Healthcare in Cuba

The Cuban government operates a national health system and assumes fiscal and administrative responsibility for the health care of all its citizens. There are no private hospitals or clinics as all health services are government-run. The present Minister for Public Health is Roberto Morales Ojeda.
Like the rest of the Cuban economy, Cuban medical care suffered following the end of Soviet subsidies in 1991 and the stepping up of the United States embargo against Cuba at this time also had an effect.
History.
Modern Western medicine has been practiced in Cuba by formally trained doctors since at least the beginning of the 19th century and the first surgical clinic was established in 1823. Cuba has had many world class doctors, including Carlos Finlay, whose mosquito-based theory of yellow fever transmission was given its final proof under the direction of Walter Reed, James Carroll, and Aristides Agramonte. During the period of U.S presence (1898–1902) yellow fever was essentially eliminated due to the efforts of Clara Maass and surgeon Jesse William Lazear.
In the 1950s the number of doctors per thousand of the population ranked above Britain, France and the Netherlands. In Latin America it ranked in third place after Uruguay and Argentina.
There remained marked inequalities, however. Most of Cuba's doctors were based in the relatively prosperous cities and regional towns, and conditions in rural areas, notably Oriente, were significantly worse. The mortality rate was the third lowest in the world. According to the World Health Organization, the island had the lowest infant mortality rate of Latin America.
Following the Revolution and the subsequent United States embargo against Cuba, an increase in disease and infant mortality worsened in the 1960s. The new Cuban government asserted that universal healthcare was to become a priority of state planning. In 1960 revolutionary and physician Che Guevara outlined his aims for the future of Cuban healthcare in an essay entitled "On Revolutionary Medicine", stating: "The work that today is entrusted to the Ministry of Health and similar organizations is to provide public health services for the greatest possible number of persons, institute a program of preventive medicine, and orient the public to the performance of hygienic practices." These aims were hampered almost immediately by an exodus of almost half of Cuba's physicians to the United States, leaving the country with only 3,000 doctors and 16 professors in the University of Havana’s medical college. Beginning in 1960, the Ministry of Public Health began a program of nationalization and regionalization of medical services. In 1965, Cuba became the first Latin American country to legalize abortion.
In 1976, Cuba's healthcare program was enshrined in Article 50 of the revised Cuban constitution which states "Everybody has the right to health protection and care. The State guarantees this
right:
Cuba's doctor to patient ratio grew significantly in the latter half of the 20th century, from 9.2 doctors per 10,000 inhabitants in 1958, to 58.2 per 10,000 in 1999. In the 1960s the government implemented a program of almost universal vaccinations. This helped eradicate many contagious diseases including polio, tetanus, diphtheria and rubella, though some diseases increased during the period of economic hardship of the 1990s, such as tuberculosis, hepatitis and chicken pox. Other campaigns included a program to reduce the infant mortality rate in 1970 directed at maternal and prenatal care. As of 2012, infant mortality in Cuba had fallen to 4.83 deaths per 1,000 live births compared with 6.0 for the United States and just behind Canada with 4.8. Experts have however noted that these statistics may reflect heavy-handed treatment of pregnant patients or that the statistics may be falsified. One expert, for instance, notes that pregnant women may be forced to undergo abortions if fetal abnormalities are detected or forcibly placed under monitoring. Doctors also have incentives to falsify statistics, as a spike in infant mortality will cost them their jobs. Cuba does not allow for independent verification of its health data.
Post-Soviet Union.
Loss of Soviet subsidies brought food shortages to Cuba in the early 1990s. The famine during the Special Period was caused by an authoritarian regime that denied people the food to which they were entitled when the public food distribution collapsed; priority was given to the elite classes and the military. The regime did not accept donations of food, medicines and money from the US until 1993.
Epidemiologist Manuel Franco describes the Special Period as "the first, and probably the only, natural experiment, born of unfortunate circumstances, where large effects on diabetes, cardiovascular disease and all-cause mortality have been related to sustained population-wide weight loss as a result of increased physical activity and reduced caloric intake".
In 2007, Cuba announced that it has undertaken computerizing and creating national networks in blood banks, nephrology and medical images. Cuba is the second country in the world with such a product, only preceded by France. Cuba is preparing a computerized health register, hospital management system, primary health care, academic affairs, medical genetic projects, neurosciences, and educational software. The aim is to maintain quality health service free for the Cuban people, increase exchange among experts and boost research-development projects. An important link in wiring process is to guarantee access to Cuba's Data Transmission Network and Health Website (INFOMED) to all units and workers of the national health system.
