Navigating Cuba's Care Crisis Amidst Demographic Shifts: Interview with Mayra Espina and Elaine Acosta
Mayra Espina, Doctor of Sociological Sciences, independent consultant, and associate researcher of the Academic Program of the Christian Center for Reflection and Dialogue (CCRD-C), and Elaine Acosta, Sociologist, Associate Researcher at the Cuban Research Institute, Florida International University, and Executive Director of Cuido60-Observatory on Aging, Care, and Rights - www.cuido60.com share their thoughts on the impact of demographic changes on Cuba’s care crisis.
May 2024
*The views and opinions expressed by the interviewees are their own and do not necessarily reflect the views or positions of CEDA.
1. What are the regional variations in Cuba’s demographic trends? Are there significant differences in population growth, fertility rates, and aging patterns between urban and rural areas? How do these regional disparities influence social and economic development within the country?
Mayra: Among the regional variations of demographic trends, historically, there have been significant differences, such as higher fertility and birth rates in rural areas and towards the eastern part of the country, with more pronounced adolescent fertility in the east, and internal migrations from east to west. Aging is widespread but is markedly observed in urban centers such as Santa Clara and Havana.
However, the general trend, without many regional differences, is towards demographic aging, low birth rates, emigration of young people and people of working age in general, and the emptying of rural and agricultural areas.
In this way, demographic trends compromise the country's development, especially due to labor resource deficits for food and agricultural production, internal migration and emigration, below-replacement-level fertility, and a growing dependency ratio (relationship between the active population and the population outside the working age).
Elaine: According to the classification by the UN Economic Commission for Latin America and the Caribbean (CEPAL), Cuba has one of the oldest populations in the region, situated in the last stage referred to as very advanced aging. At the close of 2022, Cuba had a Total Fertility Rate of 1.41 children per woman, making it the country with the lowest fertility rate in Latin America and the Caribbean, with a proportion of elderly people at 22.3%, with a population of 60 years and older of 2,478,087 people. As a result of a fertility rate below replacement levels–less than one daughter per woman–which the country has had since 1978, there has been a simultaneous reduction in the percentage of people under 15 years of age. Consequently, according to the latest population projection by the National Office of Statistics and Information (ONEI), it is expected that by the year 2050, the elderly population will represent 35.9% of the country's population. The accelerated growth of this age group on the island remains a distinctive characteristic, considering the average annual growth rate of 33.3% in 2021 and 2022. It is worth noting that between the publication of the National Population Aging Survey (ENEP) in 2019 and the latest yearbook of 2022, the proportion of elderly people has increased by over two percentage points in just three years.
This process does not behave homogeneously in geographical terms, with variations observed among provinces, municipalities, and types of areas (urban and rural). The distribution of the elderly population is relatively similar by province, with all provinces having over 20%. However, there are differences of approximately 5 percentage points between the province with the highest percentage of elderly people, which is Villa Clara in the central region of the country, with 25.3%, and Artemisa, the province with the lowest percentage at 20%. At the local level, these differences widen, considering that the most aged municipality - Plaza de la Revolución in the capital - has an elderly population of 30.3%, doubling the percentage of the municipality of Yateras in the eastern province of Guantánamo, which has 15.4%. Elderly people are concentrated in urban areas (78.8%), while only 21.2% live in rural areas (ONEI, 2019).
In terms of population growth, the outlook is very concerning, especially considering the migratory crisis – the most significant in Cuba's history, both quantitatively and in terms of its impact on various aspects of society. Data provided by the ONEI in the latest Demographic Yearbook for the year 2022 placed the average annual population growth rate in the country at -2.1% and projected a progressive decrease to -5.7% by 2035. Estimates by Professor Albizu-Campos indicate that the migratory flow in 2022-23 is greater than official statistics suggest, rising to 3.5% or more of the total population having left the island, resulting in a reduction of the Cuban population to between 10,719,112 and 9,999,576 people. However, official ONEI figures ONEI report a population of 11,082,964 Cubans as of the end of March 2023. This difference is mainly attributed to the underestimation of the migratory impact in official statistics due to the very particular way the migration balance is calculated by the ONEI, which differs from the notions agreed upon by international organizations on what constitutes a migrant.
Population growth behavior is uneven among provinces and residential areas. Pinar del Río and Holguín are the most affected provinces, showing an average annual population growth rate for 2022 of -12 and -10, respectively, while Isla de la Juventud, Artemisa, and Mayabeque are the only ones showing a positive rate in the country (7.3, 5.8, and 4.5 respectively). Urban areas show a negative rate of -2.9, and in rural areas, a rate of 0.1. If we look at the natural growth rate (births/deaths ratio) by municipality, only 8 out of a total of 168 municipalities in the entire country have a positive rate.
