Introduction

Demographic aging has now become an ethical challenge that requires older people to be considered in their heterogeneity, as holders of rights and not only vulnerable people who must be assisted and cared for. This view from a rights perspective, makes it possible to approach this group in a comprehensive and real way; in the society and in the elderly themselves; unprejudiced culturally rooted stereotypes about old age and aging.

This aging is a is a worldwide phenomenon, without precedents in the history of mankind, as expressed in the report “World Population Ageing 1950-2050” of the United Nations Organization (UN)[1]. UN projections define that the world populations over 65 years old in the years 2010 to 2050 will increase three times, from 523 million to 1486 million. In the same way, underdeveloped countries will be the center of this aging process, so their populations of more than 65 years will be increased 3.5 times, a larger rate as compared to 1.7 of developed countries[2]. This outstanding increasing of the elderly population produce macro and micro social changes which affect the economic, political and cultural life of the countries that experiment it and in the psychosocial sphere of the people in this age group.

This aging is a worldwide phenomenon, unprecedented in the history of mankind, as expressed in the World Population Aging: 1950-2050 report of the United Nations (UN) 1. United Nations population projections indicate that between 2010 and 2050 the world population of people over 65 will multiply by three, going from 523 million to 1,486 million. Developing countries will be the protagonists of this aging process, since their population over 65 years old will multiply by 3.5; while in developed countries it will multiply by 1.72. This significant increase in the elderly population generates macro and micro social changes that affect the economic, political and cultural life of the countries that experience it and the psychosocial sphere of the people of this age group.

The Cuban gerontological scenario, understood as the social framework in which multiple cultural, educational, health, political, legal, and security factors, converge around a demographically aging population, characterized by present and future accelerated aging. In the developed countries, demographic aging showed a gradual course, in parallel with the economic growth that resulted in the increase of the population's standard of living. Therefore, the structures and institutions in these countries had enough time to adapt to the emerging demographic changes and generate the necessary resources to face this new social reality.

n contrast, in Latin American and Caribbean countries this process goes beyond the strictly demographic sphere; given the asymmetry between the rapid process of demographic transformations and the slow economic and social development in the region. Thus, in countries with a more aged population, protection levels tend to be more widespread, while in those that are in transition, there are vulnerabilities derived from the precarious scenarios related to insufficient resources, scarce protection legislation, among others, that can sustain such increase of older people[3].

The demographic transformation that takes place in the world; dizzying, growing and with significant consequences for the lives of populations, will largely determine the future of countries and the planet. “The presence of fewer children and adolescents and more adults and elderly will lead to new social and cultural visions about the different segments of the population and its functioning. There will be substantial changes in the forms of work and production, patterns of demand and consumption of goods and services, healthcare, requirements for social security, the form of family relationships, the development of support networks, the sense in the transfer of resources, and the functioning of political and administrative systems”[4].

According to the population estimates prepared by the Latin American and Caribbean Demographic Center (CELADE) —Division of Population of Economic Commission for Latin America and the Caribbean (ECLAC)—, by 2025 this situation will lead to an increase in the dependency ratio and thus the number of dependent elderly people will surpass children under 15 years old around the year 2040. As the countries of the region show different stages of demographic transition, the changes in the dependency index will show notable differences between them. In Cuba, due to the very advanced stage of the transition and demographic aging, the dependency ratio of the elderly is higher than that of young people under 15 years of age since 2010; 30 years before this happens at the regional level[3].

In 2017, the population of Cuba was 11,222,142 inhabitants, 20.1% of them belonging to the over 60 years of age group[5]. The perspectives of the future evolution of the population envisage an absolute decrease of the population since growth will not be sufficient to compensate preceding decades decrease in birth rates and the negative migratory balance during more than four decades. The growth will only be observed in the population arriving at the age of 60 or more, as a result from the high levels of life expectancy that characterize the Cuban demographic dynamics. For the next 25 years the result will be a population with around 25% of its members aged 60 and over, going from 1.8 million persons in 2007 to around 3 million in 2025. Likewise, there will be a high absolute growth of the population of 75 years and over, in contrast to a low growth —or decrease— in the volumes of the population in working and procreation ages, and, consequently, very low replacement population rates and labor force[6].

Although age is the basic criterion and the starting point to delimit the stage known as old age, the sociocultural and contextual aspects are also determining factors. "Clearly, the aging of the population is more than a demographic change; it is not a modification in the number with which public policies are constructed, but rather a transformation in the way society as a whole develops and how it should face its future development"[7]. Thus, the well-being and quality of life of the elderly are strongly conditioned by their capacity to take on opportunities and risks associated with the rapid and complex changes in social settings.

