When 217 members of Cuba’s Medical Brigade landed in South Africa on 27 April, they received a heroes’ welcome from President Cyril Ramaphosa.

But, simultaneously, a planning document began to circulate which purports to show the cost of deploying Cuban health workers to South Africa to fight Covid-19. The total expenditure amounts to just shy of half a billion rand – R439,916,337 – and that total is based on only 187 Cubans arriving, rather than the 217 who have materialised.

Attempts by journalists to verify this budget have been unsuccessful. Both the Treasury and the Department of Health failed to respond to repeated requests for comment on the matter from Daily Maverick and other media outlets – which in itself may be revealing.

Health department spokesperson Popo Maja neither confirmed nor denied the authenticity of the budget to News24 on Thursday, saying: “It is not fair that anyone should focus on the price tag over the need to save lives.”

In response to questions sent by Daily Maverick to the Cuban embassy in South Africa, the embassy issued a statement denouncing a “smear campaign” against Cuba and paying tribute to the “heroism and altruism” of the Cuban doctors.

“The Cuban government pays the full salary of all our doctors while they are assisting other countries. The host countries have assumed the transportation, accommodation, food and basic means for the doctors, the minimum necessary in order to contribute to the sustainability of our healthcare services,” the Cuban embassy statement read.

On the embassy’s Facebook page, it has adopted a similarly pugnacious approach to comments from the public expressing concern about the mission’s expenditure.

“Cde, the enemies of International Solidarity will always try to create doubts,” the official embassy account responded to one such comment.

“This is not a commercial transaction. This is cooperation. Authorities will provide for the doctors just the minimum necessary in terms of accommodation and sustainability. No [sic] the luxuries and big payments that usually other doctors around the world receive. Just the basics. All our doctors are voluntaries [sic] coming to help not to enrich themselves.”

Yet the amount listed on the document for salaries, which totals R294,566,232 for the 187 health workers for 12 months, suggests that they are receiving on average over R1.57-million per year.

A doctor with knowledge of public sector healthcare salaries told Daily Maverick that this is equivalent to the salary of a top government specialist in South Africa.

If accurate, a monthly salary of over R130,000 would amount to a significant increase for a Cuban health worker. It is reported that the highest-paid Cuban doctors make less than $70 per month at home – just less than R1,300.

However, it has also been reported that relatively little of the money earned by Cuban doctors abroad is kept by the doctors themselves, with the Cuban state allegedly retaining a portion.

Brazilian newspaper El Pais reported in 2018 that the Cuban government keeps 75% of overseas doctors’ wages; the UK Guardian stated in 2013 that the state’s cut of wages is 25%; while independent Cuban media outlet ADN Cuba (DNA Cuba) maintains to the current day that the regime retains between 70 and 90% of doctors’ salaries.

What is no secret is that exporting doctors is a hugely important source of revenue to the Cuban government, bringing in an estimated $11-billion per year, and making the lease of healthcare workers Cuba’s most lucrative export.

The Economist reported in April 2020 that Cuba is particularly cash-strapped right now, with the Covid-19 pandemic having halted the important revenue brought in by tourism.

A detailed breakdown of the Cuban medical staff deployed to South Africa has not been made public, with a statement from the Presidency listing their expertise as follows:

• Experts in the fields of epidemiology, biostatistics, and public health;
• Family physicians to guide interventions through door-to-door testing and to assist local health workers in health promotion and disease surveillance at the community level;
• Healthcare technology engineers to assist in maintaining the inventory, deployment and repair of aged medical equipment; and
• Experts to provide technical assistance working with local experts.

This information offers little insight as to whether all members of the Medical Brigade have the expertise to warrant such allegedly high salaries.

The unverified budget also lists extremely high amounts for “chartered flight” [singular], at almost R10-million, and budgets for a monthly food and accommodation stipend of R50,000 each on top of salaries – calling into question the Cuban embassy’s contention that the doctors receive “just the minimum necessary in terms of accommodation and sustainability”.

South Africa and Cuba have a history of cooperation in the field of public health stretching back over two decades, with 732 South Africans having received medical training in Cuba’s internationally renowned health system to date. The presence of Cuban health workers in South Africa’s rural areas has been a staple since the late 1990s.

