HAVANA – Cuba's system of free medical care, long considered a birthright by its citizens and trumpeted as one of the communist government's great successes, is not immune to cutbacks under Raul Castro's drive for efficiency.
The health sector has already endured millions of dollars in budget cuts and tens of thousands of layoffs, and it became clear this month that Castro is looking for more ways to save when the newspaper voice of the Communist Party, Granma, published daily details for two weeks on how much the government spends on everything from anesthetics and acupuncture to orthodontics and organ transplants.
It's part of a wider media campaign that seems geared to discourage frivolous use of medical services, to explain or blunt fears of a drop-off in care and to remind Cubans to be grateful that health care is still free despite persistent economic woes. But it's also raising the eyebrows of outside analysts, who predict further cuts or significant changes to what has been a pillar of the socialist system implanted after the 1959 revolution.
"Very often the media has been a leading indicator of where the economic reforms are going," said Phil Peters, a longtime Cuba observer at the Lexington Institute think tank. "My guess is that there's some kind of policy statement to follow, because that's been the pattern."
The theme of the Granma pieces, posters in clinics and ads on state TV is the same: "Your health care is free, but how much does it cost?"
The answer is, not much by outside standards, but quite a bit for Cuba, which spends $190 million a year paying for its citizens' medical bills.
Based on the official exchange rate, the government spends $2 each time a Cuban visits a family doctor, $4.14 for each X-ray and $6,827 for a heart transplant.
It's not a luxury service though. Scarcities now are common and sanitary conditions fall short of the ideal in decaying facilities where paint peels from the walls. Patients often bring their own bed sheets, electric fans, food and water for hospital stays.
One Havana-based clinical physician applauded the campaign, saying it targets a pervasive problem: Conditioned to think about health as an inalienable right, many Cubans rush to the hospital whenever they come down with a cough or the sniffles, demand expensive tests before they've even been examined and sometimes get aggressive if doctors refuse.
"Respect for doctors has entirely been lost," he said. "Some will indulge a patient for fear of how they might react."
The physician spoke on condition of anonymity because he was not authorized to discuss health care with a foreign journalist. Interview requests were not granted by the Health Ministry, though a spokeswoman said in a brief email response that the costs in Granma were the result of careful study.
The fact that the figures were published at all suggests a sea change in conceptions about health care, said Nancy Burke, director of the Cuba Program in Health Diplomacy at the University of California, San Francisco.
"It's interesting that the health care system, which has always been touted as a basic human right, is now being put into market terms," said Burke, a medical anthropologist who makes yearly research trips to Cuba. "That says so much about Raul's market reforms and the ideology ... informing that. It's a real shift, a major shift in the way of thinking about health care."
She noted that the island's doctors are increasingly cash cows for Cuba as it sends them abroad to treat the poor in countries such as Venezuela. The international missions fulfill a humanitarian purpose but also offset a significant share of the $28.5 billion in cash and subsidized oil that the South American nation has sent Cuba since 2005, according to Venezuelan opposition lawmaker Julio Borges, who says he uses public records to track the figure.
To cut costs in Cuba, state media have urged doctors to use their "clinical eye" before ordering pricey lab tests, and target the practice of people stockpiling medicine to carry them through shortages.
In one TV spot, a woman visits a doctor and requests a long list of pills. Asked why she needs so many, she replies: "Oh, doctor, it's for my personal stash."
"I stop cold when I see that, not knowing whether to laugh or cry," blogger Greter Torres Vazquez wrote on a Cuban youth-issues website. "Maybe they've never had the experience of going to the pharmacy and asking for medicine that their aunt, their grandmother, their mother needs urgently, only for the worker to say 'Sorry, we ran out five minutes ago.'"
Some seized on the campaign to complain about corruption in hospitals.
"They should also publish the miserable salary that doctors get paid; that's an embarrassment," said Maria Soto, a 62-year-old Havana resident. "And it's serious, because it leads to the problems everyone knows about: You get bad service or, even worse, they charge you under the table."
Cuban authorities continuously brag about keeping health care free and universal despite its lightweight economy and the 50-year-old U.S. embargo.
Experts credit the government's emphasis on prevention and doctor-patient relationships for life expectancy and infant mortality rates that are on par with those of wealthy nations. Medical schools churn out huge graduating classes; every last one of Cuba's 11 million citizens is supposed to get a house call at least once a year.
Charging for care would be a dramatic and unlikely about-face, but with 15 percent of the budget devoted to health, Havana sees no choice but to make the system more efficient wherever it can.
After steadily rising over five decades to hit $206 million in 2009, health spending has dropped, slipping to $190 million last year, according to government figures. Officials hint at more cuts to come.
These days, authorities rail against "irrational expenses" and have slashed more than 50,000 less-skilled health-sector jobs, singling out overstaffed clinics and ambulances with multiple drivers.
Some Cubans say hospital wait times seem to be on the rise and medicine, equipment and soap are increasingly in short supply.
The clinical doctor consulted by the AP said neither scarcity nor complaints have worsened, though doctors still suffer heavy case loads and low pay, about $25 a month.
Cuba is walking a delicate line on health: Too much change could be seen in some camps as a betrayal of the socialist contract. Too little may not ease the burden on a strained economy, said Sergio Diaz-Briquets, a U.S.-based demographer and author of "The Health Revolution in Cuba.
"It is maybe a universal phenomenon that health care systems are expensive," he said, "but Cuba perhaps cannot afford to have the kind of services that they claim to have had in the past."
Associated Press writers Andrea Rodriguez and Anne-Marie Garcia contributed to this report.
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