an increasingly ageing population.
XV. National health system
The Cuban health system maintains a public structure with universal coverage and an extensive primary health care network. This is one of the country’s main assets and should be protected in any cooperation strategy.
Cuba has polyclinics, family medicine practices, hospitals, maternity homes, institutions for older people, and other community-based and specialised services.
The country allocates a high proportion of its public budget to health. However, interpreting health expenditure in US dollars is particularly complex because of the different exchange rates and the difference between nominal values and the real cost of imported goods.
For this reason, rather than relying on a single figure expressed in dollars, it is more useful to analyse the effective capacity of the system to acquire medicines, equipment, fuel, food, and other essential supplies.
Human resources
Until 2020, approximately 400,000 people worked in the Cuban health system. This number may have declined to around 300,000 by 2024.
The number of physicians has also declined substantially, from more than 106,000 in 2020 to approximately 75,000 in 2024. Despite this reduction, Cuba continues to maintain a high physician density by international standards.
The deterioration of salary conditions and economic opportunities in the private sector may be contributing to the movement of professionals from the public health system into other activities or to migration abroad.
The loss of human resources is probably one of the main structural risks to the sustainability of the Cuban health model. Training new professionals takes years and cannot rapidly compensate for the departure of experienced personnel.
Approximately one in six physicians works as a family doctor, integrated into basic health teams and based in the community. The country also has tens of thousands of nursing professionals.
The health system operates through thousands of basic health teams, hundreds of polyclinics and hospitals, and a network of maternal and child, geriatric, and psychopedagogical institutions.
The health information infrastructure, with thousands of units connected to Infomed, represents another important asset for training, scientific communication, and health management.
Activity and coverage of the public health system
In 2024, the National Health System provided more than 100 million consultations, of which approximately 96% were provided through primary health care. Millions of emergency consultations, hundreds of thousands of hospital admissions, and hundreds of thousands of surgical procedures were also recorded.
Vaccination coverage remains one of the main strengths of the system, with coverage close to 98–100% for numerous vaccines included in the national programme.
The national essential medicines list includes around 660 medicines, an important proportion of which are produced domestically. However, economic, energy, productive, and logistical difficulties have significantly reduced their effective availability.
Declining domestic production and imports have resulted in recurrent interruptions in supply. The problem affects not only medicines used in hospitals but also essential treatments for chronic diseases requiring continuity of care.
Informal market for medicines
Insufficient availability of medicines in pharmacies and health facilities has contributed to the expansion of an informal market. Medicines are sometimes brought into the country by travellers and distributed through social networks and personal contacts.
This market may partially compensate for the absence of certain products, but it presents important risks for health and equity. There is not necessarily any guarantee regarding storage conditions, authenticity, expiry dates, or product quality.
Prices observed during the mission show that certain medicines represent an exceptionally high proportion of the incomes of pensioners and public-sector workers.
| Medicines |
Price CUP |
Proportion of average pension |
Equivalent in Spain (€) |
| Paracetamol, 10 tablets |
850 |
24.2% |
255 |
| Ibuprofen, 10 tablets |
850 |
24.2% |
255 |
| Amoxicillin, 20 tablets |
1,700 |
48.6% |
510 |
| Nifedipine, per month |
2,250 |
64.2% |
675 |
| Salbutamol, per month |
4,000 |
104.2% |
1,200 |
| Enalapril, per month |
3,000 |
85.4% |
900 |
| Alprazolam, per month |
4,500 |
128.6% |
1,350 |
| Insulin, 300 units/month |
12,000 |
342.8% |
3,600 |
Table 4. Prices of medicines on the informal market, proportion of the average pension, and equivalent values in euros in relation to a salary in Spain
For a person with limited income, common treatments for hypertension, asthma, diabetes, or other chronic diseases may represent a substantial proportion of monthly income. Consequently, purchasing medicines on the informal market may constitute catastrophic health expenditure for some households.
This phenomenon is particularly concerning because it may lead to interruptions in treatment and, consequently, to increased complications, hospitalisations, and avoidable mortality.
XVI. General conclusions
Cuba is experiencing one of the deepest socioeconomic crises of recent decades. The combination of external restrictions, declining productive capacity, inflation, loss of purchasing power, the energy crisis, migration, and population ageing is progressively weakening the capacity of public institutions to guarantee certain basic services.
At the same time, the public system retains important capacities, particularly in health, education, and the training of professionals. The situation should therefore not be interpreted as the disappearance of these capacities, but rather as a process of erosion that may eventually compromise them if resources and productive capacities are not restored.
The development of the private sector represents an important transformation of the Cuban economy. MSMEs have created employment and new sources of income, but so far they have not demonstrated the capacity to replace the redistributive and universal functions historically performed by the State.
