CUBAN PROFESSIONAL LITERATURE - REVIEW ARTICLE

A Monitoring System for Health Equity in Cuba

 Abelardo Ramírez Márquez, MD, PhD
Cándido López Pardo, PhD, MPH

ABSTRACT: This paper summarizes essential aspects of the doctoral thesis entitled “A Proposal for a Monitoring System for Health Equity in Cuba,” presented by Dr. Abelardo Ramírez Márquez, who was First Vice-Minister of the Ministry of Public Health at the time, for his PhD in Health Sciences. The objectives of the proposed system are: to identify the inequalities in health care – both in population health status and its determinants – by territorial and population groups, taking into account time factors, and to determine the association between population health status and health determinants. Additionally, this article assesses the health inequities resulting from the inequalities identified. The prevailing approaches to the concept of equity are discussed, particularly equity in the health field. The experiences of health equity monitoring systems in Latin America are presented and certain characteristics of the proposed monitoring system are described. Also considered is the rationale for such a system in Cuba, its coverage and units of analysis, plus the information and indicators to be monitored. Information collecting procedures; general and specific objectives of analysis; system users and outputs; the characteristics of a geographic information system; and the limitations of the system suggested, are also addressed. The system is expected to reveal realities concerning the population’s health situation and its invisible determinants and to produce results to inform decision-making at all levels of the National Health System.

Keywords: MONITORING; HEALTH INEQUALITIES; EQUITY; CUBA

HEALTH EQUITY: CONTEMPORARY APPROACHES

Perhaps the most widespread and well-summarized definition of health inequity is the one proposed by Margaret Whitehead, which in essence states that inequity refers to unnecessary and avoidable inequalities that are moreover, unfair. Thus, to describe a situation as inequitable, the cause must be examined and judged unfair in the context of what is happening in the rest of society.[1] Therefore, equality does not necessarily imply equity, just as inequality does not necessarily imply inequity. An unfair equality is likewise an inequity.

Gwatkin[2] identifies several periods in which health inequalities and other aspects of health status and services have been treated in different ways. One of these was in the early 70s, when the emphasis was on the improvement of poor people’s health, so they could obtain the same health benefits available to the most favored.  Another was in the mid-80s, when, among other things, the capacity for primary health care to produce the expected benefits was placed in doubt, thus shifting interest from “health for all” to “health sector reform.”  Then, in the mid- to late-90s, the focus returned to concern for the distribution of health and health services. Gwatkin predicted that interest would be renewed in aspects of distribution, due to the growing interest in poverty and inequality in global development and as a result of developments in global health.

Peter and Evans[3] present four philosophical-moral approaches to health equity. The utilitarian approach advocates the need to maximize the sum of individual well-being, assuming that the capacity of all people to enjoy good health is equal. According to this framework, achievement of maximum health for the population implies that each person reaches the highest level of health, regardless of which groups are achieving these benefits (rich or poor), provided the benefits exert the same effect on the health of the entire population.

The egalitarian approach focuses on distribution without placing value on total health. There are different types of egalitarian theories; not all prioritizing health. For example, the “equal resources” approach states that only equal general resources - such as economic opportunity - are necessary and once such equality in resources is obtained, it simply depends on how each person wishes to use it. From this point of view, a society that guarantees its citizens equal resources does not need to give health care special attention.

The priority approach is considered a counterbalance to the utilitarian approach. It requires that health benefits be assigned to the most ill and emphasizes that differences in health outcomes are only of secondary importance, placing emphasis instead on final health outcomes. This perspective focuses on those in the worst health and not necessarily on the health of the poorest.

The approach derived from the Rawlsian ideal of society as a fair, cooperative system, understands health inequalities as a consequence of a social organization that does not satisfy the requirements of fair social cooperation. Considered unfair are inequalities of class, gender, race, region or other determinants originating in a society’s basic structure and that may be the result of a social division of labor that benefits the more well-to-do at the expense of the most disadvantaged.

The debate over health equity reveals a diversity of definitions and approaches. The objectives of the proposal at hand demand - as we found in previous work[4] - an understanding that contemporary Cuban society is legitimated on the basis of social equity, and it is this equity approach that underpins its economic and social policies. The notion of equity we start from is based on social justice criteria that do not deny diversity, but instead regard it as a socially enriching element. This notion presupposes overcoming  all discriminatory practices in every sphere of human activity. For us, health equity means equal opportunity to access available resources, a democratic distribution of power and knowledge in the health system, and health policy that benefits everyone without granting privileges due to differences in race, gender, territory, disability or any other distinguishing group or individual feature.

