Written by Jonathan Broad (MBChB, MClinEd), Research Associate in Social and Community Medicine, University of Bristol. Jonathan Broad has an interest in global health and the social circumstances, particularly in childhood, which underpin lifelong health inequalities.
I read with great interest Sundari Ravindran’s call for advocacy against neoliberal globalisation and its damaging effect on reproductive health through inaccessible health services, economic inequality and food insecurity (RHM May 2014). During my recent medical placement in maternity services in Cuba I observed a strong example of equitable and just health planning that is much needed to realise universal reproductive health, and runs counter to the commercialisation that has dominated health policy discussions since the 1980s.
Universal reproductive health services in the community
Neoliberal doctrine reduces state provision in favour of the private sector, which tends to discourage access and encourage specialised services.  An early priority of the Cuban revolution was to create universal, publicly funded healthcare at the community level, particularly in areas that had little access to healthcare. The government massively expanded primary care, focusing on the ‘polyclinic’, an interdisciplinary centre combining 22 services, including reproductive health care alongside general medical care, social work and dentistry. These community-based services are the bedrock of reproductive health care in Cuba, advising on family planning, providing free access to contraception, antenatal care, health promotion and perinatal screening. They also coordinate early abortions, which are legal, safe and free in Cuba in contrast to other countries in Latin America. 
Family doctors are emotionally and geographically close to their patients, often living in small clinics and visiting patients in their homes in bi-annual neighbourhood health checkups. This personal relationship allows family doctors to support women to be healthy in preparation for pregnancy, and it was heartwarming to see the emotional proximity of these doctors to couples preparing to start families. This is a feature of primary care, but particularly in a country with less difference in socioeconomic status between patient and doctor.
Maternal health promotion, not profit
Preventative maternal and reproductive health care is of paramount importance in Cuba, supporting women to be healthy before conception; and promoting a healthy pregnancy. A particularly impressive demonstration of this are their residential maternity services, called casas de mujeres, or women’s houses. These services were originally designed for rural families who, prior to the revolution, had little access to health care. Their success in improving skilled birth attendance for rural populations was subsequently expanded to incorporate any families at risk during pregnancy. If a woman is anaemic, underweight, a teenager, or if her family has any financial or social difficulties, the government provides free accommodation, with an in-house cook, doctor, nurse, transport and security, all provided through public money.  When the resident doctor is unable to manage a risk factor, for example if the woman has anaemia that is unresponsive to treatment, they coordinate treatment with the local hospital.
The impact of this goes beyond reproduction towards population health. By investing in early life and encouraging women’s pregnancies to be as healthy as possible, Cuba avoids the lifelong burdens associated with early deprivation, a problem that plagues countries with high levels of poverty and economic inequality, where a child’s social status has lifelong impacts on their health, from increased risk of conditions such as metabolic disorders and heart disease.
Popular education and health knowledge
Despite an ongoing economic blockade of medicines and health care technology, births take place in hospitals with safe conditions and adequate provision. Whereas western countries favour patented medications, Cuba has a large publicly owned pharmaceutical sector that is a producer of high quality generic medications for countries in the global south.  Indeed, it has been a strong advocate for the essential medicines campaign to provide a basic formulary of medicines that should be available, affordable and without patents. Health services therefore serve the public good, rather than profit pharmaceutical companies and serve the minority that can afford expensive health costs.
Cuba provides public access to health knowledge and educational opportunity by subsidising medical training for its population and for health care students from other countries, even paying students a monthly stipend and providing accommodation. Consequently, Cuba has a large numbers of doctors per population and provides other countries with the means to run their own health care systems as well.  This is in contrast to medical aid, which is short-term, may be conditional on private sector provision and is often tied to neoliberal trade policies . [7,8] In proverbial terms, you can give a man a fish to make him dependent on you and then speculate on fish prices or like Cuba you can teach him to fish and provide him with a net.  From providing non-patented, affordable essential medicine and health technology to free education for health care students, knowledge is used for community interest and public health.
Towards reproductive health equalities
Cuba has so far resisted neoliberalism, and its reproductive health
indicators, e.g. very low maternal mortality ratios, rival countries with larger, more industrialised economies in the global North.  I believe that economics based on principles of equity and justice are a viable and better alternative for reproductive health than neoliberal policy and market forces.
Yours sincerely, Jonathan Broad
AcknowledgementsThanks to Dr Siassakos and Dr Jewell for their supervision of the project. My rotation in reproductive and community health was kindly funded by the Wellbeing of Women foundation, the RCGP Severn Faculty, and the Faculty of Public Health.
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