The main concern from a public health perspective is that this economic transition may produce increasing segmentation of society between those who have access to foreign currency and those who depend on public salaries or pensions. This inequality may directly translate into differences in food, medicines, transport, energy, housing, and effective access to services.
Recent trends in mortality, life expectancy, infant mortality, low birth weight, and other health indicators constitute warning signals. Data for 2025 and 2026 are still insufficient to establish precisely the magnitude of the deterioration, but they justify strengthening epidemiological and social monitoring.
International cooperation should therefore be directed primarily towards preventing a further loss of essential capacities and protecting the most vulnerable groups.
XVII. Strategic directions for cooperation
The Cuban experience of recent decades raises a broader question: how to preserve achievements in social and health equity in a context of economic restrictions, demographic transition, and ecological crisis.
The response should avoid both an idealisation of the historical Cuban model and an interpretation focused exclusively on its deficiencies. The challenge is to identify which capacities continue to function, which are at risk, and which interventions may contribute to preserving or restoring them.
In this context, four strategic priorities are proposed.
Sustainable energy sovereignty
The first priority should be to move towards greater energy sovereignty based progressively on distributed renewable sources.
Dependence on imported fossil fuels currently represents a systemic vulnerability affecting electricity generation, water supply, hospitals, the preservation of medicines and food, transport, and communications simultaneously.
A strategy based on distributed solar generation, energy storage, and microgrids could initially prioritise health facilities, water systems, rural communities, and other essential services.
The preliminary estimate of approximately 2 kW of solar capacity per inhabitant represents a major investment and would require a specific technical and financial study. Rather than presenting it as an immediate operation, it should be considered as a reference for assessing the scale required for an energy transition.
Part of the country’s public assets, including certain tourism assets, could potentially be assessed as a source of financing for strategic investments, provided that any operation protects the public interest and is evaluated transparently.
Sustainable food sovereignty
The second priority should be the progressive recovery of national capacity to produce healthy and sustainable food.
The increasing dependence on imported food, particularly processed products, creates economic vulnerability, nutritional problems, waste, and logistical dependence at the same time.
The energy transition should be linked to a rural strategy facilitating access to land, water, renewable energy, credit, seeds, and technical assistance for agroecological producers.
Tourism could complement this strategy through rural, ecological, and cultural experiences that generate local income and contribute to financing productive infrastructure.
Fiscal equity and social protection
The third priority should be to strengthen the progressivity of the fiscal system.
In a context of growing inequality between public incomes, remittances, and private economic activities, it is necessary to ensure that people with incomes below a minimum threshold of dignity do not face a fiscal burden that compromises their basic needs.
At the same time, extraordinary incomes and activities with greater capacity to contribute should provide an increasing proportion of resources to finance public goods.
Fiscal policy could also incorporate incentives for activities contributing to the care of people, public health, sustainable food production, renewable energy, the circular economy, and ecosystem protection.
Protection of health, education, and the production of essential medicines
The fourth priority should be to preserve universal and free coverage of essential public services, particularly health and education.
In health, the first objective should be to guarantee the continuity of primary health care and essential treatments for chronic diseases.
The second should be the progressive recovery of national production of essential medicines, including raw materials, formulation, quality control, and distribution systems.
Strengthened national pharmaceutical capacity would not only reduce external dependence but could also allow the development of products of interest to other low- and middle-income countries, transforming certain Cuban capacities into regional or global public goods.
International cooperation could contribute through technology transfer, support for laboratories, joint procurement, quality assurance systems, specialised training, and strengthening supply chains.
XVIII. Final consideration
Cuba is currently facing a critical situation. The combination of external restrictions, internal problems, economic deterioration, population ageing, migration, and the energy crisis is producing a deterioration in living conditions that may compromise some of the social and health achievements accumulated over decades.
At the same time, the country retains important human, institutional, and scientific capacities. The existence of an extensive primary health care network, highly trained professionals, academic institutions, pharmaceutical capacities, and significant historical experience in public health provides a foundation on which action is still possible.
From the perspective of Médecins du Monde, the priority should be to contribute to ensuring that the crisis does not result in an irreversible loss of these capacities and, particularly, in increased inequalities in access to the basic determinants of health.
Cooperation should therefore prioritise interventions with the greatest impact on equity: essential medicines, primary health care, maternal and child health, older people, chronic diseases, mental health, water, energy, and food.
The transition towards greater energy and food sovereignty, accompanied by more progressive taxation and the protection of universal public services, could constitute a strategy capable of simultaneously reducing economic vulnerability, social inequity, and health and environmental risks.
The ultimate objective should not simply be to recover pre-crisis levels, but to build a development model that combines dignity, equity, sovereignty, environmental sustainability, and effective protection of essential public goods.
