1. THE FUTURE OF THE CUBAN HEALTHCARE SYSTEM
LAUREN BOHABOY | AMINAH GBADAMOSI | JOE GERMINO
ALEX GOOD | ROB MCCURRIE
April 25, 2014
BA 30310
Section 2

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Table of Contents
Executive Summary……………………………………………………………………………….3
Abstract……………………………………………………………………………………………7
Introduction………………………………………………………………………………………..7
Background………………………………………………………………………………………..8
Current Assessment……………………………………………………………………………….9
Relevant Experts…………………………………………………………………………………11
Stakeholders……………………………………………………………………………………...13
Current Trends…………………………………………………………………………………...16
Key Challenges…………………………………………………………………………………..23
Baseline Forecast………………………………………………………………………………...24
Expected Future – Preservation………………………………………………………………….25
Alternative Scenarios…………………………………………………………………………….27
Uncertainties……………………………………………………………………………………..34
Business Implications……………………………………………………………………………36
Conclusion……………………………………………………………………………………….38
Works Cited……………………………………………………………………………………...40

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Executive Summary
The future of healthcare systems in developing countries is an interesting topic because
these countries usually have growing populations that will need adequate medical care at some
point in the future. Cuba is unique because it has managed to achieve health statistics similar to
that of developed countries like the United States with the economy of a developing country. The
fact that the current Cuban government offers free, universal healthcare makes this achievement
all the more impressive. However, the Cuban population is made up mostly of middle-aged
citizens, who will increase the demand for high quality healthcare as they begin to age. This
trend, along with the decaying nature of current medical facilities, outdated medical equipment,
and a relatively stagnant number of physicians in Cuba will ultimately put a great strain on the
healthcare system.
Currently the Cuban healthcare system operates around the idea of community-oriented
care, in which family doctors live within the
communities they serve. These family doctors are
relied upon for the majority of medical treatment,
and patients are only referred to hospitals when
their condition is severe. Hospitals and clinics,
therefore, are not the main avenue through which
care is received, and are utilized only in cases of complex procedures or severe illnesses. Due to
this lower reliance on such facilities, the upkeep of this infrastructure is not as much of a priority
to the Cuban government, leading to numerous decaying hospitals and clinics supplied with
outdated equipment. The majority of Cuba’s physicians are sent abroad by the government to
work in remote areas of other countries, which in turn pay a fee for these services. The Cuban
government collects the majority of this revenue, while the doctors themselves receive a very

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small portion. Clean water is available to the majority of the population, but in areas where such
a basic need is scarce this could cause increased health issues in the future. Additionally, the
current trade embargo with the United States has an impact on what types of medical products
Cuban citizens and doctors have at their disposal. As a result, Cuba has established a strong
biotechnology and pharmaceutical industry, developing and producing their own medications
and technologies. These current circumstances of the Cuban healthcare system aid in
determining the expected future of the system.
Projected out twenty years, the expected future sees little change in the Cuban healthcare
system from its current state. The government will continue to offer free healthcare to every
Cuban citizen, but this benefit will come at the price of lower quality of care. The bulk of the
population will have reached old age and will therefore demand more healthcare. Family doctors,
who serve the communities they live in, will continue to be relied upon for the majority of health
issues, while hospital visits will only be made when absolutely necessary. The issue of physician
brain drain will remain prominent, as many doctors will look to practice where they can earn the
highest possible salary, instead of remaining in Cuba where the compensation is minimal. The
infrastructure of these facilities will remain in relatively poor condition, and medical equipment
considered standard in any developed country would be absent from most of these facilities. The
embargo with the United States will continue, but relations will improve slightly, suggesting
progress towards an eventual compromise. The Cuban government will still restrict foreign
business from operating within the country in an effort to minimize outside influence. This lack
of change is due in large part to the unwillingness of the Cuban government to depart from
traditional policies, such as closed-door approaches to foreign imports, lack of adequate
investment in healthcare infrastructure, and the poor compensation given to doctors who are sent

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to work in other countries. This expected future, along with several alternative futures outlined
later in the report, are determined through the analysis of major trends that affect the system.
The future of the Cuban healthcare system can be better understood by identifying and
projecting the underlying key trends. These trends include the aging population, healthcare
expenditure, exports, and the number of physicians in Cuba. The majority of the trends will
increase demand for high quality healthcare, allowing endless opportunities within this industry.
Because the bulk of the population is beginning to enter old age, they will require more medical
attention, putting stress on a system that is already struggling to serve its currently young and
healthy citizens. The
government is charged with
supplying free, universal
healthcare to the nation, and in
order to improve the quality of
this care, funds must be
allocated to this sector. If healthcare expenditure remains stagnant as the population grows, the
quality of care will be compromised. A portion of these funds must go towards physician
salaries, a significant factor that will determine the number of physicians in Cuba. Again, if the
government continues to aggressively cut costs, this will negatively impact physician salaries
and likely cause the number of doctors in Cuba to decrease. These key trends will be crucial in
determining ways to improve the healthcare system as well as identifying major issues that stand
in the way of this improvement.

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These trends pose some challenges to the improvement of the current healthcare system.
Several key challenges include the financial costs of building additional infrastructure and
purchasing up-to-date equipment,
the Cuban government’s attitude
toward opening the economy to
foreign business and influence, and
retaining medical talent. These
challenges are especially daunting
when considering the fact that
Cuban healthcare has long been
universal and free to every citizen,
and that the government’s main goal is to maintain this policy. However, these trends also
provide opportunities for the system to improve, pinpointing the issues that will demand the most
attention in the coming years.
While the expected future is based on the extrapolation of current trends and expert
opinions, many uncertainties remain and have great potential to affect the direction of the Cuban
healthcare system. These uncertainties include the future political climate in both Cuba and the
United States, the financial future of Cuba in terms of the state of the economy as well as the
amount of government expenditure on healthcare, and the reliability of statistics coming out of
Cuba. These uncertainties provide the foundation for four alternative scenarios, which are
expanded upon later. In all scenarios, foreign relations with the United States and the level of
domestic action taken by the Cuban government impact physicians, infrastructure improvements,
and potential trade opportunities with the United States.

