Pan American Health Organization

HUMAN RESOURCES: A CRITICAL FACTOR IN HEALTH SECTOR REFORM. Regional Meeting - San Jose, Costa Rica 3 - 5 December de 1997 SERIES HUMAN RESOURCES DEVELOPMENT 8 Washington D,.C. May 1998

HUMAN RESOURCES DEVELOPMENT PROGRAM (HSR) HEALTH SYSTEMS AND SERVICES DEVELOPMENT DIVISION (HSP) PAN AMERICAN HEALTH ORGANIZATION WORLD HEALTH ORGANIZATION

TABLE OF CONTENTS

Page REPORT 4 1. HUMAN RESOURCES: A CRITICAL FACTOR IN HEALTH SECTOR REFORM 1 2. THE HEALTH SECTOR REFORM PROCESSES AND THE DEVELOPMENT AND MANAGEMENT OF HUMAN RESOURCES IN THE REGION 4 3. THE CONTEXT: STATE REFORMS AND THE DEVELOPMENT OF HUMAN RESOURCES 6 3.1 State Reform and Human Resources 6 3.2 Educational Reforms 7 3.3 Labor Change Trends in Health Services 8 3.4 Human Resources for Public Health and the Teams Question 9 3.5 State Reforms, Decentralization and Public Policy 11 4. SECTORAL REFORM, FLEXIBILITY, AND HUMAN RESOURCE REGULATION 13 5. DECENTRALIZATION AND HUMAN RESOURCES MANAGEMENT 18 6. HUMAN RESOURCES AND CHANGES IN HEALTH CARE MODELS 22 7. THE FUTURE OF PUBLIC HEALTH 26 8. EDUCATION AND PROFESSIONAL PRACTICE IN SECTORAL REFORM 28 9. HUMAN RESOURCES AND TECHNICAL COOPERATION 34 Pan American Health Organization 10. EPILOGUE 38 ANNEX 1: List of Participants 40 ANNEX 2: REGIONAL MEETING: HUMAN RESOURCES: A KEY FACTOR IN HEALTH SECTOR REFORM 52

REPORT The Regional Meeting "Human Resources: a Critical Factor in Health Sector Reform," was held in the city of San José, Costa Rica, from 3 to 5 December 1997, under the aegis of the Government of Costa Rica and the Pan American Health Organization (PAHO/WHO). Of special relevance at this meeting, attended by 120 participants, was the presence of ministers, vice ministers, and high-ranking officials in the health sector; national and international university authorities; international experts; health and education officials from Costa Rica; and consultants from the different international cooperation agencies committed to the sectoral reform processes (Appendix 1). The purpose of the meeting was to make health sector officials of the Region aware of the strategic importance of human resources for the progress and achievement of the objectives of sectoral reform processes. It aimed to analyze the problems of the countries' human resources in the context of the reforms and to encourage political commitment, and an opinion and action stream favorable to the changes required for the development of health human resources. The initial objectives appear in Appendix 2. This meeting helped clarify the reforms' determining factors and constituted a step forward in the reforms' progress. It is important to point out that it generated a number of orienting criteria for the countries and for PAHO/WHO to reformulate their personnel development action. This report contains a synthesis of the most important individual and collective contributions resulting from both plenary sessions and working groups, as well as the main conclusions and recommendations. The meeting was called to order with an invitation to initiate a broad dialogue and exchange of ideas; to study existing problems; perform critical analysis; and question focuses and methods of approaching the subject of human resources in the health field. These are believed to be the best ways to establish a basis for agreement to reassess the role of personnel in health care and sectoral transformation. The task of reassessing human resources in health, is part of the global end-of-the-century trend towards recognizing the centrality of institutional subjects in the augment of social capital of the countries of the Americas. However, such reassessment is based on the recognition that the task of changing the working conditions and education of health sector personnel is still pending in many countries involved in sectoral change processes. Within the human resources field, reform processes have displaced the problematic axis by making labor matters more visible and redefining the guiding criteria for personnel education, taking into consideration decentralization and changes in financing, organization, management, and health care models. The inaugural message was clear--debate broadly on the conceptual and axiological principle that human resources constitute a basic element of sectoral reform. At present, health-sector reform in the countries of the Americas constitutes one of the most important processes in the realm of social policy, given the Region's economic, state, and social transformations. The meeting became a most appropriate opportunity to analyze the reforms and Pan American Health Organization their implications for health personnel at a very special time in history. On one hand we are about to witness the end of a century, with the premonitory messages and inevitable balances it entails; on the other hand, new paradigmatic changes are occurring in the understanding of development, the role of the State, and the participation of both subjects and collective actors in social life. In observance of the mandates of its governing bodies and in response to its Strategic and Program Guidelines, PAHO/WHO has established technical cooperation in the field of national sectoral reform processes as an essential axis for its action. Consequently, within the framework of the Systems and Services Development Division planning of activities oriented towards sectoral reforms, the Human Resources Development Program organized this meeting, heeding the call of several countries and representative regional organizations involved in training health personnel. This event was held in coordination with the national sectoral departments responsible for human resources and those responsible for the reforms.

1. HUMAN RESOURCES: A CRITICAL FACTOR IN HEALTH SECTOR REFORM(1)

The analysis and balance of almost five years of reform experience at the Costa Rican Social Security Administration illustrate in exemplary fashion the strategic role that human resources play in every change process in the health sector. An added value of this case as an example lies in the fact that the essential role of human resources was not taken into account when the reform was designed. The two years it took to design the change strategy allowed for the establishment of essential criteria, such as the determination of geographical areas, population coverages, and the redefinition of health care teams, with the intention to confront what had been defined as the reform's central problem: the lack of equitable and universal access to services. The basic health care package, the openness of the different programs, and criteria and monitoring levels for health and teamwork were also decided upon at that time. Upon completion of the design, and while facing political viability for the change, it became evident that something important was missing: human resources. Who would implement the designed proposal? What kind of training and information did they have concerning the proposal (given the confusion and fears that were aroused among the collective actors)? What motivation could they have to undertake a profound and structured reform? It was at this time that the human resources dimension appeared as the center of and the driving force for change. To continue ignoring this would have been an invitation to failure and would have created enemies of the change process. The great lesson learned is that the change in the health scene shall be accomplished with the people already there, with the existing staff. This human resource is the great capital required for change. The question was how to generate favorable and stable conditions--encompassing all possibilities, such as subsidies, recognition, incentive systems, improved working conditions, but, above all, staff education--to ensure staff participation in such change? This lesson demonstrates the need to build up a great educational capacity, make training an instrument for change, and make the induction to work a mandatory requirement. Thanks to this experience, the CCSS now provides for the broad and extensive training of all staff, the promotion of its own cadres, greater possibilities for emerging cadres, the opening of opportunities for discussion Pan American Health Organization and analysis, and the strengthening and creation of alliances. In the case of the CCSS, the signing of an agreement with the University of Costa Rica, which will assume health care responsibilities for a large sector of San José, is significant. The message is very clear: the change in sectoral reform processes begins when the human resources undertake it as their own change.

2. THE HEALTH SECTOR REFORM PROCESSES AND THE DEVELOPMENT AND MANAGEMENT OF HUMAN RESOURCES IN THE REGION(2)

Health sector reform processes are aimed at introducing substantive changes at different levels of the sector, as well as in its relations and functions, with the purpose of increasing benefit equity, efficiency in its administration, and effectiveness in its services, to satisfy the population's health needs. The final objective is to help improve the population's living conditions and health, through the reduction of inequality and the improvement of health care. Thus, there are efforts to modernize public institutions, search for new relationships between actors, and seek a new balance among the public domain, the private domain, and the necessary financial sustainability. Justification for the reforms lies as much in the need to confront the health situation as to improve performance, results, and the quality of care that the health services provide. The redefinition of health care models, the eradication of existing inequality, the resolution of efficacy and efficiency problems, and the improvement of effectiveness can no longer be postponed. The analysis of the reforms must consider macroeconomic adjustments, changes in the role of the State, democratization and political governance processes, changes in fiscal and investment policies that the countries have experienced, and new technological developments. However, equally important are the hopes for and citizen's mobilization towards equity and quality in health care, based on improvements in the problem-solving capacity and sustainability of the health care services. It may be inferred from the regional experience that the reforms are built upon five governing principles: ⋅ equity; ⋅ effectiveness and quality; ⋅ efficiency; ⋅ financial sustainability; and ⋅ intersectoral action and community participation. The main characteristics of the reform processes are defined on the basis of these principles, as regards the organization of systems and services, sectoral financing, and the strengthening of the governing function. In this context, certain important changes in the regional scene must be pointed out: - progress made in the decentralization of the State; - action by new public and private actors; - decentralization and/or spreading out of public health services, health regulations, and the provision of health care services to the population; and - separation of the financing, insurance, and service provision functions. Pan American Health Organization

Concerning the exercise of sectoral leadership, the following basic functions must be mentioned: - sectoral guidance; - sectoral regulation and development of essential public health functions that pertain to the health authorities; - modulation of sectoral financing; - insurance monitoring; and - harmonization of service provision. The development of human resources in the reform processes constitutes a great challenge. It is necessary to consider that the orientation of personnel development must respond to several processes, such as the orientation and complexity of institutional changes; scientific progress; changes in work processes (including making it more flexible), decentralization of health management, and changes in professional practices. The scenario is complex and conflictive, and the coordination among the main collective actors having an interest is required if such a challenge is to be met. This challenge implies changing certain criteria of educational policy towards a functional (not disciplinary) approach, going beyond initiatives that are limited to curricular changes, and educational programming according to requirements derived from the exercise of the governing function, the provision of public health services, and the provision of health care services.

