Latin America

AMA Journal of Ethics®
Illuminating the Art of Medicine

Policy Forum
Mar 2021
Peer-Reviewed
Health Equity, Cuban Style
C. William Keck, MD, MPH
Citation
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Abstract

The United States has not yet decided to ensure that every citizen has access to health care services at reasonable cost. The United States spends more on health care than any other country by far. Yet the health status of the US population, when compared with that of like nations, remains poor. The US system does not operate efficiently, fares poorly in terms of health equity, and has an illness and injury care industry with many uncoordinated “systems” focused on treating individuals rather than on improving health status. There are lessons for us in Cuba’s health system.

We Don’t Get What We Pay For

The United States has not yet decided to ensure that every citizen has access to health care at a reasonable cost. As many readers know, the United States spends more on health care than any other country by far—$11 072 per capita in 2019.1 Yet the health status of the US population, when compared with that of like nations, remains at the bottom of the list.2 We also fare poorly in terms of health equity, with large disparities in health status between subpopulation groups.3 We are not getting what we pay for largely because the United States does not have a health care system that runs efficiently. Instead, we have an illness and injury care industry containing many different, uncoordinated “systems” focused on treating individuals rather than on improving health status.

There are many examples of countries that have found a way to provide universal access for their populations using variations of 3 models: socialized care, socialized payment, or highly regulated private insurance.4 Some of our national policymakers seem largely unwilling to learn from others if doing so would require change at home, but if we hope to do better, learn and change we must!

I suggest that, in addition to examining the approaches chosen in upper-income countries similar to our own, we also look at Cuba, a middle-income country. Since the 1959 overthrow of the Batista regime, Cuba has focused on developing a health system that would be accessible to all at no cost to the patient, with an emphasis on reducing health inequities. It has had remarkable success, changing its population health status (life expectancy, infant mortality, infectious disease mortality, older adult health) from that typical of a low- to middle-income country to a high-income country, all while suffering for 60 years under the impact of the strongest embargo enacted by the United States.5 In an early nod to an important social determinant of health, the Cuban government understood that health and economic development are closely linked to population education levels, so universal access to free education through professional training was instituted, with the result that Cuba is ranked 13th in the world in literacy—with an almost 100% literacy rate—while the United States is ranked 125th with a literacy rate of 86%.6 Cuba’s experience indicates that population health can be achieved in the absence of wealth if existing resources are well organized and applied effectively to accomplish measurable health, education, and social welfare goals.

Lessons From Cuba

So, how has Cuba managed to improve health status so dramatically? Space constraints preclude a detailed analysis here, but a brief discussion of how Cuba has improved its infant mortality rates can provide some insight into how Cuba has improved its population’s health status overall and diminished health inequities. Infant mortality is one of the measures generally accepted as reflective of a health system’s effectiveness.7 In the United States, the infant mortality rate in 2017 stood at 5.8 deaths per 1000 live births, but that average number hides the wide range of infant death rates across individual states—from 3.7 to 8.6 per 1000 live births in 2017—or between racial groups—from 11.4 per 1000 live births among non-Hispanic Black people to 3.6 per 1000 live births among Asians in 2016.8 In comparison, infant mortality in Cuba stood at 38.7 per 1000 live births in 1970, and fell to 4.0 per 1000 live births in 2018, with a range of 2.1 to 6.3 between Cuba’s 15 provinces.9 In 2019, mortality under 5 years of age was 7.0 per 1000 live births in the United States and 5.0 per 1000 live births in Cuba.10

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