CUBA’S UNCERTAIN REVENUES FROM MEDICAL EXPORTS
Luis R. Luis
It is well known that exports of medical and other professional services are Cuba’s largest source of export income, surpassing tourism and outstripping merchandise exports. It is also a controversial income source as doctors are treated as mere appendages of the Cuban state deprived of most of their earnings and curtailed of basic employment rights. These service exports reached $7.7 billion in 2018 or 3¼ times merchandise exports and over twice tourism receipts.[i] Cuba has supplied medical services to 68 countries by 2018 according to Cuba’s Public Health Ministry[ii] They cover the wide world – 26 countries in the Americas, 29 in South-Saharan Africa and 13 in East Asia, the Middle East, the Pacific and Europe. Since 2018 medical programs have ended in a few countries such as Brazil and Bolivia. The COVID 19 pandemic is currently leading to a temporary expansion of Cuban medical missions in various countries including a handful of new markets. The aim of this note is to review exports of professional services specifically looking at Cuba’s dominant client Venezuela and gauging exports to other countries. The credit standing of Cuba’s clients helps to determine their ability to pay in hard currency for the services Cuba is providing.
VENEZUELA: CUBA’S MAIN CLIENT
Venezuela is by far Cuba’s principal market for medical and other professional services. Services to Venezuela started in the early 2000’s. Initially bilateral trade had contained concessionary financing similar to that included in Venezuela’s Petrocaribe scheme for the Caribbean basin, and after 2004 trade evolved into barter of doctors for oil. The scheme was formalized in the 2004 agreement between the presidents of Cuba and Venezuela, Fidel Castro and Hugo Chávez.[iii] The agreement mentions that Cuban medical services will be settled by oil shipments and payments in national or foreign currency.
Table 1 shows Cuba’s exports of professional services to Venezuela. These are calculated from exports of professional and support services from ONEI, the Cuban statistical agency, after subtraction of estimates from other Cuban clients which provide official data. Venezuela comprises nearly 90% of the market for Cuban professional services. This is higher than the 75% rough estimate used by Mesa Lago and Vidal (2019). It is also higher than estimates by Hernández-Catá (2019) though with similar estimates for total professional service exports in 2017 and 2018. The dominant Venezuelan market share is not altogether unexpected. The range of annual Cuban personnel reported in Venezuela over the last five years hovers between 30,000 to 40,000, a large multiple of Cuba’s operations in other nations. Second market Brazil, for example, reported 8517 Cuban health professionals in 2018.[i] Even more importantly, average compensation for personnel in Venezuela to the Cuban government is well beyond that in other nations. For example, the 2018 monthly salary in Brazil in Mais Médicos paid to Cuban doctors was R11,865 equivalent to $38,955 per year at the average real/dollar exchange rate. Implied Venezuela salary for 40,000 Cuban personnel are easily four times larger.
Exports of professional services to Venezuela declined from $7.5 billion in 2014 to an estimated $6.0 billion in 2019. This last number is tentative. It is estimated to decline from 2018 in proportion to the fall in Venezuelan oil prices plus an upward adjustment for the transfer of 2500 workers from Brazil. This is a working assumption and may have to be revised as new data becomes available from ONEI. In any case Cuban exports to Venezuela remain at a substantial level even as the Venezuelan economy collapses with real GDP per capita contracting by 63% in 2014-2019.[ii] How is Venezuela paying for these services?
While in 2014 some 45% of Cuban services were paid by barter of doctors for oil, the figure for 2018 is 35% and 15% in 2019 as both the volume of petroleum shipped to Cuba and its price took a big hit. This means Venezuela is using dollars, non-convertible bolivars, borrowing from Cuba or likely all of these to settle accounts. The precise compensation mechanism is not public, though there is a reference to quarterly settlement of PDVSA accounts.[iii]
Venezuela is currently in payments arrears in its sovereign debt obligations and is cut-off from international financial markets. This poses a hard question on its ability to fulfill obligations in dollars for services rendered by Cuban government entities. It also means debt incurred by Venezuela is subject to high repayment uncertainty.
EXPORTS OF SERVICES TO OTHER NATIONS
Beyond Venezuela there are 67 nations where Cuba provides medical services. These were listed by the Cuban health ministry in 2018. We do not have a list of countries where Cuba provides security and military assistance services such as it does to Venezuela. The most important markets for medical services were Brazil, Angola, Algeria and three nations in the Arabian Gulf, Kuwait, Qatar and Saudi Arabia. Brazil rescinded the participation of Cuban health workers in its Mais Médicos scheme in November 2018. Thereafter several nations also ended the programs including Bolivia and Ecuador. However, in 2020 Cuba has added teams abroad with new missions in Italy, Andorra, the French Caribbean and some Asian countries while expanding activity in Latin America and Africa.
Sources: Estimates by the author. See Data Sources in appendix.
Chart 1 shows estimated Cuban service exports to the main markets other than Venezuela. Second market Brazil averaged $370 million per year in 2013-2018, followed by Angola at nearly $90 million and Algeria. Three Arabian Gulf nations accounted for close to $100 million per year. These six countries are able to fund the bill for Cuban services. The three Gulf states have investment grade credit ratings from the two major credit rating agencies. On the other hand, Angola is considered highly speculative with a B3 credit rating from Moody’s and CCC+ from S&P. To be sure, Angola at the beginning of 2019 reported a debt to Cuba of €180 million that was being repaid.[i] Algeria does not have a credit rating from major agencies.
