Social Inequalities in Health

THE CUBAN EXPERIENCE IN PUBLIC HEALTH:

DOES POLITICAL WILL HAVE A ROLE?

Nino Pagliccia and Adolfo Álvarez Pérez

The role of political will in public health has been largely ignored. In
Cuba, however, for the past 50 years, political will has been the ultimate,
encompassing intersectoral action in public health. The excellent achieve-
ments in population health in Cuba during these 50 years have been widely
recognized. Researchers have sought to explain this “Cuban paradox” by
focusing on a large array of public health factors, including health promotion,
primary care activities, and intersectoral action on health determinants. These
factors constitute necessary but not sufficient conditions to achieve good
health outcomes. This article defines political will and uses the experience
of Cuba to illustrate the potential role of political will in public health.
The authors suggest a framework for the evaluation of political will aimed
at achieving good health, examining the “Five R’s of political will,” five
observable features that may provide systematic information on the direction
and realization of political will: (1) renewal of commitment, (2) reform
of the system, (3) resource development, (4) review of performance, and
(5) responsible management. These five features focus the spotlight on the
consistency between health goals and public discourse and action.

Since the early 1970s there has been no shortage of research, conceptual frame-
works, and recommendations on policies aimed at improving health outcomes and
reducing health inequity in the world. In the process, many essential theoretical
breakthroughs have occurred. Key examples are: a redefinition of the concept of
health that recognizes the impact of social factors on health (1–3), a restructuring
of the health care system to include intersectoral management of health deter-
minants (4, 5), and an ecosystem approach to human health (6).

International Journal of Health Services, Volume 42, Number 1, Pages 77–94, 2012
© 2012, Baywood Publishing Co., Inc.
doi.http://dx.doi.org/10.2190/HS.42.1.h
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But world health inequities persist, suggesting that “gaps in health outcomes
are not a matter of fate—they are indicators of policy failure” (7, p. 866).
Concurrently, “evidence [to support public policies] is an essential but not suffi-
cient basis for policy action. Several other ingredients besides evidence are
involved in the policy-making process” (8, p. 51; emphasis in original). The
World Health Organization (WHO) report of 2008 states that “evidence is
only one part of what swings policy decisions—political will and institutional
capacity are important too” (9, p. 20).
Recognition of the importance of political will in the context of primary
care can be traced back to the Alma-Ata declaration of 1978, “Health for All.”
Point 8 of the declaration stated: “All governments should formulate national
policies, strategies and plans of action to launch and sustain primary health
care as part of a comprehensive national health system and in coordination
with other sectors. To this end, it will be necessary to exercise political will,
to mobilize the country’s resources and to use available external resources
rationally” (10, p. 2).
We can safely say that in the past 30 years there has been no shortage of good
intentions about searching for solutions to improve health, but “we have much
still to do and much to learn about turning good intents into lasting actions”
(11, p. 4), and we need to encourage the strengthening of political will.
From the preceding we can assume that policy failure, as suggested by per-
sistent gaps in health outcomes (7), may have a direct association with absence of
political will. Were it not for the fact that “policy failure” in health produces real
loss of human lives, we could continue ignoring this vital association, but the call
is urgent and the response is long overdue. We therefore believe that successful
public policies amount to more than just developing sound plans or courses of
action; they urgently require a strong political will to support them, to facilitate
their implementation, and to demand effective accountability. A model developed
by Lezine and Reed (12) uses political will as a bridge between public health
knowledge and action. This bridge is essential in policy changes.
In this article we use the Cuban experience as a case study on the role of political
will as a catalyst for good achievements in public health in the past 50 years. We
chose Cuba because we have been part of a longstanding collaboration, spanning
about 12 years, between the Global Health Research Program based at the
University of British Columbia, Vancouver, Canada, and the Instituto Nacional
de Higiene Epidemiologia y Microbiologia (National Institute of Hygiene
Epidemiology and Microbiology) based in Havana, Cuba. Tangential to our main
research theme of trying to understand the workings of the Cuban health care
system, we were challenged by a missing element that we identified as political
will. We explored available international literature on the topic, as well as relevant
Cuban documentation produced after the Cuban Revolution of 1959. What we
report here is our attempt to give a form to our findings that may be a building
block for formalizing the concept of political will and its potential evaluation.
 Public Health and Political Will in Cuba / 79

We start by proposing a conceptual definition of political will, then describe

five observable dimensions or features that we consider contribute to an opera-
tional definition of political will in the context of public health in Cuba. Finally,
we suggest a simple framework that places political will in context and draw
some conclusions about political will that may generate reflections on how it
can be recognized and encouraged in other jurisdictions.

