Strategic and Programmatic Orientations, 1999–2002

2003 Pan American Health Organization

Strategic and

Programmatic

Orientations,

1999–2002 Annual Report of the Director – 2003

We are committed to health for all, to the primary care strategy, to health promotion, and to the reduction of inequities and social exclusion.

Mirta Roses Periago Inauguration Speech as Director of PAHO

Strategic and Programmatic Orientations, 1999–2002

strategies for reducing exclusion, and support the countries in their efforts to Health improve collective insurance systems.

Systems and These activities were carried out within the framework of cooperation between PASB and the Government of Sweden Services through the Swedish Agency for Inter- national Development (SIDA) and be- Development tween PASB and the International Labor Organization (ILO). The former effort supported Latin American countries in “Public Health in their efforts to address social exclusion in health and to promote social protec- the Americas” tion strategies. Projects were carried out in Ecuador, the Dominican Republic, Initiative Guatemala, Honduras, Mexico, Para- guay, and Peru. In 2002, the main lines of work in the area of health policies and systems were In order to support a diagnosis of the the extension of social protection in exclusion situation, a research protocol health; the reorientation of sector re- was developed to define social exclusion forms; the strengthening of national in health and identify its leading causes health authorities’ capabilities to provide and characteristics. The Dominican Re- leadership and guidance; and health eco- public, Ecuador, Guatemala, and Para- nomics, financing, and regulation. Tech- guay have already completed their diag- nical cooperation aims at ensuring that noses by applying the protocol, and these processes are firmly grounded in the Honduras, Mexico (D. F.), and Peru have development, execution, and evaluation begun the process. of national health policies and objectives. Ecuador and Guatemala launched a social dialogue to create awareness of Extension of Social the problem of exclusion in health, its extent, and the need to reduce or elimi- Protection in Health nate it. This will help promote consensus The strategy for extending social pro- among social actors on the most appro- tection in health strengthens Member priate methods and mechanisms for for- States’ capabilities to expand access to mulating policy and increasing social health care through activities designed protection in health. The most impor- to generate information on the extent of tant result of the social dialogue will be exclusion to health care in the countries, the development of a concerted action increase social dialogue as a way to plan. A protocol to implement social di- reach consensus on the most appropriate alogue is being designed in support of

21 Annual Report of the Director – 2003 Pan American Health Organization

countries that have agreed to participate Strengthening the in this activity. National Health Health sector reforms designed to im- Authority’s Leadership prove collective insurance systems were supported in Ecuador and Peru. The ob- and Guidance Role jective is to strengthen the health system’s One of the most important challenges capacity to provide social protection to its in carrying out health sector reforms is citizens, regardless of their ability to pay, the need to strengthen the health author- through mechanisms aimed at the cre- ity’s leadership and guidance role. The ation and extension of protection systems health authority’s main responsibilities and the promotion of a more integrated include the performance of essential and appropriate regulatory system that public health functions, such as State’s will be of use to the entire health sector, responsibility over health at the central, and not just the public sector. intermediate, and local levels. This requires the development of tools for as- In addition, through their joint work to sessing the performance of those func- extend social protection in health, PASB tions. These tools identify strengths and and ILO have been working since 1999 weaknesses in the practice and infra- to launch a regional initiative promoting structure that support the essential func- the systematic diagnosis of exclusion in tions, thereby reinforcing the institu- health, identifying solutions, and taking tional capacity to improve public health the necessary steps to support Member operations. The Pan American Sanitary Bureau States in their efforts to minimize social worked with 41 countries and territories exclusion and strengthen institutional The health sector’s transformation re- to assess the performance of 11 essential capacity to extend health protection. The quires a clear determination of its scope public health functions. Among other proposal includes the development of and function, as well as the need to im- benefits, the assessment resulted in training methodologies and tools, re- plement the concepts on which it is improved training of the health force and search, and the exchange of successful based. To accomplish this, the Bureau better professional practices. experiences and recommendations. cooperated with 41 countries and territories to assess the performance of 11 es- One of the most important support sential public health functions. This ex- measures for these activities is the man- ercise provided the basis for evaluating date that Member States gave PASB and the national authorities’ performance in the ILO Directors in 2002, requesting exercising public health functions and that they disseminate the conceptual in developing an agenda for improving basis of exclusion in health and the means them through national and international for combating it throughout the countries cooperation. of the Region. Both institutions also were asked to work with Member States to pro- The assessment carried out within the mote social dialogue in this regard and to framework of the “Public Health in the specify the cooperation mechanisms nec- Americas” initiative yielded the follow- essary to support the process. ing immediate results:

22 Strategic and Programmatic Orientations, 1999–2002

• Public health and its essential func- access to effective and efficient health tions in the Americas were defined. services. The interest in assessing the • A framework for evaluating the per- health systems’ performance increased formance of essential public health the pressure on them to strengthen their functions applicable to all countries capacity. To this end, the initiative’s sec- of the Americas was established; it ond phase, which began in 2002, focused respected the organizational struc- on the development, redefinition, and ture of each country’s own health implementation of new tools and on the system. formulation of methodologies for sup- • Public health practice was assessed porting the countries in strengthening in each country, gauging the extent their national capacities. to which essential public health functions are performed. To monitor the progress of reforms, 33 countries participating in the initiative The assessment also yielded other re- have completed the first draft of their sults, which, in addition to strengthening health systems and services profiles; with technical cooperation in the preparation the exception of Canada, Haiti, Suri- of comprehensive development pro- name, and the United States, they also grams, encouraged cooperative activities have completed a second version. A com- among countries and among areas in dif- parative regional analysis of health sector ferent countries. Moreover, the assess- reform progress was concluded. The on- ment led to an ongoing improvement of going monitoring and evaluation process the tool, its implementation at subna- makes it possible to develop national, tional and local levels, the development subregional, and regional progress re- of an analytical framework of the fund- ports on problems identified in the health ing for essential functions, improved sector reform processes, and fosters com- training of the health workforce, and im- parative analyses and the exchange of proved professional practices. The book experiences among countries. Based on Public Health in the Americas was pub- the information obtained with the profile lished; it lays out an innovative theoret- methodology, PASB recently undertook a ical and conceptual reassessment, the second evaluation of the reforms. methodology, and the Regional results of the assessment. The initiative also produced a sectoral analysis methodology that can be used as a guide for the comprehensive and sys- Health Sector Reform tematic analysis of health sector perfor- Initiative in Latin mance and, in turn, promote a solid foundation on which to formulate health America sector reform policies and strategies. The The health sector reform initiative in methodology was successfully pilot tested Latin America is designed to support the in Costa Rica, Cuba, Guyana, Nicaragua countries’efforts to reform their health and Paraguay. As a result of these trials sectors so as to promote a more equitable and the contributions of experts, the

23 Annual Report of the Director – 2003 Pan American Health Organization

methodology is being revised and ex- Health Economics, panded. A chapter on HIV/AIDS was incorporated, underlining the urgency of Funding, and strengthening the health systems and Expenditures services to address this pandemic. Technical cooperation in health eco- An investment master plan published nomics and funding was aimed at devel- in 2002 is intended to help the countries oping the Health Accounts/National achieve consistency between investment Health Accounts (HAs/NHAs); promot- plans and sectoral reform activities. The ing analysis of the relationships among master plan encourages the mobilization health, human capital, and economic of national and international resources development; and developing tools to for activities that pave the way for measure inequalities and inequities in the achievement of the national goals. Bo- health systems. The Health Accounts/ livia, El Salvador, Guatemala, Hon- National Health Accounts are tools for duras, Nicaragua, and Paraguay formu- estimating and using economic and fi- lated master plans and tested their nancial indicators to achieve greater effi- effectiveness in mobilizing resources for ciency and equity in national health sys- sectorial reform. tem funding and expenditures.

The initiative is being disseminated Actions were undertaken to strengthen through the health sector reform infor- national capabilities for estimating and mation and analysis system, as a compo- using economic-financial indicators, nent of its Web page. This system played developing and applying methodologi- an important role, integrating the first cal guidelines for the formulation of and second phases of the initiative and internationally-comparable economic offering a dynamic mechanism for com- and financial indicators, and developing piling, organizing, and disseminating in- and maintaining PASB’s database on formation on experiences in the Region. health expenditures and funding (NHExp It includes an inventory of initiative Database). products and is being updated to include on-line access to tools and methodologies To strengthen national capabilities, di- produced by specialized institutions that rect technical cooperation was provided participate in health sector reform proces- to Aruba, Curaçao, Bolivia, Costa Rica, ses. It also includes a thesaurus on reform Ecuador, El Salvador, Honduras, Pan- that has been adapted to the changing ama, and Venezuela, and support was needs of the process, and to which a provided for the design and implementa- database developed in the Region has tion of training workshops for HA/NHA been added. Finally, an on-line database development in Costa Rica, Ecuador, and was created with information on experts Venezuela. Through the institutions that and institutions experienced in health participate in the Shared Health Agenda, sector reform. country resources were mobilized to con-

24 Strategic and Programmatic Orientations, 1999–2002

duct studies on health sector expenditures and by non-profit institutions that serve and funding in Bolivia, Chile, Colombia, households.2 Haiti, El Salvador, Guyana, Nicaragua, Paraguay, Peru, and Suriname.1 In order to formulate comparable methodologies for estimating health ex- Updated estimates of internationally- penditures that will enable the countries comparable indicators of national health to obtain precise estimates based on the expenditures (NHE)—per capita NHE, National Health Accounts System, the NHE as a percentage of gross domestic Spanish version of the proposal, “A Sys- product (GDP), and public-private com- tem of Health Accounts,” prepared by position—for 48 countries and territories the Organization for Economic Cooper- of the Region can be found in Health in ation and Development (OECD), was the Americas, 2002 edition, and in the revised in collaboration with that orga- Basic Indicators, 2002 brochure. Esti- nization and Eurostat.3 mates have been developed on expenditures for and coverage of the social pro- In regards to health, economic growth, tection programs up to 2000 and on and human capital, actions were taken public investment in health for 1970– to ensure that health figures promi- 2000 for Central American countries and nently on the development agenda. To Panama. learn more about the impact of health on the quality and improvement of the PASB’s database on health sector ex- necessary human capital to foster eco- penditures and financing (NHExp Data- nomic growth and social development base) continued to be developed and by reducing poverty and inequities, a maintained as a way to generate compa- seminar on health, human capital, and rable economic and financial indicators economic growth was held in 2002 in on national health expenditures and on Washington, D.C., This seminar, which the leading macroeconomic variables focused on theory, evidence, and poli- used in deriving such indicators. The cies, was aimed at decision makers and NHExp database covers the 1980–2001 high-level researchers; it included pre- period and contains detailed informa- sentations and discussions on factors re- tion, by country, in accordance with the lated to macroeconomic growth, which items in the United Nations System of were designed to identify the importance National Accounts. It includes estimates of this global focus for the Region in of health expenditures by the economy’s terms of future lines of work on tuber- various institutional sectors: govern- culosis, malaria, and AIDS.4 ment, including social security institutions (public sector); households (private As a way to measure inequalities and expenditure); and by other institutional inequities in the health system, compar- sectors of the economy, such as health ative studies of health system inequali- expenditures by finance companies and ties and inequities and poverty were non-financial companies (businesses) conducted in Brazil, Ecuador, Guate-

1 The reports will be available on the Pan American Health Organization’s Health Accounts/National Health Accounts web page. 2 The information is available on the Pan American Health Organization’s web page and on the specialized web page on Health Accounts/National Health Accounts of the Shared Health Agenda http://www.paho.org/. Go to 25 Health Expenditures; http://www.lachealthaccounts.org 3 The Spanish version of this document was published by the Inter-Amer- ican Development Bank (IDB) as part of the collaborative program within the framework of the Group of Health Accounts/National Health Accounts of the Shared Agenda. 4 http://www.paho.org/english/DEC/shareagenda.htm Annual Report of the Director – 2003 Pan American Health Organization

mala, Jamaica, Mexico, and Peru. These tionship with the legislatures. The role of studies showed inequitable conditions in right-to-health advocacy and defense in- the countries and pointed to the feasibil- stitutions was evaluated. The IX Course- ity of using the household survey data Workshop on Health Legislation, held in (microdata) to measure the extent of Mexico by the PASB, the Inter-American these health inequalities and inequities.5 Center for Social Security Studies The studies were carried out within the (known by its Spanish acronym, CIESS), framework of research projects designed and other academic institutions of the to measure health inequalities that have Region, which emphasized regulatory as- been funded by the World Bank, the pects of health access, deserves special United Nations Development Program, mention. and the Pan American Sanitary Bureau (EquiLAC Project). Production of the Virtual Library on Legislation also was encouraged as support for the regulatory process. This is Health Legislation a component of the Virtual Health Li- and Regulation brary (VHL) coordinated by BIREME. Argentina and Mexico incorporated in- Many countries of the Region contin- formation into the Regional VHL in a ued to promote regulatory processes for decentralized manner, while the infor- health sector reforms in order to help ex- mation for the rest of the countries is tend social protection in health and im- prepared centrally with the cooperation prove the exercise of the essential public of the Global Legal Information Net- health functions. As part of its technical work, coordinated by the United States cooperation for regulation and legisla- Library of Congress. tion, PASB supported Bolivia, Ecuador, El Salvador, Nicaragua, and Panama in their efforts to revise their national health system regulations and general Assessment of laws on health in order to replace out- dated health codes. Regulations were ap- Primary Health Care proved in Ecuador and Nicaragua and are under discussion or being addressed since Alma-Ata and in the legislatures of the remaining countries. English-speaking Caribbean coun- Its Implications tries also are acrively debating the update of basic health sector legislation. The development and strengthening of primary health care (PHC) has been a As part of the process of strengthening key concern of the Pan American Health regulatory and control capabilities in the Organization and the World Health Or- ministries of health, legal advisors of ganization in the 20th century’s last ministries and departments of health three decades. The reliance on PHC as a were trained in order to bolster their rela- development strategy was aimed at im-

5 The results of this research were published in 2001 in Investment in 26 Health: Social and Economic Returns, Scientific and Technical Publication No. 582. Strategic and Programmatic Orientations, 1999–2002

proving living conditions in the commu- their development in the spirit of self- nities, reducing the burden of disease, reliance and self-determination.” and encouraging access to health care for the population. The Alma-Ata Conference also pro- claimed that PHC “forms an integral Conceptually, PHC has been variously part both of the country’s health system, defined, which, in turn, reflects different of which it is the central function and perspectives. Despite unquestionable main focus, and of the overall social and progress in terms of defining PHC, view- economic development of the commu- points remain confused. In this respect, nity. It is the first level of contact of in- the historic importance of the Interna- dividuals, the family and community tional Conference on PHC held in Alma- with the national health system bringing Alta in 1978 should be highlighted. This health care as close as possible to where importance stems from the Conference’s people live and work, and constitutes contribution to at least two complemen- the first element of a continuing health tary dimensions: progress in the concep- care process.” tualization of PHC, and the political legitimacy of promoting its development, By 2002, 25 years after Alma-Ata’s which derives from the recommen- historic milestone, the population of the dations of said International Conference Americas had made health gains attrib- subsequent to the 30th World Health As- utable to priority PHC activities in sembly (1977). At this Assembly, WHO health education and health promotion, Member States unanimously decided food and nutrition, water supply and that their main social goal was to attain, sewerage, maternal and child care and by the year 2000, a level of health for all family planning, immunization, preven- Twenty-five years after Alma Ata’s citizens that would ensure them a so- tion and control of endemic diseases, cially and economically productive life. treatment of prevalent diseases and historic milestone, the population of The States’ committment is captured in trauma, and access to essential drugs. the Americas has made health gains, the slogan “Health for All (HFA) by the including in maternal and child care and Year 2000.” The collective experience gained with family planning. primary care has enriched the theory The PHC definition set forth in the and practice of public health, while cre- Alma-Ata Declaration became a manda- ating new challenges and priorities in tory reference in analyses of the issue. both public health policy and popu- Starting with the Alma-Ata Conference, lation health interventions designed to PHC was defined as “essential health care achieve equity in health, and so revital- based on practical, scientifically sound ize the redistributive component of HFA. and socially acceptable methods and technology made universally accessible to These advances notwithstanding, the individuals and families in the commu- Region of the Americas continues to face nity through their full participation and serious difficulties in ensuring an equi- at a cost that the community and country table access to health services for all can afford to maintain at every stage of population groups. Curative, medical-