Given the current and foreseeable conditions of the gerontological scenario in Cuba, it is necessary to define a policy that allows addressing demographic aging[8]. This policy should preserve the achievements in the lengthening of life expectancy in the largest island of the Antilles; and incorporate the challenges of the country´s new reality. This paper addresses and analyzes some of the challenges to be considered in the design of such a policy. The analysis is derived from the investigative actions that take place in the Faculty of Social Sciences of the University of Camagüey, Cuba, in the framework of the project: “Strategy for a comprehensive care for the elderly”.

Emergent gerontological scenario

While in Europe the process of demographic aging took place gradually, in Cuba, the elderly population which was 9.4% in 1970 changed to 18.3% in 2012; three years after reached 19.4% (2015), and the current figures indicate that 20.1% of the population is over 60 years of age[5],[6].

The United Nations Organization estimates that by the year 2050 the world's oldest countries will be: Japan, with 42.5% of people aged 60 and over, followed by South Korea with 41.5%, Spain 41.4%, Portugal 41.2%, Greece 40.8%, Italy 40.7%, Bosnia and Herzegovina 40.5%, Singapore 40.4% and Cuba with 39.7%, the only Latin American representation[1].

This situation requires the State to determine possible action scenarios to sustain the accelerated process of aging of its population in a short period of time and in circumstances of economic underdevelopment, strengthening of the economic, commercial and financial blockade by the United States and a deep international crisis[9]. Therefore, as Ham Chande states, "... old age and aging depend on specific demographic, social and economic contexts and vary in space and time; hence each society needs to manage them in its own way"[4].

The aging process of the Cuban population shares similarities with that of other nations; but it has distinctive features that configure its current demographic profile, among which it is worth mentioning that Cuba has very low levels of fertility. The global fertility rate at present and for the last thirty years does not exceed 1.7 children per woman[10]. Another feature worth mentioning is related to the structure of Cuban households and families. The families structurally are less numerous, and, in their composition, there is a greater presence of elderly members. There is also a marked increase in single-person households and single-parent homes headed by women[11]. Finally, and related to the health situation of the elderly, there is a decrease in mortality in these age cohorts, and therefore the lengthening of life with guarantees of universal and free health care.

In the Cuban context, the economy is based fundamentally on limited production and scarce resources, unlike what happens in industrialized countries, which directly affects the population's standard of living. We must recall that the demographic aging in the industrialized countries was accompanied by an economic takeoff whose bases are currently based on high productivity technologies, enabling greater production of economic goods and high-quality services. Related to the standard of living, Cuba, as an underdeveloped country, does not have enough resources to guarantee the conditions of housing, transportation, leisure, services, family support and technological supports required by the entire aging population.

Despite the above, health indicators comparable to those of developed countries have been achieved and Cuba exhibits an average life expectancy of 80 years[5]. This is an achievement attributable to the social policies implemented in the country, specifically to health, education and social security policies. However, in the current socio-economic conditions of the Cuban context, the achievement of greater longevity poses important challenges, such as the training of human resources for support actions and care for this elderly population, achieving that the lengthening of life is accompanied by wellbeing and quality and, finally, to update the attention programs focused on the elderly group, whether they are dependent or not.

The current demographic dynamics of the Cuban population and its future perspectives predict that by 2030 people aged 60 and over will double those under 15 years of age, and by the middle of the century Cuba will be among the countries with the least capacity to renew its population with an approximate of 283 persons aged 60 and over for every 100 children under 15 years of age. By then only Japan and Germany will surpass the largest island of the Antilles. All the above leads us to reflect on the sustainability capacity of the Cuban economy to face this phenomenon and its challenges towards the State as the guarantor of the social achievement of greater longevity[11].

Several are the derivations of aging that the Cuban State must assume. As pressing challenges are more clearly seen the pressure or overload on the health and social security system, associated with the increased needs of this social group, as family networks will be over required. In the economic sphere, social spending is increased by retirement. At the same time, the demand for institutions for long-term care is growing; as well as specialized health services (geriatric and gerontological).

According to the details of the last Population and Housing Census (2012), the fastest growing age group on the island is that of the so-called "older elders"; that is, those who are 75 or more years old. Statistics indicate that, from this age range on, there are greater probabilities of functional declines, individuals show greater fragility, are more prone to develop chronic and degenerative diseases, which can trigger dependency situations that require long-term and costly medical treatments.

The First National Survey of Population Aging in Cuba yields remarkable results on the health status of the elderly; among the most frequent chronic diseases highlight hypertension, arthritis, rheumatism or osteoarthritis, diabetes, heart disease and nervous disorders. Regarding the basic activities of daily life, which are related to personal care, the study shows that 90.1% of the elderly in Cuba are independent to use the bathroom, dress, eat, move, lie down and get up.