3. THE CONTEXT: STATE REFORMS AND THE DEVELOPMENT OF HUMAN RESOURCES

Present in the international context in which sectoral reform processes take place are certain situations and conditions that influence in a determining manner their orientation and feasibility, and of which the following must be pointed out: 3.1 State Reform and Human Resources(3) An analysis of the subject shows that the human resources issue figures importantly in debates at the economic level in general, and at the microorganizational level. The importance of instituting personnel policies consistent with the organizational changes is unquestionable. It is interesting to point out that the debates on the role of the State demonstrate a reassessment thereof, although from a perspective other than that of the all-powerful State that prevailed in the 1960s, and in opposition to the trend towards dismantling the State hailed during the 1980s. The World Bank, in another moment of its pendular movement, now proclaims that "without an efficient State, neither sustainable economic nor social development is possible." There is also a trend towards revitalizing public institutions, highlighting their managerial specificity, which signals a departure from the much-praised private management concept. The theory of the spillover of economic growth benefits is also discarded as this century comes to a close, due to overwhelming empirical evidence showing a growth in poverty, the intensification of social inequality, growing unemployment, etc. The social element is pointed to as a lever for sustainable development, and as a responsibility of that new, efficient State, within the framework of Pan American Health Organization new alliances with the civil society. Another very important change is the reassessment of the public sector's human resources. An essential condition within the perspective of the new effective and efficient State is for public personnel to be qualified and motivated. It is accepted that in order to secure the services of human resources meeting such specifications, it is indispensable to develop personnel policies based on the following requirements: a) a merit-based system, b) appropriate remuneration, and c) encouragement of solidarity in job performance and within the organization. Abundant empirical evidence also is available to support this principle; however, it also shows that to the extent that changes in solidarity imply changes in the power structure of organizations, there is great opposition to them. The effective State desired also implies the development of social policies and social management. The idea of an efficient social management is based on an alliance between the civil society and the State, which differentiates it from mere conventional managerial efficiency. The Latin American challenge is enormous, the numbers are overwhelming, and the times are critical. The challenge public human resources face regarding inequality and poverty in the Region also implies the adoption of new values along the lines of an "ethic of celerity." 3.2 Educational Reforms(4) The challenges for education are enormous and strategically important in the previously described context. The greatest challenge consists of equipping all future citizens with new critical skills for the future, upon which are based a highly-developed capacity to define problems and the assurance of the capabilities required to confront them (i.e., raising performance standards in everyday life). The analysis of educational indicators in Latin America (adult literacy or educational levels) is discouraging from the perspective of the forthcoming century's requirements. The payment of such debt to the future will demand sustained educational development in the medium term to improve the universal levels of essential literacy: literacy per se, literacy in informatics, and literacy in biodiversity (an appropriate relationship with the environment). Facing the challenge of the future requires capabilities in what is known as "infonautics." Individuals must be able to navigate the information highway and work within organizations that are homologous to the human brain (beyond conventional mechanical and informatics conceptions), they must be capable of self-organization, focused on learning, and network-based. A number of governing principles of a new educational perspective emanate from this organizational (cerebral) perspective, such as the networks principle, the capacity to deal with new situations, learning with the entire brain and with the two hemispheres in balance, double-loop (Kolb) learning, flexibility in the management of learning and information, thinking and dealing with complexity, and the principle of enlightenment (adding value and satisfaction to service based on knowledge). On the subject of higher education, the dilemma is between the dinosaur or the infonaut. To overcome this, a change in direction is needed in: - mathetics (i.e., the art of learning in organizations that learn) a step beyond pedagogy; - quality, including the definition of quality standards; - the use of technological changes with regard to distance education and so- called virtual universities; - paradigmatic changes in organizations (based on mathetics). Pan American Health Organization

3.3 Labor Change Trends in Health Services(5) Health reform experience in Europe and the United Kingdom clearly shows the need to consider organizational changes at the macro level, and those that occur with human resources processes in the analysis of sectoral reform. In the European experience, emphasis is placed on the importance of in-depth analysis of four substantive processes: restructuring the public sector, privatization-commercialization of services, labor flexibility, and changes in the workplace. Through an analysis of the restructuring of the public sector, it is possible to single out, firstly, the obligations resulting from budgetary restrictions (due to globalization commitments), their impact on salary levels, and the definition of new guidelines related to productivity and work conditions. Secondly, public services were reorganized in response to market competitiveness conditions, decentralization or the return of authority and responsibilities, and the establishment of service performance and production goals. The administrative dimension comes in third in the restructuring scene. Here changes have taken place in the direction of administrative strengthening, and in the impact of the new game rules on professionals and their associations and trade unions. The British experience in privatization of services illustrates different forms of privatization: from the provision of services financed with private funds, to the externalization of services or contracts to third parties outside the public sector, to the structuring of internal markets. The impact that third party intervention had on performance, quality, and labor flexibility must be stressed. In terms of this one effect, the experience varies, and a specific analysis would be required for each particular case. The other effect was on employment terms and conditions. The organization of internal markets made it possible to bring into focus job performance, the capacity to manage amid uncertainty, and the appearance of labor instability. There, as in Latin America, temporary contracts flourished and a trend towards instability developed. The question of labor flexibility expressed itself in three forms: the so-called numerical flexibility, which implied the growth of temporary contracts and part-time work; functional flexibility, with its impact on personnel performance (in new abilities and in the broadening of the performance spectrum), changes in the composition of the work force, and modification of occupational frontiers and duties; and economic flexibility, which altered remuneration systems by emphasizing payment for performance instead of the traditional concept of payment for time and seniority. The changes that occurred at the workplace derived from decentralization and the strengthening of the local managerial capacity. One effect has been a trend towards decentralization of collective negotiations, which has translated into local agreements with the labor force, and an important change in human resources management. 3.4 Human Resources for Public Health and the Teams Question(6) The new trends in the organization of work, and in institutional architecture and dynamics, bring back into focus the matter of teams in public health work. This old ever-mentioned and never-accomplished objective is now revitalized thanks to evidence provided by the changes that have taken place in organizational styles, and the exploration of similar changes in health institutions. The subject of teamwork currently does not refer to an instrumental arrangement to obtain different or better results within the framework of conventional organizations. The current challenge is to use teams as a possible tool to prevent fragmentation of work, that is, as a unifying value in the labor force within the framework of different institutions. Pan American Health Organization Evidence from progressive organizations that place teams at the core of their development is abundant. On another front, and in relationship to the impacts of the technological revolution, the employment and occupational structure trends point to new organizational developments that also value teamwork, such as medium and small self-management, self-employment, cooperative, and family businesses, and other forms of production diversification. What would be the value in the reforms of a unified labor force, that is, an effective health team, for the improvement of health care? On the basis of which principles is it possible to move forward with such unification? The answers begin to appear upon recognition of the potential of institutional networks. Conceiving networks of work teams, effective in progressive organizations, is an enormous challenge for health sector management, for permanent training and education, and for the regulation of the system in general, because of its implications in the labor force's negotiating capacity. This Copernican change in work organization in health is presently a source of doubts as well as possibilities. What conditions are necessary to assemble such teams? How could their continuity and growth be ensured? What would happen with such teams upon the advance of decentralization, "flexibilization," and third-party intervention? These and other questions may be posed for reflection about the possibilities of teams in public health work. 3.5 State Reforms, Decentralization and Public Policy(7) The analysis of these political dimensions demands an effort to ensure the precision of concepts, since conceptual confusion and the resulting inadequate use of concepts, is common. It is necessary to establish clearly three different concepts involved in this analysis: state, government, and the public function. People talk about reform of the State, but in reality they are referring to governmental work. State reform in Latin America is closely related to democratic governance processes. The Region has made progress and accrued considerable experience in this field (concerning constitutional reform, political party laws, etc.). However, it would seem that less progress has been made with respect to governmental work and the public function. There is a growing trend towards the development of a new public administration, which, nevertheless, seems to be more of a declaration than an effective action. With regard to decentralization, a process in which Latin America also has had a rich experience, several issues must always be considered: the double meaning (structural and institutional) that prevails in the Region; the territorial question as something of great importance (decentralization as "reconstruction of the space"); and the problem of the intermediate level, which is of great importance for health and education decentralization. The question of levels translates into a public policy issue which manifests itself through the definition and distribution of competencies: what is each one going to do and how? How will she or he act at the local level? How are public policies articulated at that level? In countries such as Brazil, the desirability of a fourth level is beginning to be explored. State reforms have other implications for social policies, among them the regulation of health markets. At this point it is very clear that health cannot be left in the hands of the market. The other question has to do with intersectoral relations, and communication among the sectors as an indispensable condition for action in health and education. 4. SECTORAL REFORM, FLEXIBILITY, AND Pan American Health Organization HUMAN RESOURCE REGULATION(8)

