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SPOTLIGHT MDGs & Health Equity in Cuba
‘We live like the poor, but die like the rich,’ goes the popular Cuban saying – a simple axiom embodying the complex reality of the island’s progress towards health equity. ‘Living like the poor’ refers to the resource-scarce setting (like much of the Global South) that defines Cuba, while ‘dying like the rich’ refers to the diseases – cardiovascular disease, cancer – that are the leading causes of death in Cuba (quite unlike the Global South). The saying should also include being ‘born like the rich,’ since Cuba’s infant mortality rate places it among the privileged worldwide.[1] Enter the UN Millennium Development Goals (MDGs). Designed to measure progress towards eliminating extreme poverty by 2015, the MDGs provide a framework for a concerted, global development effort. By measuring 48 indicators, 18 directly related to health, the goals allow individual nations to measure their development progress in several key areas. While their aggregate, outcome-oriented construct has its limitations, the MDGs provide a starting point for understanding how equity and development (both economic and human) interact to affect health, well-being, and sustainability. Cuba’s MDG Scorecard Unnecessary, preventable and unjust conditions that foster and perpetuate inequity are known as ‘inherited disadvantages.’ These are social, demographic, geographic or economic circumstances into which a person is born, and over which they have no control, but which directly affect their ability to improve their personal welfare, stay healthy or simply survive the first five years of life. Exhibiting the political will to offset imbalances in such structural fundamentals that shape every society provides the first link in the chain towards equity in health and human development.
In Cuba, the combination of free and universal health care and education, public participation, and the willingness by the government to implement policies to maximize equity, has had positive effects on health outcomes. At 2004 year’s end, chief national health indicators related to reaching the MDGs included:
Taken together with an array of other indicators, this means Cuba has achieved three of the eight MDGs and is on track to achieve another trio by the 2015 deadline (Table 1). Table 1: Cuba´s Progress Toward the Millennium Development Goals
Source: Human Development Report 2005 Improving national aggregates in health and other indicators, however, is just the first step on the long road towards reaching the MDGs for whole populations, and thus promoting health equity. Indeed, reporting a country’s overall outcomes often masks inequity, an explicit shortcoming of the goals as an instrument to measure health achievements and development. “Reporting of national averages for the indicators is a very blunt instrument to use to assess whether or not changes have occurred and to provide sound explanations thereof,” stated a WHO assessment of progress towards the goals.[3] In the search for those ‘sound explanations,’ Cuba analyzes health outcomes across many variables, including gender and geographic location – two classic inherited disadvantages contributing to inequity. Vulnerable Populations & Equity Gender, age, geographic location, and mental and physical disabilities are determinants affecting equity and subsequently, health. In recognition of this, Cuba has designed programs and shaped policy specifically for those populations to provide for their health and boost human capacity. Some examples include:
The dual approach of lowering economic and physical barriers to access, while providing specific programs for vulnerable populations, has shown positive results across both time and the national territory. The latter is particularly challenging for countries of the Global South, which typically evidence a dichotomy in health indicators within their borders – more positive general outcomes in the capital and big cities, which turn abysmal upon entering the countryside. In this regard, Cuba’s history is no different. But by collecting data and analyzing outcomes across territories, health authorities have been able to target provinces that have traditionally lagged behind the rest of the country, dedicating human and material resources to closing the health equity gap between urban and rural populations (Table 2). As a result, it is not always the City of Havana (considered a province in Cuba’s political/administrative division) that exhibits the best indicators in the country. Such policy adjustments and resources transferred to tackle internal disparities have contributed to the positive trend in Cuba’s global results over time (Table 3). Taken together, Tables 2 and 3 show much progress has been made, and indicate where improvements are needed. Health authorities agree that further attention is needed to implement aggressive, systematic approaches that will improve problem areas like maternal mortality, and consistent availability of a nutritious food supply and essential medications. To this end, instruments have been proposed for measuring health outcomes across time, space and population groups to define a more equitable and efficient health policy (see Professional Literature A Monitoring System for Health Equity in Cuba). Table 2: Key Health Indicators by Province, 2004
Source: Instituto Nacional de Investigaciones Económicas, July 2005 Table 3: Selected Health Indicators, Cuba 1994 & 2004
Source: Anuario Estadístico de Salud In addition, recent adjustments to primary health care in Cuba aiming to tailor services to the local health picture, improve access, and increase technological and physical capacities of polyclinics and hospitals, indicates continued commitment to equity-driven policy making (see MR Feature Changes to Cuban Health Care Aim to Extend Equity). Another health challenge looming on the horizon is the graying of the Cuban population due to lower birth and infant mortality rates, longer life expectancies and migration: as of 2003, 15% of the Cuban population was 60 years or older. As this trend continues (by 2025, the figure is expected to reach 25%), existing health, education and cultural programs will have to be reevaluated and new initiatives - especially related to employment and productivity - launched to cope with the effects this will have on Cuban society. Significantly, Cuba undertakes comprehensive data collection to define the scope of the population’s health problems – distinguishing it from many countries which suffer from a woeful lack of reliable data. This simple lack of data is hamstringing faster progress towards the MDGs for many countries of the Global South, which Cuba leads in several indicators. Indeed, the island even surpasses many developed nations (Table 4). Table 4: Cuba vs Selected Regions in Infant & Under 5 Mortality, 2005
Source: United Nations, 2003 and Anuario Estadístico de Salud By relying on aggregate national data that is neither sensitive over time, nor weighted for those nations already evidencing positive outcomes, the MDGs cannot give a true picture of health, relative poverty or development of a country. Furthermore, such collective measurements severely limit comparisons among and within nations. By approaching health as a strategy capable of augmenting both human development and equity, Cuba has brought a fresh perspective to the MDGs and the type of progress that is possible even in resource-scarce settings. Notes & References
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