Public, private, or mixed? The Cubans deserve a quality healthcare system

One of the most revealing pieces of information from the ninth Report on the State of Social Rights in Cuba relates to how citizens believe health and education services should be provided. 66% prefer a mixed model, with both public and private participation; 21% opt for a solely public model, and 6% for a completely private one.

This 66% reflects a preference for a plurality of actors in the provision of services, where both the State and private entities can participate. In the health sector, these could include hospital and laboratory companies, cooperatives, religious organizations, foundations, and community entities.

This data challenges one of the symbolic pillars of the Cuban socialist system: the identification between universality and state monopoly, two ideas that the regime's discourse often presents as inseparable. However, that health and education are universal rights does not necessarily require that the state be their sole provider. Ensuring a right, financing it, and directly providing the service are different functions. The state can guarantee universal access and participate decisively in its financing without the need to directly manage all hospitals, clinics, or laboratories.

One particularly interesting piece of data is that support for the mixed model reaches 78% among Cubans aged 18 to 30, but drops to 53% among those over 70, although it remains the preferred option. Conversely, the preference for an exclusively public model is 12% among the young and 35% among the elderly. As with other issues analyzed in our studies, younger generations show a weaker attachment to the historical positions of the regime. However, this does not appear to be a rejection of the state's role, but rather a different conception of that role: less as an exclusive provider and more as a guarantor of rights within a pluralistic system.

The health crisis

Article 72 of the socialist Constitution states that "public health is a right of all individuals and it is the responsibility of the State to ensure access, affordability, and quality of care, protection, and recovery services." However, the gap between this constitutional provision and the everyday reality of the system is immense. Let’s look at some of the findings gathered in our reports.

According to our 2024 study, 89% rated the public health system negatively: 61% "very negative" and 28% "negative." In the most recent report (2026), 82% assessed the state of hospitals and health centers as poor, while 13% rated it as fair. This level of disapproval places the sector among the most deteriorated public infrastructures, alongside electricity, garbage collection, internet, telecommunications, water supply, and sewage systems.

The state pharmacy also does not guarantee regular access to medications for a large segment of the population: the percentage of individuals who reported being able to access them without issues was between only 2% and 3% in the years 2024 and 2025.

Another relevant fact is that 40% of respondents in 2022 stated that they had to pay or give a gift to a healthcare professional to access or expedite a service, six points higher than in 2021, when this proportion was 34%.

Health has consistently emerged among the top five social issues identified by the population.

Addressing this crisis will require a complex effort: technical, financial, investment, and the recovery of human capital. The involvement of the private sector could provide capacity, technology, incentives, specialization, and better conditions to retain healthcare professionals in the country.

There are various proposals to reform the healthcare system during a reconstruction phase. These contain valuable elements and agree on the need to ensure universality, expand freedom of choice, attract investment, and diversify providers. However, those that grant a predominantly private role to healthcare provision require a deeper discussion about the balance between the market and public responsibility. The issue is not the existence of private providers, which will be necessary, but rather the assumption that market incentives alone will suffice to ensure truly universal territorial and social coverage.

A competitive market should not be seen as a demon, but it's equally important to recognize that companies operate, legitimately, based on profit criteria. This raises the question of what would happen in geographically remote, rural, or low-density areas, where the establishment and operation of certain health services may not be profitable.

In those areas, it is likely that the market alone will not provide a sufficient or competitive supply. The State would necessarily have to intervene to ensure healthcare access and guarantee that the place of residence or the economic viability of a service does not determine effective access to health.

Likewise, in countries where both public and private healthcare coexist, it is usually public hospitals that handle a significant portion of emergency cases—obligated to stabilize anyone regardless of their ability to pay—while also playing a crucial role in epidemiological monitoring and maintaining reserve capacity to respond to epidemics, disasters, and weather phenomena. The major challenge would be to ensure that the services of these hospitals meet the highest quality standards.

In any case, Cuba faces an unavoidable urgency: to secure resources for the healthcare system and use them strategically during a transition, while simultaneously building an institutional framework with a vision for permanence.

The new model could be organized around a common public funder that gathers and distributes resources to ensure universal coverage based solely on clinical need, without discrimination based on income, employment, age, or pre-existing conditions. Care would be provided through a territorial network of primary care, with free choice of physician and participation from public entities, cooperatives, mutual organizations, community groups, religious organizations, non-profits, and private entities, all subject to common rules of quality, transparency, and regulated competition. Mutual organizations and voluntary insurance could offer supplementary coverage.

For its part, the State should have the non-delegable responsibility to ensure urgent care, rural health services, epidemiological surveillance, disaster response, and the treatment of complex patients.

The goal should not be to replace an inefficient state monopoly with a rule-free market, but to build a pluralistic, sustainable, and regulated system, where health is a universal right and the involvement of various providers helps to expand capacity, improve quality, and restore public trust.