References
- a) Garay, J. (2026). “Cuba’s Health System: From Global Reference in Equity and International Solidarity to Contemporary Crisis.” PEAH – Policies for Equitable Access to Health. Available at: https://www.peah.it/2026/06/16179/
- a) Garay, J. (2026). “Cuba: Health Equity, Sustainability and the Limits of a Universal Health System under Prolonged Crisis.” PEAH – Policies for Equitable Access to Health. Available at: https://www.peah.it/2026/06/16179/
- b) National Office of Statistics and Information of the Republic of Cuba (ONEI). Statistical Yearbook of Cuba. Latest available editions. Havana: ONEI. Available at: https://www.onei.gob.cu/
- c) National Office of Statistics and Information of the Republic of Cuba (ONEI). Studies and publications on population, demography, migration, employment, income, and living conditions. Havana: ONEI. Available at: https://www.onei.gob.cu/
- d) Ministry of Public Health of the Republic of Cuba (MINSAP). Statistical Yearbook of Health. Latest available editions. Havana: MINSAP. Available at: https://salud.msp.gob.cu/
- e) Pan American Health Organization/World Health Organization (PAHO/WHO). Basic indicators and country profiles: Cuba. Washington, D.C.: PAHO. Available at: https://www.paho.org/es/cuba
- f) World Health Organization. Global Health Observatory. Cuba: Health and Health-related Indicators. Geneva: WHO. Available at: https://www.who.int/data/gho
- g) United Nations, Department of Economic and Social Affairs, Population Division. World Population Prospects 2024. New York: United Nations. Available at: https://population.un.org/wpp/
- h) United Nations Development Programme. Human Development Report 2023/2024: Breaking the Gridlock: Reimagining Cooperation in a Polarized World. New York: UNDP. Available at: https://hdr.undp.org/
- i) World Bank. Cuba: data, indicators, and economic and social analysis. Washington, D.C.: World Bank. Available at: https://data.worldbank.org/country/cuba
- j) Economic Commission for Latin America and the Caribbean (ECLAC). Economic Survey of Latin America and the Caribbean. Recent editions. Santiago: United Nations. Available at: https://www.cepal.org/
- k) Economic Commission for Latin America and the Caribbean (ECLAC). Social Panorama of Latin America and the Caribbean. Recent editions. Santiago: United Nations. Available at: https://www.cepal.org/es/temas/pobreza
- l) Food and Agriculture Organization of the United Nations, International Fund for Agricultural Development, United Nations Children’s Fund, World Food Programme, and World Health Organization. The State of Food Security and Nutrition in the World. Recent editions. Rome: United Nations. Available at: https://www.fao.org/publications/sofi/
- m) World Health Organization and World Bank. Tracking Universal Health Coverage: Global Monitoring Report. Recent editions. Geneva and Washington, D.C.: WHO and World Bank.
- n) Sustainable Health Equity Movement (SHEM). Methodological documents and analyses on sustainable equity, avoidable mortality, and years of life lost. Available at: https://www.sustainablehealthequity.org/
- o) Pan American Health Organization. Health in the Americas+: Cuba. Washington, D.C.: PAHO. Available at: https://hia.paho.org/
- p) World Health Organization. Access to Medicines and Health Products. Geneva: WHO.
- q) World Health Organization. WHO Guideline on Country Pharmaceutical Pricing Policies. Geneva: WHO.
- World Health Organization. Medication Without Harm: Global Patient Safety Challenge. Geneva: WHO.
- r) World Health Organization. Primary Health Care on the Road to Universal Health Coverage: 2019 Global Monitoring Report. Geneva: WHO.
- s) World Health Organization. Operational Framework for Primary Health Care: Transforming Vision into Action. Geneva: WHO and UNICEF.
- t) World Health Organization. Social Determinants of Health. Geneva: WHO.
- u) World Health Organization. World Report on Ageing and Health. Geneva: WHO, 2015.
- v) World Health Organization. Decade of Healthy Ageing 2021–2030. Geneva: WHO.
- w) International Organization for Migration. World Migration Report 2024. Geneva: IOM.
- x) Médecins du Monde Spain. Institutional documents on humanitarian action, the right to health, equity, and health systems strengthening. Madrid: Médecins du Monde.
- y) United Nations. Sustainable Development Goals: Goal 3, Good Health and Well-being. New York: United Nations.
- z) World Health Organization. Everybody’s Business: Strengthening Health Systems to Improve Health Outcomes. WHO’s Framework for Action. Geneva: WHO, 2007.
- aa) World Health Organization. Monitoring the Building Blocks of Health Systems: A Handbook of Indicators and Their Measurement Strategies. Geneva: WHO, 2010.
Endnotes
[1] https://www.valyter.es/
[2] https://www.sustainablehealthequity.org/
[3] https://www.peah.it/2026/06/16179/
[4] https://www.valyter.es/atlas-de-la-equidad-global
