MR INTERVIEW

Francisco Rojas Ochoa, MD, PhD, MPH
Professor, Researcher & Author

By MEDICC Review Staff

When he recently received the Pan American Health Organization’s Health Administration award, Dr. Francisco Rojas Ochoa described his early service in Cuba’s remote mountain communities – becoming one of the first doctors seen by many of his patients - as one of the most profound experiences in his career (see Headlines Cuban Medicine Receives International Recognition). This is quite the paean from an educator and administrator who is Distinguished Professor at the Higher Institute of Medical Sciences and National School of Public Health in Havana, a member of the Cuban Academy of Sciences, Editor of the Cuban Journal of Public Health and consultant to PAHO, the World Health Organization and the United Nations Population Fund. 

As Director of the Institute for Health Development (1977-81) and co-author of Salud Para Todos, Sí es Posible (Health for All, Yes, It’s Possible), Dr. Rojas Ochoa has dedicated a lifetime career to contemplating the health equity puzzle. He shared his views recently with MEDICC Review.

MEDICC Review: In your experience, how has Cuban policy - in general and in health care - addressed inequity over the years?

Francisco Rojas Ochoa: I think the first important blow against inequity in Cuba was the Agrarian Reform [in the early 1960s], which among other things, dramatically reduced centuries-old, chronic unemployment. As a result, unemployment dropped from over 12% to less than 2% in just a few years. The unemployed live in poverty; many of them in extreme poverty. As far as I’m concerned, the fight against poverty is foremost in the struggle against inequity.

General laws also came into play, lowering rents, electricity rates and medication prices. Development of health care services and the education system also began at that time, first with the literacy campaign, and then extending primary education throughout the country. Increasing people’s education level strengthens their cultural formation, and ultimately, is a powerful weapon in the struggle against inequity.

Almost since its creation, Cuba’s health system has made efforts to root out unfair and avoidable inequalities.  The first major reform was the creation of Cuba’s first public health program – the Rural Medical and Social Services – in January 1960.  Until then, there were virtually no physicians in the countryside; they hadn’t been willing to go there, preferring to work in the private sector. But rural people couldn’t afford private medical care, and there were no public services for them either. This program gave them access to health services. All physicians who graduated that year went to work in the countryside, providing their services to everyone for free; even medicines were free. Free health care in the cities came later.

Soon after came the programs aimed at protecting the health of mothers and their children. In 1972, the first maternity home was created. There are over 200 in Cuba today. These are centers where at-risk pregnant women are looked after, their well-being ensured before delivery. By 1978, all in- and out-patient services were provided universally and free of charge, thus eliminating economic barriers to access.

The Rural Medical Service brought health care to Cuba’s most remote reaches.

MR:  How does this relate to vulnerable populations?

FRO: Vulnerable populations include the elderly, women, the poor, and the unemployed, among others. A number of initiatives have been taken to address equity in health care for these groups. Sometimes, it has been by changing laws, other times by creating new services.

One example: today the elderly account for over 15% of the Cuban population, and their number is increasing, generating concerns about their vulnerability.  As a result, health service reforms have been continually introduced to cater to their needs and well-being (see MR Feature Changes to Cuban Health Care Aim to Extend Equity). This includes the creation of a center for research on health and the elderly - the Ibero-American Center on Aging (CITED) - and social security reforms.  An increase in pensions was mandated this year, as a response to the rising cost of living and a new job initiative  allows retired people still willing and able to work to do so, while still receiving their pensions.

Elder care home capacities have also increased, and major repairs made to improve their conditions. However, many of us in the public health sector believe that old age homes are not the answer. We need to work harder to recover the tradition of Cuban families looking after their elders. Today we find more younger families who don’t want to live with their elders and try to send them away to old age homes. Alternatives have been introduced, such as daytime centers, where the elderly can go and be looked after during the day and then return to their families in the evening, maintaining the family connection.

MR: Where do you see room for improvement in the Cuban health system’s approach to equity?

FRO: I think we still need to work hard to improve the relations between health care workers and the population. I think this is one of the essential ethical responsibilities of public health service providers.