THE CUBAN EXPERIENCE

More than 50 years ago, following the Cuban Revolution of 1959, Cuba seems to
have captured the urgency of saving lives, and it initiated a consistent process
to improve the health of all Cubans, with impressive results (13). The excellent
achievements in population health in Cuba have been widely recognized. The
WHO reports Cuba as the only Latin American country among the top 35
countries with an infant mortality rate (IMR) below 6 deaths per 1,000 live births
(14). In terms of lives saved, given an IMR of 4.7 per 1,000 live births in 2008
(15), more than 7,000 additional Cuban children were still alive one year later.
Those children would have died had the IMR remained that of 1959, at 65
per 1,000 live births.
Cuba’s IMR in 2008, at 4.7 per 1,000 live births (16), is lower than that of
the United States. In 2008, life expectancy at birth was 78.7 years in Cuba
(15). By comparison, the IMR for Argentina and Guatemala was 12.5 and 30.0
per 1,000 live births, and life expectancy 75.3 and 70.3 years, respectively (15).
Figure 1 shows selected health indicators that highlight the relative position of
Cuba compared with some other countries for the years 2000 and 2008.
Cuba’s achievements have also been noticed by well-known individuals such
as the former president of the World Bank, James Wolfensohn, who has praised
Cuba for doing a “great job on education and health,” and former vice-president
of the World Bank, Jo Ritzen, who suggested that “many developing countries
[could take] the Cuban experience well into account” (17). During a visit to Cuba
in 2009, the director-general of the WHO, Margaret Chan, stated that Cuba is
evidence that excellent heath outcomes can be achieved with factors other than
national health services (18).
In fact, some researchers observing Cuba’s success refer to it as a “paradox”
(good health at low cost) (19, 20). However, Spiegel and Yassi (19) have con-
vincingly concluded that generating wealth is not a condition for good health,
but well-developed public policies independent of external forces are.
Cuba’s population health achievements, although influenced by other factors,
may not have been possible without a strong commitment to this—indeed,
without a revolution—as some Cuban authors have acknowledged (21). Whiteford
and Branch state succinctly that “the Cuban example demonstrates the power
of a consistent health policy and strong political will, even while its practice
evolves” (22, p. 8).
80 / Pagliccia and Álvarez Pérez

Figure 1. Selected health indicators for several countries, 2000 and 2008 (unless other-
wise indicated). Source: www.paho.org/English/SHA/coredata/tabulator/newTabulator.htm
(accessed July 25, 2011).

POLITICAL WILL
Political will is often used but rarely defined. In its common usage, the expression
“lack of political will” is understood to imply that no action has been undertaken
to produce needed impacts, but the presence of political will can also cause
negative or undesirable impacts.
Early critics of political will argued that the concept is “vague and unhelpful;
as a prescription for behavior, it is patronizing and unrealistic” (23, p. 243).
A document published by the U.S. Agency for International Development
dismisses the importance of political will as “more [a] rhetorical than an analytic
concept” (24, p. 13), although implicitly recognizes it by suggesting the use of
 Public Health and Political Will in Cuba / 81