On the other side, to perform instrumental activities of daily living, which involve a bigger cognitive and physical complexity and imply interaction with the environment, findings reveal that 71.0% of those persons older than 60 do not show any limitation to do activities like taking care on their own health, handling money, using means of transportation and protecting and taking care of others. It was also evident that around 30% of the elderly require aid to carry out these activities, a percentage that surpasses 55% of the elderly in the age group of 75 and over, mainly to move out of the home, go shopping and going to the doctor[12].

The Cuban State deploys important actions and resources in prevention, protection and health care for the elderly. The Integral Attention to the Elderly Program is among its prioritized programs, which is executed and directed from the Ministry of Public Health. However, health services in Cuba will be overwhelmed by the care needs arising in the immediate future without having sufficient infrastructure and resources. "The most visible consequence of the economic crisis that still affects the country has been the deficit of financial resources to invest in key sectors for development, including shortages of medicines and technology in the health sector, as well as education, safety and social aids. This situation causes significant lack of resources to invest in the restoration of hospitals and educational facilities, as well as for the acquisition of diverse materials"[13]. The latter aspect, according to the opinion of the authors, becomes a catalyst, as it urges to find solutions tailored to the Cuban scenario itself and avoiding uncritical transfers of foreign practices generated in different socio-economic and cultural conditions.

An example in which we could move forward would be to open to the private initiative, with certain regulations and professional supervision over the care actions for the elderly[8]. In Cuba, most of the services that provide care and support to the elderly are public. There is a minority group of services managed and directed by various religious institutions (Daughters of Charity of St. Vincent de Paul, Brothers of the Hospitaller Order of St. John of God, Carmelite Missionaries, Little Sisters of the Forsaken Elders), who offer care and care services with some government support. Currently, both modalities are insufficient given the growing demand for care.

Challenges in a changing reality

The Cuban state under conditions of an underdeveloped country must first prepare its economy, design and implement a flexible, decentralized economic management system, to take advantage of the opportunities inherent to the context. One of these opportunities is the demographic dynamics of its population with the presence of an aging, but qualified, human capital, with one of the highest scientific potentials in the region, with high health indexes and life expectancy rates. This is the result of a social development that surpasses the economic one[14].

We need to promote transformations that allow us to conserve the progress made in terms of social welfare, leading to a strategy to boost the economy and new policies to lead the country towards development. This must be understood as a cultural, participatory, creative, conscious process that manifests itself through human activity conditioned by the concrete social-historical context of the transformation of people and their environments in correspondence with their basic needs and the real abilities of systems to contribute to the emancipation of human beings and their quality of life[15].

Also, as the average age of the workers increases, the workforce begins to decrease in those places that require greater physical effort, mainly in basic sectors such as agriculture, construction and industry. As some researchers already endorse, a demographic structure like that of Cuba, demands a technological economy with high added value, based on a productive apparatus with productive capacities, that makes deindustrialization impossible, as well as the loss of industrial jobs, the excessive expansion of services, the persistent trade deficit and the erosion of the -mostly aged- human capital[14]. It is worth taking into consideration that the working population that must be produced in the country will be over 40 years old and will then have to generate a lot of added value. It is worth taking into consideration that Cuba´s working population soon will be over 40 years old and will thus have to generate a lot of added value.

Another significant challenge lies in time[16],[17]; the Cuban economy —dependent on the external sector— will have to confront in a short-term the social and economic cost inherent to aging, but in a more complex and precarious social scenario. Hence, the institutional responses to the demographic dynamics of the country are often in correspondence with budget possibilities. However, there is a governmental intention that recognizes the need to progress in new approaches for the attention, care, and inclusion of the elderly group in the current Cuban scenario.

Cuban society faces the challenge associated with the strategic need to preserve the achievements and the advantageous position that the country has -in health levels- in relation to the rest of the underdeveloped countries of the region as well as the opportunity, because, unquestionably, the high levels of social development allow to enhance the guarantees of development that we still exhibit[18].

Cuba is in the process of updating and conceptualizing its economic and social development model[19]. This is essential and possible based on the strengths and potentialities of the country, always preserving and consolidating the social gains achieved. It is crucial to stimulate local initiatives, creativity, knowledge of the human potential formed and the interrelation between diverse fields of scientific and cultural creation.

To move towards a knowledge-based economy based on the opportunities that Cuba has, that is, to diversify the branches of the economy where knowledge is the main resource. The sector of biotechnology and the pharmaceutical industry are two examples that consolidate the endogenous development of the island. In Cuba, knowledge is a resource resulting from education and instruction systems for all citizens and that as a common good we must enhance and enrich.