Since last year, we’ve been holding “Ethics Dialogues” - meetings with hospital and polyclinic staff and other health workers to discuss how to optimize their relationship with patients. There have been complaints from both health care workers and the population about each other’s behavior. Sometimes these complaints are based on tangible issues. Every effort is being made to improve the physical conditions of our facilities, for instance: hospitals and polyclinics that were in very bad shape have been – and are being – repaired. When physical conditions are bad, the workers may not feel like doing a good job or may be disgruntled. We’re doing our best to address this problem.  But nicely decorated hospitals or the most sophisticated medical equipment aren’t enough if health professionals and technicians don’t treat their patients correctly and compassionately.

I think this is an area where very hard work is still to be done, and it will take us a long time, maybe years, particularly with [our medical] students. We have to ensure that the ethical principle of a good doctor-patient relationship is sufficiently emphasized in their training.  Cuban doctors now serving in other parts of the world, in very poor nations – in the countryside, in mountainous areas, in the remotest places of Africa or Central America – have established excellent relations with their communities and patients. There they are faced with a different reality; they learn many things, in particular about interpersonal relationships, and they return home with a more comprehensive and solid formation. And this benefits us all. These people go to work in other countries for two or three years, but then they return home and work here for 30, 40 or 50 years. So, we’re not only giving, we are receiving benefits as well.

MR: Do you think the Cuban model is replicable in other countries?

FRO: What we call the Cuban approach, the Cuban health care model, I would say is not replicable, if we understand “replicate” as making an exact copy. Two countries will never be able to replicate each another’s ways of doing things. Certainly, some of our experiences can be considered, analyzed and adapted to the reality of another country, mainly in terms of what the Cuban government has done to fight inequity in health, but  trying to replicate someone else’s ways of doing things can be risky.

I would say in recent years, we’ve been working on creating our own ideas, and looking into the work done in health care in the rest of Latin America. We believe there is a Latin American way of thinking with respect to the delivery of health care and social services.

MR: What hurdles do you see for other countries working towards health equity?

FRO: The heart of the struggle for health equity is the development of public, state-funded services which are provided free of charge, or at very low cost, to the whole population. Whenever a country, government or society opts to depend on private health services or private health insurance, they are breeding inequity, since not many people will be able to afford these services. No developed or highly developed nation has so far stamped out poverty, so I believe the answer is a state-funded public health service – where the term “public” means accessible to all, free of charge or at very low cost. This can be a first step.

A second step would be to regulate medicine prices. As long as the pharmaceutical industry remains an incredibly powerful, transnational for-profit business, which sells vital medicines at inflated prices well above the real cost of production, this will be a source of inequity. Until governments intervene in the regulation of medicine prices, huge inequities will continue. A well-known example is antiretroviral drugs for people with HIV/AIDS. The production cost for these drugs is a fraction of what they’re sold for. Some governments have challenged these policies by manufacturing generic drugs.  Countries like Brazil and South Africa have dramatically reduced costs of antiretroviral drugs, making them accessible to many patients who could not otherwise afford them. In Cuba, antiretrovirals are dispensed free of charge to all AIDS patients who need them.

Another priority of the Cuban government has been the development of human resources in health. As far as I’m concerned – and this is what I’ve learned from the Cuban experience – the development of public health depends first and foremost on the amount and quality of people working in the sector. With too few people, or with people not fully trained and capable, providing proper health care proves impossible. In Cuba, we have worked hard to train competent doctors, nurses, health technicians and social workers. And they are the mainstay of the health system. 

MR: What do you think about progress - or lack of it - towards the UN Millennium Development Goals?

FRO: So far, the world has been unable to meet the objectives. We have the necessary technology, and we may have the necessary funds, but the political will isn’t there on a global scale. This includes the struggle to make poverty history, which should be our number one objective. Sometimes, looking at the percentages we say, ´Ah! Poverty has decreased by one or two percent.´ However, looking at absolute figures, we find that each year the number of poor people is higher. And this is due to the fact that the world population is growing. Therefore, despite one- or two-percent decreases, there are still a million more people in the world who are poor.

It’s like being on a treadmill – we’re walking a lot but getting nowhere. Or worse: we keep moving towards meeting our objectives for this millennium, but instead of making progress we’re moving backwards. We’ve set our target for 15 years and though one third of this time has already elapsed, we have not yet achieved one third of what we expected to. We are behind schedule.  The culprits?  Lack of political will from many countries, and the ever increasing power of neo-liberal policies.

To learn about Cuba and the MDGs, see Spotlight MDGs & Health Equity in Cuba.