Any positive change in health systems and services demands capable and motivated human resources. As has been clearly established by context, sectoral reform processes in the post-Fordian or "flexibility" era are influenced by national and international economic and institutional changes, which place before them the imperative of having to develop their regulatory capacity. The regulatory function is inherent to the modern State. Whether it plays the role of development promoter, guarantor of the common good, or complementary player with regard to market mechanisms, the State must intervene with a regulatory function. Inside the sector, policy options, the decentralization that characterizes almost all the sectoral reform processes, and privatization trends need to be regulated. At this time, it is convenient to establish that, within this perspective, and facing movements that advocate deregulation in health, the State must not regulate less, but better. The evidence available from processes that opted for market deregulation shows a worsening of inequality, greater concentration, and serious problems in the distribution of benefits. It is clear that along the regulate-better line, the State and its institutions regulate as a leading character together with other players: insurance underwriters, lenders, users, etc. To this effect, objectives and expected results must be established, defining framework criteria for regulation, such as volume, type, quality, cost, accessibility, and effectiveness, and taking into account user satisfaction. Regulation can occur at several points in the human resources development process: in inputs, controlling mechanisms for access to education or employment, defining types of required competencies, etc. The processes are another regulation mechanism (that defines responsibilities and competencies, productivity guidelines, performance standards, limits on the use of supplier inputs, etc.) Lastly, it is possible to regulate on the basis of criteria derived from results and impacts, such as intervention effectiveness and the satisfaction of those who receive care. With a more sociological approach, other regulatory frameworks can be established. Thus, regulation must be done taking into consideration the position and interests of the relevant institutional and collective players in the human resources field; professional and technical preparation processes, professional and occupational practice, and the work processes and markets would be regulated within this perspective. The exercise of the regulatory function requires the use of several regulatory modes: the legal framework, the administration, and the economic and social processes. Within a more instrumental view, it implies the use of coercive mechanisms, negotiation and dialogue, laissez-faire mechanisms and, more frequently, a combination thereof. As may be clearly observed, regulation consists of very complex political, economic, social, and legal processes, thus the frequent emergence of unforeseen conflicts and results. Acceptance, trust, and legitimacy must be built up in order to regulate successfully for the common good. The context in which the reforms occur defines a scene of tension for the regulatory function. On one hand, there are deregulation trends and market hegemony, and on the other, the need to develop a better state capacity to ensure the health of the population. At this point we must remember the nature of health care markets, and labor markets in the health sector, whose regulation demands effective frameworks and mechanisms. The corporate self-regulation approach pursued until recently in many countries in the Region currently has no place, nor does regulation centered on the all-powerful figure of the Ministry of Health or Education. Social and political changes have drawn a different picture, where complex and divergent interests demand dialogue, reconciliation, mutual trust, and arrival at negotiated decisions. Pan American Health Organization This new perspective of the regulatory function constitutes yet another challenge for the development of human resources. It will be indispensable to train interlocutors and negotiators for regulation, and it shall likewise be necessary to develop, in the short term, the information systems required to support such function. MERCOSUR is one currently valid case that brings the need to develop the regulatory function at the national and international level into subregional perspective. This economic and commercial integration treaty which, in its different stages, has been into force since 1991, has implications for the future development of health in the four signatory countries (Argentina, Brazil, Paraguay, and Uruguay), to the extent that health services are regarded as tradeable goods. This challenges the health sector of the subregion to assure that health be promoted with fairness and efficiency during the integration process. This challenge implies the sector's need to prepare itself to define and ensure health objectives in a scenario beyond its control, and where, foreseeable, important population segments will be excluded from the eventual benefits of integration. The human resources scenario is defined by the labor force's possibility to mobilize itself freely, the health services development patterns, and the new educational markets. Within this foreseeable framework, the sensitive points in the development of human resources in the field of health are: - personnel preparation and performance processes; - accreditation and professional practice control mechanisms; - forms of employment and supply-demand differentials for the professions; and - health worker professionalization and representation processes. The case of Chile and the regulation of working conditions of primary care personnel under municipal supervision illustrate in exemplary fashion the implications that the regulation of human resources has in the context of a far-reaching, long-term sectoral reform. Sectoral changes between 1990, the year of the return of democracy, and 1994 (the start of the second democratic administration), were oriented towards the public sector's recovery, in terms of infrastructure, equipment, remuneration, and personnel. During this period, the regulation of human resources must have necessarily taken into consideration the satisfaction of needs accumulated due to the deteriorated personnel situation, and the recovery of the trade associations. Certain important conflicts marked this period, such as a work stoppage by personnel under municipal supervision who demanded a special regulatory statute. This personnel, in contrast to personnel at other levels of health care, was governed by the Labor Code, which was common to workers in private corporations. The period from 1994 to the present has been very enlightening with respect to regulation, "flexibilization," and negotiation. Sectoral strengthening and modernization have been approached during this phase with the introduction of changes in financing, management, and health care models. During this period, legal changes demanded by personnel under municipal supervision were made to the labor framework: the primary care statute was adopted (passed in 1995, it affected the labor situation of 18,000 workers by acknowledging their local public service career, and remunerative and skills criteria, among others) and a series of measures to govern incentive systems for performance and experience were also adopted. Regulation and reconciliation issues (as well as the management of numerous conflicts), were displaced to the regulation and annotation of the effects of "flexibilization" due to the modernization of the state and public administration. The Chilean experience illustrates the complexity of the sector's present regulatory frameworks, the limitations and possibilities of "flexibilization," the dynamism of conflicts and negotiations--that go from working conditions all the way to care models and system financing, and which assume the Pan American Health Organization defense of the public sector--and, very clearly, the need to build an institutional capacity to strategically manage human resources, to exercise the regulatory function, and to take charge of the negotiation with the other players. It also illustrates certain challenges to be faced: how can the possibilities of flexibility be used to encourage cultural organizational change in the health field? How can effective specification of legal reforms for personnel development be advanced? How can government and organizations regulate and negotiate adequately to encourage the commitment of the workers to such sectoral changes as will benefit the population? These concerns were also discussed in group debates. "Flexibilization" is an undeniable element in the sectoral reform scenario, offering possibilities and entailing risk. It would seem that its acritical and vertical introduction would imply more risk than benefit. In a sectoral scenario such as that of the Region, which, in many instances, has not been able to surmount structural defects and limitations, external flexibility and its ensuing labor instability, job uncertainty, and deterioration of the basic conditions for adequate performance will not contribute to positive changes in the services, and may, instead, worsen the already existing problems. However, functional "flexibilization," with its effects on the reorganization of the work in the services, could generate possibilities to accompany and strengthen organizational changes, and to help improve the quality of health care. In this sense, the health sector's institutional weakness in managing human resources according to modern criteria and sectoral changes is a matter of concern. The capacity to regulate, as a function of State governance, also requires administrative changes. 5. DECENTRALIZATION AND HUMAN RESOURCES MANAGEMENT(9)

The question was analyzed on the basis of the panel members' own experiences, highlighting relevant and critical aspects of decentralization and certain basic general issues. To their greatest extent, the sector's reform processes will be successful only if the sector's human resources commit to pursue the reform's objectives, seeking universal access and care, and fairness on the part of the system. This implies that the personnel has flexibility to accept the change, the knowledge, the abilities, and the skills required; and a clear understanding of their role to care for and preserve the health of the communities in an integral manner. Decentralization must be viewed as an essential strategy of the sectoral reform processes' directionality. It is stressed that it must be coordinated, gradual, and planned. The idea that human resources decentralization is something that must be developed and linked to the services' work processes to meet the needs of the local realms in which they are carried out, emerges as a central theme. The impacts of decentralization on human resources management can be viewed in two major dimensions: those that emerge as part of the process of the transfer of power to the lower managerial levels, and those that emerge as a consequence or result of the manner in which decentralized managerial systems are structured. The following elements were stressed as essential in relationship to the first category: 1. adequate available human resource information; 2. complexity of the decentralization process; 3. impact of, and on, professional associations; and 4. motivation and attitude of health personnel. Pan American Health Organization Certain situations and conditions may be affected in the course of decentralization: 1. the definition of structure, organization, roles, and responsibilities; 2. the viability of the coordinated development of health and human resources; 3. sustainability of an appropriate training process; 4. maintenance of the technical and managerial capacity of health personnel; and 5. assurance of working conditions for adequate performance. Following are certain considerations to be taken into account concerning the sense of direction of human resources decentralization: - willingness and attitude of managers to guarantee a qualified and committed health team; - development of the capacity to adapt to the complex contexts the process requires (legal implications concerning rights and duties of personnel, new roles and responsibilities, promotion of incentives and better performances, authority transfer mechanisms, etc.); - strengthening of the strategic capacity for human resources development at the central and local levels; - investment in human resources development; - monitoring of the impact of decentralization on the human resources development processes (taking into consideration the fairness of distribution, access, quality, and efficiency of personnel). The case of Brazil illustrates the complexity of the processes and risks involved in decentralization when there is no adequate sectoral regulation by the State. There is, in fact, a "wild or deregulated" reform, where changes have been introduced into the different dimensions of the human resources development process, with no other justification than making services work "no matter how." In a context of deteriorating working conditions and financial constraints, forms of organization on the edge of the health policy and even on the edge of law, have appeared. The future (health and legal) implications are difficult to foresee, to the extent that there are no evaluation or control mechanisms for such initiatives. The State's governing function is a basic axis for the orientation of the human resources decentralization strategy. The governing role must be politically and socially accepted by society and the sectoral actors in order for it to facilitate the sectoral reform process. Because of the diverse actors currently involved in human resources decentralization, it is necessary to value the strength of coordination and negotiation in the definition of clear game rules and principles to guide its implementation. This may also strengthen civil society, where social control mechanisms may be developed to permanently support the search for equality and the ethics of decentralization. The experience of Saskatchewan, Canada shows a reform process (attempting to find its lost path) that bets on an approach centered on the community as a protagonist, the rationalization of resources, financing according to needs, co-ordination among players, and intersectoral relationships. Training and the development of new decentralized performance capabilities require a greater and better proximity to the countries' specific realities. There is a need to include human resources development institutions and to act jointly with the educational sector to work in a coordinated fashion and distribute and optimize resources. From this point on, the design of content, profiles, and training programs in response to the reform processes must be done in coordination. This shall make it necessary to move forward in the establishment of mechanisms for the regulation and Pan American Health Organization accreditation of public and private educational institutions, since the very quality and social relevance of the development of health professionals would otherwise be at stake. 6. HUMAN RESOURCES AND CHANGES IN HEALTH CARE MODELS(10)

