Introduction
The above quote is from a movie where an Iowa farmer builds a baseball diamond in a cornfield that ultimately attracts the greatest legends of the American game. Later, in the business world, this sentiment came to refer to the idea that if you make an investment and produce a quality product, people will come, use it, and (of course) pay for it. Somewhat ironically, the analogy is in some respects also applicable to Cuba where baseball is the island’s national sport and where the architects of the Revolution have built a public health system that rivals, and in some respects surpasses, that of some of the world’s most developed countries. Consider, for example, the following statistics (Table 1):
Comparative Public Health Data, 2024
| Cuba | US | |
|---|---|---|
| Life expectancy | 79.33 | 79.25 |
| Infant mortality rate (per 1,000 live births) | 4.027 | 5.342 |
| Doctors per capita (1,000) | 84.3 (ranked highest in the world) | 35.6 |
These remarkable results for a small developing country have been achieved within the context of a national public health system where all services and related support elements (e.g., pharmaceuticals) are available to all citizens completely free of most charges. In short, the island’s approach to public health mirrors that of the most progressive countries of the world.
A key component contributing to Havana’s medical achievements is the world-class programme that it has developed in the area of pharmaceutical research and development (R&D). The scope of these activities (circa 2018) can be briefly summarised as follows:
Cuba started biotech research and production as early as 1982 … Cuba’s Center for Biological Research, producing both natural and recombinant interferons, opened in January 1982 … Today, Cuba’s globally recognised BioCubaFarma Enterprise Group consists of 31 enterprises and eight commercial companies with over 20,000 employees and 62 manufacturing facilities. (Evans et al. 2018: 36)
These enterprises have made significant strides in developing vaccines and other medications/treatments in a wide range of high-profile and challenging areas (some examples being various cancers, meningitis, COVID-19, Alzheimer’s, diabetic foot ulcers, dengue, and hepatitis B).
In addition to building an impressive public health system, Cuba has also made a major effort in recent years to develop its tourism infrastructure. This was not, however, always the case. When they came to power, the Fidelistas were not particularly friendly toward the industry, since it had a very unsavoury reputation based on its widespread corruption, criminality, and foreign control (i.e. the US Mafia was heavily involved in various sectors thereof such as gambling, prostitution, and other unpleasant activities, which they promoted to American tourists). Indeed, as a result of the revolutionary government’s efforts to clean things up, Cuban tourism to a great extent withered on the vine. However, given the demise of the Soviet bloc and of the island’s highly favourable economic relations with it, Havana needed to find new sources of revenue (especially hard currency). A rejuvenated tourism industry was one of its major responses to this problem. Table 2 represents its recent pre-COVID-19 performance while Table 3 focuses on its post-COVID-19 record.
Cuban Tourism Data
| 2014 | 2015 | 2016 | 2017 | 2018 | 2019 | |
|---|---|---|---|---|---|---|
| Total visitors | 3,013,584 | 3,540,175 | 4,009,169 | 4,653,559 | 4,711,910 | 4,275,558 |
| Total revenues (Millions of convertible pesos) | 2,546.1 | 2,818.6 | 3,068.6 | 3,301.7 | 2,782.2 | 2,645.1 |
Source: ONEI (2020: Capítulo 15, Turismo).
Covid and Post-Covid Cuban Tourism Data
| 2019 | 2020 | 2021 | 2022 | 2023 | 2024 (thru April) | |
|---|---|---|---|---|---|---|
| Total Visitors | 4,275,558 | 1,085,920 | 356,470 | 1,614,087 | 2,436,980 | 1,024,396 |
Source: Tourism Analytics (2024).
Taking all of the above considerations into account, it would certainly appear that Cuba has laid a firm foundation upon which it can build a competitive programme of medical tourism with the potential not only to provide an alternative source of health services to people from countries where they are not readily available or where the costs are prohibitive (e.g. the United States), but also which can contribute to Havana’s pool of hard currency which is needed to finance the island’s crucial imports (e.g. food) and to service its foreign debts. As such, the following material will examine the following three facets of this topic: an overview of medical tourism, background information on medical tourism in Cuba, and challenges and prospects for Cuban medical tourism.