27 Annual Report of the Director – 2003 Pan American Health Organization

specialty, and hospital-based models of ment of certain approaches to the prac- care still predominate in the Region. Poor tice of medicine and models of care quality care also is a problem, manifest- under PHC, and developing a proposal ing itself in deficiencies of the effective- to commemorate Alma-Ata’s 25th an- ness, efficiency, acceptability, legitimacy, niversary in 2003–2004. and safety of health services. Finally, community participation is limited to The current situation’s diagnosis, the sporadic consultations in many instances, conceptual and operational revitaliza- and the political and institutional frame- tion, and the identification of potential works to ensure adequate social partici- future areas of technical cooperation are pation are lacking. being carried out within a general framework set forth in PAHO/WHO’s In terms of the services themselves, position paper on the health services for much has changed worldwide and in 2004–2009 (“Documento de Posición each of the countries of the Americas de la OPS/OMS sobre Servicios de Salud since 1978. The economic, political, and para el período 2004–2009”). The most social contexts have changed, not just as significant activity in this regard is the a consequence of the national historical global project, launched by WHO in processes, but increasingly as a result of mid-2001, to review primary care. The an ever more interdependent world sub- project has three basic components— ject to extraordinarily rapid changes in specific regional reports on PHC, re- all human life dimensions. The popula- gional advisory workshops on PHC, and tions’ epidemiological patterns and de- a consolidated, global report with policy mographic profiles have changed within guidance for member countries. Despite advances, the Region of the context of a greater exposure to risks the Americas continues to face serious and the transformations of the social Preparation of the report for the Region difficulties in ensuring equitable access and economic environment. Important of the Americas was assigned to the Uni- to health services for all population changes also have occurred in the health versity of Chile’s School of Public Health. groups. Curative, medical-specialty, systems in terms of the State’s functions The study is designed to review imple- and hospital-based models of care and the higher level of responsibility cit- mentation of policies in Latin America continue to predominate. izens take for their own health care. and the Caribbean. Overall, the study en- compassed two major themes. The first Given the above, and in view of the is a systematic review of the informa- new challenges of the 21st century, the tion on the Region of the Americas and Bureau felt the need to initiate a PHC the Caribbean available from different renewal process. To this end, PASB in sources; the second involves the develop- 2002 moved forward in diagnosing the ment and implementation of a tool to current status of PHC in the Americas, gather information from significant play- establishing the bases for initiating a ers with decision-making authority from process of conceptual and operational the countries included in the terms of ref- renewal, identifying potential future erence. To this end, 209 participants areas for technical cooperation, provid- from the following 16 countries were in- ing technical assistance on PHC issues to terviewed—Argentina, the Bahamas, Bo- Member States, promoting the develop- livia, Brazil, Chile, Colombia, Costa Rica,

28 Strategic and Programmatic Orientations, 1999–2002

Cuba, the Dominican Republic, Hon- held in Brasilia, Brazil, in November duras, Jamaica, Mexico, Nicaragua, Peru, 2001. PASB identified the international Saint Lucia, and Trinidad and Tobago. participants and financed their participation; the experiences of Brazil, Costa The other component of the global Rica, Cuba, England, Mexico, New Zea- study—a Regional advisory workshop— land, Portugal, South Africa, and Spain was held in Brasilia, Brazil, in November were reviewed. 2001, and brought together 43 representatives from 16 countries of the The second event, the VIII International Americas. The workshop helped identify Seminar on PHC and III Congress of the challenges to PHC in the Americas and International Confederation of Family potential areas and strategies for PASB Medicine in the Region: Central America technical cooperation in this area. and the Caribbean, was held in Havana, Cuba, in June 2002. At this seminar, the Also noteworthy was the publication, in Bureau identified and provided funding October 2002, of Primary Health Care for participants in two special sessions— in the Americas: Conceptual Framework, one on the results and future impact of Experiences, Challenges and Perspec- the I Ibero-American Summit of Family tives, a study prepared by the University Medicine, and the second on innovative of Illinois School of Nursing in Chicago, PHC experiences in Latin America, which Illinois, United States. examined the experiences of Brazil, Mex- ico, and the Autonomous Community of With respect to promoting the devel- Andalusia, Spain. opment of certain approaches to medical and health care practice models within In a similar activity, PASB supported a the framework of PHC, support was round table to discuss practical experi- provided for the I Ibero-American Sum- ences with PHC at the Fourth Congress mit of Family Medicine, held in Seville, of Municipal Secretaries of Health of the Spain, in May 2002. The Summit issued Americas, held in Rosario, Argentina, in the Seville Declaration and produced November 2002. PASB contributed to four technical documents on health sys- identify and provide funding for partic- tems and the demands and needs of the ipants from Brazil, Cuba, and Mexico. population, quality of care, undergraduate training, and postgraduate training In terms of technical consultations, in in family medicine. December 2002, a delegation from the Bureau participated in a workshop on Regarding technical consultations with implementing PHC strategies organized Member States for PHC, PASB supported in Montevideo by Uruguay’s Ministry of two international seminars at which Public Health. global and Regional trends in PHC were explored and challenges to PHC in the Finally, PASB developed a proposal 21st century were discussed. The first, for commemorating Alma-Ata’s 25th the II International Seminar on Experi- anniversary in 2003 and 2004. The pro- ences in Basic Care/Family Health, was posal includes the conceptual revitaliza-

29 Annual Report of the Director – 2003 Pan American Health Organization

tion of PHC through a joint participa- cation, health, and labor sectors and tory process with the member countries, their respective institutions. More than the adoption of a Resolution on PHC by 15 Central American municipalities are PAHO’s Directing Council meeting in covered, and more than 300 persons September 2003, commemorative meet- from these countries’ most affected areas ings in the member countries, and the attended 20 workshops. Workshops dealt formulation of a Regional Declaration with such issues as awareness of disabil- on PHC in September 2004. ities, CBR planning, and clinical skills for underserved communities. Three regional workshops also were carried out, Community-based addressing such topics as patient care for persons with physical, sensory, and men- Rehabilitation and tal disabilities. When the project’s first year came to a close in 2000, a more sus- Rights of the tainable model—“training of trainers”— was developed, and it has been used Disabled since. This approach allowed project resources to be better utilized to develop El Salvador, Honduras, and Nicaragua skills and knowledge among nationals, developed community-based rehabilita- who then could teach others about tion (CBR) strategies involving the edu- community-based rehabilitation.

CENTRAL AMERICA Cares for Land Mine Survivors PASB has been working with the Canadian International Development Agency’s (CIDA) Mine Ac- tion Unit and the Government of Mexico since 1999 to assist disabled persons, including land mine victims, in El Salvador, Honduras, and Nicaragua. CIDA provided substantial funds for the project, which will end in 2003. The initiative relied on a four-pronged effort to address the physical, social, and economic problems of land mine victims and persons otherwise disabled—integrating community-based rehabilitation into primary health care programs; developing a disability information system; promoting the reintegration of the disabled into their communities’ economic life; and improving access to training for personnel who provide prosthetic and orthotic devices. In order to tailor the response to each country’s needs, project activities were set during an annual planning meeting held in each country. Ministries of health, of education, of labor, and of social security, as well as NGO representatives and disabled persons participated in these meetings. Each country identified demonstration sites where most land mine accidents had occurred and where the needs of land mine victims and other persons with disabilities could be met. Regional activities also were carried out so that resources could best benefit land mine survivors in Central America. Dem- onstration sites included Santa Ana and Chalatenango in El Salvador; Tojes, Aluca, and Danlí in the Region of El Paraíso, as well as work in the regions of San Marcos de Colón, Choluteca, and Valle in Honduras; and Nueva Segovia, Estelí, Madriz, Jinotega, Matagalpa, and León in Nicaragua.

30 Strategic and Programmatic Orientations, 1999–2002

A seminar about the initiative was Socioeconomic held to consolidate and systematize the experiences gained through CBR train- Reintegration ing, and use them as part of an ongoing Noteworthy activities carried out as part overall effort to promote community of this component included workshops development. designed to create awareness among managers and employers’ organizations of the problems posed by disabilities. Workshops emphasized community-based efforts aimed at finding employment for persons with disabilities, as well as the Rehabilitation disabled’s overall socioeconomic reincor- poration in society. In all three countries, Information System the ministry of labor has been enlisted to A disability information system coordinate and actively participate in (SIEDIS, from its acronym in Spanish) these efforts. In addition, the United Na- was developed to design and tailor pro- tions Standard Rules on the Equalization grams and services so as to effectively of Opportunities for Persons with Disabil- address the needs of disabled persons; it ities has been adopted as law in some of will be eventually included in regular the countries. By providing training and health information systems. This tool is financing microenterprises, the project used to profile the changing demo- also helped to promote vocational oppor- graphic patterns of disability causes, tunities so that disabled individuals and identify the distribution and nature of their families could compete in the open facilities needed, and define appropriate labor market, facilitating their socioeco- intervention programs and plans. Sev- nomic reintegration into the community. eral training workshops were provided to health officials and technicians regarding Activities conducted under the pro- data analysis, system design, and how to ject’s socioeconomic reintegration com- tailor the software to local needs. To ponent were varied. Situational and di- date, El Salvador is using the informa- agnostic needs assessments for persons tion system in all the centers of the Sal- with disabilities were conducted in sev- vadorian Institute for Integral Rehabili- eral departments and municipalities in tation and at the Ministry of Health’s each of the three countries; a workshop statistical unit; Honduras is using the designed to provide training and in- system at the rehabilitation services in crease awareness about accessibility, San Felipe Hospital and in the Ministry employment skills, and adaptations for of Social Security; and Nicaragua has disabled persons was offered to employ- finished installing the system in eight ers and persons with disabilities; six heath centers across the country (Nueva workshops for microenterprises carried Segovia, Estelí, Madriz, Jinotega, Mata- out in El Salvador were designed to as- galpa, Granada, Chinandega and Leon). sist persons wishing to expand existing

31 Annual Report of the Director – 2003 Pan American Health Organization

initiatives and to develop skills in business plan development and marketing Virtual Campus of strategies; and a municipal strategic plan was developed in Honduras in col- Public Health and laboration with community leaders to develop short and long-term plans to the Development of look at appropriate solutions for the socio-economic reintegration of persons the Public Health with disabilities, especially those affected by land mines. Workforce

The following are highlights of accom- The Virtual Campus of Public Health plishments of the project to assist land- project is especially important because mine victims. Strategies were developed of its potential for developing human re- for the inclusion of all persons with dis- sources for the services and strengthen- abilities. Activities to this end included ing the public health institutions. Ad- workshops on community infrastructure vances in 2002 made it possible to designed to lead to barrier-free environ- launch the virtual campus in the first ments, which were held in collaboration quarter of 2003. The virtual campus’s with community and municipal leaders, basic objective is to develop human re- engineers, architects, NGOs, and univer- sources in public health, and its aim is sity representatives. Coordination was to “bring knowledge to practice.” The established at the international and na- campus will provide access to infor- tional levels to promote cooperation and mation on critical issues related to re- mobilize resources, as well as to avoid form, management, and essential public duplication of efforts. National coordi- health functions, and will offer Inter- nating committees were formed to ensure net courses developed or selected be- that all government sectors—legislatures cause they can respond to public health and ministries of health, of labor, of training needs in the countries of the education, and of social affairs—as well Region. as NGOs and representatives of associations of and advocating for persons with Directed by PASB, the campus was disabilities. Victims assistance activities conceived as a collaborative project or- were incorporated into existing national ganized as a consortium of 14 presti- rehabilitation plans, so that programs gious public health and virtual edu- would include elements needed for the cation institutions in Latin America, prevention and treatment of disabilities. Spain, and the United States. An advi- A joint project with the Polus Center for sory board composed by representatives Social and Economic Development, Inc. of health sector employers, promotes an proposed a project to make the city of active exchange of service proposals of- Leon, Nicaragua, more accessible to peo- fered by the campus and identifies train- ple with physical disabilities. ing needs.

32 Strategic and Programmatic Orientations, 1999–2002

The campus’s teaching model is geared information on the health sector’s labor toward adult education, whereby the situation. participant plays a leading role and the teacher assumes the role of facilitator. An international seminar brought to- The model entails development of an at- gether representatives from several mosphere conducive to active learning, countries to discuss the institutional with the availability of a set of teaching strengthening of human resources policy resources, reference material, tutorials, units. In support of this process, 36 ex- and exchanges. perts from 13 countries participated in a cooperative study to discover the leading As a consequence of health sector re- future trends and problems that will form processes, the scope of work in the face human resources development in health field and the development of the Region. human resources have considerably increased. Although consensus on the im- The findings of the national working portance of human capital for the oper- groups of the Observatory of Human ation of health systems has grown, there Resources Network led to support for are still challenges in terms of formulat- the review and discussion of statutes ing consistent human resources policies governing careers in the sector, both and satisfactory management models. those exclusively related to the medical Moreover, strengthening the public profession and those related to workers health capability of the national health in general. Discussion of health profes- authorities requires the urgent develop- sionals’ sphere of activity introduces a ment of human resources in this field. new vision of the regulation of profes- During 2002, PASB targeted human re- sional practice and of the role of the sources policy, regulation and manage- State and professional associations. ment of human resources, and development of the public health workforce. The decentralization of human resources management has made it increas- Many of the Region’s countries began ingly necessary for decision makers at to formulate policies and plans for cor- peripheral levels of the system to have recting human resource imbalances af- adequate tools. Methodologies for deter- fecting the health services. Seventeen mining workloads in the services and im- countries have already joined the Obser- proving the ability to forecast and make vatory of Human Resources Network and decisions about needs and staffing in hos- a cooperation initiative with Canada has pitals and care systems are under devel- been designed to extend these processes opment. In addition, an Internet distance to the English-speaking Caribbean coun- learning program on human resources tries. Through a work agreement with management for decentralized units has ILO’s Labor Information and Analysis been finalized. It is available in Spanish, System, the countries will be able to use English, and Portuguese through the Vir- statistical census data to obtain detailed tual Campus of Public Health.

33 Annual Report of the Director – 2003 Pan American Health Organization

The evaluation of the performance of port of the Andalusia School of Public essential public health functions, carried Health (Spain). out within the framework of the “Public Health in the Americas” initiative, high- A primary concern regarding the lighted the limited development of pub- strengthening of the health authorities’ lic health human resources in the Re- capacity is their interface with family gion’s countries. This is a matter of some and community care services. Given the urgency, in light of the importance of interest in health care models based on human resources in the public health primary care, community orientation of systems and in the performance of es- undergraduate training programs in sential functions. clinical sciences and the development of concentrations in family and community While it is recognized that the coun- health were encouraged. tries of the Region invest considerable resources in educational interventions to The globalization and Regional inte- improve the performance of health ser- gration processes highlight the interna- vices and programs, little is known tional dimensions of the determining about the efficiency and effect of those factors for health and the exercise of es- interventions because there is no evalu- sential public health functions by the ation framework. Based on the results of national health authorities. PASB stud- a study of 15 projects involving the ied in depth the competence required for training of health services personnel in 8 an appropriate interpretation of the com- countries of the Region, the Bureau en- plex relationships among local, national, couraged the incorporation of evalua- and global levels in health and for gener- tion modules into the training processes. ating the ability to provide leadership in international cooperation. PASB cooperated fully with the Latin American and Caribbean Association of Public Health Education to design a joint initiative for developing the work- Drug Observatory force and improving of the quality of public health education. In response to of the Americas the desire to strengthen the performance of essential public health functions set The Drug Observatory is a component forth at the Special Meeting of the of the Shared Health Agenda’s action Health Sector of Central America and plan for drugs, which the Organization the Dominican Republic (known by its signed with the World Bank and the Spanish acronym, RESSCAD), held in Inter-American Development Bank. In the Dominican Republic in 2002, the addition, the Catalán Institute of Phar- Central American and Caribbean Net- macology, a WHO collaborating center work of Academic Institutions for the for research and training in phar- Development of Essential Public Health macoepidemiology; the United States Functions was established with the sup- Agency for International Development

34 Strategic and Programmatic Orientations, 1999–2002

BRAZIL’s National Drug Policy Takes A Leap Forward Brazil’s drug policy, approved in 1998, encompasses eight basic principles: adoption of a national list of essential drugs; sanitary regulation of drugs; rearrangement of pharmaceutical care; promotion of the rational use of drugs; scientific and technological development; promotion of drug production; guarantee of the safety, efficacy, and quality of drugs; and development and training of human resources. Two 1999 legislative decisions were crucial to the subsequent achievements: the creation of the Brazilian Sanitary Surveillance Agency (ANVISA) and the passage of the Generic Drug Law. Significant progress was made in 2002 in the implementation of the policy. Advances had the full support of PAHO and the Pharmaceutical Care Center of the Oswaldo Cruz Foundation’s National School of Public Health. The last one is a PAHO/WHO collaborating center on pharmaceutical policy. The following achievements are noteworthy:

• Brazil took the lead in the international struggle to ensure that the United Nations would consider access to drugs a basic human right and that a 2001 meeting of the World Trade Organization would issue a declaration on intellectual property rights and public health. These efforts have resulted in a larger supply of generic products and a price reduction which, in turn, has increased the population’s access to drugs. • Generic products were conceived as a strategy to enhance access to and the rational use of drugs; these products were quickly accepted by the people, thanks to an intensive information campaign. According to a study conducted in November 2001, 95% of the population was aware of generic drugs and 80% believed they had the same effect as brand name products.