EXPERIENCES WITH HEALTH EQUITY MONITORING SYSTEMS

In the 90s, a good number of projects emerged related to poverty, equity and health, in which a number of countries were involved. These projects are particularly important for quantifying health inequalities, as a way of assessing health inequities. In a study for the World Bank, these projects were identified.[5]  Some of them were related in one way or another to monitoring systems, which although similar in purpose, may differ substantially in their design. The present discussion is limited to certain Latin American experiences.

In Chile, continuous health care equity monitoring is carried out at regional and communal levels through routine collection of demographic, vital statistics, socioeconomic, educational and morbidity and mortality data from different sources.[6]  In Brazil, health inequalities are monitored at regional and state levels. The system is based on information from different sources and takes into account indicators of human resources, health care capacities, access and use of health services, financing, quality of medical care, health situation and living conditions.[7] In Peru, although not conceptualized as a monitoring system, an analysis of the extent of health inequity has been carried out. The assessment aims, among other goals, to carry out more profound research into the magnitude of inequity in the health status of Peruvians, to show the need to include this issue on the national agenda, involving not only the academic community, but also politicians, public officials and civil society in general.[8]

Other health equity studies, particularly with respect to access to health services and services of equal quality, were carried out in Colombia and Venezuela.[9]  To learn of other experiences in health care equity monitoring, work carried out by the World Health Organization[10]  and the Health Systems Trust [11] may be consulted; additional research may be referred to for more general conceptual and methodological aspects related to the measurement of health inequalities.[12-20]

CHARACTERISTICS OF THE PROPOSED HEALTH EQUITY MONITORING SYSTEM 

Three elements justify the application of a health equity monitoring system in Cuba:

1. The substantive changes that have occurred in the living conditions of the population and other economic and social spheres, together with the reduction of the homogeneity that characterized the Cuban population.
2. We are still far from knowing how social disparities may affect population health status.a
3. Research is needed on diversity among human groups that are different in various ways, including in their access to health services, as well as their geographical and socioeconomic conditions. 

Objectives of the proposed system:

1. Identify health inequalities - with respect to population health status as well as its determinants - among different territories and population groups, taking time factors into account.
2. Determine the existing association between the levels of population health status and health determinants.
3. Evaluate health inequities resulting from the inequalities identified.

The system is structured on the following bases:

• It should be coherent with national health policy and its specific strategies.
• It should be developed in accordance with existing resources.
• It should be sensitive to relatively short-term changes in population health status and health determinants.
• It should have enough flexibility to respond to users’ needs.
• It should complement and integrate available information produced by other agencies of the Ministry of Public Health and other bodies.

Expected results

The system is expected to:

1. Elucidate realities of the global health status that are not currently visible.
2. Identify elements for producing alerts, within the health and other sectors.
3. Produce useful results to inform political-administrative decision-making at different levels of the National Health System, depending on the magnitude and distribution of the event under consideration.

Coverage and units of assessment

The system’s coverage is national and the units of assessment are the country’s 169 municipalities.

Information to be monitored

The system will capture information of a permanent, as well as occasional, nature. Permanent information will flow according to certain procedures, while transmission of occasional information will be determined at the necessary time according to prevailing circumstances.

In terms of permanent information, the health status of the population will be monitored, as well as its determinants. The areas of population health status to be monitored are:

• Under-five child mortality;
• Maternal mortality;
• Mortality and morbidity from specific causes;
• Nutritional status; and
• Disability.

In relation to the determinants considered (medical care, social, economic, environmental and demographic),b  the areas and indicators to be permanently monitored are shown in Appendix 1.

Indicators to be monitored

The process for selecting the indicators for the monitoring system began with the identification of potential indicators available from all municipalities in the country. These were submitted for consideration to a large group of experts from the health and other sectors to evaluate their inclusion in the monitoring system. The selected indicators associated with each area of population health status are listed in Appendix 2. The source of information for these indicators is the National Statistics Division of the Ministry of Public Health.