constituency building, public support, and mobilization of a divided public as

ways of advancing a reform “if political will is inadequate” (24, pp. 14, 16).
More recently, an “ideal-type definition of political will” has been suggested,
which “requires that a sufficient set of political actors with a common under-
standing of a particular problem on the public agenda genuinely intends to
support a commonly perceived, potentially effective policy solution” (25, p. 5,
emphasis in original). In their paper, Post, Raile, and Raile suggest a definition
that is conceptually satisfactory and provides conditions for the realization of
political will, but lacks a more operational approach to evaluate it.
In Cuba, a general definition of political will associated with public health
has been given as “the full and genuine willingness . . . to act consistently with the
public discourse in order to convert into reality what is advocated in public
policies, healthcare, well-being, quality of life and human development” (26).
Keys to this definition are the requirement of consistency between actions and
discourse by policymakers and the implied goal that is “advocated.”
Building in part on elements from Post and coauthors (25) and Álvarez and
coauthors (26), we define the political will to develop and sustain good and
equitable health outcomes as the full and genuine willingness by decision-makers
to act consistently with the public discourse and with the full and genuine intention
to support effective policy solutions collectively developed. Key to this definition
is an explicit identification of the object or goal of political will. This—together
with the consistency of actions—provides a basis for an operational definition.
Although the Cuban political system is based on a socialist ideology, we have
intentionally left out any reference to political orientation. We attempt to offer a
broad definition of political will that is devoid of ideology. The elements of the
framework we propose can be identified under any political orientation.
We use the context of public health in Cuba to provide some operational
elements that can be observed, to assess whether the political will behind the
policies is being executed. We have identified five necessary elements of political
will that we call the “Five R’s of political will.”

THE FIVE R’S OF POLITICAL WILL IN

PUBLIC HEALTH IN CUBA

The achievement of good health outcomes in Cuba is not a paradox, nor is

it a surprise among decision-makers and community leaders. Over the past
50 years, health policies have been developed with the clear vision to attain
good health for all.
Political will may not be an explicit item—albeit present and pervasive—on
Cuba’s health care policy agenda, but the agenda has a clear mandate of good
health and equity for all Cubans. Therefore, we argue that the presence of political
will can be monitored by the systematic review of factors leading toward this
national policy.
82 / Pagliccia and Álvarez Pérez

We propose five interconnected and observable features that can be systemat-

ically examined to ascertain and measure the presence of political will. We
refer to these features as the “Five R’s of political will.” They are: renewal of
commitment, reform of the system, resource development, review of performance,
and responsible management. We outline these features of political will and
illustrate them in the context of Cuba’s health care system.

1. Renewal of Commitment

It is important to be mindful that those in positions of power in a society—

the political actors or decision-makers in executive positions within national
or local government—state and restate their commitment to health care goals
in a very explicit way and devoid of political rhetoric. Due to changing decision-
makers and participation in the democratic process over time, reaffirmation of
the commitment guarantees continuity of the guiding principles, while at the
same time possibly announcing new directions. Lack of renewal of the social
promise can only be interpreted as a lack of determination and an undeclared
decision to abandon the intention to pursue the original goals. Usually, govern-
ments have special communication or public relations offices for the purpose
of promoting their actions and making announcements. The communication has
to be as explicit as possible in order to be easily verifiable. It is a statement of
policy, not a slogan.
Following the identification of appalling health problems in Cuba, such as
a high IMR (65 per 1,000 live births in 1959) and short life expectancy (58
years in 1959), there have been many displays of commitment to improving the
health status of Cubans since the triumph of the Cuban Revolution. From the
beginning, the public health discourse of the Cuban state has been to transform
Cuba into a “world medical power” (27) by making health a state priority (28, 29).
Renewed commitment can also be observed through the sharing of decision-
making on specific actions. Mobilization of the whole population through
mass organizations (akin to civil society), such as the Federation of Cuban
Women, the Committee for the Defense of the Revolution, and the Association of
Small Farmers, more or less shifted the management of some aspects of health
care into the hands of the people in their communities. It has been reported,
for example, that this popular participation in mass campaigns in which civil
society was involved as health promoter effectively contributed to the eradication
of polio in 1963 (30).
But a more recent and dramatic example of renewed commitment to health
care occurred during the Special Period (the time of economic crisis that followed
the collapse of the socialist bloc) that started in the early 1990s. At that time,
popular participation through community meetings across the country produced
an intensification of health protection that largely contributed to maintaining
equity and good health for all Cubans (27, 31).
 Public Health and Political Will in Cuba / 83

There have been many public reassurances from the Cuban government that
health care and the well-being of all Cubans are a continuing state commitment.
Noriega Bravo (32) gives a comprehensive review of 24 speeches delivered by
Fidel Castro between 1972 and 2004 to document the Cuban government’s
commitment to health.