In February 2000, ANVISA approved the registration for the marketing of the first generic drug; by February 2003, 37 pharmaceutical companies were producing generic drugs and 751 drugs with 226 active ingredients in 52 therapeutic classes had been registered. The introduction of generic products helped control the market and lower the prices of similar and innovative drugs. In fact, in Brazil, generic products are 45% cheaper than the innovative products, which in turn results in a significant decrease in the cost of treating diseases, especially chronic diseases. Moreover, this process, which receives support from the national and multinational industry, has strengthened Brazil’s technological capability to carry out the clinical bioequivalence studies necessary for approval of these products. At this time there are 27 centers authorized by ANVISA to conduct these tests.

35 Annual Report of the Director – 2003 Pan American Health Organization

(USAID); Management Sciences for Other components of the Drug Obser- Health (MSH); the Brazilian National vatory are thematic blocks or informa- School of Public Health-FIOCRUZ; the tion bases and data on the main aspects United States Pharmacopoeia (USP); the of the sector in each country. The six Institute of Health Foundation in Ar- thematic blocks that have been defined gentina (ISALUD); the Center for Stud- deal with the drug market, delivery of ies in Health, Economics, and Social Pol- drugs, pharmaceutical regulation, eco- icy (SOIKOS) in Spain; and Ohio State nomic regulation, the use of drugs, and University in the United States partici- drug prices. The Web page is expected to pate in its design and development. be launched in late 2003.

In 2002, funds were allocated for the development of the Observatory’s operating system, which will consist of a Pan American databanks source with selective information on drugs. A key component of Conference on the Observatory is a profile of each country’s pharmaceutical sector, which Drug Regulatory includes information on the drug market; national drug policy; drug legisla- Harmonization tion and regulations; quality control; the safety and efficacy of pharmaceutical The Pan American Conferences on products; the distribution, supply, fund- Drug Regulatory Harmonization are con- ing, and prices of drugs; access to essen- tinental forums held every two years to As part of the Drug Observatory of the tial drugs; and the rational production support the drug regulatory harmo- Americas, information databases have and use of drugs. nization processes within economic inte- been developed on the market for drugs, gration groups in the Americas. These delivery of drugs, pharmaceutical The Observatory will include informa- conferences ensure that constructive dia- regulation, economic regulation, use of tion about this pharmaceutical profile, logue takes place between drug regula- drugs, and drug pricing. which governments can use to monitor tory authorities and groups concerned their economic and health policies, rein- with drug regulation, and that harmo- force the pharmaceutical components, nized guidelines and proposals regarding prioritize strategies, clarify responsibili- specific aspects of regulation are adopted ties, and evaluate achievements. Inter- and technical cooperation among coun- national organizations and sponsors also tries is promoted. will benefit, as they will be able to focus on priority areas that require support The III Conference was held in April and to determine where the resources in- 2002, with the participation of drug vested will have the greatest effect. regulatory authorities from the member Other beneficiaries will be professional countries, representatives of economic groups and nongovernmental organiza- integration organizations such as CARI- tions, which will be able to direct their COM, MERCOSUR, NAFTA, ALADI, support and information campaigns. and the Andean Community of Nations,

36 Strategic and Programmatic Orientations, 1999–2002

HEALTH CANADA Helps to Fight Antimicrobial Resistance in Latin America and the Caribbean Since 1996, Health Canada’s National Laboratory for Enteric Pathogens (NLEP) has been working with the Pan American Health Organization (PAHO) and 20 Latin American and Caribbean countries on a laboratory-based surveillance project to study antimicrobial resistance associated with enteric pathogens in the Region. The project has looked at the occurrence and significance of antimicrobial resistance, and worked to develop an effective prevention and control program against three major groups of enteric pathogens that cause diarrheal disease C salmonella, shigella and vib- rio cholera. The project includes a laboratory component with workshops to introduce participating countries to the standard methodology used for identifying, serotyping and conducting antimicrobial suscep- tibility testing; a proficiency and quality control program for the exchange of strains of enteric pathogens between NLEP and participating countries; a mechanism for sharing methods for data collection, verification and dissemination; site visits by NLEPB/PAHO teams to help enhance laboratory capacity and surveillance capabilities for enteric diseases; and annual meetings to exchange information. In 2002, NLEP’s major activities included:

• an annual meeting held in Santa Cruz, Bolivia, to exchange information among participating countries; • support for the participation of 20 countries (21 laboratories) in the Proficiency and Quality Assurance Program; • a site visit to Paraguay that included an evaluation of capabilities of the reference laboratory, various regional laboratories, and various hospitals within the country’s health net; and • quality control testing of various antisera from production centers in South America and Mexico. as well as representatives of the pharma- tion groups in the Americas: Mexico ceutical industry, consumer groups, (NAFTA), Guatemala (Central America), academia, and regional professional Colombia (Andean Area), Brazil (MER- associations. COSUR), and Jamaica (Caribbean). It also includes a representative from the During the conference, rules and regu- Latin American Association of Pharma- lations governing operations of the Pan ceutical Industries and a representative American Network for Drug Regulatory from the Pharmaceutical Industry Feder- Harmonization were updated and an ex- ation. Drug regulatory authorities from ecutive committee was designated. The Argentina, Bolivia, Costa Rica, Trinidad committee is composed by five drug reg- and Tobago, and the United States func- ulatory authorities, one from each coun- tion as alternate members of the net- try representing the different integra- work’s executive committee. The confer-

37 Annual Report of the Director – 2003 Pan American Health Organization

ence approved criteria for prioritizing national courses in 18 Latin American bioequivalence studies, which include a countries. All these activities enjoyed the preliminary list of drugs required in those collaboration of college professors from studies. In the area of clinical research, Colombia, Costa Rica, Mexico, and Ve- guidelines for the establishment and op- nezuela. Some 571 professionals from eration of an ethics committee and guide- government sectors (inspectors of good lines for preparing requirements for in- manufacturing practices), the education formed consent were approved. The sector, and the private sector (pharma- conference also reported on the status of ceutical industry) received refresher the project for pre-qualification of prod- training. ucts that WHO is jointly promoting with UNICEF, USAID, and the World Bank. This project, which in its first phase is focusing on antiretroviral products, will Blood Safety later be extended to cover tuberculosis and malaria drugs. Safe blood remains as a critical issue in the Americas. Although blood collec- Also addressed at the conference was tion and screening has improved, better the struggle against counterfeit drugs. quality control is still needed to achieve To this end, results obtained by the Gov- universal access to safe blood. ernment of Colombia were presented, as were those from the external quality The emergence of AIDS in the 1980s control program being conducted in col- and the fact that HIV can be transmit- laboration with the United States Phar- ted through blood transfusions helped macopeia, and in which the official drug raise concern for risks associated with quality control laboratories of PAHO/ unsafe blood transfusions. Today, it also WHO member countries participate. is clear that other infectious diseases such as hepatitis B and C and Chagas’ The implementation of good manufac- disease can be transmitted through turing practices that ensure the quality of blood. In addition to conventional drugs is a priority in support of the screening, work is under way to make agreements among countries in terms of testing more specific. their harmonization and free trade processes. This priority was assumed by All the Region’s countries, except Cuba, the Pan American Network for Drug are experiencing blood shortages for Regulatory Harmonization and, between transfusions. According to WHO and the April 2001 and September 2002, a broad International Federation of Red Cross plan of educational activities was imple- and Red Crescent Societies, a country or mented. It included two regional semi- a community must have enough blood so nars supported by the United States Food that 5% of its population has an ade- and Drug Administration (FDA) and the quate blood supply. Only Cuba meets this University of Puerto Rico, a subregional requirement; other countries only have seminar for Caribbean countries, and enough blood to cover 1%.

38 Strategic and Programmatic Orientations, 1999–2002

Through its support of national blood for a safe blood supply is that donations programs in Latin America and national be from volunteers—the patient’s family blood banks in the Caribbean, PASB has and friends—rather than remunerated helped to improve blood safety in the Re- or replacement donors. Volunteer dona- gion. PASB technical cooperation was tions are linked directly with another based on agreements reached by consen- major problem facing the Region: the sus with coordinators of the national pro- blood shortage. PASB’s technical coop- grams or directors of the blood banks, eration has been emphatic about pro- during subregional meetings; agreements cessing blood to guarantee it is screened were followed up with discussions with properly. PASB’s technical partners. Activities aimed at improving the safety of blood PASB, in collaboration with a group of for transfusions; they were funded with anthropologists, has developed method- contributions from the Government of ological guidelines to explore the knowl- Spain, the Pan American Health and Ed- edge, attitudes, and practices of the gen- ucation Foundation (PAHEF), and the eral public regarding blood banks and Bill and Melinda Gates Foundation, were those who work in them. This research carried out with the collaboration of in- aims to gain an understanding of the stitutions and experts from Latin Amer- factors that encourage and discourage ica, the Caribbean, Europe, and the voluntary blood donation. United States. The most recent Three- year Regional Action Plan was presented PASB’s work intends to improve the to the Bill and Melinda Gates Foundation safety of blood bank services throughout and received funding for the 2000–2003 the Hemisphere and meet the targets set period. by the Region’s ministers of health— screening of all blood and ensuring that With the support of a US$ 4.9 million all blood banks participate in quality donation from the Bill and Melinda control programs. Activities carried out Activities carried out as part of the Gates Foundation, PASB launched a as part of the blood safety initiative have blood safety initiative have improved “Regional Blood Safety Initiative,” improved the coverage and quality of the coverage and quality of screening aimed at improving the quality of blood screening by blood banks. by blood banks. for transfusion in the Americas. It em- phasizes the promotion of voluntary With the participation of national blood blood donation and the complete screen- program coordinators and national blood ing of donated blood. This is especially bank directors, the factors that determine important in the Americas, where only a the need for blood for transfusions were small number of the Region’s countries analyzed at the Pan American Confer- and territories obtain blood for transfu- ence on Safe Blood. National blood re- sion from voluntary, unpaid donors. The quirements are determined by morbidity initiative envisions that all units of blood and mortality patterns, the coverage of in every country in the Americas will the health systems, and the level of tech- be screened for HIV, hepatitis B and C, nological development of medicine. In syphilis, and Chagas’ disease by the end addition, conference participants ana- of 2003. One of the main requirements lyzed the leading blood safety considera-

39 Annual Report of the Director – 2003 Pan American Health Organization

tions, such as the epidemiology of the in- fice of the United Nations High Commis- fections transmitted by transfusion, and sioner for Human Rights, and the United discussed the quality of serologic analy- Nations Children’s Fund all have adopted ses and of blood typing and grouping was the system based on the Humanitarian discussed. These discussions served as a Supply Management System (SUMA). basis for analyzing the functional aspects The importance of this system also has of the blood banks in the Region: the been increasingly recognized by several legal basis, national coordination, finan- countries outside the Region. cial matters, and PASB’s response. Also, the Canadian and Spanish experiences PASB is the Inter-American system were presented as examples of new ap- representative at the global task force for proaches to improving the efficiency of the International Strategy for Disaster blood services. The potential contribu- Reduction. The Bureau also participates tion of the Red Cross, Rotary Clubs, and in the elaboration of the Inter-American certain religious groups also was ana- Strategy Plan for risk management and lyzed. Finally, the technical areas, strate- disaster response, which will be endorsed gies, and regional activities for 2004– by the OAS member states. PASB pre- 2006 were discussed. pared most of the text for the chapters on health and potable water in ECLAC’s manual for socioeconomic impact assessment, which was finished in 2002. The Disaster long-standing relationship with the In- ternational Federation of Red Cross and Preparedness Red Crescent Societies was formalized in 2002, through a memorandum of under- and Disaster standing that includes disaster preparedness as one of the four main topics. This Management agreement has strengthened cooperation among ministries of health, national Red Cross Societies, and PAHO/WHO Coun- Incorporating Disaster try Offices in the implementation of their Management into PASB’s joint action plan. Technical Cooperation PASB has made considerable progress Institutional in mainstreaming disaster management Development over the past few years. To that end, the Bureau has worked closely with interna- in the Countries tional counterparts in disaster prepared- Working to establish a disaster pro- ness and mitigation. WHO, the United gram within the ministries of health has Nations World Food Program, the United been a PASB programmatic strategy for Nations Office for the Coordination of some time. The strength of these pro- Humanitarian Affairs (OCHA), the Of- grams and the political influence they

40 Strategic and Programmatic Orientations, 1999–2002

wield has changed due to external fac- opment in disaster management. PASB tors beyond the control of PASB. An im- has strongly supported subregional portant task of PASB’s subregional dis- organizations such as the Caribbean aster advisors has been to monitor the Disaster Emergency Response Agency functioning of these programs and tar- (CDERA) and the Coordination Center get support to where it is most needed. for the Prevention of Natural Disasters Recently, there has been a resurgence of in Central America (CEPREDENAC); it interest in strengthening national disas- also has played an important role in cre- ter programs within ministries of health. ating networks and bringing stakehold- This is particularly true in Bolivia, ers together. Colombia, Ecuador, and Peru, where these programs are exercising leadership A Central American contingency plan and acting as advisers to the highest- was developed with CEPREDENAC to level health authorities. In some cases, provide guidance for ministries of for- they handle substantial resources, and eign affairs and missions abroad in case their reach extends beyond the central of disasters. The plan was tested during level to the municipalities, which gives an exercise conducted by Humanitarian them added capacity to respond to real Allied Forces, FAHUM 2002, and coor- post-disaster needs. In Ecuador, the Na- dination problems at the national level tional Disaster Health Council (known and among countries were identified. as CONASE, from its Spanish acronym) CEPREDENAC agreed to take the lead was reactivated and given responsibility in incorporating the necessary changes for emergency planning for the El Niño; into the plan. in Bolivia, the Ministry’s disaster office managed recent emergencies. PASB’s A memorandum of understanding also focus on developing institutional capac- exists between PASB and the United Na- ity can be credited for the positive re- tions World Food Program (WFP), al- sults of these disaster programs. lowing WFP to use the Bureau’s institutional capacities in areas where the PASB’s disaster-preparedness work has former has no assets. The agreement reached beyond the health sector to in- was tested for the first time during sim- clude other government sectors, national ulation exercises—interagency coopera- and subregional disaster systems, civil tion was found to be excellent, with defense organizations, the Red Cross, WFP effectively using PASB facilities in NGOs, and academia. Major actors in the the Caribbean to deliver assistance to Region have acknowledged the Bureau’s five affected countries. leadership in strengthening disaster preparedness and response. In Guatemala, PASB has helped to enhance the Ministry of Health’s capa- Through its active participation in a bilities in disaster management, by pro- range of regional forums, PASB has viding technical support in such areas helped to increase knowledge about and as health-sector preparedness, emergency improve programming and policy devel- planning, mitigation, and supply man-