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Abstract
The purpose of this report is to explore the future of the Cuban healthcare system as it
relates to relevant trends and factors of change. This future will be determined first by analyzing
qualitative data along with expert testimony and then by extrapolating this data. The results of
this process have suggested that the likely scenario involves a greater demand for high quality
healthcare in Cuba while still maintaining the concept of free, universal healthcare for all
citizens. This increase in demand is due to a large aging population, increasing exports, and
decreasing healthcare expenditures. Additionally, medical facilities will need to undergo major
improvements in order to properly meet this demand. Equipment in these facilities also needs to
be updated, and doctors must be offered higher salaries as an incentive to stay and practice in
Cuba.
Introduction
Cuba is the most populous country in the Caribbean and has been moving toward a more
open economy, breaking away from its historically socialist closed-door policies. Since Cuba is
largely a developing country, and its population continues to grow, the future of its healthcare
system will be a major question in the next few years. This becomes very interesting as the
political environment continues to evolve in Cuba, especially as the country begins to open up to
the rest of the global economy, including the private sector. The scope of this project focuses on
the Cuban healthcare system as a whole, rather than specific sectors. When mapping the
overarching system in which Cuban healthcare lies, healthcare in developing countries acts as the
operating environment boundary, and the healthcare sector acts as the macro-environment
boundary.

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An assessment of the past and current state of the Cuban healthcare system is necessary
to project trends that will shape its future. The major stakeholders in Cuban healthcare will be
highlighted, as well as the drivers and constraints of change. The forecasts and future scenarios
formed through analysis of past and current trends will cover the next twenty years in order to
allow adequate political change. Finally, future business implications of these future scenarios
will be presented and examined.
Background
Following the Cuban Revolution in 1959, Cuba had similar health statistics to that of
third-world countries, leading the newly established Cuban government to announce that
universal healthcare would be a priority of the state. This initiated a mass exodus of nearly half
the nation’s physicians to the
United States in search of higher
salaries, leaving behind only
3,000 doctors to serve the nearly
six million citizens (World
Bank). The Ministry of Public
Health was established soon
after in 1960, and set out to
essentially build the nation’s healthcare system. The first goal was to alleviate health concerns in
areas previously deprived of care, and to achieve this there were teams of doctors sent out to
remote villages. Rural health centers were constructed with a focus on improving child health,
maternal care, and control of infectious diseases. These health centers, known as polyclinics,

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became the basic healthcare unit for the Cuban system, offering a broad range of medicines and
preventative treatments.
In the early 1980s, the Cuban government implemented a system of community-oriented
care that continues today, in which family doctors live in the community that they serve and
offer personalized medical care. If a patient required care beyond the capabilities or resources of
this family doctor, they would be referred to a specialized polyclinic or hospital. Therefore,
hospitals in Cuba play a different role in the system than American hospitals in that they are not
the main avenues through which care is received. Instead, they are utilized only in emergency
situations or if a patient’s condition is severe. The government has also instituted a program in
which they send Cuban doctors to nearby countries in need of doctors in exchange for a fee.
These doctors are often put to work in remote and desolate locations, and normally do not see
more than a third of the money paid for their services; the remainder goes to the Cuban
government.
Current Assessment
Today, Cuban citizens continue to receive the bulk of their care from the local family
doctor. As the population has expanded, the number of family doctors has risen. Currently there
are approximately 6 doctors per 1,000 people in Cuba as a result of this trend, up from about 5 in
1995 (Rogers). However, this number may be misleading if it includes the number of Cuban
doctors that are sent to work abroad instead of counting only the doctors that remain in the
country. In addition, family doctors are not equipped with adequate technologies or medicines to
deal with major emergencies, forcing patients to travel to faraway hospitals that still may not be
able to give them the treatment they need if they have obsolete equipment.

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Cuban healthcare facilities do not have much access to the basic technology seen in
similar American hospitals and clinics. Until
recently, Cuban hospitals did not have MRI
machines, and clinics did not have ultrasound
equipment. Currently, Cuba only spends about
$320 per year per person on healthcare,
compared to about $8,500 in the United Stated.
The majority of this is invested heavily in
biotechnology, especially pharmaceuticals (Cooper). As a result, the healthcare facilities in Cuba
are not as effective as they could be because they lack standard medical equipment and, in some
cases, are starting to deteriorate.
Many polyclinics are old and are becoming structurally unsound, and most are simply not
big enough to accommodate the growing population. Implementing new technology into
hospitals and clinics and making basic infrastructure improvements would allow patients to
receive higher quality of care, as well as faster diagnoses.
While not a major problem, the availability of clean water has the potential to impact the
healthcare system. According to The World Bank, 86% of Cuba’s population has access to an
improved water source. Comparatively 94% of Americans have access to clean water. The
reason for Cuba’s lower statistic is likely due to lack of availability of clean water in more rural
areas. Because clean water is necessary for basic sanitation and overall health, it has the potential
to affect the healthcare system. If someone doesn’t have access to clean water they are more
susceptible to diseases, which can also affect others in the community. While Cuba’s water

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availability has been increasing at a steady rate for over a decade, the government should look to
continue to improve it as they strive to become a fully developed country.
Cuba is also lacking “the most basic infrastructure requirement for progress in public
health”: a surveillance system that generates accurate data (Cooper). Measuring Cuban mortality
statistics against other Caribbean countries, it is apparent that the number of reported deaths in
Cuba is extremely low in comparison with their expected values. There is some controversy
around this as many skeptics suspect that the Cuban government is not being completely truthful
about their statistics. This is an attempt to make the country appear more stable and therefore
make the government itself appear more effective. However, this discrepancy could also be due
to flaws in the system. For example, 99% of infant deaths occurring in hospitals are reported on
the day of occurrence, while only 30% of infant deaths in the rural areas are reported on the same
day. If Cuba had more hospitals and other healthcare clinics, then mortality rates would likely be
reported much faster and more accurately.
Though the current state of Cuba’s healthcare system is in a slow decline, and the issues
involved with Cuba’s statistics, it is important to rely on relevant experts. These experts help
clarify what the current and future state of Cuba’s healthcare system is and what are possible
business implications to the system.
Relevant Experts
There are several relevant experts to refer to on the subject of the Cuban healthcare
system. One such expert is Melissa Rose Mitchell, MD, who has been very active in many
humanitarian causes and considers healthcare to be a social justice issue. She has also studied at
the Latin American College of Medicine. Another expert is Marcus Lorenzo Penn, MD. Penn has
visited Cuba twice with Medical Education Cooperation with Cuba. Penn is also the coordinator