Different situations in five countries of the Region, which stress different dimensions of the relationship between health care models and the development of human resources--emphasizing productivity, quality, institutional change, and managerial development--were analyzed. An unprecedented debate is currently taking place in the United States of America on the status and potential for change of its health systems. The unsuccessful sector reform proposal (1993-1994) has, nevertheless, had effects that have not yet been comprehensively assessed. However, most of the reasons for such a proposal persist, and have forced the government to develop programs and initiatives that affect both health care models for uninsured and at-risk populations, and the development of health personnel. The high cost of medical care (14% of the GDP and US$900,000 million per year), the lack of insurance coverage for nearly 40 million inhabitants, the resurgence of infectious diseases among at-risk social groups, and declining health indicators make it imperative to search for new ways to cope with such situations. The government has mobilized numerous foundations and governmental agencies to develop and implement health care campaigns aimed at those 40 million people without coverage; it has further mobilized almost 21,000 health professionals in an attempt to improve access to health services. The government's recent launch of a health insurance plan for children, which is of great social importance, was highlighted. The United States of America is witnessing an increase in the number of health professionals, and the configuration of a professional structure that is incompatible with the new orientation of the services. This has led to the redefinition of personnel policies and incentive systems oriented towards linking health services with academic institutions in order to regulate the supply of professionals and reduce educational costs. On the other hand, an important change has taken place in the professionals' performance profiles (movement towards a generalist profile), as a consequence of the growing incorporation of models of care and managed care mechanisms, particularly in the private services. There is renewed interest in increasing the productivity in services, and in its relationship to the introduction of incentive systems. This has to do with the need to contain expenditures and the increase in the demand for services. However, the productivity issue is fraught with difficulties in the health field. Health productivity concepts have evidently evolved from the initial product/hours-worked relationship towards a more integral and complex vision that recognizes not only the relationship between products or results, the resources used, and personnel, but also the complexity of the organizations, the population's health needs, and the services' different levels of care. In this vision, productivity relates to costs, goals, and results according to the type of work generated and its purpose. Therefore, one definition of human resources productivity is the quantitative and qualitative relationship between the products, the labor force, and the inputs to achieve the organizations' objectives. Within the sectoral reform framework there is consensus on the need to increase productivity in health services, which leads to the establishment of incentive systems and mechanisms. However, the Pan American Health Organization Region's experience shows that this question is plagued with improvisation and pragmatism, with no adjustment of personnel policies; even more serious is the fact that this often occurs in disagreement with institutional change objectives. This important question brings us to the need to redefine other conditions as well, such as worker participation, motivation, and performance evaluation. The experience of managerial capacity development in relationship to changes in care models in Argentina's public services reveals a certain backwardness in terms of managerial technology, and to explore some ideas on how this could be overcome. The persistence of obsolete managerial technologies makes it impossible to recognize and face the changes that the new context imposes (globalization, flexibility, efficiency, and decentralization, among others). The public sector has faced a legitimacy crisis upon the rupture of the social contract that formed the basis of its purpose. Being a health manager in the late 1990s implies the capacity to manage on the basis of accessibility, quality, and costs; an adequate combination of a global, strategic, and action vision; an interest in training and technological renovation; the handling of incentive and reward systems; and a leadership capacity to orient mobilization for change. The modernization experience of the CCSS has been based on novel strategies at different levels of the organization: reorganization of the care model according to strategic principles, changes in financial resource allocation criteria, changes in basic managerial functions, and, perhaps most interesting, the introduction of management commitments. This has led to the sustained and broad development of training programs and actions, changes in the management of human resources, and emphasis on the preparation of critical profiles. The improvement of both the quality of health or medical care and the quality of productivity is firmly established among the objectives of the reforms. Quality health care consists of accessible and equitable services, an optimum professional level, the consideration of available resources, and the ability to earn the user's loyalty and satisfaction. It also implies the adequate combination of internal and external approaches, and the participation of the different players (managers, care personnel, and users). Continuous quality improvement puts human resources in a central and irreplaceable position, where they must undertake important responsibilities, such as honoring the trust placed in them, maintaining and improving their level of professional competence, and a taking permanent scientific approach to health problems. The essential requirements to accomplish such continuous improvement are based on fundamental competencies, such as knowing what to do, measuring what is being done, and acting accordingly. Reflection on the complex relationship that exists between care models and human resources development models refers us also to questions of a political nature as important as those previously dealt with. One such question relates to the fact that in many cases the definition of the care model is essentially a political one, and is not necessarily based on a situational analysis of the population's health and the supply of existing services. It is very difficult to analyze the health care model situation without referring to management models and styles. A change in the former implies changes in management and leadership even as a requirement for their development and strengthening, as shown by the experience of the CCSS. It is from that relationship of quasi-dependence that certain criteria for the development of the human resources necessary for the model and the conditions for their effective performance derive. Worthy of note are the efforts in almost all the countries to prioritize the first care level and primary care as a strategy, and the problem-solving capacity that ambulatory services have, thanks to Pan American Health Organization promotional preventive criteria. A certain determination exerted over professional performance profiles can be clearly observed in these experiences. The need for general-practice professionals equipped with new essential and specific capabilities arises from those policies aimed at changing care models. One element that has been recognized, but which has nevertheless not been sufficiently developed, is the effective link between the services and the educational institutions. The idea, however, is not to expand the educational facilities, but mainly to adopt a strategy through which it may be possible to guarantee quality and the social relevance of professionals and technicians being prepared.

7. THE FUTURE OF PUBLIC HEALTH(11)

Ideas and concepts about public health have changed over time, and have always been controversial. It is possible to accept as a broad concept that public health includes those actions that societies and states must inevitably perform to preserve and promote the health of their populations. At present, this concept encompasses actions and dimensions of national and international scope. Within a historical perspective, it is possible to demonstrate that better standards of living have been achieved in many parts of the world; some of these accomplishments are attributable to public health actions, as demonstrated by a number of indicators on life expectancy, mortality, and morbidity. However, reflection and contemporary analysis on the status and future of public health cannot deny that in large parts of the world inequalities in quality of life, health status, and access to health services have persisted and worsened, that there are pandemics, and that old diseases are reemerging and affecting large segments of populations. Being as close as we are to the year 2000, it is important to include in this perspective of public health what health for all and primary health care meant for the countries of the world that undertook the commitment to develop health systems on new bases to reduce inequality and ensure universal access thereto, through the development of appropriate technologies and societal participation. Not only did this framework reorient the systems, it defined new references for public health by including political, social, cultural, and economic factors in the definition of the conditions under which the population can be healthy. Nor can the future of public health avoid consideration of the criticism it has received and continues to receive from within and outside the public health community. Such arguments maintain that public health has been excessively rhetorical and self-willed, that it has not fulfilled its promises, and that it has been too tolerant or passive vis-à-vis governmental constraints that affect the services' very ability to serve. This would lead to loss of prestige by public health services, and discouragement among the public health community itself. In another, more epistemological perspective, it is criticized for its alleged biophysiologism, for having lost specificity in the face of biomedicine, and for being atheoretical, dichotomous, dogmatic, and confusing, among other negative attributes. At this time, the future of public health is already present in new developments and challenges. Perhaps the most important among the latter is its explicit commitment to the defenseless sectors society, the permanent innovation of its knowledge, and the search for more precise definitions of its action. An important step forward in this perspective is the WHO proposal of the essential functions of public health. The future of public health shall be based also on those elements of public health's historical experience, and its enduring achievements and failures. This refers to the centrality of science in its thinking and action; in the use of cost-effective criteria to define and evaluate interventions; in its Pan American Health Organization alliance with the State, the civil society, NGOs, popular groups, religious groups, etc.; and in an active public health ethic that, to an important extent, includes the protection of human rights and respect for human dignity and life.

8. EDUCATION AND PROFESSIONAL PRACTICE IN SECTORAL REFORM(12)

Sectoral reforms pose a great challenge for universities and their professional preparation function, to the extent that they demand the preparation of general-practice professionals equipped with new competencies. In this context, the university will have to strengthen its participation through the design of intervention models consistent with the new realities, and with subregional integration and globalization processes, the expansion of university's reach, and the updating of its knowledge and applied research. In undergraduate studies, in addition to new content and changes in methodological strategies (student-centered learning, problem solving, and evidence-based medicine) and in the learning centers, it will be necessary to give priority to interdisciplinary and metacognitive strategies for self-learning, as a mechanism to ensure its level of professional competence in the future. The challenge in undergraduate studies is to reverse the trend towards overspecialization by broadening the problem-solving capacity of the generalist, a category that must include general practitioners and pediatricians, and the family doctor. The university is responsible for ensuring that professional standards are updated. This implies the effective development of continuing and permanent education in close cooperation with the ministries of health, the services, professional associations, and scientific associations. This new responsibility on the part of the university will consolidate the integration of education with the services, and will contribute to its adjustment and relevance. In this context, it becomes indispensable to develop certification and re-certification frameworks and mechanisms to ensure professional competence. Committed to its times and reality, the university must play an important role in the social dissemination of knowledge beyond formal educational programs. This implies a great effort to change visions and academic and administrative structures that prevent it from modifying its social mission. The context of medical practice and education, particularly that of general practitioners, must take into consideration the difficult reality of the work markets, which tend towards precariousness and unemployment. Traditionally, there has been a divergence between the academic and the services discourses, between educational and job-providing institutions. On one side, efforts are made to prepare general practitioners, while on the other, specialists are sought. Understanding that it is not possible to prepare professionals without effective integration into the services, the services' current requirement for general practitioners affords an opportunity to overcome that separation and for the discourse to correspond to reality. It is important that the discussions on educational changes reflect institutional learning, and that the new decisions be based on the accomplishments and failures of collegiate initiatives. The National Pan American Health Organization University of Mexico (UNAM) experience responds to this vision. The outcomes of the pioneering experience of Plan A-36 led to new plans, such as the 1985 plan, and the gradual incorporation of public health, nutrition, and medical information content into the curriculum; and the broadening of the epidemiologic and statistical content, and of their relationship to clinical work. New and important developments include interdisciplinary experiences in the health of the elderly and the health of the workers, and, especially, family medicine and social service practice activities. One of the most important aspects of the current educational problem is that which relates to academic evaluation and the regulatory aspects of professional education. The basic premise is that professional education must be of the highest possible quality if it is to produce human resources capable of performing adequately and competently in very dynamic and demanding environments. The evaluation and accreditation of educational programs are of the utmost importance to ensure the success of the new health systems. Inevitably, paradigmatic changes in health and education, and the reform processes in progress, delimit a number of factors that are important to determine the type of human resources necessary for health supervision and care. Health professionals and technicians identify new competencies and attitudes for teamwork and self-education to work in new organization modes and different working conditions, with a disposition and knowledge for research and the evaluation of their actions. However, such demands emerge within a context of university funding restrictions and growing unemployment in many countries. There is consensus on the importance of evaluation and accreditation. Quality in educational programs is a basic requirement to ensure better care and promote better health within the framework of sectoral changes. This is not only a requirement of the schools and the services, but of the population, including civil society, professional representations, the students themselves, and their families. All of these actors must have the assurance that the evaluation and accreditation is consistent, objective, and trustworthy, and that it truly evaluates the performance of the educational programs on the basis of relevant and accepted national and international standards. National evaluation and accreditation systems must respond to each country's political and institutional characteristics, which implies the use of flexible evaluation frameworks. In a general sense, this requires a legitimate and representative evaluation and accreditation body accepted by the actors; the development of a self-evaluation process by the respective programs; the evaluation per se (through an ad hoc study by a special team), which also takes into account self-evaluation; and the submission of a report that is reviewed by the respective body. Room must be made for possibilities and mechanisms to appeal, new opportunities, and the dissemination of information. The frequency of evaluation varies from country to country (between three and seven years, with an average of five). These processes are based on understanding and mutual recognition of educational credentials inside the educational systems, and require communication between the institutions involved, and wide access to the information. A broader perspective of the educational and professional accreditation experience emphasizes the dimension of formal recognition of accomplishments, and trust in a working group or in individuals, through formal registration granted by a representative body of institutions. Such recognition is given to the extent that a number of predetermined requirements are met. In turn, certification occurs when a group of professionals recognizes a professional with the capabilities required in a given field and grants a permit to practice, usually for a limited period of time. A license is an authorization to practice in a given territory, if laws and regulations issued by a Pan American Health Organization central or local authority are complied with. These are closely related to one another. The purpose of accreditation is to protect the public interest through the evaluation of professional competence. Institutions, as well as individuals, can be checked for quality control. In the case of educational institutions, this is done through formal processes by outside evaluators. The accreditation of individuals is done at different levels. For instance, in the case of the medical profession, it is necessary to go through evaluation processes while still studying, at graduation time (by means of national examinations), at the time of partial or final registration upon completion of the internship, during postgraduate studies after passing the examination of the specialists' association, and, lastly, when taking state examinations, during the continuing education process, and eventually, during the re-certification process. Accreditation is important since it serves to ensure the competence and trustworthiness of professionals, and, therefore, of the services, within the framework of globalization and decentralization that determine professional mobilization nationally and internationally. Emphasis must be placed on the importance of a balance between deregulation and over-regulation; coherence in the competencies of local, national, and international authorities; moderation of the political pressures involved in the processes; participation of the population; and, lastly, ensuring the participation of the health sector with implications for the job markets. The CARICOM experience highlights those items that relate to the movement of graduates between countries, exchange regulations, and accreditation mechanisms of tertiary-level educational institutions. Recent intergovernmental agreements set a framework for changes in educational programs and the practice of traditional medicine agents, who have been required to prove their competence and have been incorporated into continuing education programs. Efforts are being made to develop a subregional register of professionals, which, in the case of the medical profession, implies the introduction of an examination where priority is given to graduates from the area's schools. The registration of professionals in each one of the CARICOM countries and the accreditation of educational programs constitute the most important goal at present. It must be stressed that the leadership in the accreditation processes was undertaken by the nursing. Furthermore, it has been agreed to establish continuing education programs to maintain competencies and develop educational programs based on informatics networks. The reforms constitute an opportunity to induce evaluation processes. By indirectly promoting and encouraging an accreditation and certification culture, quality health accomplishments are being sought. One prerequisite for the progress of such processes is the effective relationship between the educational institutions and the services, through the joint evaluation of the services' needs, with emphasis on work processes. This will make it possible to revise the reasons for rejection and incompatibility between the system's human resources requirements and the educational supply. There is a long and rich experience in assistance education coordination, which has been neither assessed nor valued sufficiently. The current experiences show that this strategy is still valid and that it must be extended to include continuing education programs and educational supervision coherent with the needs of the services. With one clear permanent education perspective it shall be possible to take advantage of the new technological potential, in order to broaden the coverage of educational actions. Computer-network-based distance education can reach a large audience of workers representative of the different collective components. It is necessary to continue probing deeper into the analysis and adjustment of curricula in relationship to the final product, including aspects of the practice such as trends towards labor Pan American Health Organization flexibility and redefinition of competencies. The long history of curricular changes without substantive impacts shows us that the participation of the educators is fundamental in any change process. At present it is essential to ensure timely and adequate access to the knowledge and information available, to form a basis for strategic decision making. This assertion is valid both for the educational and the assistance sectors. How can profiles and competencies be redefined without knowing about market trends, or the changes in the organization of the work that take place in the services? How can a long-haul strategic project for educational change be supported without a strong epidemiological, social, educational, and assistance information base? Scientific research is one essential dimension of the commitment between education and health services in face of the reforms' challenges and opportunities. The universities, and the services themselves, are deficient in the production of relevant knowledge about the health and health care situations. It is imperative to agree on priorities and to articulate the capabilities required to study priority problems and to develop joint intervention models. Confirming the consensus on the need to evaluate, accredit, and certify is not sufficient. It is necessary to install institutionally coordinated and accepted systems to contribute to the regulation and improvement of educational programs and professional competence. This is not an end in itself, but part of the responsible contribution of the collective actors of the educational sector to the improvement of health care and the satisfaction of the population's needs. PAHO/WHO has experience in the coordination of institutions and the promotion of agreements. PAHO's commitment shall be required for the organization of spaces for reaching agreement, for the management of knowledge and the required information, for the design of frameworks and instruments, and to make viable the exchange and communication between institutions and countries.