41 Annual Report of the Director – 2003 Pan American Health Organization

agement. As a result, the Ministry estab- changes, project participants are now lished a new risk management unit sharing their experience with other mu- staffed with seven full-time officers, in- nicipalities in Nicaragua and with neigh- corporated other divisions into disaster boring countries. prevention, used SUMA in its central warehouse, and set up an early warning In Saint Lucia, PASB has had a sig- system in health centers. The Ministry nificant impact in promoting mitigation also prepared a national health disaster within the health sector through training plan, and developed 11 hospital emer- courses, subregional meetings, and tech- gency plans in collaboration with lo- nical materials. The country’s Ministry cal staff. The emergency plans were suc- of Health is now strongly committed to cessfully implemented during a recent mitigation, and has convinced the Min- dengue epidemic. The health disaster istry of Finance and donors such as the network has been so effective that the European Union of the need for incorpo- Ministry of Health uses it to deliver other rating mitigation in new structures and programs as well. retrofitting existing ones. The Ministry of Health has conducted a vulnerability as- In Nicaragua, through a project sessment of Saint Lucia’s 4 hospitals and funded by the Latin American Depart- 35 health centers, and has allocated ment of the United Kingdom’s Depart- 30% of its maintenance budget to retro- ment of International Development, the fit at least two facilities per year. To date, municipality of Moyogalpa formed a 80% of health facilities have an emer- municipal disaster committee, which gency water supply, compared to only prepared a health emergency plan and 25% five years ago. A PASB expert will developed a methodological guide for help incorporate mitigation in the design local health-sector preparedness. Munic- and construction of a new hospital and ipal health officials were trained in how mental health facility. The Bureau also to use SUMA in their warehouse, and has provided technical support and local health centers were equipped to booklets for a European Union project to serve as emergency shelters. Project repair and retrofit nearly 200 vulnerable participants developed teacher training homes of elderly people. materials, then incorporated disaster preparedness into the curriculum for Moyogalpa’s 3,000 students. Increased Bioterrorism public awareness about health-sector preparedness motivated the municipal Preparedness government to integrate disaster man- The risk that a Latin American or agement into their municipal by-laws, Caribbean country could be the target of development plans, and annual budgets. an international terrorist act, though The project improved cooperation among slight, is possible. Consequently, coun- the municipal government, the local tries in the Americas have identified the health department, and community lead- need to improve the capacity of their ers. Through training workshops and ex- health services to prepare for and re-

42 Strategic and Programmatic Orientations, 1999–2002

spond to potential emergencies resulting requests for assistance in helping prepare from biological, chemical, or radiologi- for and responding to BCR. At the end of cal (BCR) terrorism. Because the impact 2001, PASB convened an advisory meet- of biological terrorism can rapidly cross ing on bioterrorism, at which experts borders, timely detection and response from several countries outlined potential in any country is of paramount impor- scenarios and issued recommendations tance for the Region as a whole. to strengthen the countries’ capacity to cope with bioterrorism. Meeting results It is important to place the threat of were disseminated throughout 2002. In bioterrorism in the context of the Amer- addition, the principles for managing the icas, however. Each year, respiratory in- health consequences of BCR terrorism fections, diarrheal diseases, and a host were presented and discussed in the an- of other preventable illnesses claim a far nual meeting of the PAHO/WHO Coun- greater toll than is likely to occur from a try Representatives and Center Directors. biological, chemical, or radiological ter- A newly created bioterrorism working rorist act. Therefore, developing the ca- group is chaired by PAHO’s Director. pacity of the health sector to address any sudden epidemic outbreak or the release The curriculum of several training of hazardous substances, regardless of events was modified to reflect the con- the cause, is the most effective public cern over BCR terrorism, and the health health investment to prepare for acts of consequences of acts of biological, chem- terrorism. Countries should take steps to ical, and radiological terrorism were in- enhance their ability to detect, identify, troduced into the training of disaster investigate and respond rapidly to re- focal points in PAHO/WHO Country Of- ports of emerging infectious diseases as fices in Latin America. Similar training part of their usual programs. This may was provided to national disaster man- include establishment of rapid response agement officers within ministries of the teams, strengthening of laboratory net- health in the Region. Bibliographic ma- works, expeditious epidemiological sur- terial regarding deliberate use of biologi- veillance, inter-sectoral coordination cal, chemical, or radiological agents are and public health awareness for priority now available in CD-Rom, and WHO purposes that will be useful also for prepared guidelines on the public health bioterrorism. response to biological and chemical weapons. PASB began a broad consultation with Member Countries in order to respond to

43 Annual Report of the Director – 2003 Pan American Health Organization

Region, in the Southern Cone, and in Disease Central America. Networks aim at sharing information Prevention on a timely basis, strengthening ties between laboratories and epidemiological services, and applying common proto- and Control cols for specific diseases and syndromes using standard laboratory procedures. With the support of the United States Communicable Centers for Disease Control and Preven- tion (CDC), the Malbrán Institute in Ar- Diseases gentina, and the Evandro Chagas Insti- tute in Brazil, work has gone forward in Development of training, consulting, technology transfer, supply of reagents, and development of Surveillance Networks treatment guides. A meeting with repre- for Emerging and sentatives from the three networks, held in Atlanta, Georgia (U.S.A.), in 2002, Reemerging Diseases provided a key forum for exchanging ex- Acute communicable diseases have a periences on progress achieved and ob- high potential for spreading among the stacles encountered, and for identifying countries due to major population shifts, future cooperation needs. especially along border areas; commercial food trade; deficient health services; A subregional meeting held in San a persistently high level of poverty in Salvador, El Salvador, in 2001, exam- some countries; and frequent natural ined each country’s and the subregion’s disasters. Given these factors, the public current capabilities to respond to emer- health services’ capability to quickly rec- gencies caused by epidemics of emerging ognize and respond to these outbreaks or and reemerging diseases and to draw up epidemics caused by multiple agents is a action plans to strengthen those capabil- growing challenge. ities. The Central American Network for the Prevention and Control of Emerging For many years, the countries have ac- and Reemerging Diseases (known by its knowledged the need to set up warning Spanish acronym, RECACER) was cre- and rapid-response systems for commu- ated, and the duties of its general coor- nicable diseases with high epidemic dinating committee were established. potential, and important efforts have RECACER operates under the guide- been made to strengthen national capa- lines and mandates of the health policy bilities in this regard. Currently, three and technical coordination forums and subregional networks for the control of mechanisms of the Meeting of the emerging and reemerging infectious dis- Health Sector of Central America and eases are in operation—in the Amazon the Dominican Republic (RESSCAD)

44 Strategic and Programmatic Orientations, 1999–2002

and the Council of Central American pability for surveillance of emerging and Health Ministers (COMISCA). reemerging diseases.

The coordinating committee held two Biosafety standards were disseminated; meetings in 2002: the first, in February, guidelines were established for the oper- in San José, Costa Rica, and the second ation of containment laboratories to en- in November in San Salvador, El Sal- sure the risk-free processing of samples vador. In July 2002, a listserv was es- related to agents that pose a high risk tablished for RECACER members. It to human, animal, and environmental was subsequently incorporated into the health; and, after training technical per- electronic platform of INFOCOM, the sonnel, a manual was developed for the system of Information and Communica- use, disinfection, and maintenance of tion in Health for Central America, a biosafety enclosures. Within the frame- fast and secure communication mecha- work of implementing a unified informa- nism that enables the countries to ex- tion system on the net for public health change data, information, documents, laboratories in Central America that and technical standards. Joint actions would be compatible with the national were taken to control dengue in border systems, in collaboration with the Walter areas, and the guide for drawing up a Reed Research Institute of the United subregional plan on dengue prevention States Army, modules were designed and control was completed and submit- for the epidemiological surveillance of ted to the ministers of health at the most dengue, tuberculosis, measles, Chagas’ For many years, the Region’s countries recent meeting of COMISCA, held in disease, and HIV, and a significant grant have acknowledged the need to set Panama in March 2003. of computer equipment was finalized. up warning and rapid-response systems for communicable diseases with high Actions were taken to integrate the lab- Technical groups have been organized oratory component into the surveillance in all the countries (some are multi- epidemic potential, and strengthening ties system. Efforts consisted of defining the institutional) to coordinate activities for between laboratories and epidemiological essential functions of public health labo- the prevention and control of epidemics, services is a key piece in the success of ratories and establishing a quality con- update the technical and operational this effort. trol system in the national networks. standards, strengthen the diagnostic ca- After technical and management train- pacity of the laboratory network, and ing was provided to laboratory directors, develop contingency plans for specific the methodology used in Central Amer- diseases. In Guatemala, progress was ica was harmonized through the proce- made in the development of a medium- dural manuals, developed by consensus, term action plan to strengthen the ca- for acute diarrheal diseases, acute res- pacity of the country’s public health piratory infections, bacterial meningitis, services to detect, investigate, and con- dengue, leptospirosis, measles, han- trol emergencies caused by epidemics. tavirus, anthrax, and tuberculosis. The This plan is based on a profile of the external performance evaluation process current status of services that identified was expanded and a tool was developed the country’s strengths and weaknesses to evaluate the laboratory’s response ca- in terms of its infrastructure and per-

45 Annual Report of the Director – 2003 Pan American Health Organization

formance, with special emphasis on hu- políticas para el control de la transmis- man resources training. sion de la enfermedad de Chagas” (New strategies and policies for the control With PASB support, RECACER spon- of Chagas disease transmission). These sored two subregional scientific confer- products and their funds were transferred ences on emerging and reemerging dis- from TDR/WHO to PASB, which became eases, one in Guatemala in 2001 and responsible for all activities in January one in El Salvador in November 2002. 2002. These conferences updated professionals in the country and subregion scientifically and technically regarding patterns Research Agenda of disease in the area, new threats such Research priorities were established on as West Nile Virus, advances in diagno- the basis of proposals formulated at the sis, evaluation of reagent kits, applied meeting of a committee of experts held research in priority areas, and labora- in Brasilia in November 2000. The com- tory quality control. mittee examined all achievements of the Southern Cone efforts and the epidemi- Transfer of Chagas’ ological situation in the other endemic countries of the Region; it also issued Disease Research from recommendations and assigned research WHO to PAHO priorities. An executive committee also was set up, in accordance with TDR cri- The Pan American Sanitary Bureau teria for implementing the new strategy. and WHO’s Special Program for Re- In 2002, PASB called for the submission search and Training in Tropical Diseases of new research proposals and research (TDR) have helped expand knowledge progress reports. of various factors related to the control of Chagas’ disease (Trypanosomiasis americana) and of actions taken to interrupt its vector transmission in various Elimination, Control, countries. and Surveillance of Chagas’ Disease Based on achievements in the reduction The control and elimination of this of Chagas’ disease in the Southern Cone vector-borne systemic parasitosis, spread countries and improvements in control through uncontrolled transfusions from activities in some Andean and Central infected donors and through transpla- American countries, TDR reached an cental transmission, has been addressed agreement with the PASB to transfer to through subregional projects that link the Bureau two Chagas’ disease research the programs of endemic countries with products: “Validación de herramientas PASB. There have been coordinated ac- epidemiológicas” (Validation of epidemi- tivities in the Southern Cone among Ar- ological tools) and “Nuevas estrategias y gentina, Bolivia, Brazil, Chile, Paraguay,

46 Strategic and Programmatic Orientations, 1999–2002

and Uruguay, with Peru as a guest, and In Central America, coverage of anti- in Central America among Belize, Costa vector spraying increased, as has the Rica, El Salvador, Guatemala, Hon- sustainability of activities in vast en- duras, Nicaragua, and Panama. Work is demic areas of various countries. Tech- currently under way to revitalize efforts nical meetings such as a workshop for in the Andean countries and to address establishing technical guidelines for the the control of Chagas’ disease in Mexico. control of Triatoma dimidiata (San Sal- These country initiatives have generated vador, March 2003), a technical work- the necessary technical cooperation for shop to study Rhodnius pallescens, its control and surveillance to progress, be surveillance, and control (Panama City, evaluated, and achieve the proposed September 2002), and a workshop to es- objectives. tablish indicators for eliminating Rhod- nius prolixus (Guatemala City, March In the Southern Cone, work with the 2003), have improved activities by ap- Intergovernmental Commission of the plying a knowledge-based strategy to Southern Cone for the Elimination of Tri- combat the vectors. Progress has been atoma infestans and the Interruption of made toward the elimination of R. pro- Transmission of American Trypanosomi- lixus, a principal objective of this proj- asis through Transfusions, achieved an ect, with noteworthy cooperation among intermediate goal of interrupting the vec- countries, as has been seen in the project tor transmission of Trypanosoma cruzi involving El Salvador, Guatemala, and by Triatoma infestans in all of Uruguay Honduras. PASB also is coordinating (1997) and Chile (1999); in most of the activities with the Japan International endemic area of Brazil (2000); in the Cooperation Agency (JICA) to create provinces of Jujuy, Río Negro, Neuquén, synergistic working conditions in the and La Pampa in Argentina (2001) and control of Chagas’ disease in Guatemala; in the Department of Amambay in these actions will be extended to El Sal- Paraguay (2002). In Bolivia and the re- vador, Honduras, and Nicaragua. maining endemic areas of the subregion, household vector infestation by T. infes- At the workshop on surveillance and tans has decreased, which assumes a re- control of Chagas’ disease in Mexico, duced transmission and decreased risk of held in that country in July 2002 and or- infection. Different countries have shown ganized by the National Institute of Pub- varying degrees of progress in controlling lic Health, the Ministry of Health partic- the transfusion route of transmission in ipated in subregional activities with terms of legislation, coverage, and quality Central America countries, marking the of the serologic screening in blood banks. beginning of future control actions.

47 Annual Report of the Director – 2003 Pan American Health Organization

exceeding 80%. Success has relied on Advances in the decade-long partnership among the country programs, PASB, the Onchocer- Regional Goals for ciasis Elimination Program in the Amer- the Control of icas, and the Carter Center (USA). Onchocerciasis is considered a prob- Onchocerciasis, lem that now has a relatively easy and economical solution. Since the advent of Lymphatic Filariasis, Ivermectin in 1987 and the Mectizan donation program, the world now can Geohelminths, suppress and control the disease by chemotherapy. The Americas is begin- and Leprosy ning to experience the benefit that the Regional initiative has had upon mor- Elimination of bidity and transmission rates. It is hoped Onchocerciasis that the Americas will be the first region Current assessments place the popula- where morbidity will cease to be a pub- tion at risk for onchocerciasis at an esti- lic health problem and where transmis- mated 544,009 (Table 1). That popula- sion will be interrupted. Mexico and tion lives in 2,773 villages, of which 211 Colombia are nearing this stage, fol- are considered to be hyperendemic and lowed by Ecuador and Guatemala. Cur- exposed to a high risk of developing oc- rently, Venezuela and Brazil seem to ular disease. pose the greatest challenge to the elimination of onchocerciasis in the Region. The target of massive drug administration is the total eligible population at Lymphatic filariasis typically affects the risk, and is referred to as the ultimate Elimination of Lymphatic poorest people in the poorest countries. treatment goal, or UTG. Programs are Filariasis monitored through the percentage of the Lymphatic filariasis typically affects UTG attained every year by each of the poorest people in the poorest coun- the endemic countries. UTG-2 refers to tries of the world. Most cases are concen- the coverage attained after two treat- trated in and around urban and periur- ment rounds of all the elegible popula- ban slums. In the Americas, 3,196,464 tions at risk; it is the core activity of the persons are estimated to be infected with Regional initiative. Wuchereria bancrofti, the only known causative agent of lymphatic filariasis in The Region has made significant the Region (Table 2). progress in attaining high treatment coverage (Figure 1). Not reflected in the Lymphatic filariasis can be eliminated figure is the fact that Brazil and Ecuador as a public health problem globally, and have since attained treatment coverage has been identified as a disease that

48 Strategic and Programmatic Orientations, 1999–2002

TABLE 1. Status of onchocerciasis in the Americas, by country, endemic foci, populations and communities at risk, and high-risk communities.