United States embargo.
During the 1990s the ongoing United States embargo against Cuba caused problems due to restrictions on the export of medicines from the US to Cuba. In 1992 the US embargo was made more stringent with the passage of the Cuban Democracy Act resulting in all U.S. subsidiary trade, including trade in food and medicines, being prohibited. The legislation did not state that Cuba cannot purchase medicines from U.S. companies or their foreign subsidiaries; however, such license requests have been routinely denied. In 1995 the Inter-American Commission on Human Rights of the Organization of American States informed the U.S. Government that such activities violate international law and has requested that the U.S. take immediate steps to exempt medicine from the embargo. The Lancet and the British Medical Journal also condemned the embargo in the 90s.
The embargo forced Cuba to use more of its limited resources on medical imports, both because equipment and drugs from foreign subsidiaries of U.S. firms or from non-U.S.sources tend to be higher priced and because shipping costs are greater. The Democracy Act of 1992 further exacerbated the problems in Cuba's medical system. It prohibited foreign subsidiaries of U.S. corporations from selling to Cuba, thus further limiting Cuba's access to medicine and equipment, and raising prices. In addition, the act forbid ships that dock in Cuban ports from docking in U.S. ports for six months. This drastically restricted shipping, and increased shipping costs some 30%.
In 2000, the "Trade Sanctions Reform and Export Enhancement Act" was passed. The US is now Cuba's single largest source for imported food. The Cuban American National Foundation (CANF) states that should Cuba choose not to purchase from the U.S., it can purchase any medicine or medical equipment it needs from other countries. Such third-country transactions only cost an estimated 2%–3% more than purchases from the U.S. as a result of higher shipping costs. CANF also asserts the United States is the largest donor of humanitarian assistance to Cuba and much of this consists of medicines and medical equipment.
The US government states that since 1992, 36 out of 39 license requests from U.S. companies and their subsidiaries for sales of medical items to Cuba have been approved. The dollar amount of these sales is over $1,600,000. Furthermore, the U.S. government licensed more than $227 million in humanitarian donations of medicines and medical supplies to Cuba between 1993 and 1997. There are other factors beside the embargo explaining the lack of imports, in particular Cuba's lack of hard currency. Those with dollars can easily buy medicines and food in Cuba from Latin America and Canada. Cuba defaulted on its debt to Western banks in 1986 and lacks access to the international credit system in order to get foreign currency. In addition, the collapse of the Soviet Union caused the loss of several billions of dollars in yearly subsidies and overnight required hard currency for all imports.
In a 2006 report to the U.N. Secretary-General, Cuba acknowledged the authorization of medicines, though stated that they were subject to severe restrictions and complicated procedures. Cuba is obliged to make payments in cash and in advance, and is precluded from obtaining credit funding, even from private sources. The sale and transportation of the goods require licenses to be obtained for each transaction. Cuba cannot use its own merchant fleet for transporting these goods, but has to make use of vessels from third countries, primarily the United States. Payments are made through banks in third countries, since direct banking relationships are prohibited. The Cuban delegation concluded that restrictions on importing medical products were "so extensive that they make such imports virtually impossible". The World Health organization/PAHO and UNFPA concurred that it was impossible for Cuba to purchase equipment, medicines and laboratory materials produced by the United States or covered by United States patents, even though those products were purchased through multilateral cooperation. Cuba was not able to purchase the isotope I-125 that is used to treat eye cancer in children. The companies manufacturing reagents and equipment are 70 per cent United States owned, which makes it difficult to purchase necessary medical equipment and other items.
Present.
National health system.
Cuba's national health system is made up of multiple tiers: 1) the community containing individuals and families, 2) family doctor-and-nurse teams, 3) basic work teams, 4) community polyclinics, 5) hospitals, and 6) medical institutes.
Cuba's Family Physician and Nurse program is made up of physician and nurse teams that serve individuals, families, and their communities. They live above their government-built family medicine offices, living directly in the communities they serve and available 24 hours a day. These teams work to improve the public health concerns in the environment as well as provide medical care. They perform a neighborhood health diagnosis biannually where community risk factors are evaluated to focus priorities for improving the health of the community. Clinically, family doctor-and-nurse teams follow the Continuous Assessment and Risk Evaluation (CARE) method which monitors individual and family health by examining community and home environments, current health, and medical history. The teams make home visits to each family at least once yearly to assess and evaluate their health. Individuals with chronic illness are seen at least every three months. These teams' role combine the importance of focusing on both public health and clinical medicine.