9. HUMAN RESOURCES AND TECHNICAL COOPERATION(13)

This subject was analyzed on the basis of contributions by PAHO/WHO, the World Bank (WB), and the Inter-American Development Bank (IDB). The considerations of the representatives of these organizations led to certain comments on the part of the authorities and officials in attendance. According to the PAHO/WHO vision, the conceptual starting point for the definition of technical cooperation strategies in this field is the premise that health human resources are the essential subjects of health development, whose protagonism is based on the combination of technical solvency and the command of competencies, and committed and participatory attitudes. Health personnel are a basic part of health care's human dimension. To make such vision explicit is a must, considering certain perceptions that tend to underestimate or conceal the contribution of the health care workers. One of them is the distance or gap that separates a discourse that values the contribution made by personnel from the absence of policies and actions coherent with such a discourse; another erroneous perception consists of the homologation of the human resources concept with an instrumental idea of training; and the third one, of an administrative nature, consists of perceiving human resources, that is, people, merely as one more resource, such as money or equipment. In the end, these visions project themselves in an attitude that excludes the consideration of personnel as the protagonists of health care, and as a subject of change. As we have shown before, this can have unfortunate consequences. PAHO defines its cooperation as an integral approach aimed at the different intervention areas in the field: policy development, information systems, planning, regulation, management, and work and Pan American Health Organization educational processes. On the basis of the analysis of the reform's demands, priority is given to actions aimed at: - the development of regulatory frameworks for human resource development; - the strengthening of human resource policies; - the development of information systems appropriate for human resource planning and management; - the development of human resource management capabilities at the different levels of the health systems; - the encouragement and support of improved performance by health personnel; and - the development and strengthening of educational processes in the training institutions and services. The countries' requirements must be dealt with keeping in mind both the new circumstances of international cooperation and the development of national institutional capabilities. This is why PAHO has been using certain cooperation strategies that respond to the following principles: - technical support for the human resource components of the countries' reform processes and projects; - encouragement of active participation by the educational institutions in the reform processes; and - encouragement of articulation and coordination between the social actors to develop policies and changes in human resource development. This is why, at present, the Organization's action aims to give priority to the formation of strategic alliances with the Region's institutions of excellence in this field; human resource mobilization within a framework of cooperation among countries; research and the dissemination of knowledge and information in this field; and the permanent search for efficient, timely, and relevant technical responses. International financial cooperation organizations, the leading players in the reform processes, are likewise favoring the position of human resources in such reform processes. Since personnel is a critical factor in the reforms, the World Bank and the IDB have decided to establish matters of human resource policies and processes as an important line of support. However, its extreme complexity is acknowledged; by its very nature, this multidimensional subject requires technical, administrative, cultural, political and economic changes in the health systems. In June 1997 the World Bank circulated a policy document that defines its strategy for the health sector. In it, it establishes the importance that human resources have for this organization. In a near future, the WB will initiate a discussion process with international organizations (including WHO and PAHO) to better define its regional strategy in this field. This process should ultimately define a joint action to help the countries improve the quality of their health systems through actions relative to human resources, that shall include: - the production and dissemination of knowledge on the development of human resources; - the development of instruments for human resource planning; - support to the countries in the development of their capabilities for the analysis and development of personnel development policies and strategies; and - support for the development of a regional initiative to open a forum for the discussion of human resource matters. It must be stated that there is a need to define clear and relevant objectives to guide actions in this field, so that the different players in the political process and those responsible for the technical Pan American Health Organization interventions can devise more effective strategies to achieve the reforms' objectives. These definitions had very positive impacts among the attending health sector representatives. However, a clear message was delivered by the audience to the representatives of the cooperation agencies, that the coordination of projects, strategies, and actions be strengthened in order to avoid wasteful expenditure and to increase the impact of the interventions. Other conditions of a more operational nature, and related to financial cooperation, which must be changed for the benefit of the countries and to ensure a better use of the resources, relate to modes of interaction with the so-called national counterparts and streamlined administrative procedures.

10. EPILOGUE(14)

The meeting signified a moment of reflection and debate on the role and importance of human resources in the processes of health care for the population, and in health sector reforms. Based on the final comments by the authorities who participated in the meeting's closing panel, it is possible to assert that there is consensus on the central role of human resources in health care and on the changes to be made by the reforms. The task of improving working conditions and educational processes (both for personnel in training and those employed in a fully functioning capacity), and redefining social and institutional relations that, in turn, define the development of human resources in their political and economic dimensions, was recognized as an enormous challenge. The strengthening of the supervisory and regulatory functions of the State, in conjunction with the collective actors, is a central requirement to this end. Understood in all clarity was the message that, without technically solvent human resources with knowledge of the purposes and a commitment to the processes of change in the health sector, the reform processes have no future. The meeting also made it possible to recognize the complexity and broadness of the problem being approached. Listening to the different comments was an interesting experience, since, to a certain extent, the meeting became an intensive learning process whose continuity the participants were greatly interested in preserving. Beyond recognizing their determining factors and implications, the context of the reforms is defined in an epoch of turbulence and instability, on whose direction human survival and development depend. The visions that orient the reforms must, as one of the vice ministers present expressed, gather the best of the available theories and that which is most genuine of the hopes and responsibilities of those who, like the participants in the meeting, have decided to devote their lives and actions to public health. The great challenge of redefining the State's function for the sake of equitable and effective social action, combines with the imperative of timely action (the so-called "ethic of celerity"). The broadening gaps between the haves and have-nots demand quick but effective action and the most efficient use possible of available social resources. It is on this basis that the commitment to the life and health of the population of the Americas is defined, and such a commitment cannot be fulfilled without the participation of health personnel. Though unwritten, a mandate was issued by this meeting: continuity and sustainability in national and international efforts to define policies, coordinate efforts, develop programs, and ensure the resources necessary for the development of human resources. This is the line of action if we want the contribution made by personnel, the essential subject in the realm of health, to be effective and to constitute a guarantee of accomplishment of the reform's purposes. This implicit mandate is of great importance for PAHO/WHO technical cooperation, and for the Pan American Health Organization other international aid actors as well. The message of continuity was emphatic: this meeting must be the beginning of more intensive action along this line of work ("human resources for health in the reforms"). And such action must be defined in terms of technical accompaniment to the countries (in accordance with their peculiarities), to the promotion of the integration of efforts, and the capitalization, for the benefit of all, of the institutional lessons that each one of the countries has learned. Cooperation among countries is, therefore, one of the most important strategies responding to this need.

