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The International Journal of Cuban Studies

(Online) ISSN 1756-347X

South-south development cooperation

Margaret Blunden examines the strengths and limitations of Cuba's contribution to international development through the promotion of preventive holistic medicine in South Africa.


Summary

Cuba's health programmes in Africa, dating back some forty years, and its training of African doctors in Cuba itself, have made an original contribution to international development. Cuba's programmes have focussed heavily on capacity building within the health sector, rather than large infrastructure projects. They have been located within a distinctive discourse of solidarity among developing countries, officially repudiating the self-interest and power imbalances usually implicit in donor-recipient relations; they have been largely free from political conditionality; and their core values are preventive and holistic medicine, rather than the medical conception of health commonly seen as a legacy of colonialism in Africa. Cuba made a significant contribution to the concept of south-south development cooperation well before this concept began to influence the professional field of development studies in the 1990s - when it was identified as an alternative form of globalisation and seen as a key driver of development effectiveness in meeting the Millennium Development Goals. This brief exploration of some of Cuba's health programmes in Africa suggests that they exemplify both the strengths and limitations of south-south development cooperation, which currently accounts for between five and ten per cent of overseas development activity.

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The history and scope of Cuba's health programmes for Africa

During the Cold War period, Cuba attempted to square its close relationship with and dependency on the Soviet Union with an alternative model. Independent of both power blocks, this was based on solidarity between developing and non-aligned countries, many in the southern hemisphere. Cuban leaders developed and articulated a distinctive discourse evoking the essential commonality of poor, developing countries, sharing similar oppressive colonial legacies, with their development blocked by what Castro (1987) called "the unjust and obsolete international economic order prevailing in the world." As a prominent member of the Non-Aligned Movementand the Group of 77, Cuba persistently evoked the need for unity and cooperation among developing countries in their collaborative struggle against exploitation. Cuba's assistance to African countries in the health sector, which dates back to almost the beginning of its military interventions in the continent in the 1960s and which achieved equal priority to military assistance in the 1970s, have to be seen in this context.

Cuba's international development work in Africa expanded after the end of the Cold War, in spite of the economic difficulties suffered during the Special Period which followed the cessation of Soviet support and the increasing demands of health partnerships in Latin America. The Integral Health Programme, initiated by Cuba in Africa in 1998 and primarily earmarked for rural areas, involved the sending of medical and auxiliary personnel to thirteen African countries, with the objective of health worker capacity building (UN Special Adviser on Africa, 2004). At the Group of 77 meeting in Havana in 2000, richer African states agreed to provide finances to pay for an extra 3000 Cuban doctors to work on the African continent. That same year, Havana helped to set up, on the Cuban model, the Gambia Medical School in Banjul and the Bata School of Medicine in Equatorial Guinea. Cuban professors also currently teach in medical schools elsewhere in Africa, including Eritrea, Uganda, Ghana, Guinea Bissau and South Africa.

The Latin American School of Medicine, established in Havana in 1998, greatly extended beyond existing Cuban medical schools the capacity for medical education of African students alongside others from the American hemisphere. By 2000 there were said to be 40,000 African graduates of Cuban universities, many of them doctors, working on the African continent (Hammett, 2004). In 2005 there were 777 students from sub-Saharan Africa studying in medical schools in Cuba (Castro, 2005). A further 536 students were, in 2006, training in medical schools established with Cuban cooperation in The Gambia, Equatorial Guinea, Eritrea, Guinea Bissau and East Timor (Gorry, 2006) .

Cuba's international contribution to the capacity building of health workers is on a scale exceeding that of all members of the G8 group of leading advanced countries combined. Moreover, its international medical programmes are linked to an enduring discourse of international solidarity. Although the earliest health programmes in Africa were associated with Cuban military interventions on the continent in support of socialist movements, more recent collaboration agreements have been made with governments of various ideologies. The undoubtedly self-interested element in Cuba's medical outreach is captured in the term, frowned on in Havana, of 'medical diplomacy'. The provision of international medical aid has helped break down Cuban isolation, generate opposition to the US boycott and probably influence votes in Cuba's favour at the United Nations. But the term 'medical diplomacy' conveys only half the picture. As Gleijeses (2002) comments, Cuban assistance to Africa reflects a degree of idealism unusual in the foreign affairs of great or small powers.