Polyclinics are community-based clinics that house primary care specialists. They exist in every Cuban community and are well-acquainted with the people and the communities they serve. They can see the social determinants and environment that affect the community's health, bettering their ability to serve their patients. Specialists at the polyclinic are there to support physicians when they are needed. Each clinic of specialists supports 20-40 doctor-and-nurse teams. Basic work teams within the polyclinics supervise and evaluate the neighborhood and clinical health work of the family medicine offices.
While preventive medical care, diagnostic tests and medication for hospitalized patients are free, some aspects of healthcare are paid for by the patient. Items which are paid by patients who can afford it are: drugs prescribed on an outpatient basis, hearing, dental, and orthopedic processes, wheelchairs and crutches. When a patient can obtain these items at state stores, prices tend to be low as these items are subsidized by the state. For patients on a low-income, these items are free of charge.
Like the rest of the Cuban economy, numerous reports have shown that Cuban medical care has long suffered from severe material shortages caused by the US embargo. The ending of Soviet subsidies in the early 1990s has also affected it.
Alternative healthcare.
Economic constraints and restrictions on medicines have forced the Cuban health system to incorporate alternative and herbal solutions to healthcare issues, which can be more accessible and affordable to a broader population In the 1990s, the Cuban Ministry of Public Health officially recognized natural and traditional medicine and began its integration into the already well established Western medicine model.
Health statistics.
 All statistics from World Health Organization figures. 
Cuba had 128 physicians and dentists per 100,000 people in 1957. This was comparable to the levels in many European countries and allegedly the highest in Latin America. In 1986, Cuba had 219 doctors per 100,000 people (compared with 423.7 doctors in the Soviet Union, which had the most doctors among industrialized countries). In 2005, Cuba had 627 physicians and 94 dentists per 100,000 population. That year the United States had 225 physicians and 54 dentists per 100,000 population; the Central American isthmus had 123 physicians and 30 dentists per 100,000. As of 2005, Cuba became the world leader in the ratio of doctors to population with 67 doctors per 10,000 population as compared with 43 in the Russian Federation and 24 in the United States.
Abortion rates, which are high in Cuba, increased dramatically during the 1980s, but had almost halved by 1999 and declined to near-1970s levels of 32.0 per 1000 pregnancies. The rate is still among the highest in Latin America. The abortion rate in Cuba is 72.8 per 100 births. 
Sexual health.
According to the UNAIDS report of 2003 there were an estimated 3,300 Cubans living with HIV/AIDS (approx 0.05% of the population). In the mid-1980s, when little was known about the virus, Cuba compulsorily tested thousands of its citizens for HIV. Those who tested positive were taken to Los Cocos and were not allowed to leave. The policy drew criticism from the United Nations and was discontinued in the 1990s. Since 1996 Cuba began the production of generic anti-retroviral drugs reducing the costs to well below that of developing countries. This has been made possible through the substantial government subsidies to treatment.
In 2003 Cuba had the lowest HIV prevalence in the Americas and one of the lowest in the world. Education in Cuba concerning issues of HIV infection and AIDS is implemented by the Cuban National Center for Sex Education.
According to a 2005 report by UNAIDS and the World Health Organization, "Cuba’s epidemic remains by far the smallest in the Caribbean." They add however that,
... new HIV infections are on the rise, and Cuba’s preventive measures appear not to be keeping pace with conditions that favour the spread of HIV, including widening income inequalities and a growing sex industry. At the same time, Cuba’s prevention of mother-to-child transmission programme remains highly effective. All pregnant women are tested for HIV, and those testing positive receive antiretroviral drugs.
In 2015, Cuba became the first country in the world to eliminate mother-to-child transmission of HIV and syphilis, a major public health accomplishment.
In recent years because of the rise in prostitution in Cuba due to tourism, STDs have increased.
Training doctors.