An overview of medical tourism
Most people are not aware that tourism is, in its broadest sense, one of the biggest industries in the world. However, it is markedly different from most other international businesses because there is not one clear product line involved. Instead, tourism encompasses many distinct enterprises, including lodging, transport, attractions, travel companies, and more. This complicated and multifaceted nature makes it somewhat difficult to compare its ranking on the international scene to other more clearly defined businesses such as oil/petroleum or technology. Nevertheless, the following Table 4 provides a good indication of its elite status in the international hierarchy of major industries in the early 2000s, while Table 5 focuses on its evolving market performance over the past few years.
Direct Contribution of the Travel/Tourism Industry to the Global GDP Compared to Other Sectors
| Industry | 2011 | 2014 | 2014 | 2016 | ||||
|---|---|---|---|---|---|---|---|---|
| Rank | Interval | Rank | Interval | Rank | Interval | Rank | Interval | |
| Financial services | 1 | 4500–5000 | 1 | 5000–5500 | 1 | 4500–5000 | 2 | 4000–5000 |
| Communications | 3 | 2500–3000 | 2 | 3000–3500 | ||||
| Agriculture | 4 | 3000–3500 | 7 | 2000–3000 | ||||
| Mining | 2 | 2500–3000 | 3 | 3000–3500 | 3 | 3500–4000 | 8 | 1000–2000 |
| Banking | 4 | 2500–3000 | 6 | 2000–3000 | 9 | 500–1000 | ||
| Education | 4 | 2500–3000 | 5 | 2500–3000 | 5 | 2000–3000 | ||
| Travel and Tourism | 5 | 1500–2000 | 6 | 2000–2500 | 7 | 2000–3000 | 4 | 2000–3000 |
| Chemicals Manufacturing | 6 | 1000–1500 | 7 | 1500–2000 | 8 | 1000–2000 | 5 | 2000–3000 |
| Higher Education | 8 | 1000–1500 | ||||||
| Retail | 2 | 4000–5000 | 1 | 5000–6000 | ||||
| Automotive manufacturing | 7 | 500–1000 | 9 | 500–1000 | 9 | 500–1000 | 6 | 2000–3000 |
| Construction | 3 | 4000–5000 | ||||||
(Interval values are expressed in billions of US dollars).
Source: Bode and Corro (2018).
Market Size of the Tourism Sector Worldwide
| 2011 | 2013 | 2015 | 2017 | 2019 | 2020 | 2021 | 2022 | 2023 | 2024 (forecast) |
| 1.8 | 2.0 | 2.0 | 2.1 | 2.2 | 0.8 | 0.9 | 1.5 | 1.9 | 2.0 |
(trillions of US dollars).
Source: Statista (2024).
Within this broad constellation, medical tourism is definitely a somewhat minor niche activity. Indeed, most listings of the industry’s various components do not even mention it. Therefore, to provide some clarity to the subject, we will define medical tourism here as:
International travel where the main reason is to obtain medical or surgical treatment within a package which can also entail such tourism-related services as accommodations, travel, recreation, etc. which are available to the patient and/or relatives accompanying the patient. These elements, medical and otherwise, are usually provided within the context of specially built facilities that include modern hospitals as well as amenities common to a tourist resort.
The terms medical tourism and health tourism are often used interchangeably, but in fact they are distinct entities. Medical tourism, as noted above, focuses on providing surgical/pharmaceutical and related services, while health tourism concentrates on improving an individual’s health through such things as dietary reorientation, exercise, spa treatments, and even meditation.
Table 6 provides a basis for comparison, in terms of revenues and related indices, of medical tourism’s performances within the larger industry. Comparing the 2020 figures in Tables 4 and 5 indicates that medical tourism represents roughly a minuscule 1.88 per cent of tourism’s overall market size. While this fact might be discouraging to any country contemplating the possibility of becoming a player in this field, there are some countervailing considerations. Certainly a very important one, as indicated in line 3 of Table 6, is the extremely dynamic nature of medical tourism. A compound annual growth rate of 21 per cent is quite attractive. In addition, the ‘consumers’ tend to come from the most developed nations due to high healthcare costs or other factors, such as long wait times for surgical appointments or the nonavailability of medications due to complex bureaucratic approval procedures (e.g. it normally takes 8–10 years to get Federal Drug Administration approval for a new drug to be cleared for use in the United States). This means that the revenues involved will primarily be in hard currencies, which developing countries such as Cuba need to finance various crucial imports.
