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Cuba's Success in Child Health: What Can One Learn?

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Cuba's Success in Child Health: What Can One Learn? Open access Editorial bmjpo: first published as 10.1136/bmjpo-2019-000573 on 30 October 2019. Downloaded from Cuba’s success in child health: what can one learn? Mauro Castelló González ,1 Imti Choonara 2 To cite: Castelló González M, Cuba has excellent child health as illustrated to the effect of social determinants on child Choonara I. Cuba’s success by its low child mortality rates. Child mortality health. There is a strong emphasis on the in child health: what can one rates (under 5 years, infant and neonatal) in prevention of disease. Health promotion is a learn? BMJ Paediatrics Open 2019;3:e000573. doi:10.1136/ Cuba have all been lower than in the USA for key feature of Cuban society and involves chil- bmjpo-2019-000573 many years. WHO figures for 2016 for under dren’s TV programmes as well as schools and 5 child mortality (U5M) show that Cuba has a the mass media. Healthy eating, the impor- U5M rate of 5.5 per 1000 live births, whereas tance of handwashing and exercise along- Received 24 August 2019 Revised 7 October 2019 the USA has a U5M rate of 6.5 and Costa Rica side sexual health have all been featured in a 1 Accepted 8 October 2019 has a rate of 9.7. Cuba has the second- lowest variety of different campaigns. U5M in the Americas behind Canada with a There is a recognition that good antenatal rate of 4.9. U5M is considered to be an excel- care has a major impact on child health. lent indicator of child health by UNICEF.2 During the pregnancy, each woman is seen Cuba is a middle- income country with consid- at least 12 times.2 Women with medical or erable economic problems exacerbated by the social problems are seen more frequently. blockade imposed by the USA. How then has Screening for fetal congenital malforma- it achieved such good child health outcomes? tions is offered. One of the unique features Cuba’s achievements in child health are due of antenatal care in Cuba is the provision of to a combination of factors.2 3 Cuba has an maternity homes where women with medical integrated healthcare system with all sections or social problem are offered free residen- http://bmjpaedsopen.bmj.com/ cooperating fully. Universal healthcare and tial accommodation for several weeks.5 At universal education are the basis for good the maternity home, women are given free health. Literacy is at 99.7% and this enables meals to ensure adequate nutrition for both public health campaigns to reach the entire the women and the fetus. Education about population. Free universal education has the importance of diet and the minimisation resulted in Cuba having one of the highest of risk factors, such as alcohol and tobacco, doctor- to- population ratios. Programmes, is given. This multidisciplinary approach has such as ‘Educa a tu hijo’ (educate your seen Cuba achieve a significant reduction child), are in place to prepare young chil- in the number of low birth weight (LBW) dren for school.4 This non- institutional- based babies born.6 7 LBW babies (<2.5 kg) account on October 2, 2021 by guest. Protected copyright. programme was developed in rural areas, for 5.3% of all births in Cuba (2015 data).7 and subsequently extended throughout the In contrast, in the USA, LBW babies account 8 © Author(s) (or their country, as it was recognised that early child for 8.3% births (2017 data). Infant mortality employer(s)) 2019. Re-use development is essential for child well-being. rates are significantly higher for LBW babies. permitted under CC BY-NC. No Primary healthcare is a key feature of Cuba, thus, ensures that fewer babies are commercial re- use. See rights healthcare in Cuba. Almost half of all Cuban likely to be disadvantaged at birth. and permissions. Published by BMJ. doctors work in primary healthcare. Primary Each child is seen regularly during infancy 1Pediatric Surgery, Camaguey healthcare exists both in urban and remote (fortnightly for the first 6 months and Children's Hospital, Camagüey, rural areas. The presence of health facili- monthly between 6 and 12 months) and Cuba ties even in remote rural areas is essential to early childhood by the primary healthcare 2 Child Health, University of ensure universal access to health. The primary team. More frequent visits are arranged for Nottingham School of Medicine, healthcare team usually consists of a doctor infants with chronic illnesses. These checkups Derby, UK and nurse working together in a consultorio occur both in the patient’s home as well as (primary healthcare facility). Each team is the family doctor surgery (the consultorio). Correspondence to Emeritus Professor Imti usually responsible for approximately 300 This helps to ensure that health professionals Choonara; Imti. Choonara@ families. The team know each family both have a true picture