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Melissa Rose Mitchell, MD
Dr. Cesar Chelala
of outreach through the Helen Diller Family Comprehensive Cancer
Center’s Department of Radiation Oncology. When Penn visited Cuba he
witnessed how their unique universal free health coverage teaches
citizens about healthy lifestyles and encourages them to understand the
importance of being healthy. From their experiences, Penn and Mitchell
both developed a greater understanding of how a medical system that is
run by the state can support and provide better public healthcare.
Dr. Cesar Chelala, a New York based physician, is another expert who is a global health
consultant and is also a contributing editor for The Globalist. Along with his contributions to The
Globalist, he has conducted health-related missions in over 45 countries
for several major organizations, including UNICEF and the WHO. In the
case of Cuba he suggests a dialog with the U.S. be conducted by a
commission of reputable medical professionals to evaluate the island’s
abilities to offer healthcare and negotiate the impartial channeling of
required goods and services to a people in need (Chelala). Though his
viewpoint and recommendations have been accepted by some, his ideas have been criticized by
some, including Dr. G Martin, and his colleague, Dr. Enrique Huertas. Dr. Martin is a practicing
physician in Kansas City, while Dr. Enrique Huertas is a prominent member of the Cuban
Medical Association in Exile (Chelala).
While these experts can be looked to for a more in-depth analysis of the Cuban healthcare
system, there is a general lack of experts on the subject due to the strictly closed nature of Cuba
itself. The government is very wary about letting foreigners in, as it prefers to keep intimate
details about the country and its systems hidden from the global public eye. Therefore, while

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experts on Cuban healthcare do exist, it is likely they have only been exposed to certain aspects
of the system, and may not have a total comprehensive view of the reality.
Additionally, again due to the secretive nature of the Cuban government, all statistics on
the current situation of Cuba as well as any future statistics coming out of Cuba should used with
some caution. There is evidence suggesting that Cuba inflates certain statistics in order to
maintain its image (Cooper). While experts help to generate more realistic and correct figures, it
is impossible to know the exact healthcare statistics as they pertain to Cuba.
Stakeholders
The future of healthcare in Cuba has important implications that affect a variety of people
and organizations. The following stakeholders have been identified based on their interest and
influence, and the focus of the project is largely those who have both high interest and high
influence. However, stakeholders in the position of high interest and low influence will also be
considered.
The stakeholder with arguably the most impact is the Cuban government. Because Cuba
is still a socialist country, the government has total control over all aspects of healthcare,
including physician salaries, the quality of medical facilities, and the equipment in these
facilities. The government also controls the degree to which foreign organizations such as for-
profit businesses are allowed into the country. Historically, the Cuban government has
implemented a strict closed-door policy. Cuba is still wary of letting foreign businesses into the
country, but recently they have opened up to NGOs, or non-government organizations, implying
that they may be more lenient with for-profit businesses in the future. While the government
regulates the healthcare system, it is also influenced by it in return. Healthier citizens make for a
more productive and efficient economy, which is especially crucial in a socialist country that

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depends on the effort of its citizens to produce goods and services for the population. Because of
the currently high level of control the government has over the healthcare system in Cuba, they
are considered to be the stakeholder with both the highest influence and the highest interest.
Another important group of stakeholders in healthcare are the private interests,
particularly pharmaceutical companies. While they do not have nearly as much influence as the
government, they have a very high level of interest because the healthcare system is a major
driver of their profit. Because Cuba tends to shy away from foreign imports, they are forced to
manufacture their own medications. Therefore, as the bulk of the Cuban population continues to
age, pharmaceutical companies will likely see sharp increases in demand for their products.
These private interests also influence the system based on how much they choose to charge
either for medical care or medications. Charging higher prices for necessary medications may
force people that need them to forgo the purchase, and as a result become sicker and put a
heavier burden on the system.
The citizens of Cuba themselves have a very high level of interest in the future of the
Cuban healthcare system, but they have much less influence. Universal healthcare has been a
priority of the state since the early 1960s, and the
Cuban population has come to view it as a birthright.
However, because Cuba is a socialist country the
citizens are completely dependent on the government
for the quality of healthcare they receive. As costs for
the government rise in coordination with a rising
population, the quality of this care is jeopardized. Ultimately, this impacts the Cuban citizens
themselves, and therefore they have a great interest in the future of this system. Additionally,

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parts of the rural population of Cuba still struggle with access to clean water, which could have a
negative health impact if the problem is not addressed. While the government is very dominant
in its control over the healthcare system in Cuba, the citizens themselves do have a chance to
have some influence. As already mentioned, the state depends on the work of its population in
order to function, and if these people are not healthy then the state is at risk. In this way, the
general population does have influence on the future of the system.
Doctors and Cuban medical students are stakeholders at the same level of influence and a
slightly higher level of interest as normal citizens. This group cares a great deal about the
healthcare industry because it will shape their own livelihoods, designating them a higher interest
level than a typical citizen. Because most doctors in Cuba live in the communities they serve,
they develop an even stronger personal interest in public health, and with it a “strong sense of
humanitarianism,” according to expert Marcus Lorenzo, who has witnessed this personally in
trips to Cuba. Doctors are also very concerned about their ability to make money and pay off
possible medical school debts. Therefore, if the salaries in Cuba are not high enough, they will
not hesitate to leave. Currently there is a program in which the Cuban government pays for
medical school in exchange for the student to remain in Cuba after graduation and work in an
underserved community, but this incentive is still not enough. In 2013 alone, 29,712 people
graduated from Cuban medical schools but because of the low salaries available to doctors
within Cuba, most doctors leave (Delgado Legòn). Because doctors are such a major component
of the healthcare system, they are likely to have some influence on its future. If doctors continue
to be unsatisfied with their compensation and they leave the country as a result, this will
negatively impact the entire system.