In summary, these regional demographic disparities have differential impacts on the contributions of each territory to the country's development, whether due to the availability of human resources; the reduction of the population and the decrease in the economically active population; the imbalances in the pension system that will affect pension coverage; the deficit of care services and caregivers in families, as well as the new social and health services required to adequately respond to the specific needs of the increasing number of users over 60 years of age.
2. Taking into account the long-term implications of demographic aging, including the increased number of senior citizens and the strain on social and health services, what challenges does Cuba face in terms of providing adequate care and support for its aging population?, and how might the emigration of younger individuals exacerbate these challenges?
Mayra: It is necessary to consider the conditions under which demographic aging and the sustained increase of older adults occur. There are multiple crises that affect diverse dimensions of life on a macro and micro level: economic, health, social, and the expansion of anomie.
This poly-critical situation, which has its basis in the combination of the long-term effects of the U.S. embargo and the barriers it imposes on Cuba to access resources for development, as well as failed, erroneous, or incomplete national policies, is compounded by the aftermath of the Covid-19 pandemic.
As a result, poverty, vulnerabilities, and inequalities are expanding in the country, preventing access to a dignified standard of living (especially due to the lack of food, medicines, health services, community hygiene, and adequate housing) for a large part of the population and turning everyday life into an uncertain and insecure scenario, especially for the elderly.
From this, it follows that Cuba's challenges in providing adequate care for its older adults are strongly associated with the need to overcome the crisis.
In my view, these challenges have three levels. The first level is to address matters of urgency: to quickly recover, with targeted social programs and effective protection services for the most disadvantaged groups (elderly, children, people with chronic illnesses and disabilities, pregnant and lactating women in low-income households and vulnerable communities). These urgent issues have, in turn, two priorities: first - food, medicine, and health services; second - access to clean water and community hygiene, electricity, and urban mobility.
The second level is restoring dignified life for all, with public support and affirmative actions for vulnerable groups: improving and expanding employment opportunities, training, education, housing improvements and services, and improvements in the community environment and public spaces. And generate a favorable environment for citizen self-transformative activism, volunteering, community projects, non-state humanitarian actions, and associativism.
The third level is the strategic development perspective: transitioning to an economy of the elderly or aging, which involves generating incentives to attract people of working age who are not employed; promoting productive and service activities that can absorb older adults who are capable of working (age-friendly working conditions, teleworking, barrier-free workspaces, a strong emphasis on knowledge as a productive resource, among others); boosting technology-based productive sectors, high-efficiency and low-labor-intensive, such as the software industry, biotechnology, 3D printing, robotics for medical purposes, technology-based health services; and deploying specialized services in health, recreation, transportation, and elderly care. For the latter, one should take into account that some older adults, if capable, also take care of other older adults.
All three levels require investment resources that the country lacks, but the country can attract investment by making internal economic changes and foreign policy changes where it has the power to do so.
Obviously, the blockade and Cuba's inclusion in the State Sponsors of Terrorism (SSOT) list generates risks that nullify any possible attractions for foreign entrepreneurs to invest in Cuba, while distancing and narrowing down the possible product markets.
Elaine: To understand these challenges, it is important to understand the context in which the rapid increase in the elderly population in Cuba is occurring and the pressure this puts on social and health services. These processes take place in a highly adverse political, economic, institutional, and familial scenario, especially due to the profound crisis of a structural and systemic nature that the Cuban society is going through, which multiplies and complicates the several challenges that this demographic process entails. Some of the challenges are related to the following processes or factors:
A care crisis resulting from an increase in demand versus a reduction/deterioration of service supply and a burden on women as unpaid caregivers;
A reorientation of social policy that shortens welfare parameters, reducing resources allocated to social protection and transfers caregiving and social service solutions to families and the market;
An insufficient normative framework; the Family Code, which does not provide conditions for enforceability and guarantees of the rights of older people and their caregivers, is not implemented well;
An increase in poverty, inequality, and food insecurity affecting mainly older people;
A deficit and unequal distribution of social and health services and a growing commodification of the supply, against a decrease in the purchasing power of older people and pensioners, in particular;
Insufficient institutional approach and intervention, with government initiatives lacking comprehensiveness, transversality, sustainability, and territorial focus in actions;
Growing shortage of human resources for social and health care and the need for ongoing training for the specific needs of older people;
Unsustainability of the pension system and uncertainty in the face of the imminent silver tsunami (retirement of the baby boomer generation);
Significant political obstacles and resistance to the development of community initiatives and civil society, both national and transnational, in the provision of social and care services;
Deficit of data and research on poverty and inequality in Cuba and the impossibility of sustaining a democratic and politically-effective debate on these issues.
