HAVANA TIMES, April 16 — The Cuban public health system is another sector that has suffered deterioration due to the structural crisis of the current model. This is recognized in part by the government/party, which decided to make staff and budget cuts that have added to the decline of that sector.
This system lacks supplies, medicines and diagnostic resources, therefore forcing some to turn to the black market. Health care facilities that serve the general public (those not intended for political and military leaders or foreigners) fail to meet all the needs of patients or do so with deficiencies, despite the enormous sacrifices and efforts of the staff.
These government-exploited wage-labor health workers — though professionals — are underpaid, underfed and deprived of adequate conditions to carry out their humanitarian labor. They are subject to the demands of bureaucrats and the people but are not well appreciated, as was demonstrated in an extensive exchange of emails over the Infomed network, which was hardly reported by the official press.
Many medical professionals go on international missions — which separate families and create social problems — seeking material advantages offered by the government. As a result of the prioritization of these international programs, we have felt a specialist shortage at home.
Despite special restrictions on health care workers, many of them leave the country permanently, as do other professionals in other industries looking for personal fulfillment. As an example, I’m aware of a class of 32 dentistry graduates, of which there are only three who are now working here on the island.
At the same time, what has been occurring is a form of in-kind or cash payment for medical services rendered, usually evolving in an unplanned or un-demanded way, yet the low wages in this field make it difficult to turn down these activities. A doctor who requested a salary increase was suspended from practice for years, and it was not until he went on a hunger strike recently that the Ministry of Public Health (MINSAP) restored that right to him.
None of the measures for the system’s “updating” can solve such problems since their causes are systemic. These can only be resolved by changes in how these defects are produced: the state-centralized wage-labor exploiting form of medical service delivery.
So What Can Be Done?
What is needed is to advance processes of socialization, democratization, de-bureaucratization and getting the government out of the management, administration, operation and compensation in the structures of the health care sub-system.
This should occur in all health care facilities where there is a confluence of professional and occupational interests, health care and medical scientific interests, and the interests of administrative, workforce and social groups.
We must contemplate other forms of income beyond the current government-centralized bureaucratic budgetary approach, with it principles that fail to reflect reality in constantly changing health facilities. This causes insufficient or surplus resources to be allocated to different health care centers, while the meager funds for salaries remain stagnant.
A major part of the solution would be to open up other possibilities for raising revenues for the health care budget that would retain universal free health care. Likewise other options could be developed, such as a “mutualism movement” among trade unions and professional associations.
What could also be considered is a fair tax policy directed at continuing to subsidize health care costs though excise taxes on luxury goods and products that generate diseases, such as alcohol and tobacco.
With a budget that would include the collection of such taxes and specific percentages of the revenue generated from medical treatment to foreigners in Cuba and abroad, and the social security system should pay each health care unit for the precise services provided to the people under its coverage.
In this way, with those revenues, each medical entity could autonomously manage and finance their costs and improve the income from their workers according to their productive output.
This does not involve “selling” medical services, but finding a better way to compensate medical workers, making the services less burdensome on the state budget and making these more efficient for everyone equally.
This would move away from the current de-incentivizing system whereby salaries are fixed by job description categories, which don’t correspond to the professional’s real contributions. In addition to these categories, the on-call duty and concrete work of professionals would be paid with respect to quality and quantity.
Offer Legal Alternatives to Increase Income
Part of the overall solution would also be in making possible forms of self-employment for retirees and by workers active in the public health care sector (once they have concluded their day in the hospital).
In this manner, medical professionals could provide consultations, treat the sick and give home physiotherapy – in this way promoting these services and without criminalizing voluntary payments by patients.
This would improve the economic position of our health care workers, freeing them from having to accept “gifts,” “look for “missions,” or risk working “under the table.”
The schematic and conservative hardliners, opposed to making any change to the neo-Stalinist statism wage-labor exploiting system, would raise the cry: “They want to privatize medicine!” – these same people who have turned a blind eye to such realities and confuse statism with socialization, and confuse the state and society.
Privatizing medical care would mean turning over hospitals, laboratories, research centers, and the production and sale of drugs to private capital for the exploitation of wage-laboring scientists, doctors, paramedical staff, and the patients.
This is what’s wanted by the supporters of the free competition of capital. But that is not what is being proposed here or what is needed.
It’s a question of freeing this sector from the tutelage and exploitation to which it is subjected by the bureaucratic state, but instead socializing production, putting it directly it into the hands of its workers, making the service self-managed, and improving the care provision, well-being and health workers.
