Size and scope of the Cuban health assistance program in the Pacific
The Cuban initiative in the Pacific is relatively new and still evolving, hence, it is difficult to obtain up-to-date data on numbers and distribution of Cuban doctors on the ground. Complicating this is the existing problem of lack of accurate health workforce data in Pacific Island Countries . Although some countries have reasonably detailed and up-to-date workforce statistics including figures on non-national health workers such as the Cubans, the majority of the countries have very limited information on numbers and distribution of health workers. Our review suggests that there are 33 Cuban health personnel working in six PICs and nearly 180 students from various Pacific Island Countries studying medicine in Cuba in 2010. Considering the small populations of PICs, this is a substantial commitment and potentially influential with respect to HRH development and health systems strengthening in the region. Given the current number of doctors in some PICs (Table 2), the return of the Pacific island medical graduates from Cuba upon completion of their studies will double the number of doctors in several countries. This will change not only the doctor to population ratio but also the structure of the workforce, particularly the doctor to nurse/midwife ratio, if there is no corresponding increase in nurse/midwife numbers.
Compared to previous and ongoing medical cooperation between Cuba and other countries, the initiative in the Pacific is small in terms of absolute numbers. For example, there has been relatively much larger Cuban health personnel presence in some countries of Latin America, including Guatemala and Venezuela . Despite the limited current presence in the Pacific, however, an increasing number of PICs perceive the Cuban medical cooperation as a cheaper and more effective model for HRH development and may wish to embrace the initiative and deepen engagement with Cuba in the years to come. It is therefore important to establish mechanisms to document its evolution and to enable assessment of impact on health outcomes.
Concerns about Cuban health personnel on the ground in PICs
Cuban health personnel are reportedly working in four PICs: Kiribati, Solomon Islands, Tuvalu and Vanuatu. Of a total medical workforce in those countries of around 120, approximately a quarter (33) are Cuban. Anecdotal evidence regarding their contributions to health service delivery in those countries is for the most part favourable . However, some concerns have been expressed about clinical competence, quality of care and language. In discussions relating to participation in the Cuban medical assistance program, the PNG Doctors Association, for example, raised issues about the quality of practice of Cuban medical practitioners working in PICs and mentioned poor clinical standards as a reason to oppose the recruitment of Cuban doctors to PNG . This, however, contrasts with insights from countries such as Indonesia , Solomon Islands  and Kiribati  where Cuban health personnel have reportedly made important contributions to improving health outcomes.
The opposition of the PNG Doctors Association to the Cuban medical cooperation mirrors that of medical associations in other countries hosting Cuban doctors. In Venezuela, Villanueva and de Albornoz  report stiff opposition from the Venezuelan Medical Council (VMC) to Cuban doctors working under the government’s Misión Barrio Adentro programme. In Bolivia, the medical association (Colegio Médico de Bolivia) and the association of unemployed doctors went on strike to protest the presence of Cuban doctors . Such opposition by local medical associations may be motivated by self-interest, inadequate consultations, misunderstanding of the Cuban model of health care and language difficulties among others. Medical associations represent professional elites which often protect their interests, status and control against external ‘newcomers’ . It is reported that the Venezuela Medical Council’s opposition to Cuban doctors was, to a large extent, based on its opposition to the Chavez government’s social programs which have made medicine ‘cheaper’ for the poor majority and in the process damaged the social position and income of the medical elites . PNG, unlike Venezuela, has no Cuban doctors on the ground but the PNG Doctors Association may be concerned about potential competition which may erode their social status if the government decides to join fellow PICs in recruiting Cuban doctors.
Inadequate consultation with medical associations by governments hosting Cuban doctors may also give rise to such concerns. In Timor-Leste, some district health officers felt that the Cuban health personnel had been imposed on them from above, although they generally were not opposed to the Cuban medical cooperation . The Venezuelan Medical Counci described the Cuban doctors in the country as working illegally because they had not been registered by the Council. Misunderstanding of the Cuban model of health care may lead to concerns similar to that expressed by the PNG Doctors Association. The Cuban family medicine paradigm is centred on prevention and promotion, without disregarding by any means the curative continuum. This integrated and holistic approach, in which medical doctors are not only ‘curing’ but are also working on different aspects of prevention, is not always understood correctly by ‘classical’ medical doctors . In Venezuela and Bolivia, Cuban doctors have been described by some doctor groups as more akin to “herbalists” and “not qualified to be called doctors” due to their involvement in different health promotion and prevention activities .