Population Communities High-risk Country Endemic foci at risk at risk communitiesa

Brazil 1. Amazonas 9,067 19 5 2. Roraima Colombia 1. López de Micay 1,270 1 0 Ecuador 1. Esmeraldas 24,151 119 42 2. Satelite foci Guatemala 1. Huehuetenango 200,000 517 45 2. Sololá/ Suchitepéquez/ Chimaltenango 3. Escuintla 4. Santa Rosa Mexico 1. Oaxaca 210,155 953 39 2. Chiapas Venezuela 1. North Central: 99,366 1,164 80 Aragua, Carabobo, Cojedes, Guárico, Miranda and Yaracuy 2. Northeast: Anzoátegui, Monagas, and Sucre 3. South: Amazonas Total 544,009 2,773 211

aHyperendemic communities

can be potentially eradicated. Through- bago may have eliminated lymphatic fi- out 2002, PASB played a leading role in lariasis. Should this be confirmed, the providing technical cooperation to sup- number of endemic countries in the Re- port the implementation of eradication gion will have been reduced to four. programs, prepare national plans and Guyana has opted for a treatment scheme annual reports, prepare proposals for based on the use of diethylcarbamacine the mobilization of resources; it also co- fortified salt, and the country is expected ordinated the annual manager’s meeting to eliminate the disease within two years that took place in Haiti. after implementing the selected strategy. Two out of the three existing foci in Brazil Immunocromatographic-based tests are on the verge of being eliminated, conducted in 2002 suggest that Cota leaving only Recife and some of its sur- Rica, Suriname, and Trinidad and To- rounding areas.

49 Annual Report of the Director – 2003 Pan American Health Organization

FIGURE 1. Coverage after two rounds of treatment of all eligible populations at risk (UTG-2), by countries with endemic foci, 2000–2002.a

Colombia

Mexico

Guatemala

Brazil Country Ecuador

Venezuela

Total

0 20 40 60 80 100 Percentage

2000 2001 2002

a Data from the International Annual Conferences on Onchocerciasis Elimination (IACO), 2000–2002.

TABLE 2. Status of lymphatic filariasis in the Americas, by country, total population, population at risk, percent of total population at risk, and estimated infected persons.

% of total Estimated Total Population population infected Country population at risk at risk persons

Brazil 174,632,932 1,765,000 1.01 69,000 Dominican Republic 8,396,164 422,166 5 63,325 Haiti 8,000,000 6,000,000 75 3,000,000 Guyana 709,506 638,556 90 64,139 Suriname 450,000 35,000 7.8 0 Trinidad and Tobago 1,300,000 0 0 0 Costa Rica 3,649,000 10,000 0,27 0 Total 197,137,602 8,870,722 4.49 3,196,464

Control of Geohelminths that they affect between 20% and 30% of In the Americas, intestinal helminthic the general population. Prevalence is esti- infections represent a burden of disease mated as high as 60% to 80% in some estimated at 2.4 million disability- highly endemic areas. Significant efforts adjusted life years (DALYs) lost. Average have been made to control helminthic in- figures for helminthic infections indicate fections in several countries of the Region.

50 Strategic and Programmatic Orientations, 1999–2002

In 2002, PASB conducted an extensive national leprosy elimination plans; review of the current situation of geo- Ecuador implemented leprosy elimina- helminths and schistosomiasis in the tion monitoring; Uruguay set up a post- Caribbean and compiled a report that elimination project for low prevalence sit- will be published in 2003. Although the uations (clearinghouses and local sentinel overall tendency seems to be a reduction surveillance systems); and Brazil and in the prevalence and intensity rates, Venezuela reduced their prevalence rates geohelminth infections continue to pose at the national level and at the subna- a public health problem in some coun- tional level in several states, and certain tries and in some areas of the Americas. departments in Colombia and provinces in Argentina also reduced their rates. Geohelminths cause infections in neg- lected populations. The Regional Plan will take this into consideration, focus- HIV/AIDS ing on poverty stricken countries, areas, As the HIV/AIDS pandemic continues and population groups where transmis- unabated, the burden of disease, disabil- sion is favored by environmental and ity, mortality, expenditures, and decrease other risk factors. With PASB technical in productivity continues to climb. support, Brazil, the Dominican Repub- Health systems everywhere in the Region lic, Guyana, Haiti, and Suriname have are facing the HIV/AIDS challenge while prepared annual plans that begin mod- they also try to cope with a lack of re- estly with national activities, and then sources that prevents them from meeting ratchet up to a subregional effort. Exter- the needs associated with the increase in nal funds were mobilized to support demand for and use of services. Given pilot interventions in Suriname and the already limited capability to ensure Brazil. Efforts also were undertaken to universal access and quality care accord- articulate geohelminth control with ing to established standards, a series of other ongoing public health initiatives, actions have been undertaken to analyze such as efforts to control lymphatic fi- the barriers and difficulties that the lariasis in Guyana, Brazil and the Do- health sector faces, propose avenues of minican Republic and Haiti. action, and provide specific technical cooperation activities. Several actions have been carried out to strengthen the central Elimination of Leprosy as role of the health sector in providing pre- a Public Health Problem vention, care and treatment, mobiliza- In 2002, PASB’s leprosy elimination tion of resources, and coordination of ac- project made several significant ad- tions with other sectors. vances: Paraguay attained leprosy prevalence rates that were on a par with levels As part of the effort to analyze the situ- at which the disease is considered to be ation of health systems and services vis- eliminated a public health problem; Ar- à-vis HIV/AIDS and to find the necessary gentina, Cuba, the Dominican Republic, responses to cope with this challenge, the Ecuador, Paraguay, and Peru established Bureau held a consultation meeting with

51 Annual Report of the Director – 2003 Pan American Health Organization

representatives from Member Countries zations within the Latin America and and international cooperation agencies. Caribbean Regional Health Sector Re- Delegates from 21 countries and several form Initiative (LACHSR) in setting up international organizations participated systems for technical assistance and for in a hemispheric forum to analyze and monitoring and evaluating country ef- discuss how the HIV/AIDS pandemic forts to focus health sector reforms on jeopardizes health sector reform process the HIV/AIDS pandemic. and efforts to strengthen health systems in the Americas. The meeting, called PASB and WHO provided guidance “Challenge of HIV/AIDS for the Reform and support for developing applications and Strengthening of Health Systems and to be submitted to the Global Fund to Services in the Americas,” took place in Fight AIDS, Malaria, and Tuberculosis Ocho Rios, Jamaica, in February 2002. (GFATM) in 2002. GFATM is a new global financial mechanism designed to Participants at the meeting helped to attract, manage, and strategically dis- develop strategies and mechanisms for burse additional resources in countries strengthening the health sector’s capa- with the greatest need. The Fund aims bility to combat HIV/AIDS, improving to help in-country public/private part- health systems response to HIV/AIDS, nerships to scale up prevention, treat- and planning specific strategies for ment, care and support efforts. health systems development and reform to face the HIV/AIDS challenge in Latin All GFTAM potential financial part- America and the Caribbean. The meet- ners have highlighted the need to em- ing also sought to enhance the collabo- phasize primary prevention and rekindle ration with partners and other organi- HIV/AIDS awareness among all sectors

CANADA Works with PERU and COLOMBIA to Fight HIV/AIDS and Tuberculosis Health Canada assisted a Canadian expert on HIV/AIDS to undertake work in Peru and Colombia to:

• provide assistance to physicians and nurses giving health care to patients living with HIV/AIDS and/or tuberculosis in “Hogar San Pedro” in Lima, Peru; • help conduct and participate in conferences regarding the pathogenisis of HIV-1 infection and HIV prevention; • help conduct and participate in conferences about the pathogenesis of Mycobacterium tuberculosis infection, malaria, and leishmanasis; • deliver courses on cardiopulmonary resuscitation; • undertake child education in Lima, Peru; and • instruct on HIV/AIDS prevention education in Colombia.

52 Strategic and Programmatic Orientations, 1999–2002

of society. To that end, PASB, UNICEF Saharan Africa for brand name anti- and Mexico’s HIV/AIDS Program orga- retroviral drugs. Preparations for the nized a meeting in Cuernavaca, Mexico, in Caribbean negotiation started in Febru- March to review the current experiences ary, and the agreement with the com- in the prevention of mother-to-child panies was signed in July by the Pan transmission (PMTCT) of HIV and make Caribbean Partnership against HIV/ recommendations for Latin American AIDS (PANCAP) and the companies. and Caribbean countries. Participants Negotiations were conducted by the recommended that PMTCT’s three- Caribbean Community (CARICOM) pronged strategy be more comprehen- Secretariat, PASB/ WHO, and UNAIDS. sively pursued. Currently most initiatives in Latin American and Caribbean coun- The negotiations between the five tries focus on preventing vertical trans- Central American governments and five mission, at the expense of primary pre- pharmaceutical companies also led to vention among HIV-negative women and historic reductions in the prices of anti- prevention of unwanted pregnancies, es- retrovirals. The most common treatment pecially among HIV-infected women in the subregion (AZT+3TC+EFV) will who have decided not to get pregnant. cost between US$ 1,035 and US$ 1,600 According to the participants, PMTCT per patient per year. This represents an communication would be more accepted, average reduction of 55% over the then less threatening, and less stigmatizing if current prices of brand-name drugs in it is integrated into existing communica- Central America. The Central American Communication regarding the prevention tion efforts to promote prenatal care, negotiation began in September 2002 mother and child health, family planning and was coordinated by the Secretary of of mother-to-child transmission of HIV is and comprehensive management of child Social Integration of Central America, more accepted, less threatening, and less illnesses. with technical support from PASB/ stigmatizing if it is integrated into existing WHO. Price reductions came about as a communication efforts to promote In 2002, Latin America and the result of the countries’ concerted effort prenatal care, mother-and-child health, Caribbean made significant progress in to negotiate with pharmaceutical com- family planning, and comprehensive their efforts to expand access to anti- panies at the national and subregional management of child illnesses. retroviral drugs. Two successful subre- levels (see Figure 2). gional initiatives—one in the Caribbean and one in Central America—deserve The Accelerating Access Initiative sup- special mention. These two negotiations ported the negotiations in Central Amer- brought down the price of brand-name ica and the Caribbean. This initiative antiretroviral drugs to levels similar to brings together five United Nations those available in sub-Saharan Africa. agencies and six pharmaceutical companies to accelerate access to care for In the Caribbean, negotiations led the people with HIV/AIDS by developing price of combinations of antiretroviral public/private partnerships. A PASB/ drugs to drop to as much as US$ 1,100 WHO survey indicates that negotiation per patient per year, which is similar agreements between ministries of health to prices offered to countries in sub- and the pharmaceutical companies were

53 Annual Report of the Director – 2003 Pan American Health Organization

FIGURE 2. Price of first-line therapy (AZT + 3TC + EFV) before and after Central American negotiations.

3,000

2,500

2,000

1,500 Price in US$

1,000

500

0 Honduras Panama Guatemala Nicaragua El Salvador

Country

Price before negotiations Price after negotiations

Note: Costa Rica was not included because the country uses generic medicines; Nicaragua did not have antiretroviral treatment, so a before and after comparison could not be made.

responsible for a drop of 54% in anti- of treatment protocols. One of the current retroviral-drug prices in Latin American barriers to using these drugs is the per- and Caribbean countries. ception that developing countries must follow therapy protocols established in Subregional negotiations have brought wealthiest countries, practices that are about several benefits: lower and uniform beyond the means of many Latin Ameri- prices throughout the Region; support to can and Caribbean countries. To offset countries with smaller negotiation capa- this, PASB prepared a guide with recom- bilities; strengthening of intercountry co- mendations for treating adults with anti- operation; and rationalization of techni- retroviral drugs. Designed by a group of cal cooperation by PASB/WHO, so as to experts from 15 countries, the “Guide- help more countries negotiate in a shorter lines for Antiretroviral Treatment in period of time. The subregional negotia- Adults for Latin American and Carib- tions helped to advance a process that bean Countries” recommend the use of was already taking place at the national seven such drugs, which are expected to level, with countries looking at different cover 90% of the cases requiring treat- strategies to ensure price reductions. ment at an accessible cost. The guidelines were a response to health authorities’ Another factor contributing to the in- many requests for how to improve anti- creased access to antiretroviral drugs was retroviral treatment for people living the rationalization and standardization with HIV/AIDS in the Region.

54 Strategic and Programmatic Orientations, 1999–2002

Dengue prevention and control; the signing of an agreement with IDB to strengthen so- In September 2001, PAHO’s 43rd Di- cial communication activities related to recting Council discussed the status of dengue control in Central America; the dengue in the Region and adopted a res- preparation of a social communication olution urging the Member States to guide for program managers to promote promote intersectoral and environmen- behavioral modification in familes to tal measures to prevent and control the further dengue prevention; the presenta- disease. In response to the resolution, A tion to the Canadian International De- Dengue Decalogue was drawn up in velopment Agency (CIDA) of a plan to 2002, which establishes the critical train a working group of dengue special- points of a national dengue prevention ists that would seek to establish a new and control program. Other noteworthy way for PASB to deliver technical coop- actions undertaken during the year are eration to the countries; the launching of the distribution of “PASB Frame of Ref- Dengue Net, a global system of dengue erence,” a document that analyzes the notification by the countries; the evalua- Regional situation and the decalogue to tion of national programs; and an annual disseminate PASB strategy for dengue quality-control check of diagnostic labo-

COSTA RICA Puts in Place a Grassroots Community Strategy for the Comprehensive Management of Dengue In Costa Rica, the grassroots community strategy for combating dengue, which is part of the “Post- Mitch” project, strengthened social participation with the establishment of three community networks in three districts of the Gran Puntarenas area: Chacarita, Barranca, and Puntarenas. These districts were selected to be included in the project because they had the highest number of dengue cases. The networks have permanent operating plans that include surveillance, education, and communication activities. The experiences of these community networks have been replicated in other districts of the Region. As a way to support these networks, educational material was developed tailored to the local experience. This material includes the cartoon story, “Let’s Control Dengue,” the family plan to fight dengue, and the community plan to combat the disease. In addition, social actors in the Gran Puntarenas area were identified; technical cooperation was provided for the development of social participation and communication strategies based on the experiences, actual situations, and needs of each district; and a document systematizing local institutional and community experiences since the beginning of the dengue epidemic was prepared. Moreover, cooperation was provided for equipping and putting in operation a situation room designed to strengthen regional capacity for analysis and surveillance. The situation room is an open space where health officials at the sectoral and community levels can conduct analyses and hold technical discussions to address various problems and situations related to dengue prevention and control.