of family life. A compre- nottingham. ac. uk medically and socially, which is important due hensive immunisation programme is in place Castelló González M, Choonara I. BMJ Paediatrics Open 2019;3:e000573. doi:10.1136/bmjpo-2019-000573 1 Open access bmjpo: first published as 10.1136/bmjpo-2019-000573 on 30 October 2019. Downloaded from Table 1 Immunisation schedule in Cuba reflection of the importance of gender equality in Cuba. This empowerment is likely to be a contributory factor to Vaccine Age child health in Cuba. Unlike many other Latin American BCG Birth countries, women are in full control of their sexual and HepB Birth reproductive health through the widespread availability DTwPHibHep 2, 4 and 6 months of family planning clinics alongside specialised services. Different forms of birth control are available and abor- MenBC 3 and 5 months tion is provided where requested in a safe environment. OPV <1, 1, 2 and 9 years Socioeconomic determinants contribute to health, and DTwP 18 months to child health in particular. Inequality is a problem in Hib 18 months Cuba, like all other countries. The greatest inequalities MMR 1 and 6 years involve people working for foreign investment compa- nies, self- employees, private workers and individuals DT 6 years working in the tourist industry, who may receive signifi- Typhoid 10, 13 and 16 years cantly more than official incomes. The Cuban govern- TT 15 years ment constantly looks at ways of reducing the inequalities by either raising salaries of state employees or increasing taxes in the private sector. Additionally, Cuba’s welfare (table 1).9 Cuba was the first Latin American country to state ensures that nobody is destitute. Severe malnutri- eradicate poliomyelitis and as of 2016, had eradicated tion in children was declared absent in Cuba by UNICEF five other infectious diseases (neonatal tetanus, diph- over a decade ago and malnutrition is not considered theria, measles, whooping cough and rubella). In 2015, 12 a major problem in Cuba. This is despite the prob- the WHO validated the elimination of mother- to- child lems caused by the economic blockade of Cuba by the transmission of HIV and syphilis in Cuba. Polyclinics USA. Inequalities between regions in Cuba are less than provide a link between primary healthcare and hospitals. compared with other countries. Regional U5M rates for Paediatric specialists offer clinics in the polyclinic. This the years 2015–2018 show the highest rate in Guanta- means that children can be assessed in the community namo in the East (7.5) and the lowest in Pinar del Rio in without needing to attend the hospital. Polyclinics also 13 the West (4.1). offer clinical psychology support to children with mental The Cuban government recognises health as a priority. health problems. This ensures a waiting time of only 1–2 This is of major importance and is recognised as such by weeks for children with mental health issues. 14 groups, such as UNICEF. It is unfortunate that many http://bmjpaedsopen.bmj.com/ Breastfeeding rates are high (approximately one-third other governments do not show the same priority to of infants exclusively breastfed for the first 6 months) health, and to child health in particular. Investment in and breastfeeding is encouraged by the primary health- people through health, education and social services care team.10 The nutritional state of children in Cuba is has unfortunately resulted in less money being available good, although obesity is increasing.10 A positive attitude for other services, such as roads, transport and housing. towards disability is encouraged. The presence of an Cuba has shown that despite limited resources a country educated population reduces misconceptions and stigma can achieve excellent child health if the government and associated with diseases, such as epilepsy. citizens are committed to making health and children a Empowerment of women in civil society has been a priority. Cuba is an example of what is possible. The key major achievement in Cuba. First, all girls attend school. factors for ensuring children healthy are listed in box 1. Women have the same rights as men in Cuban law and on October 2, 2021 by guest. Protected copyright. receive equal pay. Maternity leave is 12 months and the Contributors Both the authors have written the editorial and approved the final women’s job is protected by law. The majority of profes- version. 11 sionals in Cuba are women. Additionally, the majority Funding The authors have not declared a specific grant for this research from any of Members of Parliament in Cuba are women, with Cuba funding agency in the public, commercial or not- for- profit sectors. having the second- highest proportion of women in parlia- Competing interests I, IC, am Editor- in- Chief of BMJ Paediatrics Open. ment worldwide. This representation in parliament is a Patient consent for publication Not required.
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