IN A NUTSHELL
Author's Note
For more than half a century, Cuba represented one of the world’s most remarkable public health experiences. Despite economic scarcity, external sanctions, and limited material resources, the country achieved health indicators comparable to those of high-income nations while maintaining universal free access to care. Cuba became internationally recognised for its prevention-oriented primary health care model, extensive medical education system, biomedical innovation, and unprecedented international medical cooperation.
The Cuban experience challenged the dominant assumption that excellent population health necessarily requires high national income. Instead, Cuba demonstrated that strong political commitment to equity, territorial primary care, public health integration, and universal access could produce exceptional outcomes under constrained economic conditions.
At its peak, Cuba became one of the clearest practical examples of the principles later formalised in the Alma-Ata Declaration on Primary Health Care: universalism, prevention, community participation, and equity.
Yet during the last decade, and especially after 2020, the Cuban health system has entered a period of severe deterioration. Economic crisis, tightening U.S. sanctions, shortages of medicines and supplies, migration of health professionals, infrastructural collapse, and widening inequalities in access have progressively eroded many of the achievements that once made Cuba a global health reference.
This article reviews the evolution of Cuban health care, its international contributions and innovations, and the structural causes behind its current decline
By Juan Garay
Former Head of European Union Cooperation in Cuba (2017–2023)
Visiting Professor of Sustainable Equity in Cuban universities including ELAM, UCLV and UNAH
Co-Chair of the Sustainable Health Equity Movement (SHEM)
By the same Author on PEAH: see HERE
Cuba’s Health System: From Global Reference in Equity and International Solidarity to Contemporary Crisis
Building a Universal Health System after 1959
Before the 1959 revolution, Cuba displayed major inequalities in access to health services. Physicians and hospitals were concentrated in Havana and major urban centres, while rural populations often lacked even basic medical care.
After 1959, health care became a constitutional right and a central responsibility of the state. The Cuban government nationalised health services and progressively built an integrated national system based on universality, prevention, and territorial equity.
Health policy extended far beyond hospitals and clinics. Major investments were made in literacy, vaccination, maternal and child health, sanitation, nutrition, rural outreach, and epidemiological surveillance. Cuba integrated public health and clinical medicine in ways that were rare internationally.
The results were dramatic. Infant mortality declined sharply, infectious diseases were controlled, and life expectancy increased steadily throughout the second half of the twentieth century.
According to the Global Equity Atlas analysis, Cuba reached a life expectancy of 78.65 years during 2016–2020, compared with a world average of 72.45 years.[2] Female life expectancy reached 80.65 years and male life expectancy 76.66 years.
As Keck and Reed observed, “Cuba has demonstrated that a country can achieve excellent health outcomes through prevention-oriented universal care despite limited economic resources.”[3]
Universal Primary Health Care and Territorial Equity
The Cuban model became internationally influential because it operationalised universal primary health care through territorial responsibility and prevention.
The Family Doctor and Nurse Programme introduced during the 1980s assigned each doctor–nurse team responsibility for a defined geographic population. Medical personnel usually lived within the same communities they served, conducted home visits, maintained detailed family health records, monitored risk factors, and integrated preventive and curative care.
This territorial organisation enabled very high vaccination coverage, strong maternal and child health outcomes, rapid epidemiological response, and early diagnosis of disease.
The Cuban system also linked health policy to broader social determinants including literacy, education, nutrition, women’s empowerment, and public health surveillance.
Unlike many fragmented systems centred on hospitals and specialised medicine, Cuba integrated public health and clinical medicine into a unified national strategy.
Cuba as an Equitable and Sustainable Health Model
The Global Equity Atlas analysis demonstrates why Cuba became internationally significant not only for its health indicators but for achieving them under relatively modest economic conditions.[2]
The study identifies Cuba as historically belonging to a group of “Healthy, Replicable and Sustainable” (HRS) models — countries able to achieve above-average health outcomes within globally replicable ecological and economic limits.
Compared with neighbouring countries, Cuba achieved higher life expectancy than both the Dominican Republic and the United States despite far lower GDP per capita than the United States. Cuba’s life expectancy reached 78.65 years compared with 73.69 in the Dominican Republic and 78.51 in the United States.[2]
The comparison with countries of similar GDP and ecological capacity — particularly Thailand and China — also showed Cuba with superior life expectancy despite lower ecological consumption.[2]
The analysis further demonstrated that Cuba’s GDP per capita remained below the world average while life expectancy exceeded the world average by more than six years.[2]
These findings challenged dominant development paradigms that equate health progress primarily with economic growth and high consumption.