African leaders acknowledge the exceptional nature of Cuban involvement in the continent. Nelson Mandela's speech in Havana in 1991 went beyond the usual diplomatic niceties: "We have come here feeling a great debt to the people of Cuba. What other country can show a history of greater selflessness than Cuba has demonstrated in its relations with Africa?" There is said to be a common perception among many developing countries that "Cuban aid is not tied to imperialistic ambitions" (Hammett, 2004:23).

In scale and consistency, as well as in motivation, there seems to be a contrast between the priorities of the Cuban government - whose long-standing leadership has been ostensibly unconstrained by electoral considerations - and those of the vote-driven governments of democratic states, where the electorate commonly prioritises domestic over global interests. As the conference of the UK Ditchley Foundation on Health as Foreign Policy concluded, when it comes to a choice between spending more on policies of direct interest to the voters and spending more on global health policies, the chances are that politicians get more support for the former than the latter. "We hoped, however, that over time and with proper information, enlightened self-interest would prevail" (Ditchley Foundation, 2002:1).

Cuban government spokespeople like to emphasise the difference between the Cuban principle of "selfless assistance without conditions, as opposed to a mentality of conditioned charity aid" (Diaz, 2007). Cuban international agreements for medical or other development aid take particular care to avoid what is deemed interference in the internal affairs and policies of partner states. As Daniel Hammett's case study of south-south development cooperation between Cuba and South Africa argues:

"The practise (sic) of using aid to encourage policy reform in recipient countries is undoubtedly one of the reasons why Cuban support is viewed favourably by many developing countries. Cuba not only lacks the baggage of colonial powers' history, but there is widespread acceptance of Cuba's official strategy of non-interference with sovereign government affairs." (Hammett, 2004:11)

As will be explored later, the Cuban policy of non-conditionality, meaning in this context non-interference in health policy issues, has disadvantages as well as advantages, as far as the health programmes of recipient countries, and the effectiveness of the Cuban contribution, are concerned.

Conflicting paradigms of health care

The Cuban approach to health care developed after the 1959 Revolution contrasts sharply with the colonial model of medical care bequeathed to Africa by the departing colonial powers. The Cuban approach is based on a holistic concept of health, as the product not just of individual bio-physiology but of the whole social and economic environment. Health is not seen as just the absence of disease and infirmity and health care involves more than medical care: it includes adequate housing, nutrition, sanitation and education. The emphasis is on prevention rather than cure, on public health and primary care, rather than high technology medicine. Moreover, individuals and communities participate in the development and functioning of the health care system. The intellectual and ideological sources of this conception of health are not entirely clear but they certainly owe much to Dr Che Guevara. His On Revolutionary Medicine (1960) argued that "often we need to change our concepts, not only the general concepts, the social or philosophical ones, but also sometimes our medical ones." He urged the need to orient the creative abilities of all medical professionals towards the tasks of social medicine. The outcome in Cuba approximates to rarely applied international ideals of best practice. In the view of William Keck, "Cuba's experience is practical proof of population health principles long shared by visionaries in global health" (Keck, 2007:2).

In Africa, by contrast, most post-colonial governments have focussed on medical treatment rather than health. Resources have been devoted to curative rather than preventive medicine, and spent disproportionately on hospitals, technology and imported drugs. Health policy has been exclusively the concern of ministries of health and such questions have played little or no part in the many other government policies which impact on the physical and emotional well-being of the population. The large aid programmes of international health donors in the period following independence, in Nigeria and elsewhere in Africa, reinforced this approach, which prioritises the specialised needs of urban élites at the expense of public health issues affecting the majority of the population (Alubo and Vivekananda, 1995). The World Health Organisation's Conference on Primary Health Care at Alma-Ata diplomatically concluded of Africa that, although most health care reforms had resulted in policy frameworks based on the concept of primary health care, and output indicators for disease-specific programmes had improved, the impact on equity, access to care and health status had been limited (WHO, 2003.