Sixty-two experts from 17 institutions or agencies participated in the design of the system - particularly in the selection of the indicators; seven branches of the Ministry of Public Health also took part. Twenty-seven indicators linked to population health status and 52 linked to determinants were identified.

The indicators selected for monitoring related to each area of determinants are listed in Appendix 1. The information, except for some indicators, will be collected annually.

Additionally, as part of the permanent module, results from the Public Opinion Reporting System of the Health Tendencies Analysis Unit, will be considered. This system collects feedback from patients and service deliverers about health services, permitting assessment of the fundamental problems affecting satisfaction.

Data collection procedure

At system headquarters - proposed to be located at the Ministry of Public Health - data would be centrally processed from three sources: the system’s provincial headquarters, national agencies, and the national Health Tendencies Analysis Unit. Data flow is summarized in Figure 1.

Figure 1: Information Flow for the Health Care Equity Monitoring System

Data Analysis Objectives

Analysis of resulting information has the following general objectives:

1. Identify existing gaps in the availability of resources and services in health and other sectors.
2. Monitor - in time and space - the mortality and incidence or prevalence (as appropriate) of the defined diseases and adverse effects on health.
3. Identify the extent and patterns of space-time distribution of the areas under study related to population health status and the determinants.
4. Determine the association between levels of mortality, incidence or prevalence, and levels of the determinants studied.
5. Identify the potential impact on population health status or the determinants considered of interventions undertaken in time series dynamic.
6. Determine the efficiency of defined resources on the results of population health status and the determinants.
7. Determine homogeneity of municipalities in achieving success in global health status.
8. Evaluate municipalities with respect to their global health status according to a synthetic index.

The 4th objective constitutes a key aspect of the system and conforms to the emphasis in recent years on the need to monitor the association between a population’s health status and its socioeconomic status.  This system proposes to extend monitoring of such associations to other elements of health determinants. The role played by social and economic determinants in population health status disparities is sufficiently supported, conceptually as well as empirically.[21-23] For example, Casas, Dachs and Bambas[23] document wide health differences - both in population health status and services - between those with high and low levels of well-being (whether measured by income or other material conditions); and among those registering differences in educational level, territorial distribution (for example, between geographical regions or urban and rural areas), ethnicity, gender, physical and financial access to health services and national origin.

Figure 2 illustrates specific assessment goals under each of the general objectives put forward, and the respective universes to be studied.

Figure 2: Goals & Universes to be Studied

Geographic - Information System Design

Several Geographic Information Systems were analyzed for use in this system. The most convenient found was the SIG Epi version 1.0, designed by the Special Program for Health Analysis of PAHO, due to its accessibility, computer programming attributes, multi-layer data management, and use of different spatial analysis methodologies. The data assessment layers in this system propose analysis of each variable according to territorial - provincial and municipal - references.

Treatment of  Information in Municipalities with Small Populations

Mortality and morbidity analysis performed in those municipalities with relatively small populations is always a concern when the frequency of an event considered is low and the population is very small, the rates vary widely and change notably in the same territory, by virtue of any slight change in the number of cases. The use of several methods that address this problem will be explored, among them the Bayesian model. Populations of Cuban municipalities range from 9,000 (Ciénaga de Zapata, pop. 9,037, est. June 30, 2002) to over 50 times that (Santiago de Cuba, pop. 479,475, est. June 30, 2002).[24]

System Outputs

The system will group permanent outputs for the most relevant information in tables, graphics and maps, their format designed to reflect the most relevant information. Additionally, the output module allows development of these same tools on an occasional basis as circumstances require.

System Users

System users will be management-level personnel in state, health and other sectors who require the information for their work. In principle, all institutions involved in providing information will be system users (see Figure 1). By the same token, political and civil organizations and the mass media will also be system users according to their needs. Permanent results will be published annually and occasional results will be published periodically as required. Information channels will be established in accordance with users’ characteristics.

Limitations of the System

Identification of the possible association between the levels and trends in population health status and health determinants is carried out in this system using an ecological approach, understanding that the unit for assessment is a conglomeration of individuals grouped according to geo-demographical, socioeconomic or other criteria.[25] This type of study frequently carries the potential risk of committing the common ecological error in assuming that associations found among groups are equally true for individuals. According to Susser,[26] Riley[27] uses the term aggregation fallacy to describe the error of applying associations identified among groups to individuals; and the term atomistic fallacy to describe the reverse, that is, inferring ecological relations among groups from observations carried at the individual level.

