Private medical practice, while not prohibited, likewise faded away. Though some authors suggest that private practice had ended by 1968 or 1969, Ross Danielson writes that there were still eighty full-time private physicians on the island as late at 1970.22 By the early 1970s, Cuba had a unified medical system, with a focus on the polyclinic for care delivery and all services guided by MINSAP.
CENTRALIZATION/DECENTRALIZATION
Cuban planners carefully studied health systems in the Soviet bloc, especially that of Czechoslovakia. These systems were often overcentralized, leaving little room for individual initiative by practitioners or local administrators. In response, Cuban officials developed the concept of “centralization/decentralization,” which aimed to address such risks by making the policlínico integral a unique institution of Cuban medicine.
Shortly after the revolution in August 1959 the government adopted the approach of “normative centralization and executive decentralization.” The central administration would set norms or guidelines for health care, but local executives would specify how those guidelines would be put into practice.23 Centralization increased when the year-old revolution established MINSAP with Law 717 in January 1960, and further increased with a 1966 statute creating ten new research institutes.24 By 1967, MINSAP was overseeing virtually all professional services. In addition to drafting guidelines and overseeing research, this included budgetary control, supervision of three medical schools, and training programs for a variety of health care staff.25
What may be difficult for non-Cubans to grasp is that decentralization increased alongside centralization. As mutualist clinics were drawn into the medical system, MINSAP opened new base clinics and expanded their decision-making power. Whereas certain programs were under vertical control, such as those for tuberculosis, leprosy, and venereal disease, polyclinics were given broad discretion over their implementation, improving efficiency.26 In general, the period saw a process unifying and standardizing the rapidly expanding system of clinics while decentralizing clinic management and increasing autonomy.
This made a lasting impression on physicians living through those times. Dr. María Luísa Lima recalled that “MINSAP centralized the norms and research. Hospitals and polyclinics decided how to document use of drugs and which antibiotics to use for diseases. Hospitals and polyclinics decided how to do things such as managing their equipment.”27 Dr. Julio López felt the same: “There are norms regarding medical tasks. There is not a straightjacket about how to do things. Hospitals and polyclinics have to decide how to do many things. There must be a balance between working within rules while having a lot of freedom to make decisions.”28
As the era of polyclinics began, the Cuban government charted a course that would ensure their role as the cornerstone of decentralization: the policlínicos integrales would be independent of hospital control. The clinics would be distinct entities answering to MINSAP in each region. Instead of acting as administrative branches of regional hospitals, their position would be equal to that of hospitals within the regional administration of MINSAP.29
Clinic independence was a key factor distinguishing Cuba’s approach from that of the Soviet bloc countries, as well as from other regionalized medical systems in Latin America, such as Puerto Rico and Chile.30 Cuban doctors were well aware of this distinction. Dr. Oscar Mena emphasized to me that “the hospital does not give orders to the polyclinic. Polyclinics get orders from the regional administration and MINSAP.”31
As mentioned, the proportion of health care visits was shifting sharply from hospitals toward polyclinics. This meant that “the polyclinic—predominantly an outpatient facility independent of hospital control—was regarded as the core of the health services system as a whole.”32 Though polyclinics were independent from hospitals, their daily functions were interconnected. Hospitals performed and analyzed lab work for nearby polyclinics, and hospital doctors worked part-time in polyclinics, both as consultants and care providers. Similarly, polyclinic doctors worked for brief shifts in hospitals.33 By the end of the decade, each of the country’s 268 polyclinics provided care to 25,000 to 30,000 Cubans, and each of the thirty-eight regional hospital “centers” was affiliated with an average of seven polyclinics. A larger number of provincial hospital centers provided specialty care.34
A subtle but important change that elevated the standing of the policlínico integral was the creation of primary care as a specialty, addressing everyday medical problems in clinics. Offering primary care as an option for postgraduate training put these physicians on par with other medical specialists as part of the core staff of policlínicos integrales. Other forces further decentralized control into the hands of doctors. Instead of developing into an ossified bureaucracy, MINSAP relied on physicians for many aspects of its redesign.35 Physicians were also working closely with the military amid sustained threats of invasion and nuclear war.36
MOBILIZATION FOR A HEALTH REVOLUTION
Policlínicos integrales thus became the unifying link in the structure and services of the new national medical system, which made clinics independent of hospital control and authorized them to determine how to enact guidelines, create their own specialists, and, most importantly, cover a specific geographic service area for which they became the entry point for all local patients. Yet nothing enhanced their stature more in the eyes of average Cubans or better solidified their position in the decentralization of health services than their role in coordinating health campaigns.
Fidel Castro and his comrades understood that a government could not merely decree that a campaign would occur; the literacy campaign showed that successful campaigns require massive mobilization and public enthusiasm. The policlínicos integrales walked the same path, and Fidel took a front-and-center position in the mobilization. He motivated physicians, graduating medical students, and the entire country by reminding them that “public health occupies a prioritized and sacred place in the revolution.”37 He pushed for changes that would accelerate training of medical personnel and rotate professors, instructors, and residents from Havana to new medical schools in Santiago (opened in 1962) and Las Villas (1966). By 1969, doctors were teaching at forty hospitals in Havana alone.38
One of Fidel’s most important contributions was to show that Cuba could improve on Eastern Europe’s concept of community clinics. He believed Cuba needed to create an example of public medicine that could be used by other poor and underdeveloped countries. The USSR donated equipment and 850 beds to the recently built Lenin Hospital in Holguín in 1965. Cuba’s “repayment” was to provide medical care in even poorer countries, including Guinea, the Congo, Mali, and Vietnam. International solidarity in public health would be one of Fidel’s indelible legacies.39
In Eastern Europe, the Red Cross was often central in coordinating public health efforts. But the importance of the Cuban Red Cross was tiny compared to the country’s voluntary mass organizations.40 These included the National Association of Small Farmers, which helped establish the first rural health centers and control tuberculosis; the Federation of Cuban Women, which addressed health education, family nutrition, and maternal and child health; and the Confederation of Cuban Workers, which focused on safety committees in workplaces and state farms, as well as food safety.41
By far the most important of the mass organizations were the Committees for Defense of the Revolution (CDRs), first organized in 1960 to guard against sabotage and attacks from the United States. These provided social networks for neighborhoods and soon became integrally linked to public health efforts.42 By 1962, the CDRs had almost total responsibility for coordinating polio immunizations, shortening the