Evidence emerging from some of the PICs hosting Cuban doctors suggests that some Pacific Islanders are concerned about insufficient language skills which make doctor-patient interaction and their effective integration and collaboration with local doctors difficult. Informal discussions between one of the authors of this paper [JN] and key individuals from some host countries in the Pacific confirmed this. The early termination of the contract of 11 Cuban doctors who arrived in Nauru in 2004 according to the Minister for Health of Nauru was partly due to language difficulties . Concerns about insufficient English language skills of Cuban doctors have been expressed in other countries hosting Cuban doctors. A report from Timor-Leste noted that communities there have expressed concern about the language skills, cultural knowledge and sensitivity of the Cuban health workers , although this issue has since received considerable attention.
Concerns about integration of Islander medical graduates trained in Cuba
While the importation of trained and experienced Cuban personnel is a valuable and immediate contribution to health service delivery, the return home of substantial numbers of Islander graduates from Cuba is of greater long term significance. Concerns have been expressed about integration of the students studying in Cuba into the health systems of the various PICs upon completion of their studies. Specifically, some have questioned whether the returning students will be registrable according to existing accreditation rules and what will be the cost of such integration.
As mentioned above, in PNG where the Cuban initiative has not yet been accepted, the medical association has raised issues with the quality of clinical competence and standard of practice of the Cuban brigade. While no such specific concerns have been raised by any of the countries with students in Cuba, this to some extent foreshadows the level of resistance with regards to registration that may await the Cuban-trained Pacific Island doctors. The process by which returned Cuban-trained doctors will be accredited and their standards assessed is unclear and is likely to vary by country. Medical graduates from Cuba are treated differently in different Latin America countries. In Guatemala, graduates from the Latin America Medical School (ELAM) in Havana can practice in the national health system after a year of hospital based social service which enables them to develop skills required to deal with specific health issues of Guatemala . However, in Honduras ELAM graduates could not practice within the national health system following a dispute over accreditation between the Honduras Council of Higher Education and the country’s medical association. The Council of Higher Education reportedly decided to recognise ELAM degrees and validate the one year clinical clerkship done in Cuba but the Honduras Medical Association opposed the decision arguing that all foreign medical graduates must do a year clerkship and another year social service in-country before being allowed to practice .
With regards to the cost of integrating the new medical graduates, governments of countries to which graduates are returning may need to allocate substantial additional recurrent budgets for that purpose. The Solomon Islands, for example, currently have about 75 students in Cuba who will be completing their studies within a few years. This means they will be returning home around the same time and the government may need additional revenue to cover their salaries and other recurrent expenditures associated with their operations. As mentioned elsewhere, it is expected by Cuba and countries with students in Cuba that once the local medical graduates return home, they will replace the in-country Cuban personnel who will be withdrawn. While this arrangement is rational, in terms of cost there will still be the need for additional funding as the in-country Cuban doctors receive an allowance which is not as high as the actual salaries of local medical doctors. In the Solomon Islands, it is reported that the government pays about US$ 300 (SBD$ 2250 Solomon Islands dollars) per month as an allowance for each Cuban doctor. However, a local Solomon Islands doctor is paid a salary of about SBD$ 170 000 (approximately US$ 22 700) per annum .
Implications for training providers
There are two main regional medical training institutions in the Pacific, the Fiji School of Medicine (FSMed) and the University of Papua New Guinea Medical School. Privately run and funded medical schools have recently been established in Fiji and Samoa . While small numbers of PIC students study medicine in Australia and New Zealand, by and large it is the two long established medical schools which have provided the majority of the medical graduates for PICs . Currently, there are not enough places in the two medical schools as staffing and resources are over-stretched . The Cuban medical cooperation may therefore be seen as complementing local training efforts. However, if PIC governments deepen engagement with Cuba and opt to train more medical graduates there, an option which is cheaper for both PIC governments and their students, the initiative can affect enrolment in the regional medical schools with consequent implications for their staffing and funding.