Nevertheless, concern for this fallacy may be exaggerated (constituting the fallacy of the ecological fallacy), because there may be no interest in extrapolating to individual levels what was found at the group level. Moreover, in many instances, it would make no sense to carry out an analysis at the individual level since the characteristics of the variables studied can only be interpreted at a group level. According to Silva[28] - who revives use of this approach - ecological studies have lost popularity in contemporary epidemiological research, partly due to the fear the ecological fallacy engenders and partly due to prejudices. Of these last, the most well established and pernicious is the conviction that the variables measured at group level do not represent causal agents of disease.

Additionally, as Kunst and Mackenbach[29] point out, the value of ecological studies lies in that they can indicate the effect of socioeconomic inequalities on health when there is no information available at the individual level. Moreover, these authors note, the comparison between areas may provide highly relevant information for local policies, since they clearly identify areas with excessive health problems.

CONCLUSIONS

A health care equity monitoring system is justified in Cuba because of the substantive changes that have occurred in the living conditions of the population and other economic and social spheres, together with the reduction of the homogeneity that characterized the Cuban population; because we are still far from knowing how social disparities may affect population health status; and because research is needed on diversity among human groups that are different in various ways, including their access to health services, as well as their geographical and socioeconomic conditions.  There is also the political will of the Cuban government to eliminate unjust inequalities that may exist in the country.

Implementation of the system is feasible thanks to the availability of the information required and because the inherent procedures have been designed.

An evident need exists for an inter- and trans-disciplinary approach to design a monitoring system that would allow the identification of health inequalities using an integral approach that includes the health status of the population and its determinants

RECOMMENDATIONS

• The leadership of the Ministry of Public Health should evaluate the proposed health care equity monitoring system for its application.
• The experiences of this study should be taken into account in future monitoring system designs for health or other sectors, related to population health status and/or its determinants.
• Those interested in analysis of territorial development should take into account this work and are encouraged to design other monitoring systems at the local level.
• Health sector specialists should become familiar with the conceptual aspects considered in this paper, with which in general, there is not sufficient familiarity.
• The National School of Public Health, the Higher Institutes and Schools of Medicine and other academic institutions in health and other sectors should consider incorporating the contents of this paper in their curricula.

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This paper was originally published in the Cuban journal Revista Cubana de Salud Publica, 31; 2: April-June, 2005. Reprinted by permission.

Acknowledgments

We thank Drs.  Miguel Márquez and Francisco Rojas Ochoa for their collaboration in this paper, with regard to the project’s precursor in the proposal of Health Situation Surveillance System According to Living Conditions and a Project for Monitoring Equity and Health in Cuba proposed in the nineties. We also acknowledge the working group composed of Dr. Guillermo Mesa Ridel, Maritza Cedeño, BS, and Iraida Rodríguez, BS, later joined by Drs. Eduardo Zacca, Daniel Rodríguez Milord, Roberto González, Radamés Borroto and Pastor Castell-Florit. We are also grateful to Roberto González, BS,  for his contribution to the design of a Geographically- Referenced Information System and Drs. María del Carmen Pria and Giselle Coutin, Angela Tuero, BS  and Ana María Clúa, BS  for their contributions to the section on the treatment of information in municipalities with small populations.

THE AUTHORS

Abelardo Ramírez Márquez, 2nd Degree Specialist in Health Organization and Management, was a professor at the Havana Higher Institute of Medical Sciences and the National School for Public Health. (Deceased)
Cándido M. López Pardo, Doctor of Health Sciences, Full Professor at the School of Economics, University of Havana; Visiting Professor, National School of Public Health

Appendix 1: Indicators to be Monitored According to Determinant Area

Legend: Abbreviations

PHD:  Provincial Health Department
MPH:  Ministry of Public Health
SD:  Statistics Division
PPOS: Provincial Pharmacy and Optical Services
NDCE:  National Department of Care for the Elderly
PDEP: Provincial Department of Economics and Planning
POS:  Provincial Office of Statistics
PHOD:  Provincial Housing Department
PDAS: Provincial Department of Aqueducts and Sewerage
PSD:  Provincial Sports Department
PTD:  Provincial Transportation Department
ETECSA:  Cuban Telephone Company
PCD:  Provincial Culture Department
PDCS:  Provincial Department of Community Services