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Other countries, especially developing countries, have a fair level of interest but little
influence on the Cuban healthcare system. The system is a model for developing countries
because they have effectively lowered infant mortality rates and raised life expectancy to the
levels of developed countries while having the economy of a developing country. Developing
countries like those in Africa and the Middle East can look to Cuba as an example and
implement policies that fit the unique conditions they face individually. This model for universal
healthcare can also apply to developed countries, like the United States, who are still looking to
improve upon their own systems. Additionally, outside countries may have newly discovered
business interests in Cuba if the government decides to open the country to foreign trade.
However, these countries currently have very little impact on the Cuban healthcare system
because of the high-level government control in regards to outside influences.
Current Trends
In order to project the future of the Cuban healthcare system, significant trends are
identified as drivers or constraints of change and then extrapolated using past data.
Aging, Educated Population
Cuba, much like the rest of the world, is dealing with an aging population. In 1997 13.1%
of the population was over the age of 60,
and this number is expected to rise to
24% of the population in 2025 (Cuban
National Statistics Office). This aging
market will place a heavy burden on the
healthcare system due to their increased
needs for medication and higher
Figure 1: Cuban Population Distribution by Age

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frequency of doctor visits that come with old age. This increase in demand for healthcare will
likely be amplified because 35% of adults in Cuba smoke and 69% of adults suffer from
hypertension; these rates are almost double those of the U.S. (National Statistics Office, Fast
Facts). However, the Cuban population is growing at much slower rates than other developing
countries, due largely in part to widespread sex education. The Cuban contraceptive prevalence
rate is 74.3%, compared to the world average rate of 63% (Central Intelligence Agency,
Contraceptive Prevalence Rate). Higher levels of sex education allow for fewer unnecessary
births, and this makes for a smaller burden on the nation’s healthcare system. In contrast,
developing countries in Africa with lower levels of sex education typically have more problems
with their systems simply due to the volume of people. More people with the same amount of
doctors puts a much larger strain on the system, leading to lower quality care. The population is
still growing very quickly, and therefore demographic changes will be a driver of change in the
healthcare system.
A metric that can be used to project the trend of the aging population is the age
dependency ratio, a measure of the number of people from age 0 to 14 and 65 or older divided by
the number of
people from 15
to 64. These
numbers
generally
signify the ratio
of people in the
labor force and
Figure 2
Source: Index Mundi

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those who are not, usually young children and the elderly. Therefore, there is pressure on the
labor force to provide for those who do not work. A high ratio means that those working face a
greater burden trying to support children and the elderly, and vice versa. From 1960 through
1970 Cuba faced a “baby boom” in which the average woman had 4.5 children, an increase from
about two children in the years prior. This baby boom was largely due to the higher quality living
conditions of this time as well as widespread optimism about the future. After the 70’s, women
on average had less than two children, a trend that has continued into the present. As Figure 1
shows, the baby boomers are now in and around their forties, and they will cause problems in the
age dependency ratio when they retire. Figure 2 depicts the likely increase in the age dependency
ratio that will result from the aging of the baby boomers. This problem will likely be amplified
by the smaller generation that will follow, as they will be charged with the task of supporting the
baby boomers once they reach the labor force. This support will include providing adequate
healthcare, placing a major strain on the entire system.
Physicians
The growing population makes the number of physicians in Cuba a major driver of
change for the
future of the
country’s
healthcare
system because
more doctors
will be needed
to serve more
Source: Index Mundi
Figure 3

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people. In order to keep the number of doctors in check with the rising population, the Cuban
government offers incentives for them to stay in Cuba. Cuban physicians receive government
benefits such as housing and food subsidies, and the government also offers to cover medical
school costs (Campion). Cuba currently has about 6 physicians per 1,000 people, compared to
the 1.76 physicians per 1,000 in Cuba’s major trade partner, Brazil, and 2.42 per 1,000 in the
United States (Central Intelligence Agency). While these statistics may look promising, it is very
possible this number includes the number of Cuban doctors who are sent to work abroad, instead
of only including the doctors who live and work in Cuba. Therefore, the true number of
physicians in Cuba could be much lower depending on how the statistic was calculated.
While recent data shows that the number of physicians has increased in the past decade,
there are concerns that this number may plateau or even decrease. This concern is mostly due to
the currently low physician salary, which is causing many doctors to leave the country in search
of higher compensation (Central Intelligence Agency). Doctors in Cuba only make about $240
per year, compared to the average $191,520 doctors in the U.S. are paid (Campion, and
Physician: Salary). Mechanics and waiters can earn more than a Cuban doctor practicing in
Cuba. This could also potentially dissuade other Cubans from pursuing a medical career, leading
to a further decrease in the number of physicians. A lack of qualified medical professionals
would mean that Cubans would be unable to receive the care they need, causing the general
health of the population to suffer as well as the entire system to suffer. Therefore, the number of
physicians is considered a constraint of change in the Cuban healthcare system.
Healthcare Expenditure
Healthcare expenditures are also an important trend to analyze in order to determine the
future of the Cuban healthcare system. As a Cuban, free healthcare is essentially considered a

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birthright, but maintaining the system is difficult as the population continues to grow. As Figure
3 shows, healthcare expenditures began to fall in 2009, 2010, and 2011. According to Cuban
officials, this is a result of the government’s attempt to increase efficiency within the system.
The government closed more than 54 hospitals and more than 400 clinics in 2011 in order to cut
costs (Cuba Trims Healthcare Par.2). In an attempt to keep universal healthcare a reality, the
Cuban government is cutting costs, but ones that are extremely vital to the whole system itself.
After analyzing past data, healthcare expenditure is projected to decrease, as depicted in
Figure 3. This is largely due to the Cuban government’s attempts to cut costs in order to preserve
the concept of universal
healthcare. Unfortunately,
this current policy of
spending contraction has a
negative impact on the
healthcare system.
According to patients,
costs are being cut in the
most basic areas; patients
have to bring their own
food, water, bed sheets, and fans to hospitals/clinics (Barghi Par. 8). Basic things such as medical
equipment and soap are scarce in hospitals. Even the hospitals themselves are in bad condition,
as many are beginning to decay. Decreased spending has also affected physician salaries because
the government is responsible for paying doctors. Doctors are receiving lower salaries and many
are leaving in search of better compensation, causing lines at hospitals and clinics are getting
Source: World Data Bank
Figure 4