Regarding the training needs of the newly graduated doctors returning from Cuba, regional training institutions may have to expand their activities to offer orientation courses for these graduates. As indicated above, one of the major concerns of local medical associations is the quality of clinical training medical students undergo in Cuba. The training program completed by Islander students in Cuba does not include a post-graduate internship or residency. To standardise practice, quality and clinical competence, ministries of health in PICs may mandate a period of in-country orientation for the returnee medical graduates. Additionally, some in-country arrangements will be needed to provide for the supervision, mentoring and continuing education of the returnees. All of these could pose additional burden on training facilities and put further pressure on staff and resources.
Another matter for consideration at some point is the entry of some of the returned doctors into post-graduate specialist training programs. Specialist training opportunities in the PICs are limited and their expansion will call for resources not readily available. It may be necessary to upgrade the qualifications of would-be trainee specialists and mobilise funding to enable them to participate in specialist training programs outside the PICs.
Implications for donor assistance for health in the region
The wider geo-political and development context of the Cuban assistance program is also relevant. The Cuban engagement comes amidst a crowded development field in the Pacific. In addition to the traditionally prominent actors such as Australia, New Zealand, the World Bank, Asian Development Bank and Japan, new bilateral partners have been providing increasing amounts of development assistance. China ; China (Province of Taiwan); and Cuba have all increased their presence in the region. The South Pacific has become a much more crowded neighbourhood. This has implications for harmonisation and coordination of activities as well as raising the possibility of donors being played off against one another. The Cuban model does not have to be seen as separate from other development assistance, and indeed in other parts of the world, Cuban health assistance programs have been funded by various OECD and new donors: Germany supports programs using Cuban doctors in Honduras and Niger; Japan does the same in Guatemala; and South Africa supports Cuban activities in Mali . In 2010, the Australian Foreign Minister expressed Australia’s readiness to collaborate with Cuba citing Cuba’s renowned medical assistance work . This may highlight an openness on the part of the Australian government to the emergence in the region of this form of development assistance for health.
Opportunities and challenges of the Cuban health assistance program
The Cuban health assistance program in the Pacific provides avenues for the pursuit of national interests and international activities beyond simply the delivery of health care and the training of medical students. These matters are somewhat outside the scope of this paper. So far as the health services and health personnel are directly concerned, the establishment of the program has opened opportunities for Cuban medical personnel to contribute to, and learn from, activities within PIC health systems to the benefit of themselves, PIC health personnel working with them, the island health systems and the people of the PICs.
The Cuban engagement provides PICs with additional numbers of health personnel that several countries desperately need. However, it is not just the increase in numbers of doctors that the Cuban initiative brings but also the mix of specialist and general practitioners which makes it attractive to PICs . For the Solomon Islands, Cuba has committed to sending a total of 40 medical doctors including surgeons, gynaecologists and other specialists . A willingness on the part of Cuban personnel to work in rural and underserved areas is a further attractive feature of the Cuban health assistance program, built on the premise of health as a right rather than a commodity. In line with their medical philosophy of prioritising rural and community health, a significant number of the Cuban brigade work in remote areas to which local doctors often refuse to go . This provides host countries the opportunity to address the maldistribution of health workers between urban and rural areas. It remains to be seen, however, the extent to which the Cuban-trained Pacific Island doctors will commit to working in rural and remote areas once they complete their studies and return home.
The availability of scholarships for medical training in Cuba represents an extremely generous opportunity for some young PIC people to prepare themselves for a professional career, become literate in another language and gain life experience far wider than that of students who complete their medical school course in one of the PIC regional medical schools.
Our discussion has drawn attention to a number of challenges, some of which are being met as Cuban doctors, their counterparts and support personnel work together in the PICs. Others relating to training and subsequent integration of the Islander graduates from medical schools in Cuba need to be worked through carefully by the respective PIC governments. A review of the long experience of Cuban brigades working in developing countries and of countries successfully integrating newly graduated young doctors into the health system of their home country will provide assistance to the PIC health authorities in foreseeing, forestalling and managing these and other challenges as the partnership Cuba-PIC partnership matures.