Medical Tourism Market Report Scope
| Report Attribute | Details |
|---|---|
| Market size value in 2020 | USD 54.4 billion |
| Revenue forecast in 2027 | USD 207.9 billion |
| Growth Rate | CAGR of 21.1% from 2020 to 2027 |
| Base year for estimation | 2019 |
Source: Radiant Insights (2020).
The acronym CAGR in line three stands for ‘compound annual growth rate’, which is the mean annual growth rate of an investment over a specified period of time longer than one year.
With respect to Cuba, another favourable characteristic of medical tourism in the Caribbean Basin is the relative lack of competition. As of early 2021, the only Basin country listed in the top ten medical tourism destinations is Costa Rica at number seven (Collier 2021). Others probably meriting ‘honourable mention’ are Mexico and Panama.
Medical tourism in Cuba: Background information
International tourism was, along with sugar and tobacco, one of the island’s major hard-currency-earning industries in pre-revolutionary Cuba, hosting approximately 347,500 arrivals (many from the US) in the latter years of the Bastista regime (Goodrich 1993: 36). Medical tourism, however, was not a major component thereof, one major exception being the government’s willingness to cater
… to American women wanting an abortion; indeed, the ‘Havana weekend’ was a standard package including airfare, medical care, and hotel accommodations. (Ramírez de Arellano 2011: 289–290)
However, as noted previously, tourism was by no means a high-priority concern for the revolutionary government that came to power in 1959. In addition, the US dried up as its main source of tourists as Washington imposed tight restrictions on Cuban travel as part of its programme of economic sanctions designed to help in its efforts to drive Castro from power. Consequently, for roughly the next two decades the island’s tourism industry languished and fell into disarray.
This situation began to change in the mid-to-late 1970s as Havana became more positive with respect to tourism. This was due to its perceived potential as a generator of hard currency, which could be used to finance imports from countries other than those in the Soviet bloc as well as to service any debts that the Revolution might incur with such trading partners. As such,
… the Instituto Nacional del Turismo (INTUR) was created and assigned the task of developing tourism policy and collecting touristic data (e.g. tourist arrivals and expenditures). In 1987, another tourist development agency, Cubanacan, S.A., was created to share responsibility with INTUR for policymaking in the tourist industry. (Goodrich 1993: 36)
Initially these organisations concentrated on developing traditional recreational tourism. Later, however, faced with the necessity to expand wherever possible its international trade relations in order to deal with the economic disaster (known as the Special Period) confronting the island due to the disintegration of the USSR and the Soviet bloc, medical tourism was added to the equation. Consequently, reports Ramírez de Arellano, in 1995–1996 Cuba hosted about 25,000 such tourists who generated revenues which were the equivalent of roughly 25 million US dollars (Ramírez de Arellano 2011: 292). Table 7 provides some additional information regarding medical arrivals during this period.
Number of Health Tourists Per Year
| Year | 1993 | 1994 | 1995/6 | 1997 | 2000 | 2006 |
|---|---|---|---|---|---|---|
| Number of health tourists | 6,500 | 6,323 | 25,000 | 30,000 | 4,000 | 20,000 |
Source: Hernández Nariño (2008).
Data such as that in Table 7 does not seem to be readily available for subsequent years since Cuba does not publish statistics on medical tourism. 1 However, fragmentary information based on such sources as news stories suggests that a figure of 20 to 25 thousand medical tourists per year, generating estimated annual revenues of 40 million dollars, has remained the general norm during the 21st century.
A brief sketch of the Cuban medical tourism sector’s main elements follows. Patients are mostly [almost 80 per cent] from Latin America followed by Canada, Europe, and America. The Cuban medical services (SMC) offers 280 comprehensive programmes through 13 branches all over the country, including five specialised hospitals, nine international health clinics, and a robust network of pharmacies. It has diversified its services to cover not just chronic illness treatments, but also plastic surgery, spa treatments, and physical and drug rehabilitation. It also has a comprehensive health centre, spa and air ambulance transportation services in the wings, which are being developed with foreign investment support (Jagyasi and Team 2021).