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Source: Trading Economics
Figure 5
longer due to smaller staffs. The Cuban government wants to continue to offer free, universal
healthcare, but these costs are quickly beginning to add up, and this balance will become harder
to maintain as time goes on. Whatever changes are ultimately made, Cuba must ensure that these
improvements are realistic and affordable, in that they meet the needs of the people without
crippling the government’s ability to spend money elsewhere.
Exports
Cuba’s exports serve as an indicator of where Cuban healthcare is likely to go, as they
can help determine the state of the economy as well as gauge possible government leniency on
allowing foreign imports. As depicted in Figure 4, Cuba has experienced a large increase in
exports in recent years, and this number will likely continue to rise. Cuba’s top export is hired-
out professional services, with medical services making up the majority. Cuba sends doctors to
countries in need to help in underserved areas in exchange for a fee. These doctors are often sent
to remote locations
and are forced to
work in very harsh
conditions. The
doctors only see a
fraction of this
money while the
Cuban government
pockets the rest. Figures on physician salaries while abroad are uncertain, but the fact that no
data is available demonstrates that the Cuban government may be taking advantage of these
doctors. Cuba earns over $6 billion a year from this practice, and there are currently around

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40,000 Cuban doctors working in over 66 countries around the world, of which 40 receive these
services for free (Cuba Nets Billions Each Year Par. 3). According to Bloomberg Business
Week, Cuba’s government forecasted that it will earn around $8.2 billion from sending nurses
and doctors abroad (Cuba Forecasts $8.2 Billion Par.1). Because it is such a lucrative practice,
Cuba wants to increase the number of doctors exported, and both for profit and for free to
countries in need. Exporting to these non-paying countries will mean lower salaries for
physicians, which could have problematic effects.
A major consequence of this practice is that fewer and fewer doctors will want to work in
Cuba due to fear of being sent abroad to work in poor conditions or to avoid a lower salary than
they can get elsewhere. Additionally, the doctors who do stay will most likely be less skilled than
the doctors that are sent abroad because the more talented doctors will be the ones with the
highest earning potential. Cuban healthcare will continue to struggle due to this program, but it
seems to be a priority for the Cuban government due to the high amount of revenue it returns.
Cuba also has strong pharmaceutical and biotechnology industries that contribute
significantly to the exports. Because of the trade embargo with the U.S., medications cannot be
imported from American pharmaceutical companies. As a result, Cuban pharmaceutical
companies develop and produce medications for both domestic use and international trade.
Historically Cuba has had a strong focus on biotechnology, investing at least $1 billion in the
industry over the past 15 years (Carr Par.4). As a result of this investment, the entire sector is
expected to double in the next five years, adding over $5 billion in export revenues (Central
Intelligence Agency). This significant portion of the economy devoted to the medical industry
has the potential to affect the entire healthcare system. As this sector of the economy expands,
medications will become more widely available due to lower prices. This will, in turn, increase

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Cuban exports as other countries look to take advantage of these advancements, and will
ultimately drive the healthcare system as a whole.
Key Challenges
Attempts at improving the current healthcare system in Cuba will be met with several
challenges, one being the high cost of building and improving upon existing medical facilities
and equipping them with the necessary equipment. Most hospitals and clinics are deteriorating,
they lack the most fundamental medical equipment and medicines, and they are in desperate
need of updating (Scheye). Until recently, these facilities did not even have MRI machines,
equipment considered standard in any American hospital, resulting in a lower quality of care for
patients. Since Cuba is a socialist country, the government has complete control over the
healthcare system and the funding it receives. However, the government is also responsible for
providing free healthcare to every Cuban citizen, the cost for which continues to rise as the
population grows. The challenge will be ensuring that Cuban citizens still receive high-quality
care while allowing the government the flexibility to allocate funds to other areas, such as
national defense.
Another factor that may prove problematic is the Cuban government’s attitude toward
foreign imports. In order for Cuba to gain access to the updated medical technology its hospitals
need, foreign trade is necessary. An open-door trade policy could also benefit the healthcare
system by allowing construction companies to offer cheap solutions to the infrastructure
problems mentioned above. Additionally, allowing goods to flow freely between Cuba and
outside countries will improve the country’s overall economy, which would then enable the
Cuban government to spend more money on healthcare. However, if the Cuban government

24. 24
remains strict on the subject of foreign imports, improvement of the healthcare system could be
difficult.
A final challenge that may be encountered is the drain of medical talent to other
countries. Since Cuban doctors earn significantly less in Cuba than they could in other countries,
they have very little incentive to remain in the country. If too many physicians decide to leave,
this will create a shortage of doctors and put a major strain on the entire healthcare system. The
Cuban government is responsible for paying these doctors, and if they are not offered
competitive wages the entire healthcare system could be affected.
Baseline Forecast
Cuba has been praised for having the health statistics of a developed country while
having the economy of a developing country, an achievement made possible through universal
healthcare. For example, the reported life expectancy in Cuba is 76-80 years, similar to that of
the U.S. Additionally, the probability of dying under the age of five is .6% in Cuba compared to
.7% in the United States (WHO). However, given the current trends in the population, healthcare
expenditures, number of physicians, and exports, the healthcare system is likely to change in the
future.
The aging population will be the most important driver of change within the healthcare
system. The majority of the population is made up of middle-aged adults, who will put a strain
on the system as they continue to age and demand more healthcare. Potential issues will arise if
healthcare expenditures continue to level off, resulting in decreased quality of care for the sake
of decreased costs to the government. This in turn may affect the number of physicians in Cuba,
who are dependent on the government for their salaries. If they feel they are not being paid
enough, doctors will leave the country in search of better compensation, further compromising