The study concluded that Cuba historically represented one of the few examples of high wellbeing achieved within relatively sustainable and globally replicable ecological limits.[2]
Medical Education and International Training
A central pillar of Cuban health success was its large-scale investment in medical education.
Cuba developed one of the world’s highest physician-to-population ratios through publicly funded and socially oriented medical training. Medical education was strongly integrated into community practice and primary care rather than centred exclusively on tertiary hospitals.
The Latin American School of Medicine (ELAM), founded in 1999, became one of the largest international medical schools in the world. Tens of thousands of students from Latin America, Africa, Asia, and underserved communities in the United States were trained in Cuba under scholarships emphasising prevention, public health, and service to disadvantaged populations.
Cuba thus exported not only medical personnel but also an entire philosophy of socially accountable medicine.
International Medical Cooperation and Solidarity
Cuba became globally recognised for international medical cooperation on a scale unmatched by most countries.
Since the 1960s, Cuban medical brigades have worked across Latin America, Africa, Asia, and the Caribbean, particularly in underserved rural areas and during emergencies.
By 2019, more than 600,000 Cuban health workers had participated in missions in over 160 countries.[4]
Cuban medical teams responded to earthquakes, hurricanes, cholera outbreaks, the Ebola epidemic in West Africa, and the COVID-19 pandemic. The Henry Reeve International Medical Brigade became internationally recognised during Ebola and COVID-19 emergency deployments.
One of the best-known programmes was “Operation Miracle” (Operación Milagro), developed with Venezuela in 2004, which provided free ophthalmologic surgery to millions of patients across Latin America and other regions. Cataract surgery and other sight-restoring procedures became emblematic of Cuban medical solidarity.
Ironically, some ophthalmologic services and surgical supplies associated with those programmes are now increasingly difficult to access within Cuba itself because of shortages and system deterioration.
As Feinsilver observed, “Cuban medical diplomacy became one of the country’s most important forms of international influence and solidarity.”[5]
Criticism and Debate around International Medical Cooperation
Cuban international medical cooperation has generated both admiration and criticism.
Supporters regard the programmes as one of the largest and most sustained examples of South-South solidarity in modern history, bringing medical services to remote and underserved populations neglected by local systems.
Critics — particularly the United States government — have accused Cuba of exploiting medical workers because a substantial proportion of salaries paid by receiving governments is retained by the Cuban state.
However, this redistribution mechanism can also be understood within the framework of progressive taxation systems commonly applied in OECD countries. Depending on mission conditions and salary levels, Cuban physicians generally retain between 30% and 70% of remuneration, while the remaining proportion finances Cuba’s universal systems of health care, education, and medical training.
Many participating physicians also report that international missions provide significantly higher earnings than domestic salaries and opportunities for professional advancement.[4]
The debate therefore reflects broader tensions between solidarity-based public financing models and market-oriented approaches to health workforce mobility.
Biomedical Research and Cuban Scientific Innovation
Another frequently overlooked aspect of the Cuban model has been its substantial investment in biomedical research and biotechnology.
Despite economic limitations and external sanctions, Cuba developed advanced scientific institutions and a sophisticated biotechnology sector. Cuban research centres produced vaccines, cancer therapies, diagnostic technologies, and pharmaceuticals with international recognition.
Baracca and Franconi described Cuba’s biotechnology strategy as “one of the most ambitious scientific development models undertaken by a middle-income country.”[6]
The COVID-19 pandemic highlighted these capabilities. Cuba developed several domestic COVID-19 vaccines, including Abdala and Soberana, becoming one of the few countries in the Global South capable of producing its own vaccines during the pandemic.
This achievement was particularly remarkable given the severe constraints on imports, financing, technology access, and raw materials associated with the U.S. embargo.
The Impact of the U.S. Embargo on Health and Living Conditions
Any serious assessment of the evolution and current deterioration of the Cuban health system must analyse the long-term effects of the United States embargo, not only on the health sector itself, but on the broader Cuban economy and living conditions that ultimately determine health outcomes.
The embargo has never functioned merely as a bilateral trade restriction. Through financial sanctions, extraterritorial penalties, shipping restrictions, banking limitations, and secondary sanctions affecting third countries and companies, it has constrained Cuba’s access to international markets, credit, technologies, fuel, industrial inputs, and medical supplies for decades.[7]
Its effects became especially severe after the collapse of the Soviet Union and intensified again during the Trump administrations, which implemented more than 240 additional coercive measures targeting tourism, remittances, fuel imports, banking operations, shipping, and international commercial relations.[8]
These restrictions dramatically reduced Cuba’s access to foreign currency and worsened shortages across all sectors, including food, electricity, transportation, and health care.
The health consequences are therefore both direct and indirect.