Beyond investment, another example of the ‘foreign support’ mentioned above is an agreement reached in May 2022 with the Meliá hotel chain, a Spanish company with two five-star hotels in Havana along with other properties scattered throughout the island, according to which Meliá will market and provide Cuban health tourism packages to its clientele (Redacción OnCuba 2022).
Challenges and prospects for Cuba medical tourism
Challenges/problems
US sanctions
As is very often the case when dealing with Havana’s foreign relations, the economic sanctions that Washington has been imposing on the island for six decades come into play with respect to medical tourism. As noted previously, the US is potentially a major trade partner in general for Cuba, and especially so with respect to tourism (including medical as well as general tourism). However, the sanctions regime pays particular attention to prohibiting practically all travel by US citizens to the island, 2 with tourism of any kind being deemed illegal and therefore subject to enforcement/punishment action by Washington.
There was a brief relaxation of travel restrictions during the Obama administration as the president used his executive powers to reduce some sanctions and thereby hopefully set into motion a process of long-term reconciliation between the two governments. However, the subsequent Trump administration re-embraced and even expanded Washington’s traditional hard line toward Havana, a policy that was continued by the Biden White House. Thus, once again, the island was closed to the average American citizen, including those who might wish to avail themselves of Cuban medical services.
In addition to travel restrictions, US sanctions also negatively impact the ability of Cuban companies such as those dealing in medical supplies to acquire medications and state-of-the-art equipment. It is not only US companies that are vulnerable to retaliation for violations of the sanctions regime, but also those headquartered in other countries. Why? – because the US law states that any product of a non-US company whose components comprise more than ten per cent of US origin and are involved in trade with Cuba can render that company vulnerable to retaliation by Washington. In short, the sanctions are designed not only to deter US companies (including medical suppliers) from doing business with Cuba, but also the international business community in general. Obviously the entire Cuban medical community, including its medical tourism sector, is adversely impacted in terms of its ability to operate at maximum efficiency.
Cuban marketing expertise
Given its state-run economy, Cuba tends to lack extensive in-house marketing expertise, especially with respect to highly competitive and complicated venues such as the United States. As such, prospective clients are not likely to have much familiarity with the achievements of the island’s public health system in general and its medical tourism opportunities in particular. One example of a possible short-term ‘fix’ to this problem was Havana’s 2022 decision to enter into an agreement with the Meliá hotel chain to act as an intermediary providing medical tourism packages to Cuba (see above). While this Meliá partnership might prove useful in reaching customers in Europe, Canada, and some parts of Latin America, it is questionable whether it does or is likely to provide much visibility in the US, Cuba’s most lucrative potential market for medical tourism. Granted Meliá is a major player in the international tourism industry and the Western Hemisphere is one of its major locales, it nevertheless has only two properties in the United States, one in New York City and the other in Miami (Meliá n.d.). Thus, even if a dramatic improvement in US–Cuba relations should occur in the foreseeable future (which is not likely), this minimal US presence on Meliá’s part strongly suggests that the Havana/Meliá agreement would have little significant impact on alleviating the island’s lack of experience/expertise in marketing medical tourism to what is potentially its most lucrative source of clients – Americans looking for a quality alternative to the ridiculously high cost of medical care in the United States.
Social discontent with respect to ‘privileged foreigners’
In the past Cubans have occasionally expressed discontent over Havana’s practices with regard to tourists. For example, at one point (pre-2008) Cuban citizens were prohibited from staying at hotels that catered to the tourist trade, the ideological rationale being that such a policy contributed to social equality by removing a manifestation of ‘luxury privilege’ while serving on a more pragmatic level to combat the reappearance of sex tourism which had flourished in the island’s pre-revolutionary period. Indeed, these restrictions often made the average Cuban reluctant to even enter such hotels, leading to critics to characterise the situation as ‘tourism apartheid’. The ban was rescinded by Raúl Castro’s new government in 2008. But such reservations have once again surfaced concerning medical tourism. The basic complaint here is that in its efforts to acquire hard currencies, the government is redirecting resources (i.e. money, equipment, etc.) and personnel (doctors, nurses, technical personnel, and others) away from the national public health system that serves Cuban citizens to foreigners. This sentiment is being exacerbated by similar misgivings among some members of the public about Havana’s massive and highly praised medical internationalism programme whereby thousands of Cuban physicians and related specialists are being sent abroad, primarily to developing countries, to provide both sorely needed medical services and assistance in developing public health systems which will serve previously neglected marginalised communities.