2. Reform of the System

Reaffirmation of goals must be accompanied by concrete actions that reflect

true willingness to produce positive change. Deep structural and organizational
reforms may be required at the beginning of the process of change. Later, when
necessary, continued improvements can be made by introducing new legislation
to strengthen the importance, maintenance, and performance of the health care
system. Observation of this reform process can be a valuable indication of a
parallel strengthening of political will.
Cuba presents many instances of the dynamic approach to reforms under the
revolutionary government. Following the early reforms—such as consolidation
of the Ministerio de Salud Pública (Ministry of Public Health) in August
1961, creation of the first public health program, the Rural Medical and Social
Services Program, in January 1960, and provision of medical services and
teaching through Policlínicos Comunitarios (Community Polyclinics) starting
in 1974—Cuba embarked on more radical reforms toward more comprehensive
health for all.
In advance of the international recognition of the importance of social deter-
minants of health, Cuba introduced major reforms beyond the health sector. In
fact, the “ten year health plan” established in 1969 had the main task of investi-
gating the social factors of morbidity. This plan was further formalized through
the program of Medicina de la Comunidad (Community Medicine) in 1974
as an integrated health approach toward “environmental, biological, social, and
psychological factors that interrelate as determining variables in the health-illness
process” (33, p. 94). The recognition of social needs involving other sectors of
society has led Cuba to use an intersectoral approach to health management.
Further reforms of the Cuban system were introduced to reflect the shift
toward health promotion. This was done through the Comprehensive Polyclinics
and the special training of family physicians who were better prepared to address
the primary care of the population, from infectious to chronic diseases, and to act
as public health officers. The first class of Médico General Integral (Compre-
hensive General Physician) graduated and was deployed in 1984.
By far the most transcendent reform in post-revolutionary Cuba has been
the recognition of health as a human right in the Cuban Constitution. Its article
50 states: “Everyone has the right to health attention and protection.” This can
be interpreted as the most visible sign of political will. Cuba is listed among
the 60 (of 194) countries that recognize health as a human right in their national
84 / Pagliccia and Álvarez Pérez

constitution or equivalent (34). (Canada and the United States do not recognize
health as a constitutional right.) Health care in Cuba is universal, accessible,
free for all, and the full responsibility of the state.
Development of plans—procedures as well as organizations, agencies, and
capacity in the health care system—must be a dynamic and flexible process in
order to respond to newly identified objectives or to implement new knowledge.
During the Special Period in the 1990s, Cuba’s quick strategic response focused
on increasing efficiency and quality of services, strengthening primary health
care and family medicine, and expanding numerous programs (35, 36). Struc-
tural changes were also put into practice through a decentralization process
that later facilitated an intersectoral approach to health, with the “active and
organized participation of the population and other sectors, institutions and social,
political and mass organizations” (37, p. 3). As part of this process, in 1995
Cuba established the Consejos de Salud (Health Councils) as intersectoral spaces
at the national, provincial, municipal, and local levels, with independent decision-
making powers on local health matters. A recent study of two Health Councils
in two Cuban municipalities underlines Cuba’s advancement in intersectoral
action for health (38, 39).
Currently, Cuba is developing the necessary framework to address health
status and its relationship with quality of life (40) by more actively addressing
chronic diseases and lifestyles, in its desire to extend the life span of Cubans
from 78.7 years in 2008 to 80 years by 2015 (41).
Detailed accounts of the development of the Cuban health care system since
1959 are given elsewhere (27, 37, 42–44).

3. Resource Development

Development of resources is probably the most controversial issue around

political will, because it is connected more closely to social values. Given that
health care deals directly with human lives and that resources are scarce, hard
questions need to be asked: What is the value of human life? What acceptable
trade-off—if any—can we make for a human life? What sacrifices are we willing
to make as a society to save the life of a child? These are more than philosophical
questions. A deep analysis of political will to provide good health cannot ignore
them and will have to include them in the political discourse in relation to
resources for health care and related sectors.
Lack of resources is frequently claimed as the main reason for the difficulty
of implementing necessary health policies, for their failure, or even for the
reversal of good policies. The deployment of health policies without the prompt
and proper financial backing is a futile and deceptive exercise doomed to failure.
Barring issues of efficiency, one of the main indicators of the priority given
to population health is the proportion of financial resources assigned to the
health care sector relative to other sectors. The Cuban national health care system
 Public Health and Political Will in Cuba / 85