Indeed, only 11 of the 68 countries with Cuban medical services have an investment grade rating, that is, higher than BB+ in the S&P scale. Most of these are small nations: Botswana, Curacao, Kuwait, Portugal, Qatar, Trinidad and Tobago and Uruguay though investment grade China, Mexico, Peru and Saudi Arabia have hosted small Cuban medical teams. An additional five countries are rated in the slightly speculative BB range and can be counted to meet payment obligations. The most important in this group is Brazil. Countries rated below BB- comprise 25% of the client list and have appreciable payment risk. About half the countries are unrated. This is usually the result of a perceived inability to access capital markets by the borrower country and an unwillingness to lend by creditors. Lack of a sovereign credit rating by the two major agencies, S&P and Moody’s, underline weaknesses in a country’s ability to service its external financial obligations.
Countries rated below BB- and those unrated together are 75% of the client list and will face sizable balance of payments stress when hit by external shocks. Many if not most of the nations with low creditworthiness receive Cuban medical cooperation as a donation and are not a source of hard currency income.
THE PANDEMIC, A CHALLENGE FOR CUBA’S MEDICAL EXPORTS
The Covid 19 pandemic is a massive shock. As a consequence, the pandemic is both an avenue for Cuba to provide needed services in existing and new markets and also a major challenge as many clients face new payments difficulties. With Venezuela able to make solely payments in-kind through barter of petroleum or in national currency and many other clients facing liquidity constrains, it does not look Cuba will be able to benefit much from its new activities. New creditworthy clients such as Italy, France and Andorra are unlikely to make use of such services in the long-term as the pandemic eases over the next two years. Some of the Cuban personnel sent to Italy has already returned to the island. Assistance from third parties including donor countries is a possible source of funding. Official development data suggests a modest involvement of multilateral and bilateral agencies in financing medical services provided by Cuba. Recent controversy involving the Pan American Health Organization’s role in the Cuba-Brazil program suggests future multilateral involvement as intermediaries will be limited. Cuba is gaining goodwill through its pandemic activity. It is hard to see how it will translate into enduring commercial relationships.
Cuban professional services are the country’s most important source of export income. Venezuela accounts for nearly 90% of professional service income in 2014-2018. A group of 16 mostly small countries are able to pay in full in hard currency for Cuban services. As many as 50 other countries with low credit standing depend on Cuban aid or may be accruing debt to Cuba. Venezuela is currently unable to settle payment with Cuba beyond swapping falling shipments of petroleum, paying in non-convertible bolivars and assuming debt. Venezuelan debt to Cuba faces much repayment uncertainty. New activity by Cuban medical missions arising out of the Covid 19 pandemic will be temporary as the emergency recedes while liquidity pressures limit the ability of many countries to pay for Cuban services.
Banco Central de Venezuela, www.vcv.org.ve
Bank for International Settlements (2020), stats.bis.org/ Table A6
Brasil, Camara dos Deputados (2013). Medida Provisoria No. 621, de 8 de julio de 2013.
Diariooficial.com.br (2018). Programa Mais Médicos, November 21, 2018.
International Monetary Fund (2020A), Direction of Trade
International Monetary Fund (2020B) , International Financial Statistics, data.imf.org
Journal Officiel de la République Algérienne (2020), Journal Officiel No. 30, 2020.
Ministerio de Salud Pública (2019), Anuario Estadístico de Salud 2018
ONEI (2016), Anuario Estadístico de Cuba – Sector Externo 2015
ONEI (2019), Anuario Estadístico de Cuba – Sector Externo 2018
PDVSA (2015), Informe de Gestión Anual 2014
Republica de Angola (2020), Despacho Presidencial, 5/29/2020
U.S. Energy Information Administration (2020), www.eia.gov
World Bank National Account Data (2020), data.worldbank.org
Acuerdo (2004). “Acuerdo entre el Presidente de Venezuela y el Presidente de Cuba, para la aplicación del Alba.” Fidelcastro.cu/es/documentos.
Diario de Noticias (2019), “Angola yá pagou 60% da dívida de €180 millões a Cuba”. dn.pt, 1/07/2019.
Hernández-Catá, Ernesto (2020), “Cuba’s Swaps of Petroleum for Doctors and the Impact of Cutbacks of Venezuelan Oil,” Cuba in Transition, volume 29, 2020.
Luis (2019), Luis, Luis R. “Venezuela’s Cuban Burden,” ascecuba.org/blog, May 10, 2019.
Euronews (2021). “Medicos-cubanos-em-angola-custam-71-milhoes-de-euros.” pt.euronews.com/2020/06/01/
Mesa-Lago and Vidal (2019), Mesa-Lago, Carmelo and Vidal, Pavel, “El Impacto en la economía cubana de la crisis en Venezuela y las políticas de Trump”, Madrid, Instituto Elcano de Estudios Internacionales, May 2019.
PDVSA (2014), Informe de Gestión Anual 2013
SELA (2015), Evolution of the Petrocaribe Energy Cooperation Agreement, Caracas 2015.
[i] Diario de Noticias (2019)
[i] Diario Oficial (2018) [ii] World Bank National Account Data (2020) [iii] PDVSA (2014)
i] Derived from ONEI (2019) [ii] Ministerio de Salud Pública (2019) [iii] Acuerdo (2004)