Cuba's healthcare system persists, in part, due to its medical education system. In Cuba, the medical university is not a separate entity from health services, but it exists within the system. Medical and nursing students mentor and intern within the national system from the first years of their training, specifically within primary care facilities rather than hospitals. This creates a community-based teaching method rather than a typical hospital-based teaching method. Primary care, being the first level of contact to a patient, is closely located to the patient's home and work. Here, students are exposed to medicine and the social, economical, and political factors that influence health. At primary care facilities, ethics and values are a taught as a large part of the Cuban healthcare system alongside science and technology. Students graduate capable of resolving health issues and knowing when to report to a person higher in the healthcare pyramid. Students graduate with a commitment to providing and preserving quality and equity within healthcare for their communities. The largest medical university in the world exists in Cuba, the Latin American School of Medicine.
Cuba and international healthcare.
Cuba provides more medical personnel to the developing world than all the G8 countries combined. In the 1970s, the Cuban state initiated bilateral service contracts and various money-making strategies. Cuba has entered into agreements with United Nations agencies specializing in health: PAHO/WHO, UNICEF, the United Nations Food and Agriculture Organization (FAO), the United Nations Population Fund (UNFPA) and the United Nations Development Fund (UNDP). Since 1989, this collaboration has played a very important role in that Cuba, in addition to obtaining the benefits of being a member country, has strengthened its relations with institutions of excellence and has been able to disseminate some of its own advances and technologies
Cuban doctors have been part of a large-scale plan by the Cuban state to provide free medical aid and services to the international community (especially third world countries) following natural disasters. Currently dozens of American medical students are trained to assist in these donations at the Escuela Latino Americana de Medicina (ELAM).
Cuba's missions in 68 countries are manned by 25,000 Cuban doctors. Medical teams have worked in crisis such as the South Asian tsunami and the 2005 Kashmir earthquake. Nearly 2,000 Cuban doctors are currently working in Africa in countries including South Africa, Gambia, Guinea Bissau and Mali. Since the Chernobyl nuclear plant exploded in 1986, more than 20,000 children from Ukraine, Belarus and Russia have traveled to Cuba for treatment of radiation sickness and psychologically based problems associated with the radiation disaster. In response to the 2005 Hurricane Katrina disaster, Castro offered to send a "brigade" of 1,500 doctors to the U.S. to provide humanitarian aid, but the U.S. never accepted.
Cuba currently exports considerable health services and personnel to Venezuela in exchange for subsidized oil. Cuban doctors play a primary role in the Mission Barrio Adentro (Spanish: "Mission Into the Neighborhood") social welfare program established in Venezuela under former Venezuelan president Hugo Chávez.
Cuba also successfully exports many medical products, such as vaccines.
Health tourism.
Cuba attracts about 20,000 paying health tourists, generating revenues of around $40 million a year for the Cuban economy. Cuba has been serving health tourists from around the world for more than 20 years. The country operates a special division of hospitals specifically for the treatment of foreigners and diplomats. Foreign patients travel to Cuba for a wide range of treatments including eye-surgery, neurological disorders such as multiple sclerosis and Parkinson's disease, cosmetic surgery, addictions treatment, retinitis pigmentosa and orthopaedics. Most patients are from Latin America, Europe and Canada, and a growing number of Americans also are coming. By 1998, according to the Economic Commission for Latin America and the Caribbean, the Cuban health sector had risen to occupy around 2 percent of total tourism. Some of these revenues are in turn transferred to health care for ordinary Cubans, although the size and importance of these transfers is both unknown and controversial. At one nationally prominent hospital/research institute, hard currency payments by foreigners have financed the construction of a new bathroom in the splenic surgery wing; anecdotal evidence suggests that this pattern is common in Cuban hospitals.
Medical research.
The Cuban Ministry of Health produces a number of medical journals including the ACIMED, the Cuban Journal of Surgery and the Cuban Journal of Tropical Medicine. MEDICC Review is an English language journal which works to bring Cuban medical and public health policy, research, programs, and outcomes to the attention of the global health community. Because the U.S. government restricts investments in Cuba by U.S. companies and their affiliates, Cuban institutions have been limited in their ability to enter into research and development partnerships, although exceptions have been made for significant drugs.
The Center of molecular immunology (CIM) developed nimotuzumab, a monoclonal antibody used to treat cancer. Nimotuzumab is an inhibitor of epidermal growth factor receptor (EGFR), which is over-expressed in many cancers. Nimotuzumab is now being developed with international partners.