55 Annual Report of the Director – 2003 Pan American Health Organization

ratories in collaboration with the Pedro In the Department of San Martín, Peru, Kouri Institute of Havana. a demonstration project is under way to evaluate the effectiveness of two screen- Finally, several documents were pre- ing methods—visual inspection with pared and distributed in 2002 to facili- acetic acid (VIA) and magnified visual tate technical cooperation with the inspection (VIAM)—and an ambulatory countries; these were uploaded to the treatment method for precancerous cervi- PAHO web page for easy access (http:// cal lesions—cryotherapy. These alterna- www.paho.org/dengue). tive screening and treatment methods have been integrated into the routine pri- In cooperation with the collaborating mary care health services for women centers and CEPIS, the virtual course on since November 2001. Data is now being healthy households, which focused on analyzed to compare the sensitivity and dengue control, was delivered, and specificity of VIA, VIAM, Pap, HPV-DNA dengue control activities were supported testing, liquid-based cytology and the ef- with the Ecoclubs of 11 countries. fectiveness of cryotherapy. This could result in the implementation of innovative cervical cancer prevention programs in low-resource settings. Noncommunicable In El Salvador, two service delivery Diseases approaches are being evaluated in the health regions of Nueva Concepción and Chalatenango. An analysis of the effec- Cervical Cancer tiveness of the two will be used to or- Latin America and the Caribbean ganize cervical cancer screening services have some of the world’s highest inci- in the country as a whole, as well as dence and mortality rates for cervical in other Central American countries. In cancer, despite the fact that most of the the Department of Cabañas continuous Region’s countries have been screening quality improvement model (CQI) is women with the Papanicolaou (Pap) test being tested; this effective, low-cost infor more than 30 years. PASB has eval- tervention for routine health service de- uated alternative approaches to screen- livery is intended to reduce barriers for ing and treatment in Peru and in El Sal- women’s participation in screening ser- vador; tested methods for improving the vices. In this demonstration area in El quality of care in El Salvador; and sup- Salvador, health personnel and national ported Antigua and Barbuda, Bolivia, health authorities have developed CQI Guatemala, Honduras, Jamaica, Pan- plans to be executed within their avail- ama, Suriname, and Venezuela, as well able material and human resources. as efforts of the the Caribbean Cervical Cancer Prevention Program and the After six months of implementing the RedPAC Program to strengthen existing CQI plans, the following improvements cytology-based cervical cancer preven- have been observed: all health clinics, tion programs. with the support of hospitals, have

56 Strategic and Programmatic Orientations, 1999–2002

trained personnel in how to better ad- prevention program. As a result of minister and fix Pap smear samples, the assessment and through PASB’s which has improved the quality of the financial assistance, the Ministry of tests; turnaround time for Pap test re- Health is strengthening secondary sults has been reduced; flow of supplies health services and improving the has been streamlined; infection preven- capacity for screening and treatment tion measures have been improved; at the primary care level. client privacy in pelvic exams has been • In Guatemala, following the recom- ensured in clinics that previously had mendations of a PASB-sponsored none; efforts have been increasingly needs assessment to strengthen the targeted to at-risk and rural women organization of services, the Ministry by community health workers; health of Health and an interinstitutional workers are coordinating community re- committee have launched a demon- sources to organize transportation and stration project in Guatemala City child and elder day care for women at- that organized a screening program tending the clinics; and educational ma- using Pap smears and possibly VIA. terials on cervical cancer and its preven- • In Honduras, PASB has assisted the tion and care were developed and tested Ministry of Health to strengthen its for use in all health services. Based on national cervical cancer prevention the success in this demonstration area, program, targeting health education this model will be promoted for use in and health promotion, retraining other regions of El Salvador and in other health personnel in administering countries of the Region. taking the Pap smear test, and strengthening the performance of its In terms of support for enhancing the cytology laboratories. effectiveness of cytology-based cervical • In Jamaica, based on an assessment cancer prevention programs, PASB proof the citylogy laboratory and asso- vided the following technical cooperation ciated information system conducted in the countries: by PASB, the Ministry of Health is working to strengthen the cytology • In Antigua and Barbuda, a needs laboratory’s performance and man- assessment revealed deficiencies agement structures, in order to meet such as a lack public services for cy- the demand to process Pap smears tology and diagnosis. As a result, the generated by the screening program. Ministry of Health is improving the • In Panama, PASB supported the situation so that women can have Ministry of Health’s collaboration access to public health services for with the country’s Cancer Institute screening and treatment. in launching a national cervical can- • In Bolivia, PASB and its partner, cer prevention program that will in- EngenderHealth, worked with the volve health education and recruit- Ministry of Health to conduct a ment campaigns; the dissemination comprehensive needs assessment to of national screening and treatment identify gaps, weaknesses, and guidelines; training of health per- strengths in Bolivia’s cervical cancer sonnel in screening, diagnosis, and

57 Annual Report of the Director – 2003 Pan American Health Organization

treatment; and strengthening the na- laboratories in the Region, has been tional cancer registry. conducting proficiency testing of 45 • In Suriname, the Lobi Foundation, laboratories in Bolivia, Chile, Costa Leiden University of the Nether- Rica, Ecuador, Mexico, Peru, and lands, and PASB have begun a cervi- Venezuela. Test results and feedback cal cancer screening and treatment from experts to the laboratories have project in the country’s Hinterlands. led to improvements in reporting ac- The project aims to provide cervical curacy, especially in Costa Rica. cancer screening with immediate treatment for indigenous women from Suriname’s interior, and will Violence and Injury assess the performance of VIA and Prevention Project Pap smear test as the screening methods. Recruitment of women will PASB has concentrated its violence- begin in 2003; 4,000 women 25–50 and injury-prevention efforts on coun- years old will be screened over a nine try-specific strategic plans, hospital- month period. based surveillance systems, workshops • In Venezuela, PASB supported an related to traffic injuries for preparing evaluation of the structure, process, the “World Report on Traffic Injury,” and effects of the cervical cancer and launching the World Report on program in the State of Aragua, Violence and Health in the Region of which has been functioning since the Americas and the “Inter-American 1996. The program has achieved a Coalition for the Prevention of Vio- Pap screening coverage of about lence.” PASB worked with WHO in the 32% among women 25–64 years old, preparation of the World Report on Vio- has shown good follow-up of women lence and Health, the “World Report on who screen positive, and has begun Traffic Injury,” and the implementation to show a slowly decreasing trend in of the Global Campaign for Violence mortality rate from cervical cancer. Prevention. The Ministry of Health is strengthening its cytology laboratories and sec- The World Report on Violence and ondary health services, improving Health recommends that strategic plans the organization and management of for the prevention of violence be devel- its program, and improving the na- oped in each country. To date, Bolivia, tional cancer registry. Costa Rica, Honduras, and Jamaica • The Caribbean Cervical Cancer have such a plan under development. Prevention Program, with a secre- The Special Meeting of the Health Sec- tariat at CAREC, has developed tors of Central America and the Domin- Caribbean-specific screening and ican Republic (RESSCAD) requested treatment guidelines, is undertaking PASB’s support for developing a strate- advocacy activities. gic plan for violence prevention, and the • The RedPAC Program, as a way to unit has assisted in the development of enhance the performance of cytology these mulitisectoral plans.

58 Strategic and Programmatic Orientations, 1999–2002

BOLIVIA Moves from Words to Local Action In the Cosmos 79 area of the PAHO Centenario District, Municipio de El Alto, La Paz, an initiative for citizen participation and the prevention of violence was put in place. The model used involved the community’s participation along three levels—individual, group, and organized, which channels activities toward the prevention of the most commonly seen forms of violence and abuse. The Community Orientation Unit, which is part of the Residents’ Association, serves as a liaison between the community and those institutions that are charged with dealing with the problem. The Unit’s main roles involve orientation, information, referral, and, when appropriate, the settlement of cases. The unit provides support to community surveillance through the production of “risk maps,” suggestion and complaint boxes, recording of data, and the holding of monthly “action” meetings, which are designed to foster coordination with the institutions in charge of responding to the problem of violence. The initiative’s major accomplishments are:

• More than 60% of cases of abuse are handled within the community, without the need for bringing in outside institutional attention. • In a simple way (“neighbor to neighbor”), the people in the community learn about their rights and where to go if problems occur. • Through the Community Orientation Unit, the community lets the institutions in charge of maintaining public order know where the danger areas are and what the most common types of violence are. Together they take action, thereby optimizing resources. • The members of the Unit enhance their self-esteem and develop sensitive, solidary behaviors.

To date, the departments of Santa Cruz, Tarija, Cochabamba, and La Paz are working to repli- cate the model in different areas along the urban periphery, benefiting from the experience acquired in community projects such as this one.

PASB and the United States Centers pursuing efforts focused on hospital- for Disease Control and Prevention have based surveillance systems and to de- co-funded the development of hospital- velop a universal patient history form to based injury surveillance systems in San be used throughout Central America. Pedro Sula and Tegucigalpa, Honduras; San Salvador, El Salvador; León, The World Report on Violence and Nicaragua; and Cali, Colombia. An in- Health was launched in October 2002 in ternational workshop was held in Janu- Brussels, and subsequent presentations ary in order to present the work of the in Brazil, Colombia, Costa Rica, and El different researchers. At this gathering, Salvador served to promote the book a commitment was made to continue and the violence prevention strategies in

59 Annual Report of the Director – 2003 Pan American Health Organization

it; presentations in other countries also nicipalities (FEMICA) (Guatemala); the are planned. PASB has been an integral mayor’s offices of Bogota (Colombia), part of these efforts and of the global San Pedro Sula (Honduras), Quito campaign against violence throughout (Ecuador), and La Paz and Santa Cruz the Americas. de la Sierra (Bolivia); and the Center for Latin American Studies at Georgetown Traffic-related injuries and deaths University. These partnerships facilitate plague the countries of the Region. A the incorporation of intentional and un- workshop was held in Mexico in Decem- intentional injury as an item in the ber to address traffic accidents, and agendas of policy makers in the coun- Costa Rica has been working on preven- tries, giving the problem greater visibil- tion and surveillance of traffic-related ity and raising the potential for better injuries. addressing it.

PASB is a member of the Inter-Ameri- can Coalition for the Prevention of Vio- lence (IACPV), along with the Inter- The CARMEN Initiative American Development Bank, the World In September 2002, in response to the Bank, the (U.S.) Centers for Disease impact of the noncommunicable disease Control and Prevention, the Organiza- epidemic in the Region’s countries, the tion of American States, the United 26th Pan American Sanitary Conference States Agency for International Devel- endorsed an approach for combating the opment, and UNESCO. This coalition epidemic. The Conference also approved acts as a catalyst for preventing vio- a resolution endorsing the CARMEN6 ini- lence, and works at the national and tiative as one of the main strategies for local level. preventing chronic diseases, and requested that PASB provide technical co- A woman participates in painting a The Bureau has entered into several operation to Member States in developing mural as part of an effort to promote partnerships with collaborating centers an integrated approach to noncommuni- peace at the local level. such as the institute devoted to conduct- cable diseases based on the initiative. ing research and to develop violence prevention and promote harmonious so- CARMEN aims to improve the health cial coexistence (CISALVA) at the the status of the populations in the Americas Universidad de Valle in Colombia; the by reducing risk factors associated with Centers for Disease Control and Preven- noncommunicable diseases. The initia- tion’s National Center for Injury Preven- tive has two components: risk reduction tion and Control and National Center and capacity building. With its risk- for Health Statistics; the University of reduction component, the initiative pro- California, Los Angeles; Emory Univer- motes and supports the reduction of sity in Atlanta, Georgia (U.S.A.); and noncommunicable disease risk factors the University of Quebec, as well as with and conditions through community- other agencies and organizations such as based interventions. To carry this out, the Federation of Central American Mu- the following three strategies are applied:

6 The initiative is known for the Spanish acronym for Conjunto de Acciones 60 para la Reducción Multifactorial de las Enfermedades No-Transmisibles, meaning “A Set of Actions for the Multifactoral Reduction of Non-Communi- cable Diseases.” Strategic and Programmatic Orientations, 1999–2002

CARMEN in Chile Chile was the first Latin American country to join the CARMEN network. Chile has chosen its national program—CARMEN-Chile—as the strategy for attaining greater health equity and the country’s health objectives for 2010. Achieving the national health objectives still poses a challenge for CARMEN-Chile, as it requires interprogramatic and intersectoral actions that will lead to a jump in quality in the health care system so as to be able to control noncommunicable diseases and their synergistic risk factors. CARMEN-Chile has, however, succeeded in implementing CARMEN demonstration areas in various locations. Currently, there are demonstration sites in five regions or areas, covering a total population of approximately 5.3 million persons. These demonstration areas are working at two intervention levels and in three learning projects.

• Low-intensity, Broad-coverage Intervention. The CARMEN MIRAME targets Chile’s primary- school student population and aims at improving the quality of life starting from childhood. This subprogram is part of CARMEN “Niños” MIRAME project being carried out by the Pontificia Uni- versidad Católica de Chile. • High-intensity, Narrow-coverage Intervention. This project aims to foster cardiovascular disease prevention through the control of risk factors in patients participating in the Cardiovascular Health Project. It is being implemented in thirteen physicians’ offices in two regions. • Continuous Skills-Training Programs in Primary Care. The continuous skills-training programs in primary care is intended to encourage professionals in all areas of the health services sector to work toward the early detection and intervention of cardiovascular disease risk factors; to issue clinical guidelines for health care professionals; and to prepare educational materials for patients. A technical team formed by experts from the Pontificia Universidad Católica de Chile, the Min- istry of Health, the National Institute of Food Technology (INTA), USACH, and PASB/WHO sys- tematized an integrated therapeutic plan in a series of clinical guides delivered to professionals through a training cycle. • Skills-Training Project in Nutrition for Public Health Care Professionals. This CARMEN project was carried out by INTA and the Ministry of Health, under the auspices of PAHO/WHO Country Office and WHO Headquarters. An evaluation process is currently in place to see if there was a difference in the utilization of the nutrition tool kit aimed at primary health care professionals that was used in demonstration areas compared to the rest of the country. • Distance Learning Project for the Prevention and Control of Noncommunicable Diseases. A curriculum with specific courses and models is being prepared. The University of Santiago, the Min- istry of Health, the PAHO/WHO Country Office, and the Archives and Abstracts Corporation are collaborating on the project. The program will be used internationally for distance education.

61 Annual Report of the Director – 2003 Pan American Health Organization

• Integrated prevention entails si- WHO and the Caribbean Community multaneously preventing and reduc- Secretariat, a strategic plan for the pre- ing a set of risk conditions common vention and control of noncommunica- to major noncommunicable diseases. ble diseases for the Caribbean was cre- • Demonstrative effect involves con- ated in September 2002. Through the ducting interventions in a demonstra- Caribbean Lifestyle Intervention pro- tion area, so that their acceptability, gram, the Caribbean has joined the safety, and ultimate effectiveness can CARMEN Network. be evaluated within a given context. • Promotion of health equity pursues strategies aimed at reducing overall population risk, while simul- Integrated taneously reducing gaps among different population groups. Management of

The initiative also pursues the follow- Childhood Illness ing lines of actions: policy building, community-based actions, and respon- (IMCI) sive health care services. The objective is to increase the technical capabilities of The Integrated Management of Child- Latin American and Caribbean coun- hood Illness (IMCI) strategy aims to im- tries for preventing risk factors of non- prove the health of children under 5 communicable diseases. years old by focusing on the well-being of the whole child and stressing the care The CARMEN initiative promotes and of children at the community and family Thanks to activities undertaken under the supports networking efforts among levels. IMCI is an integrated approach banner of the Integrated Management Member Countries so they can learn that considers the various factors that of Childhood Illness, mortality in children from each other in regard to the preven- put children’s health at serious risk. As under 5 years old has dropped for the tion of noncommunicable diseases. The such, it is considered a key strategy for second time in the initiative’s two years. Region’s CARMEN network is linked to the continued reduction of childhood similar networks in the other five WHO mortality, especially from infectious and Regions, as well as to the Global Forum respiratory diseases, and for increasing on Noncommunicable Disease Preven- the life expectancy in the Region of the tion and Control. The 3rd Meeting of the Americas. Global Forum will be held in November 2003 in Brazil and PASB is already pro- PASB has been strengthening the im- viding the necessary technical support. plementation and expansion of IMCI in health facilities and at the community CARMEN has received much support level within the context of the “Healthy in the Americas. Argentina, Canada, Children: Goal 2002” initiative. Mor- Chile, Colombia, Costa Rica, and Cuba tality in children under 5 years old are the network’s most senior members. dropped for the second year in the ini- Through the collaboration of PASB/ tiative’s two years, and the number of

62 Strategic and Programmatic Orientations, 1999–2002

FIGURE 3. Mortality from diseases targeted by IMCI in children under 5 years old, Region of the Americas; trend for the first two years of the “Healthy Children: Goal 2002” initiative; number of deaths and proportional mortality, 1998–2000; assessment 2002.