Directly, the embargo complicates the acquisition of medicines, spare parts, laboratory reagents, diagnostic equipment, medical technologies, and pharmaceutical raw materials. Even when humanitarian exemptions formally exist, banking restrictions, licensing requirements, freight limitations, insurance barriers, and fear of secondary sanctions among international suppliers substantially raise costs and delay procurement.[7]
Indirectly, the broader economic effects of sanctions have contributed to declining living conditions, reduced state revenues, inflation, electricity shortages, deterioration of transportation and housing, nutritional insecurity, and declining real salaries — all of which affect population health and the sustainability of the health workforce.
The impact on human resources has been particularly severe. The progressive economic deterioration and widening gap between professional salaries and the cost of living have accelerated the migration of physicians, nurses, scientists, and other skilled professionals.
Cuba’s Pharmaceutical Industry and Dependence on Imports
One of the least understood aspects of the Cuban health system is the strategic importance of its domestic pharmaceutical and biotechnology sector.
For decades, Cuba developed one of the largest state-led generic medicine production systems in the Global South. By the early 2000s, nearly 80% of medicines consumed in Cuba were domestically produced.[9]
The country also developed internationally recognised biotechnology capacities, including vaccines against meningitis B, cancer therapies, interferons, monoclonal antibodies, and later the domestic COVID-19 vaccines Abdala and Soberana.
However, domestic pharmaceutical production has always depended heavily on imported active pharmaceutical ingredients (APIs), chemical precursors, industrial equipment, spare parts, and laboratory inputs.
India became one of Cuba’s most important partners for pharmaceutical imports and technical cooperation. Indian collaboration contributed historically to the establishment of Cuba’s generic medicine manufacturing capacity and continues to supply critical pharmaceutical materials.[10]
Yet sanctions and financial restrictions have increasingly complicated Cuba’s ability to purchase and import those materials. Even when medicines themselves are not formally prohibited, sanctions affecting banking systems, maritime transport, insurance, dollar-denominated transactions, and credit access create major obstacles for procurement.
The result is that Cuba’s pharmaceutical industry — despite its scientific sophistication — often lacks the imported raw materials needed for large-scale production.
This contradiction has become one of the defining paradoxes of the current Cuban crisis: a country capable of developing advanced vaccines and biotechnology products increasingly struggles to guarantee stable access to antibiotics, antihypertensives, analgesics, insulin, or basic surgical materials.
The Gradual Decline of the Cuban Health System
Over the last decade, Cuba’s health system has progressively deteriorated.
Economic stagnation, declining Venezuelan support, reduced tourism revenues, inflation, infrastructural decay, and the COVID-19 crisis intensified longstanding structural weaknesses.
Hospitals increasingly suffer shortages of medicines, diagnostic materials, surgical supplies, electricity, and water. Patients often rely on relatives abroad, informal markets, or personal networks to obtain basic medications.
The Global Equity Atlas analysis already detected early warning signs before the pandemic. Relative burden of health inequity compared with feasible HRS standards increased progressively after 2000, especially among women aged 40–69 years and adults older than 65 years.[2]
The study estimated that by 2016–2020 Cuba experienced 3,483 excess annual deaths relative to feasible HRS standards represented by Sri Lanka — equivalent to more than 10 avoidable deaths per day.[2]
When compared with Costa Rica — the Latin American country that historically evolved in parallel with Cuba as one of the region’s most equitable health success stories — excess mortality reached 16,552 annual deaths, equivalent to approximately 50 avoidable deaths per day.[2]
These findings suggest that deterioration had begun well before the acute post-pandemic crisis and increasingly affects the most vulnerable age groups.
Declining Life Expectancy and Health Outcomes
One of the clearest signs of decline has been the deterioration of mortality indicators after 2020.
The COVID-19 pandemic exposed serious vulnerabilities in infrastructure, medicine supply, and workforce capacity. Life expectancy declined significantly during the pandemic years due to excess mortality associated with COVID-19 and broader system shortages.
The decline contrasted sharply with Cuba’s historical trajectory of continuous health improvement.
Brain Drain and Physician Exodus
The progressive economic deterioration and widening gap between professional salaries and the cost of living have accelerated the migration of physicians, nurses, scientists, and other skilled professionals.
Recent estimates indicate that Cuba lost more than 30,000 physicians between 2021 and 2024, while overall losses in the health sector may exceed 77,000 professionals, including nurses, technicians, and specialists.[11]
Primary care appears particularly affected, weakening the family doctor system that historically formed the backbone of Cuban public health.
The “brain drain” affecting Cuba cannot be understood separately from the broader deterioration in economic and living conditions linked to both internal structural weaknesses and external economic pressures.
Informal Markets and Unequal Access
Perhaps the most profound transformation has been the emergence of unequal access mechanisms.