Socialism Isn’t Only Distribution
The “state revolutionaries” are committing the same reformist mistake in this field as they are in the rest of the economic sectors. They understand socialism as something regarding the sphere of distribution, and not production.(1) and (2)
Medical professionals, like other professionals, have needs that the government by his own admission cannot ensure. The least it should do is allow them to develop autonomous, collective or individual pathways to improve their living conditions.
By implementing these proposals, workers would feel more committed to their service, take better care of resources (the “diversion” of these would decline or disappear), discipline would be assumed consciously and people would be treated by the doctor they want and not by one they “get.”
It would solve the infinite basic problems that today require patients to visit clinics and hospitals, and thus easing such pressure on our health facilities.
If all this was done, someone told me, many doctors wouldn’t choose to go on missions, which would affect one of the primary sources of foreign exchange for the government.
This notion is the state-centric, market-driven vision that focuses on worker’s being exploited abroad – a view that predominates in medicine, tourism, biotechnology and other sectors that are hyper-prioritized for investment given the revenue they bring in to the state.
This is a philosophy that has slowed the development of other areas of the economy and entire regions of the country to the point of impoverishing them. What’s more, this idea has commercialized and driven the emigration of our most important productive force: skilled workers.
The changes outlined here would upend the orientation of medicine, currently aimed more at the goals of the bureaucratic state (e.g. obtaining more foreign exchange through internationalist labor and presenting good statistics for a good public image) than solving specific health problems defined by the people themselves or for the good of specialists, who would be better paid. Overall, everyone would be more involved in the solutions.
“Without that hard currency, we couldn’t have the health system we have,” says the bureaucrat.
It’s true. We would have another one — a better one — and it too would seek sources of hard currency, but it would be less profit-oriented than the state’s present system. Can anyone say exactly how much money has come into Cuba through this system and how and where it has been used? Guidelines 110 and 111 of the Communist Party’s reform document of the Sixth Congress partially addressed this issue.
Moreover, in continuation, there would be fewer opportunities for the “brain drain.” With improved living conditions, many young professionals wouldn’t leave, they would have their children here and our population would not continue declining and aging.
Indeed, population aging is the most serious strategic health problem that we are experiencing (if we look at health care in its broadest conception: beyond pills, injections, operations, exercise, hygiene and nutrition) because it involves the gradual extinction of the Cuban population, a problem whose roots are being ignored by the state, for obvious reasons.
The state is reducing social benefits and, at the same time, is retaining the bulk of the billions paid by foreign governments and businesses for the work performed abroad by of our doctors and other professionals, musicians, artists and athletes. If other opportunities for developing their skills and earning a decent living are not given to everyone equally, we will see the continuation of defections (the “betrayals” and “treachery”), embezzlement of resources, family divisions and other social problems in general.
Therefore the exorbitant taxes imposed on public health care workers and on all other professionals for providing services abroad should be reduced, thereby enabling them to produce or freely associate on their own.
Ethics and Quality
Medical ethics is embodied in the quality and humanism of the service provided, not what the doctor does or doesn’t charge for their work. If an operation that costs $10,000 in the US is “free” in Cuba, this is due to the low pay received by all medical personnel and the devaluation that the national currency has undergone precisely because of the meager pay provided to the workforce, which of course is the element that adds value to goods and services.
As long as the workforce is poorly paid, there will be no abundant or excellent products. This economic law is as valid for beans as it is for medical services.
The government must assume these necessary changes in a consistent and comprehensive manner. It must resolve the problem of the dual currency. Likewise, it needs to respect the value of the labor force (firstly the rights of the worker, what the “trade unions” have forgotten) and free all constraints on self-employment and cooperativism in all areas – breaking with the inertia, red tape and bureaucracy.
This snail’s pace of change and lack of comprehensiveness only benefit immobilism and the full private capitalist restoration – extremes that provide mutual support and do everything they can to prevent a real socialist breakthrough in Cuba.
1- Marx. Critique of the Gotha Program, Progress Publishers, Moscow. “Vulgar socialism (and from it in turn a section of the democrats) has taken over from the bourgeois economists the consideration and treatment of distribution as independent of the mode of production and hence the presentation of socialism as turning principally on distribution.”
2- Marx. Capital. Volume III. Chapter 51, Chapter 51. Distribution Relations and Production Relations. “The distribution relations essentially coincident with these production relations are their opposite side, so that both share the same historically transitory character… The so-called distribution relations, then, correspond to and arise from historically determined specific social forms of the process of production and mutual relations entered into by men in the reproduction process of human life. The historical character of these distribution relations is the historical character of production relations, of which they express merely one aspect.”