Cuban Polyclinics: A Model for New Zealand?

Jack Haines explores the way our health system is woefully in thrawl to the logic of the market, and ponders a possible solution. First published in May 2023 for volume three of The Commonweal.

During a visit to a large GP practice I experienced a culture shock, both as a nurse suddenly experiencing life as a patient, and as a public healthcare worker navigating the unfamiliar world of private healthcare. I had come to raise some concerns about having a high resting heart rate, likely driven by nightshifts, workplace stress, and coffee abuse over any pathological cause, but enough of a concern I felt it justified to get seen. After a simple assessment and history taking the GP asked if I wanted to have an ECG completed for a fee. I was completely baffled that it was an option to opt in or out of a clinical test based purely on the price, a test I could personally do and analyse in about five minutes. Whilst the care my GP provided was appropriate and the ECG had limited utility in my case, this all seemed secondary to the fact that this test had a cost, and as a consumer I had the ‘right’ to pay or refuse, regardless of its potential relevance. It’s a sobering thought as to how many other patients engaging with primary healthcare have refused tests or not even been able to see a GP due to a financial barrier, exemplified by the countless ‘if only we had caught this earlier’ stories. There is little doubt that the provision of primary care within the private economy and its associated fees has killed patients, or lowered their quality of life, and hampered the development of useful primary health initiatives which are only possible within a public health environment.

A large portion of New Zealand’s healthcare services is held captive in the private industry,but in the eyes of most of centre-right New Zealand this simply provides a useful market alternative for those with the means to access it. Yet while private elective surgeries completed by Southern Cross healthcare are often advertised as ‘alleviating’ pressure on the public health system, in the context of a local shortage of nearly every type of clinician required for surgery it is hard to imagine that this isn’t done at the expense of public health.  This can be seen recently in the number of operations in Christchurch being cancelled or delayed due to a shortage of anaesthetic technicians, while scheduled surgeries at the local Southern Cross hospital continue. Additionally, as private hospitals don’t have a mandate to provide complex surgery, provide emergency surgical services, or staff areas such as intensive care wards,which are vital in the post-operative care of complex surgical patients, they simply are not as efficient in providing the same quality and quantity of care as a public hospital. Accordingly staffing these private hospitals limits the full potential utility of surgical nurses or surgeons in alleviating New Zealand’s elective surgery backlog, wasting a large portion of New Zealand’s surgical capacity.

This combination of public and private care in Aotearoa/New Zealand  leads to a disjointed jigsaw puzzle of a healthcare system, with issues impossible to resolve without the economy of scale, centralised management, and resources available to a health system conducted purely within the public sphere. What would such a system look like? One model I have examined is that of the Cuban polyclinic.

Prior to the Cuban revolution Cuba had a patchwork of unintegrated and overlapping medical structures, including fee-for-services practices and  public assistance for the poor. Medical practices rarely offered preventive medicine and never a complete range of services. Following the revolution Cuba pioneered a ‘family doctor and nurse’ model, every neighbourhood having a family doctor responsible for keeping track of every patient in their area, with nurses and social workers making regular house visits. They are based in a network of some 450 community polyclinics and 1500 smaller clinics. A polyclinic is a large primary care facility providing some 20 specialist services such as radiology, counselling, laboratory testing, dental surgery, and others, with a rotating staff of visiting medical specialists.. Each clinic has at least a GP, a nurse, a paediatrician, an obstetrician/gynaecologist, and a social worker; it  serves a population of between 30 and 60 thousand and collaborates closely with between 20 and 40 local clinics All Cubans have free access to a family doctor and a nurse. The health professionals are responsible for the primary medical care of the population, and prioritise the most vulnerabl:, children, the elderly, and pregnant women. The emphasis is on prevention, close attention being paid to hygiene, nutrition and exercise. Polyclinics are structured around tight internal integration, offering a full range of services at a single location. They provide a single point of entry into the medical system, and maintain a complete record of patients’ medical histories.  They deal with 80% of cases, the remainder being referred to specialist hospitals.