In the view of Global Health Watch, the prevailing medical and curative model is one of the core impediments to the improvement of health in developing countries:
"The dominant development paradigm is one which focuses on the delivery of medical technologies and pre-determined packages of interventions without considering adequately the process of health development, and without considering how health interventions can simultaneously change the political and social landscape in which are constituted the fundamental social and economic determinants of health." (Global Health Watch, 2005:2)

Alubo and Vivekananda attribute the widespread failure of African health systems to this development paradigm:

"The poorer African countries have tended to copy the philosophy and development priorities of the developed world even though the problems and population structures are different. In following the health delivery trends of the technologically sophisticated societies, African countries have so far failed to make their health systems effective, let alone sufficient." (Alubo and Vivekananda, 1995:215)

Cuban doctors and other health workers in Africa do therefore bring to this exercise in south-south cooperation a potentially valuable antidote to an inappropriate western model. They are, however, working within an alien paradigm - which their government's commitment to non-interference in policy issues may inhibit them from challenging. What can be achieved in these circumstances?

Exploring Cuban medical aid to Africa as south-south development cooperation

A paper for the Global Facility for Disaster Reduction and Recovery offered the following criteria for successful and sustained south-south partnerships: they respond to needs articulated on the basis of special national and local analysis; they have contexts or relate to issues that have some commonality or complementarity; they involve exchange of knowledge and expertise in both directions; they bring mutual benefits on a reasonably equitable basis; they build institutional capacity; and they provide good value-for money compared with alternative modes of operation (Global Facility, 2007). To these criteria may usefully be added two further conditions of robust health development policy for a state to be resilient to health challenges, suggested by Owen and Roberts: prevention as part of the policy mind-set; and involvement and consent of an empowered civil society (Owen and Roberts, 2005) .

A systematic assessment of Cuban health development assistance programmes in Africa in the light of these criteria is not yet possible, given the paucity of independent evaluation of these programmes, except in the case of South Africa. Some tentative preliminary points may however be offered at this stage, in the light of the evidence available.

The medical assistance offered by the Cuban Government to Angola in the 1960s provided an early indication of the advantages of what would later be termed 'south-south cooperation'. The Cuban medical brigades had three distinctive assets: they were cost-effective; they shared experience of similar challenges and hence brought particularly appropriate skills and capacities; and were culturally compatible with their patients.

"The MPLA (Popular Movement for the Liberation of Angola) were keen to employ Cubans as opposed to western doctors for several reasons, not least because the average Cuban cost a quarter of a similarly qualified doctor from the World Health Organization. But Cubans were also willing to endorse more basic living condition - medical teams often shared apartments and were happy to eat meals as a group - and were more sociable, easy-going and more racially tolerant than their Soviet and East European comrades." (George, 2005:158-9)

The Cubans had no linguistic advantages - many patients did not speak Portuguese, let alone Spanish. But they had an ability to improvise where equipment or supplies were deficient, a skill they had had to acquire in Cuba. The evidence from this early deployment of Cuban health workers in Africa suggests that their experience was more suited both to patients' needs and to good working relationships with colleagues - and provided better value for money - than that of health workers from developed countries, as south-south development cooperation theory would predict.

Cuban health programmes in Africa, expanding greatly in the decades following the dispatch of the medical brigades to Angola, were considered in Havana to be mutually beneficial in both ideological and professional terms. In ideological terms, experience of working in some of the most deprived areas of the world was intended to reinforce the revolutionary ethos of health workers: medical as well as military service abroad was a good vehicle for politicising Cuban youth. In professional terms, international experience provided valuable developmental experience for the staff concerned. As Francisco Rojas Ochoa, Professor at the Higher Institute of Medical Sciences and National School of Public Health, observed in 2005, of Cuban doctors serving in other parts of the world:

"They are faced with a different reality; they learn many things, in particular about interpersonal relationships; and they return home with a more comprehensive and solid formation. And this benefits us all. These people to work in other countries for two or three years, but then they return home and work here for 30, 30 or 50 years. So, we're not only giving, we are receiving benefits as well."

