Eye on the prize
Improving health systems' management, efficiency and quality can be the source of improved population health. But only if the systems themselves are equity-based. If drug and technology innovation, streamlined patient care and enhanced prevention simply reflect societal divisions and generate results for the few, then such advances can only worsen health disparities. Hence, the title of our editorial, which begs the question: better management, efficiency and quality towards what end? Towards better population as well as individual health, towards health equity.
In this context, Cuba is both fortunate and cursed. Its five-decade-old single, universal public health system-and most importantly the good health indicators it has produced-embodies an ethical as well as constitutional commitment to achieving the highest order of wellbeing for its citizens, individually and collectively. But maintaining such a massive national effort in ever leaner economic times and under the shadow of the US embargo can become a crushing burden that threatens to break the back of both health professionals and the system itself. In this sense, the commitment becomes a curse, unless Cuba's health authorities and government can achieve the magic mix of greater efficiency and new resources to create long-term sustainability.
This goal is at the heart of the health reform now under way on the island, as José Luis Di Fabio, PAHO/WHO Representative in Cuba indicates in this issue's Interview. In these pages and issues to come, MEDICC Review will be following this overhaul of Cuban public health. As with other developing countries facing the perfect storm of global economic, climate, food and health crises, the way forward is far from certain. However, Cuba's experience during its economic collapse of the 1990s provides some evidence that making health a priority in the worst of conditions makes a difference: over that decade, the main health indicators held firm, resting on a number of strategies already in place, not the least of which was a strong primary care network. A 1999 report published by the UNDP indicated that, of 25 countries in the region, Cuba was making the best use of its few health care dollars to improve population health.
Today, the country's publicly-funded health system spends $672 per capita annually, a far cry from the nearly $8,000 spent in the USA. How these scarce dollars are used raises critical and complicated questions, whose answers may have meaning well beyond Cuba and the Caribbean. Some of the questions are old, but require fresh thinking: who participates in decisionmaking on where funds are spent, nationally and locally? What evidence do they have to make such decisions? Where does it come from, and how fast does it get to decisionmakers? What role do individuals, communities and health professionals play in this process, and in building the social construct of a healthy society? How can successful institutional and local strategies be scaled up to national implementation? How does the health system pay attention to public satisfaction and monitor results of its reform, to keep disparities from widening?
In Cuba, how can the most be made of the fact that the system is geographically based, with a strong data subsystem fed by family doctors and community polyclinics charged with the health of all residents in a particular territory-digging in with epi-mapping to best aim strategic resources? How can innovations in biotech and other advanced technologies be introduced quickly and most effectively, respecting the regulatory framework? How can Cuba's decades-long investment in human resources for health pay off through more export of new products and services, reverting dollars to the health system and designing new salary formulas that appropriately award excellence?
The search for better ways of doing things begins, of course, by understanding the problem in order to suggest more effective action. In this issue, Armas addresses a gap in Cuban studies on one of the main causes of death in Cuba, her findings arguing for creation of a national registry for acute myocardial infarction.
Creating the evidence base for decisions-particularly in developing countries haunted by resource constraints-also calls for simultaneously improving reliability and efficiency of populationbased surveys (Le and Vu on interview techniques in Vietnam) and sampling approaches for important contributors to morbidity and mortality (Silva et al. on NCD surveillance in Cienfuegos, Cuba). González suggests another step forward that concerns fine-tuning old and developing new indicators needed to reach specific health targets, in this case elimination of TB in Cuba.
Introducing strategies for quality patient care to achieve significantly better outcomes is the subject of Navarro et al., who describe a multifaceted interventions at the Cienfuegos' provincial hospital, a WHO Collaborating Center in Hospital Organization, Management and Quality. Their evidence raises the obvious question of how and how soon such an experience might be translated into national use. This is the same question raised by results of Aragonés' review of software developed for improving care for Cubans living with HIV/AIDS. Encouraging are Fernández' findings on another software, for cognitive rehabilitation.
Two papers point to the health sector's fundamental and complex relations with society at large-with people, their communities and their culture. Luis urges further personal responsibility, particularly community engagement, in Cuba's health reform process, arguing for better use of Cuba's considerable social capital to transform the way health is constructed and health care organized. In her Viewpoint, Marcheco calls on health professionals to examine their practice in caring for cancer patients, noting that the cultural underpinnings of the patient-physician relationship may be an obstacle to prevention and healing-perhaps inadvertently raising the important question of the social sciences' role in conceptualizing Cuban public health.
We take this opportunity to relay two important messages: first, a hearty congratulations to Editorial Board member Dr Paulo Buss for receiving PAHO's 2012 Abraham Horwitz Award for Excellence in Leadership in Inter-American Public Health. And second, a welcome note to participants in Cuba Salud (December 3-7). We wish you a stimulating conference, contributing to more effectively and equitably managed health systems and societies.