50.0 200,000

45.0

40.0 150,000 35.0 32.5 29.6 30.0 27.8

25.0 100,000

20.0 Number of deaths 15.0 Proportional mortality (%) 50,000 10.0

5.0

0.0 0 1998 1999 2000 Year

Proportional mortality Number of deaths

deaths prevented increased to more than targeted faculties of medicine, was con- 43,000, as compared with 1988 figures, ducted and published with the Latin which is the baseline for the goal of American Association of Pediatrics reducing 100,000 such deaths in the (ALAPE); its results are now being dis- 1999–2002 period. seminated throughout the Region. The other, targeting nursing schools, was co- Most deaths averted (83.9%) were ordinated with the Latin American Asso- from causes targeted by the IMCI strat- ciation of Nursing Schools (ALADEFE); egy, mainly pneumonia and diarrheal its results are being processed and will be diseases. The number of deaths from published in 2003. PASB also provided diseases targeted by IMCI dropped technical assistance to develop perinatal 14.4% during the first year of the initia- and neonatal activities and formulate tive and 7.9% during the second year. district-level plans in this regard. These rates of reduction were higher than those observed for mortality from PASB distributed IMCI Operational all causes which was reduced by 5.6% Research Guide, which gives health for the first year and 2.8% for the sec- workers in the countries the basic ond year of the initiative (see Figure 3). methodological tools to carry out low- cost, short-term research studies to an- Two important surveys have been con- swer specific questions related to health ducted to gather information on the worker skills, health systems, and the teaching of pediatrics. The first, which family and community. The Bureau pro-

63 Annual Report of the Director – 2003 Pan American Health Organization

vided technical assistance so countries working with the most vulnerable pop- could carry out studies in priority areas. ulation groups. The United Nations Foundation provided additional funds Member Countries have requested that to support IMCI community activities in PASB strengthen and expand IMCI im- Bolivia, Ecuador, and Peru. plementation. The 26th Pan American Sanitary Conference approved a resolu- From the onset, the project sought to tion urging Member Countries to re- provide the necessary leadership and inforce their commitments to achieve support to render IMCI’s community universal access to IMCI and stressing component a national programming the need to work in the most vulnerable strategy, not have it function as merely population groups. The resolution urges a pilot activity. As such, the project PASB and countries to introduce IMCI planned for the component’s expansion teaching as part of the pre-service and from the onset, and coordinated with post-graduate courses of medicine, nurs- other agencies and organizations to cre- ing, and other health disciplines, thus ate sustainable partnerships. providing students with the necessary knowledge and practices to give children Expansion efforts are now under way the best quality of care. in ten countries, with international and national organizations and NGOs involved in the effort. To date, more than 115 community-based organizations Community Component and institutions, international agencies, In the past few years, the international and NGOs are engaged in the imple- community has increasingly expressed mentation of community projects in nine an interest in providing technical coop- countries. In 2002, training activities eration to support IMCI’s community continued, as did activities aimed at component. In a joint effort, PASB and strengthening local capacity to formu- the American Red Cross have begun to late community projects in the ten coun- develop the “Regional Community IMCI tries. More than 1,600 health workers Project,” a five-year, ten-country effort and local actors took part in training that relies on the WHO/UNICEF “Key courses and more than 2.1 million peo- Family Practices” for preventing com- ple have direct access to project inter- mon childhood illness and changing be- ventions. As a result of these advances, haviors at the household and commu- many major international NGOs—for nity level. example, CARE, Save the Children, and Project Hope—as well as other agencies The project is rapidly spreading such as the Junior Chamber Interna- throughout the Region, thanks to local tional and the International Federation level efforts of ministries of health, local of Red Cross and Red Crescent Societies, Red Cross offices, nongovernmental or- are working with PASB to expand the ganizations, and other partners who are community component.

64 Strategic and Programmatic Orientations, 1999–2002

Preventing Diarrheal sure that they receive a higher priority on the public agenda. Diseases through Behavior Change Work also was carried out with the Latin American Federation of Faculties This joint project between PASB and of Social Communication (known by its USAID’s Environmental Health Project Spanish acronym, FELAFACS) and the aims at establishing hygienic activities United States Agency for International in selected areas of Nicaragua and Peru. Development (USAID) on incorporating During two years, this project will put in health issues into the training of social place a behavioral change methodology, communicators in the Region and gener- actively involving the target community. ating more interest in public health is- Subsequently, educational and social sues among communication schools. communication interventions tailored to the community’s needs will be developed. Specific actions to be promoted are the adoption and consistent practice Veterinary of proper handwashing, sanitary excreta disposal, and use of safe water. Public Health

PASB cooperates with Member States Social communication in formulating policies and executing plans and activities to prevent and con- After having his dog immunized in IMCI trol zoonoses and foodborne diseases and against rabies during a mass canine Within the IMCI strategy, social com- to eradicate foot-and-mouth disease. vaccination campaign, the dog’s owner munication serves two major purposes. First, improving the quality of commu- In recent years, PASB has sought receives his certificate and information nication among health professionals, closer integration with the agricultural on the disease. PASB’s current goal, health service providers and users, and sector. An agreement signed in 2002 endorsed by the countries of the Region, the community at large. Second, stimu- with the Inter-American Institute for is to eliminate human rabies transmitted lating the adoption of key messages and Cooperation on Agriculture (IICA), by dogs by the year 2005. practices by individuals and the com- which entails the development of a joint munity that will lead to embracing action plan to support the countries of healthy behaviors. PASB prepared an the Americas in achieving health and orientation manual for journalists (Ayu- prosperity in the rural communities, is dando a crecer: información de referen- noteworthy. The plan defines its sphere cia sobre el desarrollo integral de niñas of cooperation in terms of strengthening y niños menores de seis años) that pro- the organizational management capacity vided reference information on the inte- of directors and supervisors in national gral development of boys and girls agricultural health and veterinary pub- under 6 years old. This manual seeks lic health programs; promoting the use to increase the amount and quality the of information from existing systems; press devotes to health issues that affect and increasing the exchange of informa- children from 0 to 6 years old and en- tion and experiences.

65 Annual Report of the Director – 2003 Pan American Health Organization

The CARIBBEAN PROGRAM COORDINATION Strengthens Alliances in Veterinary Public Health Veterinary public health remained a priority for the Caribbean Program Coordination office, especially in terms of progress to be made with food security and safety. In 2002, the office continued to work to strengthen national- and subregional-level alliances in this regard. Recent challenges in international trade, tourism, and economic competitiveness, driven by implementation of the World Trade Organization’s Sanitary and Phytosanitary Measures, have made it imperative to foster closer links among the various agencies involved in food safety. To that end, veterinary public health activities focused on maximizing subregional achievements of targets and goals through links that allowed for synergistic work between PASB and other agencies, which, in turn, allowed limited resources to be used more efficiently. Where appropriate, subregional programs that were shared by several countries served by the CPC office were administered jointly. The office, PASB, and the subregional office of the Food and Agriculture Organization (FAO) jointly hosted two events in Saint Lucia: a group meeting on street food vending operations and a workshop on risk analysis for 41 participants from every country within the Organization of East- ern Caribbean States, plus Jamaica, Barbados, Suriname, Montserrat, and the British Virgin Islands. Both of these events were intended to foster alliances and enhance the delivery of technical cooperation to the countries involved in the exercise.

PASB also strengthened its relation- Prevention and Control ship with other organizations, such as the International Epizootic Organization of Rabies and other (IEO) through a cooperation agreement Zoonoses promoting joint action in the control of foot-and-mouth disease, the imple- The elimination of human rabies trans- mentation of the International Animal mitted by dogs is one of the mandates of Health Code, and in animal welfare. the Organization’s Governing Bodies Joint actions for surveillance of zoonoses and one of the priorities of the Bureau’s such as equine encephalitis were carried technical cooperation. PASB’s current out with the Regional International Or- goal, endorsed by the countries of the ganization for and Animal Health Region, is to eliminate human rabies (known by its Spanish acronym, transmitted by dogs by the year 2005. OIRSA). The Inter-American Network of Food Analysis Laboratories (INFAL) In the early 1980s, the countries com- was set up with the Food and Agricul- mitted themselves to eliminate urban ra- ture Organization of the United Nations bies from the Region’s major cities. In (FAO), and epidemiological surveillance 2002, 19 of the 21 Latin American cap- of swine fever was established. ital cities reported no cases of human

66 Strategic and Programmatic Orientations, 1999–2002

FIGURE 4. Human rabies cases, Region of the Americas, 1992–2002 (partial notification).

250

200

150

No. of cases 100

0 1992 1993 1994 1995 1996 1997 1998 1999 20002001 2002

Year

Source: PAHO, PANAFTOSA, Regional System for the Epidemiological Surveillance in The Americas (SIRVERA).

rabies transmitted by dogs, and just with PASB support—mainly in mass ca- 12% of the major cities (state or provin- nine vaccination campaigns. cial capitals) reported cases. In October 2002, Santa Cruz de la Cases of human rabies have decreased Sierra, Bolivia, hosted the IX Meeting of significantly in the Region of the Ameri- Directors of Rabies Control Programs cas in the last 10 years, dropping from (known by its Spanish acronym, 227 in 1992 to 56 in 2001, with a 75% REDIPRA) to bolster the strategic plan reduction in deaths from that disease. for the elimination of human rabies In 2002, partial notification reports transmitted by dogs in Latin America, showed an even greater reduction, with study the current situation of the differ- 25 human cases. Trend analysis shows ent components of the regional action that between 1992 and 2001, the aver- plan, and define technical cooperation age reduction was 20 human cases per strategies and activities for formulating year (Figure 4). the 2003–2004 operating plan.

The trend in canine rabies was similar. In 2002, external evaluations of Bo- In the last 10 years, canine rabies de- livia’s and Brazil’s national rabies pro- clined 76%, with 1,652 cases reported grams were carried out. The objective in 2001. In 2002, partial data show that was to verify the effectiveness of the 432 cases were reported. This success elimination measures that the coun- was possible thanks to efforts by the tries have implemented and to make governments of the Region’s countries— recommendations for the respective pro-

67 Annual Report of the Director – 2003 Pan American Health Organization

gram adjustments. The Meeting of Di- Paraguay. Control programs based on rectors of Rabies Control Programs of mass vaccination of sheep and goats Central America was held in Guatemala were implemented to combat it. that same year, as was the International Seminar on Human Rabies Treatment In 2002, the Southern Cone countries after Exposure. Support for Haiti’s held working sessions and embarked on canine vaccination campaign also was the selection of common strategies for noteworthy. combating brucellosis and the harmonization of procedures to establish a Bovine brucellosis and tuberculosis subregional program. According to a continue to be an important problem for PANAFTOSA survey, 22 countries were Latin America’s public health and econ- actively working to control brucellosis in omy. Canada is free of the two diseases, 2002, compared to 16 in 1998. Bolivia, as is much of the United States (41 of Brazil, Colombia, Ecuador, and Vene- the country’s 50 states). In most of the zuela drew up or revised their projects countries and territories of the English- with assistance from PANAFTOSA, thus speaking Caribbean, the presence of increasing to 10 the number of countries brucellosis has not been confirmed. implementing brucellosis-free land cer- These diseases remain endemic in al- tification projects. most all the countries of Central Amer- ica and South America. In terms of bovine tuberculosis, national coordinators of Southern Cone There is still only partial information country programs held working sessions on the presence of brucellosis and tuber- in 2002 to improve surveillance, health culosis in reservoirs and in people, given intervention, and coordination among that the Integrated Continental Brucel- countries, and developed a proposal to losis and Tuberculosis Information Sys- create a Regional strategy for transform- tem is in its final phase of preparation ing the affected zones into zones that at the Pan American Foot-and-Mouth can be officially recognized as free of Disease Center (PANAFTOSA). During the disease. The proposal is based on 2002, however, information about seven these countries’ experiences in the strug- countries was obtained by validating gle against foot-and-mouth disease and data capture forms. with the use of surveillance in order to take the most appropriate measures. Brucellosis control programs were strengthened in Mexico, Peru, and the In 2002, PANAFTOSA began to pro- Southern Cone countries. Brucellosis duce a bovine purified protein derivative caused by Brucella melitensis, which is (PPD) standard to enable the official mainly transmitted by caprines, contin- national control laboratories to carry out ues to be a serious public health problem potency tests on their respective tuber- in Mexico and Peru, as well as on the culin production. The bovine PPD stan- border between Argentina, Bolivia, and dard will be available in April 2003.

68 Strategic and Programmatic Orientations, 1999–2002

Eradication of mouth disease vaccination campaigns in the region, with an annual average of Foot-and-mouth Disease 250 million doses distributed. In 1995, The eradication of foot-and-mouth vaccination coverage of the bovine pop- disease is critical for the health of the ulation reached 94%. But the situation economies of South American countries, changed in the second half of 2000, with especially those that export meat and outbreaks in Argentina, Brazil, and meat products. In 1987, the countries of Uruguay—which were promptly eradi- the Americas adopted the Hemispheric cated. In early 2001, the region suffered Plan for the Eradication of Foot-and- a major setback when Argentina and Mouth Disease, and in the 1990s they Uruguay (recognized as being free of made important headway in the control foot-and-mouth disease without vacci- and eradication of the disease. The Cen- nation) and the state of Rio Grande do tral American, North American, and Sul in Brazil (recognized as free of foot- Caribbean countries remained free of and-mouth disease with vaccination) the disease. experienced a reintroduction of the disease and lost their favorable epidemio- With the adoption of the Hemispheric logical status. With the cooperation of Plan, South American countries began PANAFTOSA, and based on the experi- to undertake changes that a decade later ence gathered over the years, affected translated into the strengthening of vet- countries reacted quickly and the situa- erinary systems and the fostering of a tion was controlled. In December 2002, joint public/private management model a focus of foot-and-mouth disease de- for planning executing, and evaluating tected in Paraguay resulted in that eradication strategies and activities. country’s losing its status as an area free These changes have enhanced the effec- of this zoonosis. tiveness of animal health policies and improved the infrastructure of programs Important determinants of the reintro- and services in almost every country. duction of foot-and-mouth disease in the Southern Cone are the institutional In South America, 41% of cattle herds and financial erosion of the official and 60% of the geographic area had health programs, the weakening of the no clinical manifestation of foot-and- binational or multinational border mouth disease in 1999. Up to mid-2000, health programs, and the trends in in- an area covered by Argentina, Chile, ternational trade in animals and animal Paraguay, Uruguay, and all states com- products, which increased the risk of the prising Brazil’s southern, west-central introduction and spread of the disease. (except El Dorado de Mato Grosso do Sul), and eastern livestock circuits re- The Amazon Basin Project in Brazil mained free of the disease. made significant progress, and 16 of Brazil’s and 27 of Guyana’s federative This positive epidemiological situation units were recognized as free of foot- was largely due to systematic foot-and- and-mouth disease.

69 Annual Report of the Director – 2003 Pan American Health Organization

In the Andean countries, Colombia and the organization and implementation was internationally recognized as free of of local surveillance efforts for foodborne foot-and-mouth disease with vaccina- diseases. In specific geographic/population, in an area that encompasses the At- tion spaces, PASB sought to coordinate lantic Coast Project, with an estimated with the national surveillance system and population of 7 million head of cattle. the prevention and control response in- PASB is working with the Community of frastructure, adapting its work to local Andean Nations to promote programs in conditions; an action plan encompassing that area, and thus reach the goals of objectives, technical development, mon- the hemispheric program—eradication of itoring, evaluation, and management the disease in the South American coun- mechanisms was drawn up. To support tries by 2009. this initiative, workshops were held throughout the Americas, highlighting The intensification of the disease in the the local experiences of Maldonado Southern Cone during 2001 prompted (Uruguay) and Gálvez (Argentina), sites the ministers of agriculture of that sub- in which an integrated food safety pro- region to seek ways to strengthen vet- gram was established. erinary services and promote the trans- parency of information on structures and As a way to better understand the epi- services in their countries. In that re- demiology of foodborne diseases, in spect, it was decided that PANAFTOSA 2002 PASB prepared and published would lead a group of professionals from training material intended for doctors national programs in Argentina, Bolivia, and primary care service personnel, Brazil, Chile, Paraguay, and Uruguay in which included 12 modules of technical, carrying out annual inspections, making self-assessment, and reference material. The Pan American Sanitary Bureau has it possible to periodically evaluate the It also published a book (Enfermedades supported public health surveillance in the national programs at all levels. By the transmitidas por alimentos en Uruguay) countries and the organization and end of the second inspection, various on foodborne diseases in Uruguay, with implementation of local surveillance problems had been resolved and the sys- the support of well-known Uruguayan efforts for foodborne diseases. tem of veterinary care responsible for professionals. combating foot-and-mouth disease had been strengthened. With regard to the updating of inspection services, PASB helped officials from Argentina’s National Institute of Food plan strategies for formulating a com- Control of prehensive program for the sanitary handling of food in “barter clubs,” a Foodborne Diseases new modality for the exchange of products and services in the community by Working through the Pan American In- people with limited resources. A manual stitute for Food Protection and Zoonoses of recommendations for handling food (INPPAZ), in 2002 PASB supported pub- in those venues was a noteworthy result lic health surveillance in the countries of this effort.