The recognition of demographic aging as a singularity of current Cuban society requires stimulating multidisciplinary research on the subject and improving the mechanisms for the implementation of results in decision-making by agencies, entities, and institutions as it is one of the priorities of the Cuban society.

A pending challenge in the development model of the Cuban State is the design and implementation of an integral policy on aging that brings together the multiple actions that are carried out today by various ministries, agencies and institutions, and that in turn, would incorporate new approaches and attention services.

In broad terms, we could say this integral policy should contain aspects that guarantee the Cuban State the following:

• To consolidate and expand services for the elderly that allow the coverage of their necessities and at the same time respond to emerging social needs (education, participation and social integration, leisure, and friendly environments).
• Diversify the training of professionals with specific knowledge about older people to help reduce the prevalence of biased approaches in health care, medical care and the assistance approach. This would contribute to maintain and promote the skills and experiences of the elderly as beings with their own autonomy[20].
• Institute continuing education programs for health and social services professionals with a view to applying an integrated approach to the health, well-being and care of the elderly, as well as the social and psychological aspects of aging.
• Support and encourage volunteer actions that favor the participation of people, who feel eager to collaborate and can do so, including the elderly group, the ideal scenario for intergenerational relations.
• Insert into the educational programs at all levels of education, issues about old age and aging for respectful coexistence with the elderly, to prepare the process of active aging from an early age and, to dismantle myths and stereotypes associated with the elderly.
• Adapting housing, means of transport and cities for the elderly. It is a challenging demand for the Cuban State with an economy of scarce resources. However, the housing and living conditions of the elderly must be improved, adapting the spaces to their needs, in addition to the provision of support services for them and their families, according to their degree of autonomy.
• Expand the normative framework in relation to the rights of the elderly by identifying them as a subject of law and sensitizing citizens in this regard.
• Renew the coverage and quality of the state services of attention and the diffusion of information related to elderly people. It includes bringing the different State services closer to people, avoiding long distances of displacement for fulfilling their needs as well as allowing the dissemination of information about the services and benefits delivered to the elderly.
• Prioritize and diversify research on issues related to aging and old age. Promote in the country the multidisciplinary research on a topic, which in Cuba has also become a public concern. In correspondence with Lage-Dávila "we have to stimulate in an active and programmed way, the circulation of knowledge within society and the recombination between different fields of scientific and cultural creation"[14].
• Develop the legal and regulatory framework that allows the evaluation and optimization of the contribution of the policies to the subjective well-being of the elderly.

Final considerations

Demographic aging in Cuba has become a public agenda issue. The social development model updated by the Cuban State recognizes the need to gradually implement a policy to face the high levels of aging, which in turn guarantees the achievements made in terms of protection for the elderly. At the same time, this model must diversify the services for this age group and enable the optimization of existing ones. Cuba, a country with high levels of demographic aging, together with underdeveloped economic conditions, will have to outline in its development model, the quality of life it expects to guarantee for its elders in the immediate future, in correspondence with actual features characterizing the Cuban context. The State will have to readjust and/or design new policies of social protection for the group of older people customized to the singularities of this age group. To do so, it would be wise to consider the following:

• The great heterogeneity that distinguishes this age group: expressed in the multiple situations of functional independence and autonomy, family support, socioeconomic and educational level, area of residence (rural or urban) and personal biography.
• Social environments: the spatial mobility of the elderly is affected by personal and environmental factors, the offer of services should enhance the community level, which would promote the responsibility of the communities with their elderly and bring services closer to their places of coexistence.
• Services adapted to the different conditions and stages of old age: for healthcare, care (temporary and/or long-term care and even care at the end of life), for inclusion and social interaction and recreation.

Incorporating the growing number of elderly people in the country's gerontological scenario within the country's development process, is undoubtedly an opportunity and a complex challenge, which will require the support of the State, families and the elderly community itself.

Notes

From the editor
The authors originally submitted this article in Spanish and subsequently translated it into English. The Journal has not copyedited this version.

Authors’ contribution
AMRM: substantiation, investigation, preparation of the manuscript, revision and edition, administration of the project. MJYG: substantiation, investigation, data presentation, preparation of the manuscript, revision and edition.

Financing
The authors declare that there were no external sources of funding.

Conflict of interests
The authors have completed the ICMJE Conflict of Interest disclosure form and declare that they have not received funding for the published article; have no financial relationships with organizations that may have an interest in the published article in the last three years; and have no other relationships or activities that could influence the published article. Forms can be requested by contacting the responsible author or the editorial management of the Journal.