25. 25
Good Foreign Relations with U.S.
Bad Foreign Relations with U.S.
Domestic ActionLack of Domestic Action
the quality of Cuban healthcare. Future leadership will also have an extraordinary impact on the
future of the Cuban healthcare system. Raul Castro’s announcement to leave power in 2018 has
created the possibility for political change in Cuba, including opening up the country to foreign
imports. This potential shift in power could have a considerable impact on the future of the
healthcare system, but without it, major changes in the system are unlikely.
Expected Future – Preservation
There are several different possible futures that could occur based on the relations with
the U.S. and the level of domestic actions. The future scenarios are illustrated on both a micro
and macro level by the following fictional account of a seven-year-old Cuban boy named Luis.
One morning, Luis, a seven-year-old boy who lives in a small village in Cuba, gets
kicked hard in the shin while playing soccer with his friends. After his mother inspects the
injury, she decides a doctor’s opinion is needed to determine if his leg is broken. She phones the
local family doctor, Dr. Hernandez. Dr. Hernandez comes to Luis’s home to do some basic
International
Focus
All-Inclusive
Focus
Non-
Inclusive
Focus
Home Focus
Preservation

26. 26
medical tests, examining Luis using the very little equipment he has. Dr. Hernandez ultimately
diagnoses him with a bone contusion, but he wishes he could have done more extensive tests to
make sure that the bone is not broken, possibly with an X-ray machine. Unfortunately, Dr.
Hernandez does not have access to such technology, and the local hospital has run so low on film
necessary to run the X-ray machine that they are reserving the film for more crucial and life
threatening cases. Luis is instructed to take it easy for the next few days, and the doctor believes
the contusion will heal itself within the next few weeks.
The expected future of the healthcare system involves very little change from the current
circumstances. Family doctors will continue to be heavily relied upon for the majority of medical
issues, and patients will only resort to
visiting a hospital if the injury or illness
is severe. Hospitals and clinics will
remain outdated and the medical
technology inside will become
increasingly obsolete. There will not be
enough qualified doctors to meet the
demand of the population because most
doctors that choose to stay in Cuba are sent off to work in other countries, a continuing source of
revenue for the government. The embargo with the United States remains, although there have
been recent talks between the countries of reaching a trade agreement. Until that time, the Cuban
government continues to restrict foreign businesses from operating within Cuba.

27. 27
Signposts
There are a variety of potential signposts that are associated with the expected future
scenario. A continued increase or no change in the number of Cuban doctors leaving the country
to work elsewhere could indicate that the Cuban government has refused to increase healthcare
expenditures and that working conditions for doctors are not improving. As a result, the quality
Cuban healthcare is likely not improving or possibly worsening due to a shortage of qualified
doctors. Additionally, the continuance of the trade embargo with the United States accompanied
with strong political leaders of both countries publicly stating a refusal to work with the other
would be another strong indicator that Cuban healthcare is not improving. If one or both of these
signposts are observed, there will be sufficient evidence to suggest the expected scenario is
occurring.
These are the some major signposts to look out for but this is not an all-inclusive list.
Entrepreneurs should be aware of any other signposts closely related to these that indicate
worsening international relations or decreasing domestic action, as these are also signs that the
expected future may be occurring.
Alternative Scenarios
When looking at alternative scenarios there are a couple other possibilities for how the
Cuban healthcare system would treat Luis.

28. 28
All-Inclusive Focus
Luis’ mother takes him to one of the many
hospitals that serve the area, hopeful because this
hospital just received some new medical
equipment from the United States. In the hospital,
they have no problem finding a doctor to consult,
who diagnoses a bad bruise with the help of the
new X-ray machine.
Cuba’s relations with the United States are the best they have been since before the Cold
War. While Cuba still has marked characteristics of a socialist economy, such as the lack of
private doctors and hospitals, the two governments have lifted the long-lived trade embargo and
• Doctors stay in Cuba, are paid more
• More infrastructure
• Accurate medical statistics (no embargo)
• Perfect relations with U.S.
All-In Focus
• Doctors stay in Cuba, are paid more
• More infrastructure, but could be expanded further
• More clinics
• U.S. embargo still in effect (relations still strained)
Home Focus
• Lack of doctors due to inadequate salaries
• Lack of infrastructure
• Better medical technology, accurate medical statistics
• Perfect relations with U.S. (no embargo)
International
Focus
• Lack of doctors due to inadequate salaries
• Very little infrastructure
• Limited medical technology
• U.S. embargo still in effect (relations are strained)
Non-Inclusive
Focus

29. 29
allowed goods to flow freely between the two countries. This attracts entrepreneurs of all kinds,
both native Cubans and Americans, looking for new niches and markets to explore within Cuba.
This economic freedom allows more advanced medical technologies, including
equipment and medicine itself, to be easily implemented in Cuba. Additionally, more and more
doctors are remaining in Cuba to practice after
they graduate medical school due to the higher
salaries now available to them. New hospitals
and clinics are built in order to best serve the
health-related demands of the growing
population, and clean water is available to
every Cuban citizen. These factors will enable
medical professionals to give better treatment
to their patients, and thus result in a healthier population overall. The Cuban government is also
now willing to report accurate medical statistics.
Signposts
There are several potential signposts associated with this alternative scenario. First, if
political candidates begin to place an emphasis on improved relations between Cuba and the
United States, this would be a strong indication of a collaborative future between the two
countries, especially if these candidates are elected demonstrating the public’s desire to repair
relations with Cuba. Also, if reports start to surface of the United States’ desire to lift the
embargo at any time in the near future, this can prove to be another strong indication of
improving relations. Additionally, it is crucial for this scenario to come to fruition to see
increasing domestic action in the healthcare sector. One of the major signposts associated with

30. 30
increased domestic action is a lower defection rate of Cuban doctors. Less doctors leaving could
be signs of higher salaries and improved working conditions, which are indicators that the Cuban
government is taking more domestic action.
Home Focus
Luis still has options available to him in terms of getting the care that he needs, but he
has to travel a bit farther because the nearest full-service hospital is a few more miles from the
local clinic that serves his village’s minor needs. The hospital does have a full staff of doctors
and the equipment necessary to make a complete diagnosis, which is the reason he and his
mother are willing to travel.
Doctors that have been educated in Cuba’s exceptional medical schools are willing and
motivated to stay in Cuba for their careers, as their salaries now compete with those of other
countries like the United States. Treatment
of injuries and illnesses are improved due to
this fact, as well as the increased number of
formal hospitals within Cuba. This new
infrastructure is an important step to
providing the best possible healthcare to its
citizens, but the Cuban government still has areas in need of such improvements. The health of
the rural population has also gotten better as clean water has become available to almost
everyone. Relations with the United States are still strained, and there are no signs of any open-
mindedness by either nation.