The government, on the other hand, counters that such complaints are seriously flawed and short-sighted for failing to take into account the fact that part of the (hard-currency) revenues generated by tourism in general and medical tourism in particular (as well as medical internationalism) serve to support the operation and indeed the expansion of the island’s national health system. In other words, the relationships between these various enterprises are symbiotic rather than competitive.
Advantages/prospects
Low cost of Cuban medical services
In many if not most cases, especially for nationals of countries such as the United States where the costs of medical services are high and national health care support is not available for the average citizen, the prices that one pays in Cuba for comparable help are a main attraction. A personal experience on the author’s part illustrates this point. On a visit to Havana in March 2023, I dislocated my shoulder and went to the Clinica Central Cira Garcia Hospital, which is where tourists and other foreign nationals go for treatment. A doctor there took x-rays, reset the shoulder, and attended to various cuts/abrasions related to the shoulder separation. When I returned home, I asked our family doctor what the cost would be for similar treatment in the US. His estimate was about $1,500. The bill in Havana was $240.
Not only are the costs of Cuban medical services much lower than those in the United States, they likewise are lower than other Caribbean Basin countries that represent Havana’s main potential medical tourism competitors. Consider, for example, the following comparisons using US prices as the benchmark for cost savings available to medical tourists in various Caribbean destinations (Table 8).
Medical Tourism Cost Saving Using US as the Benchmark
| Costa Rica | 45–65 per cent lower than the US |
|---|---|
| Mexico | 40–65 per cent lower than the US |
| Cuba | 90–99 per cent lower than the US |
Sources: The Costa Rica/Mexican figures come from Shortlister (n.d.). The Cuban figures are based on calculations made by the author based on data from The Spokesman-Review (2024).
In countries such as Canada and Great Britain which have national healthcare systems that cover medical expenses, the wait time for anything other than major emergencies can be considerable. In Canada, for example, the Fraser Institute reports that the average wait time between referral from a general practitioner and receipt of treatment by a specialist is 58.1 weeks for plastic surgery and 58.9 weeks for neurosurgery (Moir and Barua 2022: 13). In such cases the quick-service Cuban option with the modest costs involved may be very much preferable for some people.
It should likewise be noted that these low costs do not imply low-quality service – quite the contrary. Public health care has been one of the two “crown jewels” of the Cuban Revolution from its very inception (the other being public education). In both cases the government has, despite the challenges involved, poured in resources to provide the support infrastructure and especially the highly trained personnel necessary to assure excellence. Its success in doing so is demonstrated in the kind of healthcare statistics noted in Table 1.
Admittedly medical tourism was for many years not a high-priority item within this constellation of health care endeavours. But that situation is definitely beginning to change.
High government developmental priority
Dr Yamila de Armas Águila is President of the Comercializadora de Servicios Médicos Cubanos (SMC), which consists of seven departments within the Ministry of Health, and among other things is responsible for the marketing and delivery of Cuba’s medical tourism services. 3 In a 2018 interview and a 2022 follow-up she stated the following with respect to medical tourism’s current priority:
The first priority and the most important Servicios Médicos Cubanos (SMC) future direction goal of SMC will be to increase the number of people coming to Cuba for medical reasons to resolve their health problems. To achieve that goal, we have made a huge investment in technology to improve the quality and the type of services we are offering …
Now we are going all out in communicating that we are ready for medical tourism promotion to give … We have a communication strategy for different audiences for medical tourism promotion of … Geographical proximity for medical tourists will have an important specific weight, so the Caribbean has priority. We also plan actions in the Asian and African markets in another dimension because of the distance that separates us. (Hernández 2022)
Among the initiatives the government has supported to achieve these goals, Cuba has diversified its medical services available to foreign patients to include plastic surgery, drug and physical rehabilitation, and spa treatments, in addition to its initial focus on more “conventional” concerns. Overall, as of early 2022, it had 280 various treatment programmes available on its medical tourism menu. 4
In addition to the domestic developmental resources flowing from this prioritisation, the SMC is also seeking foreign partners to help promote its activities, the agreement with the Meliá chain mentioned previously being an example. Accordingly, the Cuban government held the First Annual International Health and Wellness Tourism Fair (FITSaludCuba) in October 2022, as well as the II International Forum on Foreign Investment in the Health Sector, to promote and deepen foreign investment opportunities with new development prospects. FITSalud has scheduled a second conference for 2025. Through such gatherings, says the Cuban Business Report, Havana aims to expose the products, experiences, and advances of health tourism on the island, and to forge new alliances in the sustainable development of its medical tourism industry (Cuba Business Report Staff 2022).