is publicly financed, with about 10 percent of the national budget assigned to

health in 2008 (45).
There is no better time to show political will to sustain the delivery of good
health care than a time of crisis. Post-revolutionary Cuba has had at least two
serious emergency situations. The first occurred in the early 1960s, when about
50 percent of the 6,000 Cuban physicians abandoned the country, worsening
the already limited supply of physicians. Immediately, Cuba undertook to develop
the Rural Medical and Social Services program to ensure coverage of the most
affected rural areas, and to expand medical schools to train new physicians.
By 2006, Cuba had more than 70,000 physicians covering virtually 100 percent
of the population (more than 11 million) (46), at the same time that more than
29,000 Cuban physicians were in 68 countries on health solidarity missions (45).
The second crisis occurred at the onset of the Special Period in the early 1990s,
with a 35 percent decrease in gross domestic product that seriously threatened
every aspect of Cuban life. In spite of the extreme economic contraction, Cuba
slightly increased its per capita funding for the health care system. (47).
This measure, together with creative and adaptable human resources,
adopting natural and traditional medicine, maintaining a fair distribution of
scarce food, and developing urban vegetable gardens to increase food production,
undoubtedly contributed to avoiding a major human tragedy and to sustaining
good population health levels.

4. Review of Performance

Perhaps performance review is the most intricate aspect of political will. There is
strong support for the need for continuous monitoring of impacts and outcomes
as measures of performance in order to evaluate the efficacy of health policies,
and the need to redirect those policies and to identify new needs (8). A close
look at impacts and outcomes is essential. In broad terms, good health and health
equity are the expected effects of health policies, while outcomes are the direct
results of those policies. A simplified analytical process is this: if we observe
positive outcomes corresponding to our expected impacts, we can conclude that
health policies have been effective (the system has had good performance),
and therefore we can confidently infer (at least as far as this feature is concerned)
that political will is pointing in the desired direction—that is, we observe con-
sistency between policy and actions.
Given that social production of health is a complex and dynamic process, we
are in a continuous progression toward good health and equity that requires a
continuous reexamination of performance of our actions to detect trends in the
right direction. This aspect of the health care system has been widely covered by
global health researchers and analysts, particularly in the context of evidence-
based decision-making, health indicators, and general surveillance frameworks
grounded in a national information system (9, 48). As important as evidence-based
86 / Pagliccia and Álvarez Pérez

decision-making may be, however, inaction due to lack of evidence may also be
perceived as a willing or unwilling avoidance of implementing needed policies.
The health information system in Cuba is a core component of the health
system. It runs parallel to the health system, providing the information that is
needed for decision-making. Cuba has a National Statistics Information System
(SIEN), under the Oficina Nacional de Estadística (National Office of Statistics)
(49), that collects and processes all statistical information about the nation.
Cuba currently collects all the indicators recommended by the WHO report
(9). Most importantly, the Ministry of Health has developed a methodological
approach to a regular analysis of the Situación de Salud (Health Situation) in
Cuba, to identify “the occurrence of the main health problems, their trends and
prognosis, [and] the intervening risk factors in their behavior” (50, p.1).
But perhaps the most detailed and comprehensive performance review in
Cuba is done at the local level through the information collected by the médico
general integral (comprehensive general physician) and nurse team. The
information is channeled through the Public Health Complementary Statistics
Information System to analyze impacts and outcomes, and through the Unidades
de Análisis y Tendencias en Salud (Health Analysis and Trends Units) for
surveillance of the health situation of the community (51). Summary indicators
collected for the analysis cover biological, psychological, socioeconomic, and
environmental aspects of the community (52). Examples are at-risk populations,
sanitation, employment status, social integration, and family dysfunction. Finally,
the data collected for the purpose of analyzing the health situation are used to
produce a health diagnosis of the community. This is done in monthly and
biannual meetings of the Grupo de Trabajo (Working Group), with the partici-
pation of, among others, the family physician and nurse, the director and vice-
director of teaching of the polyclinic, and a representative of the Centro de Higiene
y Epidemiología (Center of Hygiene and Epidemiology). One of the tasks in
these meetings is to review every death that has occurred in the community and
its causes. This type of examination of the health situation at the local level
produces direct feedback for immediate response.