ANNEX 1: List of Participants

Argentina Rosa María Borrel Bentz, Advisor Human Resources Program PAHO/WHO/Argentina Marcelo T. De Alvear 684 4to. Piso Buenos Aires, Argentina Tel.: 541-314-4847 Fax: 541-311-9151 María Cecilia Bottindari, Advisor Ministry of Health and Walfare Av. 9 de julio 1925 piso 11 Buenos Aires, Argentina Tel.: 541-379-9045 Marta Novick, Researcher CEIL/CONICET Institute of Industry, General University Hipólito Yrigoyen 1780 1 A Buenos Aires, Argentina Tel: 541-451-4575 Fax: 541-372-5322 Alfredo Maximiliano Stern General Director Fundación Hospitalacia Cramer 4601 Buenos Aires, Argentina Tel.: 541-703-2306 Fax: 541-703-2320 Barbados Pan American Health Organization Karen Sealey Caribbean Program Coordinaor PAHO/WHO P.O. Box 508 Bridgetown, Barbados Tel.: 246-42638a60 Fax: 246-469779 Errol Ricardo Walrond, Dean School of Clinical Medicine and Research University of the West Indies c/o Queen Elizabeth Hospital Marindales Road St. Michael, Barbados Tel.: 246-429-5112 Fax: 246-429-6738 Sylvester O. Welch Senior Personnel Officer Ministry of Health Jemmotts Lane Bridgetown, Barbados Tel.: 246-426-5080 Fax: 246-426-5570 Jean Yan Human Resources Advisor CPC/Passo Barbados #3 Maple Gardens Hastings, Christ Church Barbados Tel.: 246-426-3860 Belize Jorge Nabet, Counterpart Health Policy Reform Project Ministry of Health Belmopan, Belize Tel.: 08-22059 Fax: 08-22055 Bolivia Víctor Barrios Mesve National Director, Human Resources Ministry of Health La Paz, Bolivia Tel.: 223-589-792935 Fax: 591-222-9589 Pan American Health Organization

Buddy Lazo de la Vega President, School of Medicine Association Universidad Mayor de San Andrés P.O. Box 396 La Paz, Bolivia Tel.: 223-589-792935 Fax: 591-222-9589 Carmen Rosa Serrano Nunberg National Consultant Human Resources Development Program PAHO/WHO - PWR-Bolivia Casilla No. 9790 ED. Foncomin 3er. PisoAve. 20 de Octubre La Paz, Bolivia Tel.: 591-2-362646 Fax: 591-2-391296 María Elena Zabala Rueda Director, Health Department Unit Prefectura del Departamento de La Paz La Paz, Bolivia Tel.: 390042-315961 Brazil Mario Roberto Dal Poz Assistant Director Social Medicine Institute UERJ Ruta San Francisco Xavier, 574-7001 Maracaná Río de Janeiro, Brasil Tel.: 55-21-587-7540 Fax: 55-21-264-1142

Hugo Fernández Jr. Legislative Advisor House of Representatives Anexo III - Gabinete 50 Brasilia D.F., Brasil Tel.: 061-318-6739 Fax: 061-318-2112

Canada

Gilles Dussault Professor Pan American Health Organization University of Montreal C.P. 6128, succ. Centre-Ville Montreal, Canada H3C357 Tel.: 514-343-6181 Fax: 514-343-2448 Con Hnatiuk Deputy Minister Department of Health 3415 Albert St. S4S6X6 Regina, Saskatchewan, Canada Tel.: 306-787-3041 Wendy McBride Executive Director Canadian Association of University Schools of Nursing Suite 325-350 Albert St. Ottawa, Ontario, Canada Tel.: 613-563-1236 Fax: 613-563-7739 Chile María Soledad Barría Irontié Chief, Human Resources Division Ministry of Health Me Iver Su 1- Santiago, Chile Tel.: 6300347-345 Fax: 6333228 Pedro Francisco Crocco Abalos Director, Management Unit Health Service Ministry of Health, Chile Me Iver Su 1- Santiago, Chile Tel.: 562-6300-596 Fax: 562-6642-336 Francisco León Delgado Social Affairs Officer CEPAL Casilla 179 D Santiago, Chile Tel.: 2102530 Fax: 2080252 Eduardo Patricio Palma Carvajal Technical Assistant, Main Government Project UNDP UNDP (United Nations Development Program) Av. Dag. Hammarskjold 3241 Pan American Health Organization Santiago, Chile Tel.: 337-2424 Fax: 337-2401 Colombia María Cristina Aitken de Taborda Human Resources Consultant PAHO/WHO Colombia CRA 13#32-71 5to. Piso Bogotá, Colombia Tel.: 3367100 Fax: 3367306 Blanca Aguirre de Gabel Director, School of Nursing Universidad del Valle Vice-President ALADEFE Universidad del Valle Calle 51 Norte No. 8B10 El Bosque Cali, Colombia Tel.: 665-8244 Fax: 665-8244 Jorge Iván Vélez Uribe Chief of Planning, Health Directorate in Antioquia Directorate of Health Section in Antioquia CAD La Alpujarra Piso 8 Colombia Tel.: 3811580 Mario Alberto Zapata Consultant, Municipal Health Systems Ministry of Health Carrera 13#32-76 Santafé Bogotá, Colombia Tel.:336-5066 ext. 1617 Fax: 3362181 Costa Rica Lucía Alfaro Guerrero Director, School of Nursing University of Costa Rica Ciudad Universitaria San José, Costa Rica Tel.: 207-5219 Patricia Allen Flores Directorate of Regulation, Accreditation, and Evaluation Ministry of Health Pan American Health Organization P.O. Box 123.000-1000 San José, Costa Rica Tel.: 233-7872 Fax: 255-1167 Gladys Araya Ugalde Director, Department of Nursing Ministry of Health Ciudad Universitaria San José, Costa Rica Tel.: 223-0333 Fax: 257-9854 Carlos Argüello Director, Social Dentistry University of Costa Rica Univ. de C.R. San Pedro, Facultad de OdontologíaSan José, Costa Rica Tel.: 207-5449 Fax: 237-9217 Jorge Arias Sobrado, Physician Social Christian United Party P.O. Box 323-1007 San José, Costa Rica Tel.: 506-233-7362 Fax: 506-233-8154 Carlos De Céspedes, Dean Faculty of Medicine University of Costa Rica San José, Costa Rica Tel.: 207-4560/207-4512 Fax: 225-6961 Eduardo Doryan, Minister Ministry of Public Education P.O. Box 10087 San José, Costa Rica Tel.: 221-9616 Fax: 233-0390 José Miguel Esquivel Chief, Research and Biotechnical Unit Cendeisss-C.C.S.S. Cendeisss San José, Costa Rica Tel.: 290-5744 Merlín Fernández PAHO/WHO Representative Costa Rica Ministry of Health, Pan American Health Organization Calle 16, Avenida 6 y 8 Distrito Hospital San José, Costa Rica Francisco Gólcher Valverde. Strategist Ministry of Health 308-2150 Moravia San José, Costa Rica Tel.: 240-2773/380-3106 María Elena López Nuñez Director, Health Development Directorate Ministry of Health P.O. Box 158-1200 San José, Costa Rica Tel.: 232-1812 Fax: 255-1167 Alfredo Martén Cendeisss Director Costa Rica Institute of Social Security 10105 San José, Costa Rica Tel.: 290-2270/290-5744 Fax: 232-7451 Guido Miranda Professor, School of Public University of Costa Rica P.O. Box 5961-1000 San José, Costa Rica Tel.: 232-0476 Fax: 296-1141 Carlos Muños Retana Health Development Unit Ministry of Health 411-2100 San José, Costa Rica Tel.: 506-256-8410 Fax: 506-255-1167 Zaday Pastor Chief, Evaluation and Follow-up Unit Cendeiss-C.C.S.S.- Cendeisss San José, Costa Rica Luis Jorge Pérez Calderón Subregional Advisor, Disaster Prevention Program PAHO/WHO P.O. Box 3745-1000 San José, Costa Rica Tel.: 257-2141 Fax: 257-2139 Pan American Health Organization Julieta Rodríguez Rojas Medical Manager Costa Rican Institute of Social Security P.O. Box 10105 San José 1000 Costa Rica Tel.: 233-5916 - 233-5150 Carlos Rosales Subregional Consultant PAHO/WHO, HSR 942-1000 San José, Costa Rica Tel.: 290-0742 Fax: 232-7786 Hilda María Sancho Ugalde Director, School of Medicine (U.C.R.) University of Costa Rica San José, Costa Rica Tel.: 224-6903-228-1648 Fax: 207-5667 María Griselda Ugalde Salazar Professor of Nursing University of Costa Rica Apto. 177 Alajuela, San José, Costa Rica Tel.: 442-1796 Fax: 442-1796 Mauricio Vargas Fuentes Director, School of Public Health University of Costa Rica 846-1200 Pavas San José Costa Rica Tel.: 207-456 Fax: 253-6436 Cuba Juan José Ceballos Director, National Specialization Institute Ministry of Public Health Calle I#202 esq. Línea Vedad Plaza La Habana, Cuba Tel.: 537-326169/325162 Fax: 537-326169 Jorge Luis Haddad Director, National School of Public Health Ministry of Health, Cuba La Habana, Cuba Tel.: 537-336278/213179 Pan American Health Organization Fax: 537-336278 Dominican Republic Antonio Emilio Mena García Human Resources Consultant PAHO/WHO/Dominican Republic P.O. Box 1464 Santo Domingo, Rep. Dominicana Tel.: 562-1519 Fax: 544-0322 Porfirio Quesada Delgado National Coordinator, Public Administration Reform Presidential Committee on State Reform Galván 18, esquina ave. México Gascue Sto. Domingo Sto. Domingo, Rep. Dominicana Tel.: 809 686 1800 ext. 224 Fax: 809-686-2148 Sergio Sarita Valdéz Undersecretry of Public Health Secretariat of Public Health Calle Tiradentes, esquina San Cristóbal Santo Domingo, Rep. Dominicana Tel.: 809-562-3090 Fax: 809-541-1333 Spain Pedro J. Saturno Hernández Professor of Public Health Universidad de Murcia - Facultad de Medicina U.D. Medicina Preventiva y Salud Pública 301Espinardo, Murcia Spain Tel.: 34-68-363948 Fax: 34-68-363947 Ecuador Guadalupe del Pilar Lima Abásolo National Director on Human Resources Ministy of Public Health, Ecuador Juan Larrea # 444 entre Río Frío y Checa Quito, Ecuador Tel.: 544-550 Fax: 544-550 Rodrigo Yépez Human Resources Consultant Health Network Modernization Project Pan American Health Organization Ministry of Health, Ecuador/World Bank P.O. Box 17 11-0-6292 Quito, Ecuador Tel.: 593-2-455797 Fax: 593-2-464412 El Salvador Jorge Luis Prosperi Ramírez Advisor on Health Systems P.O. Box 1072 San Salvador, El Salvador Tel.: 233-5582 Fax: 298-1168 Carlos Alfredo Rosales Argueta Director General on Health Ministry of Health Calle Arce No. 827 San Salvador, El Salvador Tel.: 222-7360 Fax: 222-1001 Grenada Lana McPhail Permanent of Health Ministry of Health Carenage, St. George's Grenada Tel.: 1-809-440-2962 Fax: 1-809-440-4127 Guatemala Edgar Axel Oliva González Dean, Faculty of Medical Sciences, President, USAC; Vicepresident: ACAFAM Ciudad Universitaria Zona 12, edificio M-Z 2do. Nivel, Ciudad de Guatemala, Guatemala E-mail: [email protected] Tel.: 4767370 al 73 Fax: 4769651 María Eugenia Rivera Búcaro Chief, Human Resources Development Ministry of Health and Welfare Contiguo al Incap 2.11 Guatemala CA. Guatemala, Guatemala Tel.: 59-475-2157 Guyana Pan American Health Organization Frederick Duncan Consultant PAHO/WHO (Guyana) Brickdam, Georgetown Guyana Tel.: 592-2-53000 Sarah Julia Gordon Director, Health Sciences Education Ministry of Health Brickdam, Georgetown Guyana Tel.: 592-22-4414 Fax: 592-22-4413 Randolph Leitch Chief Training Officer Public Service Managemente Office of the President Training Division Public Service Management Durban St. Vlssengen Rd Georgetown, Guyana Tel.: 592-025-7350 Fax: 592-02-57899 Honduras Ramón Pereira Coordinator, Access Program Ministry of Health - PAHO Acceso tercer piso, Ministry of Health Tegucigalpa, Honduras Tel.: 504-380976 Fax: 504-380976 Jamaica Richard Alexander Van West Charles PAHO/WHO Representative Jamaica PAHO/WHO 60 Krunts Ford Blvd. First Life Building 3rd. Floor Kingston, Jamaica Tel.: 876-926-1990 Fax: 876-929-1182 Carl Fitzgerald Browne Permanent Secretary Ministry of Health and the Environment Kingston, Jamaica Saint Vincent and Grenadines Tel.: 809-457-2586 Fax: 809-457-2654 Pan American Health Organization Horace Alexander Williams Senior Director Human Resources and Administration Ministry of Health, Jamaica 10 Cavedonia Ave. Kingstown 5 Jamaica WF Jamaica E-mail: [email protected] Tel.: 926-9220-9 Fax: 960-1076 Mexico Alejandro Cravioto Director (Dean) Faculty of Medicine Universidad Nacional Autónoma de México P.O. Box 70-443 México D.F., 04510, México Tel.: 525-5507577 Fax: 525-6161616 Ernesto Díaz del Castillo Assistant Director, Hospital Development General Director of Regulation, Health Services, Secretariat of Health Ave. Insurgentes Sur 1385, 5to. Piso México D.F., México Tel.: 525-563-8779 José Rodríguez Domínguez Coordinador Collaborating Center WHO/FACMED Faculty of Medicine Universidad Nacional Autónoma de México C.U. México D.F., México Tel.: 525-623-2407 Fax: 525-519-7761 Jorge Domínguez Pastrana General Director on Human Resources Secretaría de Salud Reforma 506 Piso 11 Mexico D.F., Mexico Tel.: 525-533-3706 Fax: 525-553-4233 Enrique Alfonso Gómez Sánchez Chief of Technical Staff Development Institute of Mexican Social Security Ave. Cuantemoc #330 Centro Médico Siglo 21, Col. Doctores 06725 México D.F., México Pan American Health Organization Tel.: 525-761-2436 Fax: 525-761-9649 José Luis Zeballos PAHO/WHO Representative, México Ave. Paseo de las Palmas 530 Lomas de Chapultepec México DF, México Tel.: 525-520-4302 Fax: 525-520-8868 Nicaragua Philippe Lamy PAHO/WHO Representative, Nicaragua 1309 Nicaragua Managua, Nicaragua Tel.: 505-289-4200 Fax: 505-289-4999 Ernesto Medina Sandino Dean, National Autonomous University of Nicaragua P.O. Box 68 León, Nicaragua Tel.: 505-311-4467 Fax: 505-311-4970 Julio Piura CIES Managua, Nicaragua Panama José Federico Hernández Pimentel Advisor on Health Systems and Development PAHO/WHO P.O. Box 7260-Zona 5 PanamáTel.: 507-227-0082 Fax: 507-227-2270

