1. Health Equality & Equity: Case Study of Cuba
Merlyn Dorsainvil, DHSc, MS, MPH, RN

2. Health Equality vs. Health Equity
Equality: being the same in number, amount, degree, rank, quality, etc.
Equity: fairness or justice in the way people are treated.
Will all things ever be equal?
If there is not equality can there still be equity?
We live in a democratic country; will all things ever be equal? Will there be some people with more education, more money, a bigger house, etc? Yes. But even if there is not equality can there still be equity? YES! Just because your house is bigger, we both should still have sanitation and clean water running in both houses, regardless of size or luxury. You might make a six-figure salary and I only make $25,000/ year but we should both have access to high quality health care. You may have a masters degree and I have a GED but I should have equal access to education as you did, should I decide to get a masters degree.

3. Health Equity
Health equity is achieved when every person has the opportunity to “attain his or her full health potential”
Health inequities are reflected in differences in:
length of life
quality of life
rates of disease
disability, and death
severity of disease
Access to treatment
CDC, 2015

4. Cuba
“An evaluation of 25 countries in the Americas measuring relative inequalities in health revealed that Cuba is the country with the best health situation in Latin America and the Caribbean. It is also the country which has achieved the most effective impact with resources, though scarce, invested in the health sector”
(Study on Human Development and Equity in Cuba, UNDP, 1999)
Cuba is 90 miles from Key West, Florida. Cuba is closer to Key West than Miami.

5. Lesson Learned
Economic measures alone are poor predictors of physical well- being within a society

6. The beginning: 1959 Castro’s rebel army overthrew the Batista regime.
Castro pledged to address rural poverty, illiteracy, & health disparities
1st question: How to improve Cuba’s health status?

8. Historical context: 1959-1989 Accessibility, Quality, Equity, Outcomes
Havana to provinces to rural and mountains
Social determinants led to literacy campaign and social programs
Hospitals, community clinics (1970s), family doctor-and-nurse (1980s)
Changed ethos of health from curative practice to preventive then to integration of prevention, treatment and research

9. (cont.)
Unreliable data to epidemiological surveillance to early warning system
From sparse medical research to expanded priority-driven research production for public health

10. 1990-2000 Economic crash known to Cubans as “The Special Period.”
From Cuba lost 85% of its foreign trade
U.S. embargo tightened in 1992
From , Cuba’s economy shrunk by 35%
Hard currency for medicines/equipment by 70%
Daily caloric intake dropped 33%, proteins 39%

11. The Paradox Health indicators continued to improve. 10.7 in 1990
Infant mortality
Life expectancy
10.7 in 1990
9.4 by 1995
6.5 by 2002
75.2 in in in 2002

12. How? Health as a priority: Right and responsibility
Resources concentrated: Most vulnerable first
Human resources: Highly trained and dedicated
The doctor and nurse next door: Community-oriented primary care, active community participation
Health status: Solid foundation addressing social determinants

13. Public health accomplishments
1962: First country to eliminate polio
1996: First country to eliminate measles (Special Period)
Most effective Dengue control program in the Americas
Adult literacy rate in 2015: 99.7%
Improved water source 2015 (% of population with access/% rural population): 95/90

14. Health Care System in Cuba

15. 2012 Resources Hospitals 152 Polyclinics 452 Dental services 496
Doctor-nurse offices 11,550
Maternity homes 150
Nursing homes 144
Seniors day homes 233
Medical sciences universities 14
Research centers 13
Physicians 82,065 (1/137 pop… In US, 1/390 in 2007)
Dentists 13,998 (1/804 pop)
Nurses 92,131 (81.9/10,000 pop)
Allied health professionals 195,045

16. Bloomberg’s Ranking of Health Care System Efficiency, 2013

17. Latest Health/Social Indictors (2015)
Cuba
United States
Life expectancy at birth (females/males): 81.6/77.6
Infant mortality rate (per births): 4.0
Unemployment (% of labor force): 3.o
Education: Govt expenditure (% of GDP): 12.8*
Seats held by women in national parliaments (%): 48.9
Life expectancy at birth (females/males): 81.3/76.5
Infant mortality rate (per births): 6.0
Unemployment (% of labor force): 5.3
Education: Govt expenditure (% of GDP: 5.2*
Seats held by women in national parliaments (%): 19.5
Source: UN Human Development Index
* 2011 data

18. Rural Health US: 15% live in rural areas (Cuba: 23%)
Major health disparities in the US
Why? Inequality of inequity?
Greater risk of death from: heart disease, cancer, unintentional injury, chronic lower respiratory disease, and stroke. Also higher rates of poverty, less access to healthcare, and less likely to have health insurance.

19. Human Development Index
Societies can’t be measured by economics alone (Lesson learned)
“Who has been left behind and why?”
Three dimensions:
Long & healthy life (life expectancy)
Knowledge (education)
Decent standard of living (income)
It does not reflect on inequalities
It recognizes that in every society certain groups are far more likely to suffer disadvantages than others and identifies deep-rooted, and often unmeasured, barriers to development.
HDI does not reflect on inequalities, poverty, human security, empowerment, etc

20. Human Development Index 2016
Cuba
0.775 (Rank 68)
United States
0.920 (Rank: 10)

21. Inequality Cuba United States HDI: 0.775 Inequality-adjusted HDI: n/a
Inequality in life expectancy: 5.5%
Inequality-adjusted life expectancy index: 0.866
Inequality in education: 10.9% (adjusted index: )
Inequality in income: n/a
HDI: 0.920
Inequality-adjusted HDI:
Inequality in life expectancy: 6.1%
Inequality-adjusted life expectancy index: 0.855
Inequality in education: 5.6% (adjusted index: 0.850)
Inequality in income: 27% (adjusted index: 0.692)

22. Conclusion Address inequalities to improve rural health outcomes
Cuban population: 11, 393 GDP: 82, 775
American population: 324, 119 GDP: 17, 348, 072