5. Responsible Management

The last aspect of political will, responsible management, is possibly the most
difficult to assess and implement but at the same time the most central for ensuring
compliance. As early as 1988, the Adelaide Recommendation on Healthy Public
Policy stated (53):

Public accountability for health is an essential nutrient for the growth of

healthy public policy. Governments and all other controllers of resources
are ultimately accountable to their people for the health consequences of
their policies, or lack of policies. A commitment to healthy public policy
 Public Health and Political Will in Cuba / 87

means that governments must measure and report the health impact of their
policies in language that all groups in society readily understand. Community
action is central to the fostering of healthy public policy. Taking education
and literacy into account, special efforts must be made to communicate
with those groups most affected by the policy concerned.

Credibility and accountability of political actors are vital elements for the
concept of political will in health care. Health policies require responsible
management because of their critical impact, and officials in charge of programs
and development of health policies must be seen to act responsibly. Lack of
accountability at any level may be perceived as a willingness to condone policy
failures and, consequently, as an acceptance of lack of political will.
A performance evaluation of programs with specific reference to account-
ability must have a built-in process that also evaluates the responsible manage-
ment of the program. This is not done to impose penalties but rather to improve
performance through feedback (as noted above) and to encourage conscien-
tiousness and dependability.
Usually, in Cuba, there are systematic evaluations of elected delegates every
six months at the national, provincial, municipal, and electoral district levels
(54). A delegate has to respond, face-to-face, to his or her electorate in com-
munity meetings called rendición de cuentas (literally, giving accounts). Neigh-
bors discuss planteamientos (expositions)—that is, concerns, complaints, and
dissatisfaction about a wide range of local issues that have been filed in the
banco de problemas (bank of problems). The elected delegate can be recalled
by majority votes in the corresponding electoral district. Perhaps a unique feature
of these participatory meetings is that planteamientos do not become the sole
responsibility of the elected delegates. Rather, the community is often called on
to be involved in the problem solutions. For example, in 2008 in the province
of Granma, 23,600 planteamientos were filed and discussed in meetings at
which 80 percent of the electorate participated. Seventy-four percent of the
problems involved community participation. In this way, state and community
share responsibilities.
More explicitly in health care, regular controls and indicators are established
as part of the program. For instance, the “work plan of the family physician and
nurse, the polyclinic and the hospital” establishes (a) the rationale for controls:
“to measure positive and negative results”; (b) what is observed during the
control: among other things, “people’s opinion about the care received”; (c) who
performs the control: “medical professors” (from teaching polyclinics) and the
“nurse supervisor”; (d) frequency: “no less that once every two weeks”; and
(e) procedure: among others, “random checks of at least five medical histories
a month” and “direct observation of clinical work in the clinic” (52). There
is good reliance on people’s opinions and suggestions on how to gather this
kind of information. Full discussion of all indicators is done at the Working
88 / Pagliccia and Álvarez Pérez

Group meeting, where “mass organizations’ representatives must be invited”

(52, p. 28).

POLITICAL WILL IN CONTEXT

Our main goal has been to characterize in a more operational way a concept of
political will. However, we think it is important to see political will as part of a
process within a larger context. Figure 2 outlines such a context graphically.
The pentagon in the figure depicts the five elements, described above, that make
up the core of political will. At the top of the figure, the explicit goal that conforms
to our definition is clearly stated as good population health. The intersectoral
action envelopes, so to speak, political will, or is guided by it, and acts upon
population health.
Political decision-makers—those elected or appointed to positions of power—
and community, civil society, and stakeholders receive feedback about the
outcomes of population health. The thick arrow in the figure from political

Figure 2. The context of political will for population health.