It’s important to recognize the link between U.S. policies towards Cuba, particularly the embargo - which is often the most controversial issue to address- and the characteristics and basis of the current crisis facing Cuban society. The crisis is multifactorial, and the embargo is one of the elements. It is important to note that the official estimate of the embargo’s impact (1962 to present) hasn’t been constant over time, due to fluctuations in its application. Nevertheless, its impact cannot be disregarded. To understand it, it is important to reflect as well on how external economic support, internal economic policies, and attempts at reforms have not only failed but also contributed to demographic and social dislocations that are often ignored. The most visible consequences in demographic terms are the current migratory crisis and the increase in poverty and inequality.
3. What social support systems and policies are in place to address the specific needs and challenges faced by Cuban women in terms of work-family balance, childcare, and caregiving responsibilities? How can Cuba promote gender-responsive policies and initiatives that empower women, support their reproductive choices, and ensure their equal participation in shaping the demographic and socio-economic landscape of the country?
Mayra: Only two pieces of data are enough to illustrate the solid gender gaps existing in Cuba: around 2018, the National Gender Equality Survey identified that women spend, on average, 14 more hours per week than men on unpaid work and caregiving at home, regardless of whether they are employed or not. This seems to have increased during Covid-19. The survey also established that 26.7% of women aged 15-74 had been victims of some type of violence in their intimate partner relationship in the 12 months before the study, and 22.6% reported having experienced it at some point earlier in their lives.
In recent years, various social sectors have deepened their awareness of these disadvantages and generated demands for gender equity, which have crystallized in policies and benefits focused on women. Highlighted are the Women's Advancement Program, the new Family Code, and the Strategy for the Prevention of Gender Violence in the school setting.
These three policy instruments create a favorable institutional, legal framework for affirmative and targeted actions to improve women's access to training and employment, strengthen the enjoyment of labor rights, and improve home service and protection systems against violence.
Existing social support systems focus on benefits such as paid maternity leave, access to elderly care centers, access to daycare centers and kindergartens for working mothers, priority access for single mothers to housing repair subsidies, housing allocation for mothers with three children or more, psychological and legal support services in Women and Family Houses (of the Cuban Women's Federation); and the delivery of a food module for underweight children, diets for pregnant women, among others.
However, these benefits are still below real demand. The critical resource restriction situation and the slow pace of implementing concrete actions limit their practical scope and transformative impact.
A strong contribution to gender equity substantially depends on affirmative actions for training, access to employment, and provision of assets to access new opportunities, including the Small and Medium Size Enterprise (SMEs) sector, where women sometimes suffer from exclusion, being underrepresented as owners and partners. They tend to concentrate on lower-paying occupations; and the expansion of widespread care services, economically and spatially accessible. Improved incomes and reduced caregiving time will contribute to women's autonomy and better conditions for making decisions about motherhood.
However, I don't believe that the established fertility pattern will change due to these improvements. This pattern establishes itself and generates inertia that does not depend linearly on the conditions that initially generated it. It is also intertwined with cultural elements and expectations that are difficult to modify.
Elaine: The structural and systemic nature of the crisis currently affecting Cuban society has expanded social vulnerability, with women being one of the most affected groups. Significant inequalities are also existent among women, based on skin color, age, or rural living. The impact of the decrease in the state's participation in social protection is cushioned by women’s unpaid care work, as they continue to be the mainstay of sustainability of life on the island, a task that currently has incalculable economic, physical, and emotional costs. Whether directly or through policies and practices that perpetuate discrimination and inequality, the Cuban state is exercising institutional violence against women. Several specialists have coined the idea of the feminization of precariousness in Cuba, that is, on how successive crises have affected women and girls more severely.
Let's briefly analyze some policy efforts that aim to address the challenges of gender-sensitive policies and initiatives. In the design of the policy on aging, for example, which was updated in April 2021, a reductionist approach has prevailed, deficient in a gender perspective and, consequently, focused on natalist policies that prioritize measures to stimulate fertility. On the other hand, the creation of a National System for Comprehensive Life Care has recently been announced, which has been working for approximately three years on more specific projects such as the Unpaid Work Project and national programs such as the National Program for Dignified Work. However, there are no public documents regarding the proposed design of said system, its feasibility, and economic sustainability, although we have seen more academic publications and policy recommendations . There is also the Women's Advancement Program (PAM), which, being a long-term and wide-ranging policy, does not have a periodic agenda that allows it to be implemented and monitored in the short term, or monitored by citizens. The official press covers momentary pronouncements by institutional representatives, but the current plan is unknown. It is thus impossible to evaluate its scope and limitations.