Repeal of Roe v Wade
An admittedly unique element with respect to the prospects for Cuban medical tourism is the repeal of Roe v Wade by the US Supreme Court. The original Roe decision (1973) set a national standard governing abortions which made them much more available in the US than had previously been the case. 5 Roe’s reversal essentially returned control of abortions to state governments, many of which quickly moved to reimpose severe restrictions on the availability of abortions, and in some instances essentially abolished them. 6 Consequently, women seeking abortions have had to find new providers, and it is here that Cuba becomes a potential option. This is especially true for women in the southern US states with close geographical proximity to the island, where strong anti-abortion sentiment in their state legislatures was translated into new anti-abortion laws. In a sense, the ‘Havana weekend’ mentioned previously could once again become an element of Cuban medical tourism. Granted Washington’s sanctions on travel to the island remain a problem, but they are not insurmountable to anyone determined to get an abortion. And, of course, any significant relaxation of those restrictions could open the floodgates for US women to pursue the Cuba option.
Conclusion
Cuba’s existing tourism infrastructure, as well as its deep reservoir of medical personnel, would certainly appear to provide a firm foundation upon which to build a vibrant medical tourism programme, as indicated by Havana’s recent emphasis on developing it. At this point, however, and for the foreseeable future, its “income productivity” (i.e. its contribution to the island’s GDP) cannot compare to that generated by its medical personnel working overseas. Cuba does not provide official income statistics on either programme, but the consensus is that medical tourism generates income in the millions while overseas operations bring in billions. 7 Thus one might question whether the recent emphasis on medical tourism is “worth it.” One important consideration to take into account here is that overseas programmes are dependent on governmental relations which sometimes can vacillate dramatically. For example, in late 2019 Havana began withdrawing the 8,000+ doctors that it had working in Brazil when its far-right president-elect Jair Bolsonaro threatened to cut relations with Cuba and modify the conditions of a five-year-old agreement between the two countries. Medical tourism’s clientele, on the other hand, are individuals who normally are free to make their own independent decisions regarding their medical providers. Thus it would seem to be a good idea to have both operations in place, with a vibrant medical tourism programme not only providing its own income flow, but also serving to help cover any downturns in Havana’s medical internationalism due to the vagaries of international politics.
Referring back to the section on challenges facing Cuban medical tourism, all except the US sanctions are within the ability of its government to overcome through its own efforts. Admittedly that exception is indeed a major problem, for the sanctions cut off Havana’s access to what is its largest potential market for medical tourism. However, this liability might be offset somewhat as Cuba’s relations with Russia continue to expand and become more cordial, thus opening a potentially massive new market for its medical tourism.
Finally, with respect to Havana’s ability to compete with others for a share of the medical tourism market, one study notes that
… the competitive status of a health service will depend on many factors such as: cost, human resources, service differentiation, technology and accessibility to health amenities. These comparative advantages are enhanced by other elements: geographical proximity, cultural and linguistic affinities, natural endowments, and the ability to market the advantages effectively. (Hernández Nariño 2008)
Cuba scores well on most of these competitiveness indices. One item not mentioned where Havana is weak is air travel, which is a major tourism expenditure. Its national airline, Cubana, currently appears to have rather limited international service 8 and is not a member of any airline alliance. Hence it finds it difficult to compete with other carriers (both private and governmental) for a share of this major expenditure category.
Will ‘they’ (medical tourists) come, as suggested in the quote at the beginning of this article? Cuba has been quite successful in building both a vibrant recreational tourism industry and a truly world-class medical system. Thus it would seem to make perfect sense to merge the two in order to further diversify the island’s economy by moving boldly into the realm of medical tourism. As such, what one is dealing with here is not some utopian ‘dream’, but rather a very pragmatic undertaking which has considerable potential to serve the interests not only of the Cuban people, but also others (e.g. Americans) looking for high-quality, low-cost, medical care.