Reina Gisela Roa Rodríguez Chief, Human Resources Planning Ministry of Health, Panama Panamá, Panamá Tel.: 225-3348/225-0015 Fax: 227-40008 Paraguay María Teresa León de Fatecha General Director, International Cooperation Pan American Health Organization Ministerio Salud Pública - Paraguay Bogerón 541 Asunción, Paraguay Tel.: 201003 Fax: 207328 Diego Victoria Mejía PAHO/WHO Representative/Paraguay Mcal. López 957 c/E.E.U.U. Casilla 839 Asunción, Paraguay Tel.: 450-500 Fax: 450-498 Alfonso Mateo Ruiz Peralta President, Private Hospital and Clinics Association Association of Private Hospitals and Clinics Colón 99 Manduvirá Asunción, Paraguay Tel.: 492-912-421-889 Fax: 492-912-421-889 Peru Pablo Augusto Meloni Navarro General Director, Office of Financing External Cooperation and Investments Ministry of Health Lima, Perú Tel.: 432-394 Alicia Consuelo Ramírez Seminario Executive Secretary for Health Sector Program for Public Administrasstion Modernization Chair, Council of Ministers Ave. 28 de Julio # 878 Miraflores Lima 18 Perú Tel.: 424-9228 - 446-9800 Fax: 241-0367 - 432-177 Gladys Aida Zárate León National Consultant - PAHO/WHO-Perú Los Cedros 269 - San Isidro Lima, Perú Tel.: 421-3030 Puerto Rico Luis A. Salicrup Director, International Health Center University of Puerto Rico 365-067 San Juan Pan American Health Organization Puerto Rico Tel.: 202-3422322/787-753-4978 Fax: 202 965-6438 José Hawayek Assistant Dean, Graduate and Continuing Education School of Medicine, University of Puerto Rico Suite 552-497.E Pol Ave. San Juan, Puerto Rico 0096 Tel.: 787-758-2525 Ext. 1832 Fax: 787-758-0760 St. Vincent & Grenadines Carl Fitzgerald Browne Permanent Secretary Ministry of Health and the Environment Saint Vincent and the Grenadines Tel.: 809-457-2586 Fax: 809-457-2684 Suriname Rinia Codfried-Kranenburg Director Ministry of Health, Government Gravenstraat 64 Bou. Paramaribo, Suriname Tel.: 597-477601 Fax: 597-473923 Switzerland Eric Goon WHO Geneva, Division of Human Resources Development and Capacity Building WHO 1211 Geneva 27 Switzerland Tel.: 022-791-2580 Fax: 022-791-0749 Aissatou Koné Diabí Assistant Director General WHO/Geneva WHO 27 A. Appia Geneva Geneva, Switzerland Tel.: 412-2791-2214 Fax: 412-2791-4832 Trinidad & Tobago Pan American Health Organization Ashford Sankar Manager of Human Resources Ministry of Health Cor. Duncan St. Independence Port of Spain, Trinidad Trinidad & Tobago Tel.: 1-809-627-0040 United Kingdom Stephen David Bach Lecturer in Industrial Relations Warwick Business School University of Warwick Coventry CU4 7AL Coventry, United Kingdom Tel.: 44-1203-522-866 Fax: 44-1203-524-656 United States of America Rita M. Carty Dean, College of Nursing and Health Science George Mason University 4400 University Dr. Fairfax, Virginia 22030 U.S.A. Tel.: 617-524-7799 Fax: 617-524-2825

George B. Dines Senior Advisor, International Health U.S. DHHS-HRSA 5600 Fishers Lane Rockville, Maryland 20857 U.S.A. Tel.: 301-443-6152 Fax: 301-443-7834

Bernardo Kliksberg Coordinator, Inter-American Social Development Institute Inter-American Development Bank (IDB) New York Avenue Washington, D.C. - U.S.A. E-mail: [email protected] Tel.: 202-623-3765 Fax: 202-623-3682

Ritta-Liisa Kolehmainen-Aiken Senior Program Associate Pan American Health Organization Management Sciences for Health 165 Allandale Rd. Boston, MA 02130 U.S.A. Tel: 617-524-7799 Fax: 617-524-2825

Uruguay

José Raúl Bustos Minister of Public Health Ministry of Public Health 18 de julio 1892 Montevideo, Uruguay Tel.: 400-1086 Fax: 408-5360

Félix Rígoli Director, CASMU Asilo 3336 Montevideo,Uruguay 11600 Tel.: 598-9-44-5685 Fax: 558-2-480-7710

Eduardo Andrés Scasso Bellini General Director, State Secretariat Ministry of Public Health, Uruguay Montevideo, Uruguay Tel. 400-5222

Eduardo Touyá Dean, Faculty of Medicine University of the Republic, Uruguay General Flores 2125-11800 Montevideo, Uruguay Tel.: 598-2-924-3414/3333-3337 Fax: 598-2-924-3414/3338

Venezuela

Rutilia Calderón Consultant, Human Resources Development Program PAHO/WHO Venezuela Caracas, Venezuela Tel.: 00582-267-1622 Fax: 00582-261-6069

Rolando Moreno Executive Director Pan American Health Organization Children's Rehabilitation Program Caracas, Venezuela E-mail [email protected] Tel.: 573-3910 Fax: 572-4474

Pablo A. Pulido M. Director FEPAFEM / Pan American Federation of Schools of Medicine Apdo. 50676 Caracas, VenezuelaE-Mail: [email protected] Tel.: 58-2-9308-75 / 943-2840 Fax: 58-2-934275

PAN AMERICAN HEALTH ORGANIZATION/ WORLD HEALTH ORGANIZATION 525 Twenty-third St., N.W. Washington, D.C. 20037 U.S.A.