 Public Health and Political Will in Cuba / 89

decision-makers to political will identifies the ultimate source of political will

and the actors who are accountable. The community and stakeholders act on
political will indirectly through, or may work in conjunction with, decision-
makers, as indicated by the bottom arrow. This latter relationship is crucial
insofar as it stresses the fact that political will is not imposed from the top
down but is the joint product of a continuous social interaction. It is, in fact,
the lack of this relationship, or the divergence of goals, that results in lack of
political will.
We note that the process in this representation may be valid at any level
of governance—national, provincial or municipal—by simply qualifying the
decision-makers, community, and health goals accordingly. In the case of Cuba,
the health care system is decentralized geographically in the provision of health
services, with a central government oversight (19, 55, 56). This type of organi-
zational structure requires that political will be exerted at all levels.

CONCLUSION

Cuba has achieved outstanding health outcomes and equity (9, 22, 29), even at
times of economic austerity and limited resources, which has induced some
observers to examine the factors behind such success. Aside from a national health
system that is based on strong principles and flexible programs, Cuba’s success
can plausibly be attributed to the fact that good population health has been a
state policy for more than 50 years, which in turn has been translated into
action through public health policies. Former Cuban vice president of the council
of state, Carlos Lage, clearly stated that “health (together with education) has
never been considered [in Cuba] as a distal consequence of economic develop-
ment, as proposed by other models of development, rather it has been taken
on, in concept and in practice, as a human right to be immediately fulfilled and
as a prerequisite for any other economic development attempt to be viable”
(57, p. 4). In other words, there has been the political will to provide good health
and, indeed, well-being.
Political will has been recognized internationally as the necessary factor for
effective health policies and a reflection of commitment to the value system of a
society. Structural and organizational plans, strategies, guiding principles, and
courses of action, although important, can only be the tools of the deep com-
mitment—political will—to accomplish valuable health goals. In other words,
political will is the catalyst of policies generating good health outcomes and
impacts. It is, indeed, the ultimate intersectoral action involving many sectors
of society.
Understandable difficulties have been raised about how to define and how
to measure political will, as well as how to bring it about. These difficulties
should not be used as a deterrent to accepting the challenge. Although political
will may not be directly observable, we suggest detecting its presence (or
90 / Pagliccia and Álvarez Pérez

lack thereof) by observing the behavior of those components on which it exerts

an influence.
We use the experience of Cuba to illustrate the potential role of political will in
public health and raise the possibility of an evaluation of political will, aimed
at achieving good health and equity, by examining what we call the “Five R’s of
political will”—five observable features that may provide systematic information
about the direction and realization of political will. In short, we put forward
the evidence from Cuba through the experience of decision-makers and com-
munity leaders, which suggests that (a) the explicitly stated health goals of
political will must be genuinely consistent with the public discourse; (b) actions
and results must be shared as a joint state-community responsibility; and
(c) the responsibility needs to withstand the test of public scrutiny of achieve-
ments with clear accountability.
We emphasize the importance of defining the object of political will. For
instance, political will to achieve good health is not the same as political will
to achieve cost reduction. While good health may bring about reduced health
costs by reducing the demand for health services, the relationship does not
necessarily work in the other direction. Furthermore, the stakeholders of those
two alternatives are not the same and, in fact, have competing interests.
Cuba is definitely a good example to observe and learn from (58). By the
1980s, Cuba had already met the goals set by the Alma-Ata declaration (59),
as well as those set by the Millennium Development Goals (60, 61), and has
so far implemented most of the recommendations produced by the WHO
Commission on Social Determinants of Health, including the development of
political will.
When looking at the knowledge we have today about health, health policies,
and health systems, the real “paradox” that seems to emerge is, how can there
still be so much poor health and so much inequity in the world in the face of
so much knowledge on how to reduce both efficiently?
Political will is necessary, but only as a true act of sovereignty that takes into
account a country’s context, history, and culture. Each society has to develop its
own way to include public will through local communities by making them part
of the process of developing public policies from the initial stages of political-will
building. This is particularly true in the case of public health policies, for which
public involvement is often required. Cuba appears to have found its own way;
it has extended the old saying “where there’s a will, there’s a way” to “where
there’s a political will, there’s an impact.”
Finally, our goal was not to offer a definitive methodology for measuring
political will; this would require more insight into the nature of political
will, maybe looking at different contexts. However, we hope we have pro-
vided a framework capable of generating further reflections on how we
can ultimately muster the power of political will in a positive way for the
benefit of all.
 Public Health and Political Will in Cuba / 91

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