31. 31
Signposts
There are many potential signposts associated with this alternative scenario. If political
candidates start to focus on and discuss improving relations between Cuba and the United States,
this would be a strong indication of a much better future between the two countries. If the
potential candidates were elected, this would indicate that the public has a strong desire and
realized the importance of repairing relations with Cuba. If reports are brought up about the
United States’ aspiration to lift the embargo in the near future, this could potentially prove to be
another strong indicator of improving relations. If more people are healthy and the number of
people going to the hospital decreases. This can be an indication that the scenario is occurring. If
less doctors are leaving could and staying to work in Cuba, this could be a result of higher
salaries and improved working conditions which are both indicators that the Cuban government
allocating more money towards their healthcare.
International Focus
Luis’s mother takes him to the local clinic to get his leg treated. Although the clinic does
not have a full staff of doctors, the medical technology brought in from America helps to
alleviate this and returns a proper diagnosis of a bad bruise instead of a fracture.
Relations between the United States and Cuba are very strong: the trade embargo of
previous years has been lifted, allowing goods such
as the medical technology mentioned above to reach
Cuban citizens in need. Cubans and Americans alike
are able to start their own businesses in Cuba as the
government permits more and more private
entrepreneurship. In tune with a more open economy,

32. 32
the Cuban government begins to release more accurate statistics reflecting the state of the entire
population, not just the subsets that paint the overall health of the population in the best light.
The country is still lacking in medical infrastructure though, particularly hospitals. While
there are local family doctors that can tend to basic injuries and illnesses, hospitals are needed to
better serve all the needs of the population. Doctors are still paid much less in Cuba than in the
U.S., and therefore most of them leave the country after completing medical school. The ones
that do stay are commissioned by the government to work in other countries. These doctors often
work in remote locations in these countries and typically only see a third of the total pay they
earn, while the rest goes to the Cuban government.
Signposts
There are several potential signposts associated with this alternative scenario. If political
candidates begin to focus on improving the relationship between Cuba and the United States, this
would be a strong indication of a strong future between the two countries. If these candidates
were elected this would clearly demonstrate that the public has a strong desire to repair relations
with Cuba. If the United States’ desire to lift the embargo at any time in the near future starts to
be discussed, this could potentially prove to be another strong indication of improving relations
between the two countries. An increase in both Cuban and American doctor’s starting their own
practice in Cuba would also be an important indicator of a more open economy. More advanced
medical equipment in hospitals may also be a sign that the relations between the two countries
has improved and that the United States is helping Cuba improve their medical equipment.

33. 33
Non-Inclusive Focus
Luis has very few options for tending to his injured leg. His mother finds one of the local
doctors who is currently working at one of the few area clinics, knowing full well that there will
likely be very outdated (if any) medical technology to aid in a diagnosis.
There is a general lack of doctors as well as infrastructure. Any doctors that stay in Cuba
to work are paid dismal salaries for
their work, resulting in a major
brain drain to other countries
offering higher pay. There are very
few clinics, and even fewer actual
hospitals within the country,
severely limiting the options for
care for Cuban citizens.
Additionally, clean water has become even scarcer in rural communities, resulting in
more health problems in these areas. Relations with United States are still tense, as the trade
embargo between the countries continues due to inability of both countries to reach a
compromise. Goods are unable to pass between countries, especially important medical
technology that is crucial for the Cuban population. Success in private entrepreneurship in Cuba
is very rare due to tight government control.
Signposts
There are many potential signposts that indicate that this scenario is occurring. Cuba is
usually very secretive and strives to maintain a strong image for its government; any reports
leaking through the media of worsening conditions or declining medical schools would be a

34. 34
major indicator that this scenario is occurring. If one or both of these signposts are observed,
there will be sufficient evidence to suggest the scenario may be occurring. If people are
beginning to get sick do to a lack of clean water, quality infrastructure, and medical equipment,
this indicates that Cuban healthcare is progressively getting worse.
Uncertainties
One of the most critical uncertainties faced by the healthcare system is the future political
climate both in Cuba and the U.S. Projecting trends
twenty years into the future should allow ample time for
the current Cuban president Raúl Castro to vacate his
position. Because the Cuban government controls all
aspects of the healthcare system, the leaders at the helm
of this government will essentially determine the future
of this system. In recent years, Cuba’s government has been moving away from the traditional
hardline socialist approach, allowing NGOs into the country. However, there is no guarantee as
to what types of policies Castro’s successor will implement; he may continue to tentatively
explore open trade and increase healthcare expenditure, or he may revert back to the traditional
closed-door policies of the past. While the Cuban government is one of the most important
factors to consider in determining the future of the healthcare system, there is a large degree of
uncertainty associated with it.
The future of the political landscape in the U.S. also remains in doubt. While the U.S. is
currently led by President Barack Obama, a Democrat, there is no way of knowing which party
will be in the White House in twenty years’ time. Determining how dedicated the U.S. will be in
attempting to repair its relationship with Cuba will depend largely at the leadership of the time.

35. 35
Currently, a trade embargo between Cuba and the U.S. is in effect; however, Hillary Clinton, the
former U.S. Secretary of State, recently suggested that the U.S. is “open to changing with
[Cuba]” and ending the embargo. If the embargo were to be lifted, this would open up
tremendous opportunities for U.S. businesses in Cuba, especially within the healthcare sector.
Unfortunately, political climates are constantly changing and are nearly impossible to predict.
Therefore, these conditions will be a major uncertainty moving forward.
Another significant uncertainty is the financial future of Cuba. With these potentially
changing political conditions, Cuba could see a dramatic change in GDP if the embargo is lifted,
likely experiencing significant growth as increased exports and imports allow more healthcare
spending. Cuba is also typically rather secretive about its government spending, and the
information that is available is subject to much speculation. This is a problem because there is no
guarantee as to historically what percentage of Cuba’s GDP has been spent on healthcare,
making it difficult to project future spending. Given current circumstances, there is no assurance
as to if Cuba will have the means or the willingness to commit to this type of spending.
As mentioned above, a final uncertainty is the lack of reliable statistics coming out of
Cuba. The current situation in Cuba is not completely transparent because many of the statistics
may be inaccurate. This makes measuring improvement going forward very difficult. Many
observers are skeptical, stating that “the number of deaths attributed to ill-defined causes is very
low (0.7%), an important indicator of incomplete or inaccurate vital statistics” (Cooper). Many
medical experts believe that Cuba is inflating statistics such as the country's mortality rates as
well as life expectancy rates. There is also evidence to suggest that doctors are forced to abort
babies in problem pregnancies before the 21-week mark, at which the child would be counted
towards the mortality rate. Unfortunately, issues like these make it impossible to know the exact