In April 2007, the Cuba IPV Study Collaborative Group reported in the New England Journal of Medicine that inactivated (killed) poliovirus vaccine was effective in vaccinating children in tropical conditions. The Collaborative Group consisted of the Cuban Ministry of Public Health, Kourí Institute, U.S. Centers for Disease Control and Prevention, Pan American Health Organization, and the World Health Organization. This is important because countries with high incidence of polio are now using live oral poliovirus vaccine. When polio is eliminated in a country, they must stop using the live vaccine, because it has a slight risk of reverting to the dangerous form of polio. The collaborative group found that when polio is eliminated in a population, they could safely switch to killed vaccine and be protected from recurrent epidemics. Cuba has been free of polio since 1963, but continues with mass immunization campaigns.
In the 1980s, Cuban scientists developed a vaccine against a strain of bacterial meningitis B, which eliminated what had been a serious disease on the island. The Cuban vaccine is used throughout Latin America. After outbreaks of meningitis B in the United States, the U.S. Treasury Department granted a license in 1999 to an American subsidiary of the pharmaceutical company SmithKline Beecham to enter into a deal to develop the vaccine for use in the U.S. and elsewhere
Contrasting views on Cuba's health system.
The issue of the effectiveness of the Cuban health system is politically polarized. According to William Ventres in his review of five books about Cuba's medical system (including one by Katherine Hirschfeld; see below), it is "difficult to make sense of the reality of Cuban health care."
Praise.
In 2006, BBC flagship news programme "Newsnight" featured Cuba's Healthcare system as part of a series identifying "the world's best public services". The report noted that "Thanks chiefly to the American economic blockade, but partly also to the web of strange rules and regulations that constrict Cuban life, the economy is in a terrible mess: national income per head is minuscule, and resources are amazingly tight. Healthcare, however, is a top national priority" The report stated that life expectancy and infant mortality rates are nearly the same as the USA's. Its doctor-to-patient ratios stand comparison to any country in Western Europe. Its annual total health spend per head, however, comes in at $251; just over a tenth of the UK's. The report concluded that the population's admirable health is one of the key reasons why Castro is still in power. A 2006 poll carried out by the Gallup Organization's Costa Rican affiliate — Consultoría Interdisciplinaria en Desarrollo (CID) — found that about three-quarters of urban Cubans responded positively to the question "do you have confidence to your country's health care system".
In 2000, Secretary General of the United Nations Kofi Annan stated that "Cuba should be the envy of many other nations" adding that achievements in social development are impressive given the size of its gross domestic product per capita. "Cuba demonstrates how much nations can do with the resources they have if they focus on the right priorities – health, education, and literacy."
The Kaiser Family Foundation, a non-governmental organization that evaluated Cuba's healthcare system in 2000-1 described Cuba as "a shining example of the power of public health to transform the health of an entire country by a commitment to prevention and by careful management of its medical resources" President of the World Bank James Wolfensohn also praised Cuba's healthcare system in 2001, saying that "Cuba has done a great job on education and health", at the annual meeting of the Bank and the International Monetary Fund. Wayne Smith, former head of the US Interests Section in Havana identified "the incredible dedication" of Cubans to healthcare, adding that "Doctors in Cuba can make more driving cabs and working in hotels, but they don't. They're just very dedicated". Dr. Robert N. Butler, who was president of the International Longevity Center in New York and a Pulitzer Prize-winning author on aging, traveled to Cuba to see firsthand how doctors were trained. He said a principal reason that some health standards in Cuba approach the high American level is that the Cuban system emphasizes early intervention. Clinic visits are free, and the focus is on preventing disease rather than treating it. Furthermore, London's "The Guardian" newspaper lauded Cuba's public healthcare system for what it viewed as its high quality in a September 12, 2007 article.
In 2001, members of the UK House of Commons Health Select committee travelled to Cuba and issued a report that paid tribute to "the success of the Cuban healthcare system", based on its "strong emphasis on disease prevention" and "commitment to the practice of medicine in a community".
The Parliament of the United Kingdom also drew up an analysis of the key features of Cuba's healthcare system, drawing comparisons with the state funded National Health Service (NHS). The overall conclusion was that many of the features identified would not have occurred had there not been an obvious commitment to health provision demonstrated by the protection and proportion of the budget given the health care. The study concluded the following.
Margaret Chan, former director of the World Health Organization, recommended other countries follow Cuba's example in health care.
Criticism.
