Resource distribution, accessibility, and health equity: from global analyses to the Cuban case
This dissertation examines interrelated questions concerning distribution of healthcare financing and human resource for health (HRH), access to healthcare services, and health outcomes on international and national levels of analysis. The dissertation is comprised of three papers, addressing the following questions: What is the relationship between the government’s share of total health spending and infant mortality? How do developing countries cluster along the lines of critical health and development indicators? How successful has Cuba been, a country with a highly public health and development model, in reducing inequality in human resource for health distribution? While this study does not ignore the relationships among inequality, per capita gross national income, food security and health outcomes, the central focus is on key dimensions of healthcare accessibility - the distribution of human resources for healthcare services and the extent to which governments reduce financial barriers to care.
Although previous research has examined the relationship between public health spending and the infant mortality rate (IMR), few if any studies have examined the impact of government expenditure on healthcare services as a percentage of total expenditure on health (GEHPTEH) on the IMR. In the first paper, I employ additive and interactive multivariate regression models with cross-sectional data gathered from the World Health Organization and the World Bank to examine the relationship between GEHPTEH and IMR while controlling for gross national income, doctor density, the percentage of children under 1 year vaccinated for polio, and the percentage of the population with access to improved water sources. The findings of the additive models indicate a non-trivial inverse association between GEHPTEH and IMR, while the interactive model indicates that the level of GEHPTEH makes a greater difference among poorer nations.
The second paper contributes to the social science literature on health and development by creating a typology of primarily non-Organization for Economic Cooperation and Development (OECD) countries to more precisely understand the nature of the challenges facing them. Using cluster analysis to classify developing nations on the basis of eight health and development variables, I find that a tier of countries in above-average and below average situations of health and development subdivides into a tier of Mild, Moderate, Severe, and Critical situations, which then further subdivide into nine relatively distinct groupings. These results indicate the importance of designing development strategies that address particular configurations of per capita gross national income level, inequality, food insecurity, healthcare financing and vaccination coverage.
Though much past research has examined developments and transformations in Cuba’s healthcare system, national IMR trends, and the government’s commitment to universal healthcare access in the face of economic difficulties, the reduction of HRH and IMR spatial inequality among and within Cuban provinces has received less attention. Drawing from Cuban Ministry of Health data, the third paper examines the changes in absolute and relative inequality in HRH distribution by personnel type and IMR among Cuban provinces over time, and contrasts these distributions with the global, OECD, and developing country distributions using formal and informal inequality measures. Using municipal level data from Cuba’s National Statistical Office, the paper also examines the levels of absolute and relative inequality in HRH distribution and IMR within Cuban provinces in 2010. This paper’s contribution to the broader literature lies in the significance of the measurable strides towards greater within country equality of HRH within a global context of high between and within country disparities of HRH. Cuba’s experience in this regard is especially salient when taking into consideration the high levels of spatial inequality in HRH prior to 1959 as well as a set of particularly adverse economic circumstances, particularly during the ‘special period’ of the 1990s, characterized by material and financial resource scarcity.