The case of South Africa

Although published evaluation of the effectiveness of Cuban medical aid programmes in Africa is generally scanty, there are recent studies of Cuban cooperation with South Africa. This is where Cuba-South Africa collaboration programmes have provided for South Africans to be trained in Cuban medical schools and for Cuban doctors to serve in South Africa. The first group of ninety-two Cuban doctors arrived in 1996 and a further eleven Cuban medical academics in 1997. The initial cooperation agreement signed in 1995, subsequently extended, covered cooperation in health research, academic collaboration (some Cuban professors in South African medical schools), health policy and programmes, biotechnology, vaccine production and pharmaceutical development. In the following years, the number of doctors on the programme rose at one point to more than 400 and that of medical academics to about thirty-five. By 2005 the numbers had declined to 168 doctors and twenty-six medical lecturers, because of shifting Cuban government priorities to other parts of Africa and Latin America - and possibly dissatisfaction in Havana with the number of Cuban doctors marrying locally and opting out of the programme (Breier and Wildschut, 2006). The cooperation programme provided sixty scholarships a year for South Africans to study medicine in Cuba and by 2005 about three hundred medical students had been or were being trained there (Breier and Wildschut, op.cit).

The Cuban-South African cooperation programme was intended to meet specific needs and shortages in the transition process of post-apartheid South Africa. Hammett argues that whereas donors' failure to recognize the heterogeneity within recipient states and communities often leads to poorly prescribed policies, the Cuban-South African collaboration made a serious attempt to target areas of special need. A preliminary dialogue ensured that the programme addressed specific problem areas in the South African health service, and particularly the rural areas, where shortages were greatest (Hammett, 2004). The students selected for training in Cuba, as from elsewhere, were predominantly drawn from poor or marginalised communities and were expected to return to work there. Cuban medical professors were concentrated in the medical school of Walter Sisulu University, a school located in a poor, rural area of the Transkei, set up with the express purpose of training more rural and black doctors, and one which struggles to recruit local doctors to its staff (Breier and Wildschut, 2006).

The health system in apartheid South Africa heavily prioritised resources on curative medicine, including leading edge medical technology such as heart transplants which primarily benefited the white population - and spent tiny amounts on preventive medicine, to meet the needs of the black population. In 1994, following the end of apartheid, the Government of National Unity adopted a primary health care philosophy and an effort was made to incorporate traditional African medicine, banned under apartheid, into current health policy. The Cuban health care philosophy, associated as it is, in classic south-south development cooperation terms, with the rejection of colonial legacies, an emphasis on racial equality and independence from the interests of multinational drug companies, is consistent with South Africa's new health care policy. Cuba is considered exceptional even among developing countries for its reliance on the public sector, an attribute generally considered to be one of the advantages of south-south development cooperation (see UN Special Adviser on Africa, 2004).

One measure of the effectiveness of Cuban health workers and professors in development terms, might be how far they help to further the dramatic policy shift from curative medicine to holistic health care in a supportive social setting, rather than acting as a mere stop-gap, plugging immediate shortages of health care workers. But Cuban government policy explicitly dissociates itself from any attempt at policy change:

"Cuba did not come here to change any system. The people of South Africa and the government of South Africa have to make the change. We are only here to render services, not to colonize. That is a principle we have always respected because we believe that each country should select its own methods of organization, its own systems. Cuba has always upheld this principle with pride at all international meetings." (David, 1999)

Not surprisingly, many South African health officials see the importation of Cuban doctors merely as a short term expedient:

"Whilst it is not seen as a panacea for all their health care ills, nor as a long-term solution, government officials were very positive about the short-to-medium term role for such cooperation. This view echoes that of South African medical professionals, that the employment of Cuban doctors as an efficient and sensible short-to medium-term strategy, but with long-term strategy based upon South African personnel." (Hammett, 2004:64)

Carmen Mercedes Báez' study of the Cuban Health Programme in Gauteng province found that the Cuban doctors' major dilemma was the persistence in South Africa of a heavy bias towards curative services, to the detriment of a curative approach (Báez, 2004). The doctors interviewed believed that, because they were providing mainly curative services, they were under-utilised. They unanimously agreed that it would be more cost effective for South Africa to review the character of the programme, envisaging a different role for them by looking at the potential contribution to improving the quality of comprehensive primary health care, emphasising preventive strategies and models (op.cit).

Only occasionally have individual practitioners been able to influence policy changes at a local level, as in the case of an initiative suggested by a Cuban doctor to a provincial manager in 1998:

"I am the person who created primary health care research after convincing Dr X that there is no primary care without associated research. After convincing him, I formed part of the organising committee and I think that it is one of the biggest contributions I have made." (Quoted in Báez, 2004:28)

Hammet concludes optimistically that "the presence of Cuban doctors has brought with it a greater awareness and application of the ideas of holistic primary health care, a component of the ANC's health care strategy from the inception of democratic government. The experience of Cuban doctors of working within such a framework in Cuba has allowed these principles to be applied in rural areas from the outset" (Hammett, 2004: 56).