36. 36
conditions in Cuba. Personal testimonies from Cuban physicians and experts who have visited
Cuba indicate that the situation is worse than the public statistics dictate, but it is impossible to
know exactly how much worse. This uncertainty makes accurately determining the future of the
healthcare system very difficult. Therefore, the projections made are based on published
statistics, with the realization that these statistics may very well be misleading.
Business Implications
After examining the current state of the Cuban healthcare system, associated trends, and
determining expected and preferred futures along with alternative scenarios, there are several
significant business implications that emerge from the Cuban healthcare system. Given the fact
that the government still has extensive control over entrepreneurship opportunities in Cuba, all
business implications will likely involve some type of negotiation with the Cuban government.
Currently one of the most crippling aspects of the Cuban healthcare system is the lack of
adequate infrastructure, such as hospitals and clinics. If domestic action improves in Cuba and a
greater emphasis is placed on developing adequate infrastructure, we can expect to see some
business opportunities for several different companies. For example, construction companies that
can negotiate with the Cuban government and offer them fair and low prices for such
developments have some major opportunities in this area. These opportunities could be even
more extensive if such companies can offer sustainable infrastructure at lower costs, which will
ultimately lower the cost of maintaining these buildings in the long run. As the Cuban population
grows, providing necessary health-related infrastructure will be essential to maintaining a healthy
working population and, as a consequence, a properly functioning and efficient economy. As
stated above, these opportunities are most likely to occur with improved domestic action in
Cuba. Therefore, these business implications only exist within our All-Inclusive Focus and
Home Focus scenarios.

37. 37
Cuba will also likely experience a need for more advanced medical technology, including
equipment and medicine. The research and development costs associated with this technology
are too great for Cuba to develop it on its own. Instead, in order for Cuba to make medical
advancements with new technology, there will need to be a greater domestic emphasis on
spending on these technologies as well as improved government relations with the United States
and repeal of the trade embargo so that Cuba may purchase these technologies from a country
that has already developed them. If this occurs, substantial opportunities will exist for companies
that are able to supply them to those in need, especially as the complementing infrastructure will
begin to emerge. Additionally, doctors will want to work in more advanced facilities with newer
technologies more than older facilities with obsolete technologies. Therefore, if the Cuban
government increases physician salaries in an attempt to keep doctors in Cuba, they will likely
reinforce the desire to stay through investment in such technologies. This business opportunity
only exists in the All-Inclusive Focus scenario because it requires both domestic action and
improved foreign relations.
While clean water is available throughout the majority of the country, approximately
15% of the population is still without access. This lack of availability is mostly restricted to the
rural areas of Cuba. Advancements have already been made in cleaning up the water supply in
Cuba, but more must be done. As a result, while it is feasible for Cuba to have a clean water
supply under current circumstances, increased domestic action will most likely be necessary. As
such, businesses relating to water storage and transportation infrastructure could benefit from
this opportunity, as Cuba strives to make clean water available to all citizens. These businesses
have potential to thrive under all scenarios but will most likely succeed in the All-Inclusive
Focus and Home Focus scenarios.

38. 38
Finally, easing tensions between Cuba and the U.S. in recent years can have very
significant and legitimate business implications, especially if the trade embargo between the two
countries is either altered or lifted completely or if the Cuban government increases domestic
action and focus on its healthcare sector. These developments have the potential to up an entirely
new market for healthcare companies, both domestic and foreign, for everything from consumer
goods to healthcare-specific goods like medical technologies.
Conclusion
Cuba’s healthcare system, as it stands, is filled with medical facilities that are inadequate
and incapable of filling the needs of the Cuban population. After considering that the drivers and
constraints of change - the aging and educated population, healthcare expenditures, and exports -
and how they affect the stakeholders in the system - the Cuban government, private interest,
doctors, the Cuban citizens, and other countries - the Cuban healthcare system is likely to remain
a system that is failing to take care of the citizens that rely on them.
If current trends continue, which is the expected future, the Cuban government will
continue to minimally finance the healthcare industry. The limited interactions with foreign
entities and private interest, especially pharmaceuticals, do not allow for further growth and
development to the system. Doctors will continue to be paid minimal salaries, and work in
conditions far from ideal. The quality of care will continue to be inadequate, and with the
growing population, more stress will be put on the doctors that care for the citizens they serve.
Though the expected future is not ideal, there is hope that through partnerships with
businesses, relations with foreign entities, and the continual domestic action to improve the
system, the possibility of having a system that will fully cater to the needs of an aging and
growing population is possible. The implementation of better infrastructure that would not only

39. 39
allow for 100% of the population having access to clean water, services that provide preventative
and diagnostic medicine, as well as the improved treatment and pay of doctors, would be a major
indicator of a healthcare system moving in the ideal direction.
Unfortunately, without the encouragement of these business ventures from the Cuban
government, Cuba’s ability to supply sufficient free healthcare will no longer be possible. These
opportunities in the All-Inclusive and Home Focus scenarios are essential, because with the aging
of the baby boomer population, the working force is not large enough to support the needs of this
aging population. The partnerships and relationships the government would create, would allow
for private businesses to not only ease this pressure off the Cuban government, but provide
preventative care services, like vaccines, that would decrease overall healthcare expenditures and
help increase the health of the Cuban population.
If there is either increased domestic action or improved foreign relations, multiple
business opportunities in the Cuban healthcare system will drastically improve the quality and
efficiency of the system in place. However, caution must be exercised, as these businesses
opportunities primarily exist in the alternative scenarios. If the expected future occurs, minimal
business opportunities will exist in the Cuban healthcare sector as the system overall deteriorates.
It is important to watch out for the signposts associated with each of the alternative scenarios, as
tremendous business opportunities may exist with increased government action either
domestically or internationally.

40. 40
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