A South African doctor who worked with Cuban doctors in Mpumalanga in 1999 described his Cuban counterparts as “a great bunch of guys”.

Internationally, Cuban doctors have won admiration for work in some of the toughest public health contexts on record. When Ebola struck West Africa in 2014, Cuba sent more healthcare workers to assist than any other country. Cuban doctors were praised for their role in treating Chernobyl victims, and doctors dispatched to Honduras after hurricanes in 1998 had a significant impact on improving live birth and maternal mortality rates.

But the proficiency of most Cuban doctors has not stopped their arrival being controversial in many countries. In May 2018, Reuters reported that doctors’ unions in Kenya were enraged by a plan to bring in 100 Cuban doctors rather than employ some of the over 2,000 Kenyan doctors and specialists awaiting deployment by the ministry of health.

Tensions have been running even higher over the deployment of the Cuban Medical Brigade to 23 countries during the Covid-19 pandemic.

In Argentina, health officials recently had to meet with doctors’ representatives who complained that there were already 170 foreign doctors residing in Argentina who were willing to work on Covid-19 and were still waiting to have their qualifications approved by the health ministry.

A petition on change.org asking the Argentinian government to reconsider allowing Cuban doctors to enter garnered over 170,000 signatures, with the petition organisers pointing out that Argentina has one of the highest doctor-to-patient ratios in the world and that the resources to be spent on the Cuban doctors could better go towards protective gear for health workers.

In March this year, an Italian news outlet ran an opinion piece denouncing the arrival of a Cuban medical mission in Italy as “expensive and unprepared”, pointing out that hospitals in Lombardy then had to seek translators, who would be exposed to the virus.

In the small European principality of Andorra, to which Cuban healthcare workers were also sent, local media reported in April that a “significant” quantity of the Cuban delegation turned out not to have sufficient training or experience to work in frontline medical contexts and had to be redeployed to less critical roles.

Many of these currents are already evident in South Africa too, where both the South African Medical Association (Sama) and the nurses’ union Denosa have expressed concern over the deployment of the Cuban doctors. Sama termed their arrival “premature”, while Denosa described the South African government’s actions as “unpatriotic” in a context where many local nurses and doctors are sitting without work.

Health Minister Zweli Mkhize defended the move at a media briefing on Tuesday night, telling journalists: “Cuban doctors will not take anyone’s post. They will be working alongside South Africans.”

Mkhize also said that currently unemployed local doctors and nurses should contact their provinces.

“We have fast-tracked new hires in the Eastern Cape. We would like to say, we will take in more doctors and healthcare workers. Provincial departments will indicate how to do this,” Mkhize said.

The Cuban doctors in South Africa were seemingly able to have their medical registration organised with the Health Professions Council of South Africa (HPCSA) within days, at an alleged cost of more than R700,000 to the South African government.

This has caused particular unhappiness in the South African Internationally Trained Health Professionals Association (SAITHPA), which put out a statement on Wednesday pointing out that their members – South African citizens who have obtained medical degrees from institutions outside South Africa – have battled for years to obtain registration with the HPCSA in order to be able to work.

SAITHPA’s statement read:

“Their bewilderment and disappointment in relation to the disregard shown by the HPCSA to them is now further enhanced by the recent importation of medical personnel from Cuba, as these unemployed medical graduates wonder why R440-million of money from their taxpaying parents has been used to import doctors whilst they remain unemployed and willing to serve through the necessary channels.”

Questioned about this issue at Tuesday’s press briefing, Mkhize said: “That one is a difficult one. Everyone has to be registered by the HPCSA. But some of them have challenges related to the schools where they trained.”

He advised local doctors in this position to take the matter up with the HPCSA – counsel which is certain to anger the relevant doctors, some of whom have been forced to approach the courts in recent years in response to the HPCSA’s intransigence.

Mkhize and other health officials have insisted that the Cuban doctors are necessary to bolster South Africa’s fight against Covid-19. Local doctors canvassed by Daily Maverick were in general agreement that the Cubans’ contribution would be welcome. As one put it: “Any doctor will be helpful.”

But the government still has pressing questions to answer: about the price tag of the mission, whether the expertise offered by the Cubans could truly not be replicated locally at a lower cost, and ultimately whether the real beneficiary of the deployment is South Africa, or perhaps the cash-strapped Cuban state. DM