Nearly all polyclinics have national accreditation to teach medical, nursing and allied health students, offering direct patient engagement and community-based learning. Cuba has an average of 9 doctors per 1000 people, compared to an OECD average of 3.4, with New Zealand slightly above that at 3.6. To promulgate messages around good health and disease prevention, Cuba employs a community-based approach using a train-the-trainer method. Health professionals, community leaders, and other volunteers receive training on specific programs and practices, and then become the go-to in their local communities. The newly trained community leaders then help to spread awareness or troubleshoot health issues as they arise, especially cases of sexual and mental health problems. The cornerstone of the Cuban healthcare system is health promotion and disease prevention, with the primary goal to prevent or control health issues before they progress into deadly, costly, or otherwise unmanageable conditions. It provides a single, universal, public health system with the ability to mobilise and adapt  human resources to confront new situations, and this in spite of considerable resource restraints. As one commentator has remarked Cuba provides a first-class public health service in spite of having a third-world economy.

It’s possible to compare the services of a larger private practice to a polyclinic, but this integration between its different internal services and other external services is impossible if referrals or new diagnostic tests incur a cost. These costs and the associated bureaucracy create a friction that slows treatment, wastes the time of clinicians, and prevents poorer patients from seeking essential care. Simply put, if conducted within the private economy a polyclinic is simply a larger GP practice with more services to be segregated by financial barriers, nullifying the utility behind its premise.

 When first implemented in Cuba a central aim was to improve access to basic and specialist medical services for rural populations, underserviced for years with most doctors working in more lucrative metropolitan centres such as Havana. Only through state control could polyclinics be built in ‘un-profitable’ regions where the need was highest, with appropriate clinical labour allocated. While a dramatic comparison the central driving forces of our own massive rural health inequalities are similar; rural locations often don’t necessitate a large public hospital and aren’t profitable enough for adequate private care to fill in the vacuum.  Even when in place these services, whether public or private, simply can’t compete with metropolitan centres in terms of recruitment, with lacklustre to non-existent government initiatives to encourage clinicians to work rurally. These ramifications are primarily felt by poorer rural New Zealanders, who must pay the travel and accommodation fees associated with seeing distant primary or specialist health services, and are additionally more likely to regularly require these services due to the inverse relationship between health and socio-economic status.

This struggle over recruitment and labour allocation is worsened by the continued lack of government support for young New Zealanders studying health. Nurses for example must complete more than a thousand hours of clinical placement whilst studying, with no financial reimbursement. Although this time is intended to be educational, due to chronic understaffing student nurses are treated as free labour, spending most of this time on simple tasks such as cleaning and washing patients. Given the degree of time and money required of health students when studying, it is a legitimate question as to why a cardiologist or specialist renal nurse shouldn’t work privately, maximising their return on their educational investment, instead of working within public healthcare. Provision of specialist services to Cuban polyclinics is only possible through its centralised management of the labour market, supported and made legitimate by the provision of free training and supported study for students. While this may seem draconian to some on the right this simply involves clinicians listing preferences for their future hospital and clinic location and the state allocating accordingly, functionally expanding a system identical to how first year doctors and nurses are placed within certain wards and hospitals in New Zealand.

This article is not meant to construct a business case for a polyclinic model in New Zealand, but to illustrate it is fundamentally impossible to implement certain services and initiatives when public healthcare coexists and competes with a private care system. The very idea of providing high-quality care within a private system is dubious when the profit motive by its very nature reduces the scope and quality of care offered. Many aged care services, for example, have payment models built specifically around the pension, with a large group of their residents paying through this method. To make a profit a certain portion of this pension must be diverted from their care. I have personally worked in a facility for a short time with an unwritten rule of only three incontinence pads for residents per day, with the worker actively penalised if this was broken. This facility, by the nature of the model it operates within, implemented this to increase profits and maximise the amount of a resident’s pension it could divert from their care. This is the efficiency lauded by the proponents of private health care, not the efficiency of treatment or care but the efficiency at which patient or government money is redirected into their own pockets. The idea of expanding public health to cover aged care, primary care, and other private services may seem impractical to some but we are already  providing these services to these patients by virtue of the government paying for much of it through the pension, ACC, local service contracts and outsourcing. The biggest functional change is simply the removal of the private middleman, who exists only to feed off a portion of the funding intended for patient care. Simply put, patients of New Zealand unite, you have nothing to lose but your co-payments.