Rodrigo A. Barahona H. Coordinator Human Resources Development Program Tel.: 202-974-3805 Fax: 202-974-3612

Pedro E. Brito Quintana Regional Advisor Human Resources Development Program Tel.: 202-974-3295 Fax: 202-974-3612

Oscar R. Fallas Coordinator HSP/HSO Tel.: 202-974 3215

Charles Godue Regional Advisor International Resident Program Human Resources Development Program Tel.: 202-974 3296 Fax: 202-974 3216

Alberto Infante Short Term Consultant Tel.: 202-974-3818 Fax: 202-974-3641 Pan American Health Organization

Daniel López-Acuña Director Division of Health Systems and Services Development Tel.: 202-974-3221 Fax: 202-974-3613

Luisa Josefina López Moreno International Health Development Program Tel.: 202-974 3847

Maricel Manfredi Regional Advisor Human Resources Development Program Tel.: 202-974-3298 Fax: 202-974-3612

José M. Marín Regional Advisor Health Administration Tel.: 202-974-3821 Fax: 202-974-3641

Maria Alice Roschke Regional Advisor Human Resources Development Program Tel.: 202-974 3828 Fax: 202-974-3612 Luis Ruiz Regional Advisor Human Resources Development Program Tel.: 202-974-3297 Fax: 202-974-3612

María Cristina Schneider Short Term Consultant Tel.: 301-279-0567

ANNEX 2: REGIONAL MEETING: HUMAN RESOURCES: A KEY FACTOR IN HEALTH SECTOR REFORM

San José, Costa Rica, 3-5 December 1997

Currently, the Health Sector Reforms taking place in the countries of the Americas constitute one of Pan American Health Organization the processes with great significance for social policies, within the framework of the major economic, governmental, and social changes that are occurring in this Region. These reforms are directed towards introducing substantial changes at the different levels and in different functions of the sector to increase equality in the delivery of services, efficacy in its management, and efficiency in its actions, achieving the satisfaction of the health needs of their populations.

To respond to the Directing Council mandates and its Strategic and Program Orientations, the Pan American Health Organization (PAHO/WHO) has established the technical cooperation as an essential axis in the field of national sectoral reform processes. It adopted the concept of sustainable human development and the strategic renewal for Health for All as the framework within which to cooperate with Member States and coordinate its activities with other agencies.

Within this context, one of the issues that has been considered essential is the development of human resources. This occurred after the initial period, when issues related to health personnel were considered secondary among the major concerns for the reform processes and were considered an additional hurdle to overcome. This view is changing significantly.

The perspective that the processes, issues, and actions related to the technically qualified people (who work with health services to meet the health needs of the populations), are fundamental to the success of the sectoral reforms' changes, has been greatly enhanced. Human resources are a key reform factor. They are not only a problem to be resolved, but also an essential element in the solution of problems in this area, and the attainment of reform objectives.

1. Purpose To promote the commitment of health leaders in the Americas and bring to their attention the strategic importance of human resources development for the achievement of the objectives and the successful progress of the sectoral reform processes. 2. Objectives

a) With the participation and cooperation of all, analyze and discuss the key elements of reform and other processes, and events that determine the trends and status of Health Human Resources Development.

b) Analyze and discuss the main problems, conditions, trends, theories, and proposals for solutions that are currently present in the sector reform processes. c) Analyze and discuss the ways and means for strategic intervention, feasible and effective at national and international levels, to contribute with a human resources development that is in accordance with the requirements of the reforms and needs of the population. 3. Work Plan

Emphasizing the exchange of ideas and discussions within working groups, the meeting will be carried out based on expert presentations and panels that will provide theoretical, methodological, and operational inputs on the main agenda items for health human resources development.

The outcome from the presentations, panels, and group work will be organized in a report which will be submitted to the invited sector authorities. The objective of this document is to estimate the generation of joint agreements and projects and to improve the technical cooperation guidelines of Pan American Health Organization the Organization.

4. Program

Wednesday, 3 December

07:30- 08.30 hrs. Registration of participants

08.30 - 09:00 hrs. Opening session:

Dr. Merlín Fernández, Country Representative, OPS/OMS Costa Rica Dr. Rodrigo A. Barahona H., Coordinator HSR/HSP/OPS Dr. Daniel López-Acuña, Director HSP/OPS Dr. Aissatou Koné-Diabi, OMS Dr. Herman Weinstock, Minister of Health of Costa Rica

09:00 -09.30 hrs. General information and meeting dynamics

Dr. Rodrigo A. Barahona H.

09:30- 10:00 hrs. Presentation: Human Resources, Sectorial Reform in Latin America and Human Resources Development

Dr. Daniel López Acuña

10:00 - 10.30 hrs.

10:30 - 12:00 hrs. Round table : Context Framework: State Reforms and Human Resources Development

Coordinator: Eduardo Palma Eduardo Doryan Bernardo Kliksberg Mirta Roses Stephen Bach

12:00 - 13:00 hrs. Discussion groups

13.00 - 14.30 hrs. Lunch

14:30 - 16:00 hrs. Panel 1: Sectoral Reform, Flexibility and Human Resources Regulation

Coordinator: Augusto Meloni María Soledad Barría Gilles Dussault Félix Rígoli Pan American Health Organization Daniel Purcallas

16:00 - 16:30 hrs.

16:30 - 18:00 hrs. Discussion groups

18:00 - 19:00 hrs. Plenary session

20:00 hrs. Cocktail offerred by the Ministry of Health of Costa Rica and the President of the Caja Costarricense del Seguro Social

Thursday, 4 December

08:30 -09:00 hrs. Panel 2: Human Resources, Decentralization and Management

Coordinator: Pablo Pulido Hugo Fernandes Mauricio Vargas Ritta-Liisa Kolehmainnen-Aitken Mario Alberto Zapata Con Hnatiuk

9:30 - 10:00 hrs. Presentation: Human Resources: Critical Factor of the Health Sector Reform

Dr. Alvaro Salas (CCSS, Costa Rica)

10:00 - 10:30 hrs.

10:30 - 12.00 hrs. Discussion groups

12.00 - 13.00 hrs. Plenary session

13:00 - 14:30 hrs. Lunch

14:30 - 16:00 hrs. Panel 3: Human Resources and Changes in Health Care Models

Coordinator: Guido Miranda George Dines Mario Dal Poz Alfredo Stern Bernardo Sáenz Pedro Saturno

16:00 - 16:30 hrs. Pan American Health Organization 16:30 - 18:00 hrs. Discussion

18:00 - 19:00 hrs. Plenary session

Friday, 5 December

8:00 - 08:30 hrs. Conference: The Future of Public Health

Dr. José Rodríguez Domínguez

08:30 - 10:00 hrs. Panel 4: Professional Health Education and Practice in the Sector Reform

Coordinator: Gabriel Macaya Eduardo Touyá Alejandro Cravioto Wendy McBride Eric Goon Karen Sealey

10:00 - 10:30 hrs.

10:30 - 12:00 hrs. Discussion groups

12: 00 - 13: 00 hrs. Plenary session

13: 00 - 14:30 hrs. Lunch 14: 30 - 16:00 hrs. Panel 5: Human Resources and Technical Cooperation

Coordinator: A. Koné-Diabi Rodrigo A. Barahona H., OPS/OMS AID Gilles Dussault, BM Alfredo Solari, BID

16: 00 - 16: 30 hrs.

16:30 hrs. Plenary session

Reading of the Report of the Meeting: Baudilio Jardines Comments from the Deputy Ministers of Health

17:30 hrs. Closing session

Dr. Daniel López Acuña Dr. Herman Weinstock, Minister of Health of Costa Rica Pan American Health Organization 1. 1 Dr. Alvaro Salas, CCSS

2. 2 Dr. Daniel López-Acuña, PAHO/WHO

3. 3 Dr. Bernardo Kliksberg, IDB

4. 4 Dr. Eduardo Doryan, Minister of Education of Costa Rica.

5. 5 Dr. Stephen Bach, Warwick University, Great Britain.

6. 6 Dr. Mirta Roses, PAHO/WHO

7. 7 Dr. Eduardo Palma, UNDP

8. 8 Panel 1, coordinated by Dr. Augusto Meloni, with the participation of Drs. María S. Barría, Gilles Dussault, Félix Rígoli, and Daniel Purcallas.

9. 9 Panel 2, coordinated by Dr. Pablo Pulido, with the participation of Drs. Ritta-Liisa Kolehmainenn-Aitken, Hugo Fernandes, Mauricio Vargas, Mario Zapata, and Mr. Hnatiuk.

10. 10 Panel 3, coordinated by Dr. Guido Miranda, with the participation of Drs. George Dines, Mario Dal Poz, Alfredo Stern, Mario León, and Pedro Saturno.

11. 11 Lecture by Dr. José Rodríguez-Domínguez.

12. 12 Panel 4 coordinated by Dr. Gabriel Macaya with the participation of Drs. Wendy McBride, Eduardo Touyá, Alejandro Cravioto, and Eric Goon.

13. 13 Panel 5, coordinated by Dr. A. Koné-Diabí, with the participation of Drs. Rodrigo Barahona, Gilles Dussault, and Alfredo Solari.

14. 14 The closing session was presided over by the Minister of Health of Uruguay, Dr. José R. Bustos; other members were the Minister of Health of Costa Rica, Dr. Herman Weinstock, and Drs. Sergio Sarita, of the Dominican Republic, José Narro of Mexico, Augusto Meloni of Peru (who presented a summary of the meeting's discussions), Lana Mc Pheil of Grenada, Daniel López-Acuña, and Rodrigo Barahona of PAHO.