Historically, the Cuban model was characterised by relatively egalitarian access to services. Today, however, medicines and supplies are increasingly obtained through remittances, black markets, dollar stores, tourism-related income, or relatives abroad.
Access now frequently depends on foreign currency and social networks rather than purely universal entitlement.
This development represents a major departure from the ethical foundations of the Cuban health model and risks undermining the legitimacy of a system historically associated with social equity.
Global Responsibility and Solidarity with Cuban Health Care
There is also a broader global responsibility in recognising both the historical achievements and the present vulnerabilities of the Cuban health system.
For decades, Cuba demonstrated that universal access, prevention-oriented primary care, medical internationalism, and public investment in health and education could achieve extraordinary outcomes even under conditions of limited economic resources.
The Cuban model contributed not only to the health of its own population, but also to millions of people across Latin America, Africa, Asia, and the Caribbean through medical cooperation, training, disaster response, epidemic control, and solidarity programmes such as Operation Miracle.
The international community therefore carries a responsibility not only to analyse the Cuban crisis, but also to defend the principles of equity, solidarity, and universalism historically embodied in the Cuban health model.
This responsibility also includes condemning the continued United States embargo against Cuba, which has been overwhelmingly rejected for decades by the United Nations General Assembly through near-unanimous annual resolutions.
Solidarity with Cuban health care should therefore go beyond symbolic recognition. It should include practical international cooperation in access to medicines, medical technologies, scientific exchange, energy resilience, and support for the recovery of primary health care and pharmaceutical production capacities.
Lessons from the Cuban Experience
The Cuban experience offers two major lessons for global health.
First, Cuba demonstrated that universal access, prevention-oriented primary care, community medicine, and strong public health systems can achieve extraordinary health outcomes even under limited economic conditions.
Second, the current crisis illustrates the vulnerability of health systems facing prolonged economic scarcity, geopolitical isolation, infrastructural deterioration, and workforce exhaustion.
The Cuban case therefore remains globally relevant not only as a historic success story but also as a warning regarding the fragility of equitable health systems when economic sustainability and institutional adaptability weaken.
Conclusion
For decades, Cuba stood as one of the world’s most influential examples of equitable health development. Universal access, community-based primary care, international solidarity, biomedical innovation, and socially accountable medical education transformed the island into a global reference in public health.
The Global Equity Atlas analysis confirms that Cuba achieved life expectancy levels substantially above international averages while remaining within relatively replicable economic and ecological conditions.[2]
Yet the last decade has marked a profound reversal. Economic crisis, intensified sanctions, shortages, migration of professionals, infrastructural collapse, and growing inequalities in access have progressively eroded the foundations of the Cuban health system.
The net burden of health inequity — practically non-existent until around 2010 when compared with HRS reference countries — has now risen to more than 10 avoidable deaths per day relative to the present HRS reference represented by Sri Lanka, and approximately 50 avoidable deaths per day when compared with Costa Rica, the Latin American country whose equitable health trajectory historically paralleled Cuba’s.[2]
These avoidable deaths increasingly affect middle-aged women and older adults, revealing the human cost of the present deterioration.
The Cuban experience nevertheless remains historically significant because it demonstrated that high levels of health and wellbeing can be achieved without the levels of wealth and consumption characteristic of many industrialised societies.
There is therefore a global responsibility to recognise the achievements and principles of the Cuban health and solidarity model, to condemn policies that undermine access to health and medicines, and to support renewed international solidarity with Cuban public health.
Whether Cuba can preserve the principles of universal equitable care while adapting to contemporary economic and geopolitical realities remains one of the most important public health questions in Latin America today.
References
World Health Organization. Alma-Ata Declaration on Primary Health Care. 1978.
Garay J. Global Equity Atlas – Cuba Equity Profile. Available at: https://www.valyter.es/atlas-de-la-equidad-global
Keck CW, Reed GA. The curious case of Cuba. American Journal of Public Health. 2012.
The Guardian. “Poorest to suffer from Trump drive to stop Cuba sending doctors to its neighbours.” 2026.
Feinsilver JM. Healing the Masses: Cuban Health Politics at Home and Abroad.
Baracca A, Franconi R. Cuba: the strategic choice of advanced scientific development.
American Association for World Health. Denial of Food and Medicine: The Impact of the U.S. Embargo on Health and Nutrition in Cuba.
Reuters. Reports on impact of U.S. sanctions and shortages in Cuba. 2026.
IPS News. “Nearly 80 Percent of Medicines Produced Locally.” 2001.
UNIDO. “Laying the Foundations of Cuba’s Pharmaceutical Industry.”
Reports on Cuban physician migration and workforce losses, 2024.