Addressing the promotion of gender-sensitive policies and initiatives that empower women, support their reproductive choices, and ensure their equal participation cannot be disconnected from the complexity of these challenges in authoritarian environments like Cuba. This is why the impact of many of the norms and programs oriented in this direction has limited scope, remaining in discourses or statements of principles but not having an effective impact on improving women's living conditions or their empowerment.
5. Recent trends in Cuban migration show a high rate of young Cubans, and a growing participation of women. How are these trends tied to the current crisis of care facing the island? What are the potential consequences for gender equity and societal development?
Elaine: The feminization of Cuban migration (133 migrant women per 100 men since 2019) and the high participation of women of reproductive age in the new migratory flows are intimately connected with the worsening of the care crisis that Cuban society was already experiencing, both at the family and institutional levels. These crises cannot be seen in isolation. On the contrary, it is one of the components of a general crisis, not only of care but also of social reproduction in its broadest sense. One of the most obvious consequences is that with increased migration, family welfare and care management take on transnational dimensions. And with this, gender inequalities continue to propagate.
On the one hand, mostly Cuban migrant women manage the sending of food, medicines, and payments for family care services in Cuba, among other tasks associated with family responsibilities In the case of women who remain on the island, their caregiving duties for dependents of those who migrate (children, grandchildren, nieces, nephews, etc.) increase, but with less support from state and family networks. Cuban households continue to reduce their size and the number of those where older people live alone increase. This last phenomenon also requires specialized social interventions, for which the social protection system in Cuba lacks an adequate strategy.
With the migration of women, many children and adolescents are left in the care of other relatives, mostly also women, with all the challenges that this implies. Many older people experience feelings of abandonment and loneliness in the face of the massive emigration of their close relatives. At the same time, caregiving is becoming a new labor niche in the emerging private sector in Cuba, following the approval of licenses to perform these types of self-employed work, initially, and more recently, the creation of Small and Medium Enterprises dedicated to offering care services to older people at home and in hospitals. The growing commodification of care on the island, while expanding the supply and establishing an option for some families, only does so for those with higher incomes, as the prices for these services are inaccessible for the majority.
On the other hand, the emigration of young people of working age strongly impacts the country's development in the medium and short term. Firstly, it influences the decrease in the economically active population (EAP) and Cuban society's decapitalization (material and human). The current deficit of human resources due to migration is a phenomenon that impacts all labor spheres and is felt in social and health services, with education and health being the most notable. Meanwhile, it causes imbalances in the pension system, making it unsustainable in the long term due to the lower number of contributions to the system. The reduction of the EAP, parallel to the growth of the cohort of 60 and over, diminishes the ratio of the number of active workers (employed EAP) to passive (retirees and pensioners), which has decreased from 3.6 in 1989 to 2.7 in 2018 and, according to projections, will continue to decrease to 1.3 in 2040.
In summary, the heavier burden of care that Cuban women bear, as well as the position they occupy in their households, are impacted by migration in terms of time, costs, and workload, making them more vulnerable and overrepresented among the poorest. Surveys and research have confirmed that the lack of support services and infrastructure that alleviate domestic and care work is one of the biggest challenges
6. How does emigration impact the labor force and the creation of a middle class in Cuba, given the significant outflow of people in prime working ages, and what challenges does the country face in utilizing its available workforce effectively within its current economic model?
Mayra: Studies show that around 80% of people who emigrated between 2020 and 2023 are between the ages of 15 and 59, which implies a significant loss of working-age people.
There is not much information about the occupational and economic qualifications, of emigrants, but given the age range and the relatively high costs of the current migration routes, which have led people to sell houses, cars, and various properties, it is expected that there is a high proportion of people with middle and higher qualifications, and belonging to middle class groups. This represents a drain of qualified labor resources and shows trends of instability and turnover in middle-class sectors.
However, some experts point out that even with this loss, labor resources in the country cannot be considered scarce because there is a reserve of close to three million people capable of working outside the economically active population. The most serious problem, which also acts as a centrifugal force and migration push, is that the economic model fails to absorb that potential or offer quality options to attract it.
The challenge lies in a change in the economic model, in a policy of fostering and incentivizing work and production.