Given the Cuban government's explicit rejection of interference in the government policies of collaborating states and the focus on sending doctors rather than non-medical experts in public health, the extent to which the Cubans can help to further the shift from curative medicine to holistic health care would seem to rest largely in the long term on their influence on the training of doctors in medical schools in South Africa itself and in Cuba. There is at the moment very little in the public domain on which to make a judgement about the effectiveness of Cuban medical education for Africans as an exercise in south-south development cooperation. As far as those trained at the Walter Sisulu medical school in the Transkei are concerned, where training for rural and black doctors focuses particularly on a problem-based learning curriculum, Professor E.L. Mazwai, Dean of the Health Sciences Faculty, credits the Cuban implementation of the programme with sensitising students to the health needs of the community and increasing their commitment to serve (Gorry, 2005).

It is not yet clear whether the graduates of Cuban style medical schools, in Cuba or in Africa, are disproportionately likely to pursue careers long- term in the neediest areas of their home countries, as intended, or indeed whether their training in a holistic approach to health care - in its social and environment setting as opposed to a narrow focus on medical treatment - will eventually come to reinforce the much needed paradigm shift in African health care. The political and ideological nature of the medical model of health, and the extent to which the dominant paradigm of western style medicine serves the interests of political and medical élites and of international medical suppliers, suggests that this will be no easy task. If, as Alubo and Vivekananda (1995) argue, the struggle for health care in Africa is intertwined with that for a more just, humane and egalitarian society, there may be serious limitations to the importation of the Cuban health care model.

Conclusion

The somewhat limited evidence on Cuban medical cooperation with Africa suggests that it meets many of the criteria for effective south-south development cooperation. The focus on human capacity building, rather than large infrastructure projects and the care taken to work with governments to define programmes which meet the needs of the poorest and most marginalized communities both suggest that these programmes are exceptionally well tailored to need - at a time when, as the WHO indicates, current primary care policies are making little impact on equity and access to care in Africa.

The greater degree of communality and complementarity of health issues and working conditions between Cuba and their African collaborators, as opposed to that in north-south collaboration, is one of the strengths of the cooperation. The experience of Cuban health workers fits them better than most doctors (for example, provided through the World Health Organisation) for working in the demanding circumstances of deprived areas of Africa. Partly for this reason, Cuba-Africa collaboration generally appears to have been mutually beneficial. Most importantly, prevention of illness rather than its subsequent cure, is an intrinsic part of the policy-mind set of Cuban and Cuban-trained health workers.

Cuban health workers in Africa are, however, working predominantly in somewhat alien policy frameworks, where the dominant paradigm continues to be that of curative medicine. Even in South Africa, where post-apartheid health policies have aimed to promote primary health care, benefiting the majority black population, Cuban doctors have felt under-utilised in a system enduringly focussed on curative medicine. Their long-term effectiveness, in development terms, depends on their being seen as more than temporary stopgaps for short-term shortages of health workers. The Cuban contribution to medical training, both in Africa and in Cuba, provides the most promising avenue for transforming the health policy of collaborating governments in the long term. Ironically, given the widely understood need for a paradigm shift in health policies in much of Africa, the Cuban government policy of what it calls "selfless assistance without conditions" and of non-interference in the overall policies of collaborating governments, which is at face value a potential strength, may in practice prove a significant limitation as regards change.

Margaret Blunden is Emeritus Professor of the University of Westminster, UK. She has published widely in the fields of international relations and security studies, recently contributing to a new think-tank report on future relations with Cuba, Opting for engagement, produced by the Washington Office on Latin America.



Also read

Good Health! A review of !Salud! : the documentary film which provides personal testimony of the impact of Cuba's health programmes with the Gambia and South Africa as well as Honduras and Venezuela.


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Copyright for this work is held jointly between Margaret Blunden and the International Journal of Cuban Studies under a Creative Commons Attribution-NonCommercial-No Derivative 3.0 Licence
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