The preceding study also pointed to problems within Cuba's health system, including:
Katherine Hirschfeld, an anthropology professor at the University of Oklahoma, did her Ph.D. thesis on the Cuban health system, spending nine months conducting ethnographic work in Cuba in the late 1990s. According to Hirschfeld, "public criticism of the government is a crime
in Cuba", which means that "formally eliciting critical narratives about health care would be viewed as a criminal act both for me as a researcher, and for people who spoke openly with me". Nevertheless, she was able to hear from many Cubans, including health professionals, "serious complaints about the intrusion of politics into medical treatment and health care decision-making". She points out that "there is no right to privacy in the physician-patient relationship in Cuba, no patients’ right of informed consent, no right to refuse treatment, and no right to protest or sue for malpractice". In her view medical care in Cuba can be dehumanizing.
Complaints have also arisen that foreign "health tourists" paying with dollars and senior Communist party officials receive a higher quality of care than Cuban citizens. Former leading Cuban neurosurgeon and dissident Dr Hilda Molina asserts that the central revolutionary objective of free, quality medical care for all has been eroded by Cuba's need for foreign currency. Molina says that following the economic collapse known in Cuba as the Special Period, the Cuban Government established mechanisms designed to turn the medical system into a profit-making enterprise. This creates an enormous disparity in the quality of healthcare services between foreigners and Cubans leading to a form of tourist apartheid. In 1998 she said that foreign patients were routinely inadequately or falsely informed about their medical conditions to increase their medical bills or to hide the fact that Cuba often advertises medical services it is unable to provide. Others makes similar claims, also stating that senior Communist party and military officials can access this higher quality system free of charge. In 2005, an account written by Cuban exile and critic of Fidel Castro, Carlos Wotzkow, appeared showing apparent unsanitary and unsafe conditions in the "Clínico Quirúrgico" of Havana; the article claims that health care for Cubans occurs in worse conditions in the rest of the country.
A recent ABC-TV 20/20 report on Healthcare, based on footage taken from within the island, criticized Michael Moore's portrayals of the Cuban Healthcare system in the movie Sicko. In that film, Moore took a number of Americans to a hospital in Havana where they bought affordable drugs, and were given treatments for free that they could not afford in America. The report highlights the dilapidated conditions of some hospitals that are accessible to regular Cubans by pointing to the bleak conditions of hospital rooms and the filthy conditions of the facilities. The report also addressed the quality of care available to Cubans by arguing that patient neglect was a common phenomenon. Finally, in discussing the infant mortality rate, the report highlights the government's alleged efforts to promote abortions of potentially infirm fetuses and other alleged government efforts to manipulate the rate.
Cuban medical professionals are not paid high salaries by international standards. In 2002 the mean monthly salary was 261 pesos, 1.5 times the national mean.
A doctor's salary in the late 1990s was equivalent to about US$15–20 per month in purchasing power. Therefore, some prefer to work in different occupations, for example in the lucrative tourist industry where earnings can be much higher.
Cuban doctors that have been sent on international missions by the Cuban government have reported being paid less than the local doctors and treated poorly by the local government. They are sometimes monitored by the local government in case of defecting. The "San Francisco Chronicle", the "Washington Post", and National Public Radio have all reported on Cuban doctors defecting to other countries when on international missions. Cuban doctors at home have experienced an increased work-load to cover for the doctors abroad, although there is no evidence that this has negatively affected health outcomes.
A 2020 study using a synthetic control method found that infant mortality increased in the first years of the Castro regime relative to other similar countries, but that infant mortality reverted to trend during the 1970s irrespective of foreign aid.
Black market healthcare.
The difficulty in gaining access to certain medicines and treatments has led to healthcare playing an increasing role in Cuba's burgeoning black market economy, sometimes termed "sociolismo". According to former leading Cuban neurosurgeon and dissident Dr Hilda Molina, "The doctors in the hospitals are charging patients under the table for better or quicker service." Prices for out-of-surgery X-rays have been quoted at $50 to $60. Such "under-the-table payments" reportedly date back to the 1970s, when Cubans used gifts and tips in order to get health benefits. The harsh economic downturn known as the "Special Period" in the 1990s aggravated these payments. The advent of the "dollar economy", a legalization of the dollar which led some Cubans to receive dollars from their relatives outside of Cuba, meant that a class of Cubans were able to obtain medications and health services that would not be available to them otherwise.