70 Strategic and Programmatic Orientations, 1999–2002

BOLIVIA Builds Healthy Marketplaces The municipal government of Santa Cruz has established policies for the construction of healthy public spaces—including marketplaces—whose sanitary conditions must ensure the proper supply, preservation, sale, and handling of food and drink. In 2002, close coordination by the municipal government of Santa Cruz, the departmental health service, the Bolivian Evangelical University, and the Food Research and Technology Center resulted in a proposal for pursuing active interventions along three fronts: health-hygiene and the environment, education-nutrition, and economics-productivity. The interventions were aimed at increasing the knowledge base and improving the practices and attitudes of small producers, sellers, and consumers. Efforts included training in health, hygiene, food safety, proper food handling, and improvements in the workplace. Based on the human development policies established in the municipio, a work team was set up. Its analysis of the situation revealed existing deficiencies, which were the starting point for strategic planning carried out in conjunction with the people who work in the marketplace. The study conducted by the interinstitutional work team found a high rate of food contamination. It showed that fully 45% of the food sampled had levels of fecal coliforms that exceeded 100 microorganisms per gram, and it also was contaminated with such pathogens as salmonellae, shigel- lae, and fungi. Since these levels of contamination entail a high risk of diarrheal diseases, operating strategies were developed for the construction of healthy, community-based marketplaces.

Another PASB priority in terms of the sponsibility. The objectives of this phase modernization of inspection services, in- of the project include training the volved the development of a project with human resources that will be assigned to authorities of the Brazilian National food inspection duties, thereby develop- Health Vigilance Agency (known by its ing a critical mass of trainers who will, Portuguese acronym, ANVISA), through in turn, ensure that training continues which a training program for food in- over the long term. Some 214 inspectors spection personnel in the states was de- were trained during the first phase. veloped. This program will strengthen the adoption and verification of good To strengthen cooperation in referral manufacturing practices and standard services, INPPAZ created the “laborato- operational hygiene procedures, as well ries of excellence” system. To date, five as the system of Hazard Analysis and laboratories have completed the process Critical Control Points (HACCP) in es- and four have been designated as centers tablishments that are part of the food of excellence: LATU (Uruguay, covering production chain under ANVISA’s re- 159 tests), SFDK (Brazil, 128 tests),

71 Annual Report of the Director – 2003 Pan American Health Organization

Xenobióticos (Argentina, 10 tests), and labeled food safety, and topics of specific the National Institute of Nutrition and interest to the Coordinating Committee. Food Hygiene (Cuba, 9 tests). In 2002, PASB developed an Internet As part of the effort to guide technical site for consumers—“Community Chan- cooperation, a survey of the Inter-Amer- nel”—which provided scientific infor- ican Network of Food Analysis Labora- mation in accessible language. The site tories concluded in 2002. The network includes various key messages on food currently has 66 laboratories in 32 safety in English, Portuguese, and Span- countries. The survey was evaluated by ish. They have been made available to a team of outside consultants, and 54 the leading media outlets in the Ameri- laboratories in 27 countries partici- cas, and the information has been used pated. The survey showed that countries in various training programs by public need to strengthen quality assurance, organizations and institutions. This ef- conduct tests of laboratories, and sup- fort is designed to benefit high-risk port the development of standards and groups, such as children and indigenous reference material. communities.

As part of the cooperation for institu- As part of the cooperation with the tional harmonization and development, World Health Organization, a food legis- PASB worked with the countries to com- lation manual using the Codex Alimenta- pile and organize their food legislation. rius as a reference is being revised and As of 2002, the computerized system of adapted. This manual also includes guides food legislation (Legalim) had been in- that the countries can use as models. stalled in Argentina, Brazil, Costa Rica, Cuba, Nicaragua, and Venezuela. The Diarrhea caused by foodborne diseases database is designed to analyze the coun- remains a challenge to health authorities, tries’ laws in order to harmonize food particularly in countries and communi- safety regulations. ties that lack basic sanitary services. Outbreaks of foodborne diseases con- With regard to the Codex Alimentar- tinue to affect tourism, which is the ius, PASB drew up a strategic document major source of revenue in many of the to support participation by the countries Region’s countries. In 1999–2002, 22 of the Region. It also supported the countries of the Region reported 2,266 Codex Alimentarius Coordinating Com- outbreaks with 77,605 cases and 70 mittee for Latin America and the deaths to the Regional Foodborne Dis- Caribbean by setting up virtual discus- ease Surveillance Network (known by its sion forums on the INPPAZ web page. Spanish acronym, SIRVETA). Bacteria There are currently five active discus- were the most common etiological agents sion forums for biotechnology, additives, of foodborne disease outbreaks (63%).

72 Strategic and Programmatic Orientations, 1999–2002

in November 2002 (Figure 5), and no Progress in the indigenous measles cases have been reported in the Region since. This extraor- Control of Diseases dinary achievement has come about because of the firm commitment of every Preventable by government in the Region to fully implement PASB’s recommended vaccination Immunization strategy.

Measles The Americas will continue to be un- The Region of the Americas has made der constant threat of importations of impressive progress in reaching the goal measles virus from other areas of the of interrupting indigenous transmission world where the disease remains en- of measles. Since September 2001, a demic. The experience in the Americas, new measles genotype, d9, was intro- however, shows that country programs duced in the Region, causing outbreaks with high (95%) routine and campaign in Venezuela and subsequently being ex- coverage, supported by systematic and ported to Colombia. After intense vacci- thorough supervision, including active nation efforts, the outbreaks were suc- case finding and house-to-house moni- cessfully controlled. The last case of d9 toring, can successfully interrupt measles genotype measles occurred in Venezuela transmission.

FIGURE 5. Measles in the Americas, by week and year of rash onset, January 2001 to December 2002.

210

180

150

120

Cases 90

60 End of transmission genotype d9 End of transmission genotype D6 30

0 1 47 10 13 16 19 22 25 28 31 34 37 40 43 46 49 52 3 6 9 12 15 18 21 24 27 30 33 36 39 42 45 48 51 2001 2002

Week and Year

Dominican Republic/Haiti outbreak (genotype D6). Venezuela-Colombia outbreak (genotype d9). Sporadic known imported cases.

73 Annual Report of the Director – 2003 Pan American Health Organization

Haemophilus influenzae Rubella Since the introduction of H. influenzae Rubella and congenital rubella syn- type b (Hib) vaccine to the Americas in drome are now recognized as high prior- 1994, significant advancement in the ity public health problems. In 1999, disease’s control has been achieved. As of PASB developed an accelerated rubella 2002, the Region’s countries included control and congentital rubella syn- Hib vaccine in their immunization pro- drome prevention strategy for the Amer- grams, with the exception of Haiti, icas, which followed the successful adult Guatemala, and Suriname (Figure 6). mass vaccination campaigns in Cuba The fact that countries have well struc- and the English-speaking Caribbean. tured surveillance systems has been fundamental for the success of the new vac- By October 2002, 41 countries and ter- cine introduction. Hib vaccination efforts ritories in the Americas had introduced have led to a substantial decrease in bac- rubella-containing vaccine in their na- terial meningitis cases (Figure 7). PASB tional childhood immunization programs. will continue to support surveillance to The Dominican Republic, Haiti, and Peru monitor the impact of Hib immunization will launch such immunization cam- and to assist in investigating possible paigns in 2003 and 2004. Many countries vaccine failures and changes in the Re- also have initiated specific strategies for gion’s epidemiological status. the accelerated control of rubella and

FIGURE 6. Global status of countries using Hib vaccine in their national immunization program as of October 2002.

Routine Hib implementation status Yes No

74 Strategic and Programmatic Orientations, 1999–2002

FIGURE 7. Number of cases of Haemophilus InfluenzaeInfluenzae meningitis, before and after vaccine introduction, Brazil, Chile, Colombia, and Uruguay.

2,000 200

Introduction

1,500 150 Introduction

1,000 100

Cases Brazil Cases Chile

500 50

0 0 1997 1998 1999 2000 2001 1996 1996 1998 1999 2000 2001 Year Year

100 75

75 Introduction 50 Introduction

50 Cases Colombia Cases Uruguay 25 25

0 0 1995 1996 1997 1998 1999 2000 2001 1993 1995 1997 1999 2001 Year Year congenital rubella syndrome (Figure 8). tional goal, PASB has placed renewed As countries launch accelerated rubella emphasis on accelerating local-level ac- control campaigns, documenting the en- tivities to improve coverage. Municipal- demic strain in each country will become ities with insufficient coverage levels critical for determining whether the case constitute high-risk areas for epidemics. is imported or not. Even though a country Using information from seven countries may have eliminated rubella, importa- in which coverage data by municipality tions of the virus may occur and can only is available, the percentage of munici- be avoided when other areas of the world palities with greater than 95% DTP3 carry out similar efforts. vaccine coverage increased from 44% in 2000 to 50% in 2002 (Figure 9). Equity in Immunization: PASB, in collaboration with the coun- Reduction of Disparities tries, has pursued specific initiatives to In deciding to make equity in the pro- increase equity. In November 2002, with vision of health services a key organiza- PASB’s support, all ministries of health

75 Annual Report of the Director – 2003 Pan American Health Organization

FIGURE 8. Countries with accelerated rubella control strategies as of 2002, Region of the Americas.

Rubella vaccination coverage English-speaking Caribbean, Costa Rica, Honduras, Brazil and Chile

100 90 80 70 60 50 40 30 20 10 Countries with accelerated control of rubella/ 0 a b a congenital rubella syndrome in women. English Costa Honduras Brazil Chile a b Countries with accelerated control of rubella/ Caribbean Rica congenital rubella syndrome in men and women. Source: Country reports. Countries that used MMR for many years, protecting a Vaccination men and women. major cohorts of women of childbearing age. b Vaccination women only. Vaccination of selected groups.

Utilization only in routine programs.

in South America set for themselves the PASB also is collaborating with other goal of improving immunization cover- partners in specific initiatives to im- age of high-risk and low-coverage areas, prove equity in various countries. For including underserved populations. They example, PASB is working with Bolivia’s agreed to designate the first week of Ministry of Health and the World Bank June 2003 as the “South America Vacci- in the design and implementation of a nation Week.” Some Caribbean, Central strategic plan aimed at reducing the American, and North American coun- number of municipalities at risk by tries have since joined this initiative, and seeking local level commitment through PASB has already initiated discussions communication with community leaders with Member Countries for this initia- and support of the national immuniza- tive to become the “Pan American Vac- tion program. cination Week” starting in 2004.

76 Strategic and Programmatic Orientations, 1999–2002

FIGURE 9. Percentage of municipalities with DPT3 coverage ≥ 95%, selected countries of The Americas,a 2000–2002.

100

40 ??????????????? 30

0 Bolivia Ecuador Guatemala Honduras Paraguay Uruguay Venezuela Average

2000 2001 2002

a Countries for which data has arrived as of April 9, 2003.

Greater Attention to pact of national immunization programs to enable their continued growth. Sustainable Financing The ongoing economic crises in the Re- PASB is advocating the development gion, coupled with the uneven manage- of legislation that establishes a specific ment of the Region’s health reform and line item in national budgets committing decentralization processes, call for re- resources for recurrent costs associated newed policies and strategies by coun- with the purchase of vaccines and sy- tries and the international community to ringes. The basis for this initiative is that maintain and expand the accomplish- vaccination is a human capital invest- ments in the field of vaccination. Fluctu- ment. The interruption of vaccination ations in the allocation of resources due efforts, even for a limited time, harms to economic downturns jeopardize the the continuity of the program, increases implementation of the national immu- morbidity and mortality, and under- nization programs, potentially opening mines this human capital investment. the way for higher morbidity and mor- Six countries have enacted legislation tality and, consequently, higher health toward this end. costs. PASB has facilitated critical dialogue with Member Countries and the Efforts also have been made towards international community, including fi- clarifying the stewardship role of min- nance ministries, to safeguard the public istries of health in immunization, and health achievements and the proven im- strengthening technical and financial

77 Annual Report of the Director – 2003 Pan American Health Organization

HAITI’s National Program of Immunization Makes Important Gains In 2002, the work and success of Haiti’s National Program of Immunization tracked along four broad objectives—preserving the gains made in earlier immunization campaigns, strengthening the epidemiological surveillance of diseases covered under the Expanded Program of Immunization, strengthening the regular immunization program, and strengthening the cold chain. The following are some highlights of successful efforts in 2002.

Preserving the gains from earlier vaccination campaigns. In 2002, a national campaign against the epidemics of measles and of poliomyelitis due to mutant vaccinia virus was conducted. The Min- istry of Public Health and Population decided to launch this third round in order to consolidate im- munity among children under 10 years old and infants 6–23 months old, two groups that had received two vaccination doses against polio and one against measles in 2001. In this campaign—as in those in 2001—95% of the 3.3 million children under 10 years old to be vaccinated received a third dose of oral polio vaccine, and 95% of the 500,000 infants 6–23 months old received an additional dose of measles vaccine. The success of these campaigns is attested to by the fact that the last confirmed case of polio due to mutant vaccinia virus dates to July 2001, and that the last confirmed case of measles dates to Sep- tember of that year. Haiti—and the Dominican Republic—are working to stop the polio epidemic that threatens the recertification of the eradication of this disease in these two countries, and in the Region of the Americas as a whole. It should be noted that the epidemics of polio and measles that buffeted the country in 2000 and 2001 resulted from the significant number of susceptibles that have accumulated between 1995 and 2000, and which testify to the inefficacy of the quarterly catch-up campaign conducted in 1998, as well as to some weakness in the regular vaccination program. The success of the 2002 campaign is in large measure due to the mobilization of some 24,000 schoolteachers, 5,000 volunteers, 1,200 Ministry staff members, and 40 support staff. The campaign also benefited from the technical, financial, and logistical support of PASB, UNICEF, the World Bank, the Centers for Disease Control and Prevention (CDC), and CIDA. The National Program of Immunization will use the lessons learned from these campaigns to guide the development of a new five-year plan for 2003–2007, which will aim at consolidating gains made in the fight against polio and measles, reinforcing the regular immunization program, ensuring that the country’s Expanded Program of Immunization (EPI) is financially viable, reinforcing epidemiological surveillance, and improving the program’s management.

Reinforcing the epidemiological surveillance of EPI diseases. To this end, the national program actively investigated cases of flaccid paralysis and of measles throughout the country’s hospitals. In 2002, this effort was carried out through the technical support of PASB consultants, who also helped train and retrain national professionals in the investigation of cases. As part of this objective, wild poliovirus or mutant vaccinia virus were contained in the country’s laboratories, for which PASB consultants provided much assistance. In addition, 100 epidemiological sentinel sites were put in operation. Nurses that PASB had engaged to reinforce the regular program at the health department level, received training in epidemiological surveillance.

78 Strategic and Programmatic Orientations, 1999–2002

responsibilities at the state and local Northern Ireland, and United States of level for decentralized systems. America.

Technical presentations overviewed the basic concepts of climate variability and change; reviewed health status in the Health Caribbean Region with particular reference to climate variability and change; presented frameworks for evaluating the and the vulnerability of the health system to climate variability and change; presented Environment frameworks for assessing and responding to climate-related health risks; examined linkages between climate and human Climate Change health; and examined public health policies and strategies for adaptation to cli- PASB/WHO organized the “Climate mate variability and change. Variability and Change and their Health Effects in the Caribbean Conference and Major health issues taken up at the Workshop,” held in May in St. Philip, conference were vector-borne diseases Barbados. This event was conducted (dengue, malaria), waterborne diseases, under the auspices of the Government of heat stress, asthma, disaster response to Barbados and the Interagency Network climate and weather phenomena, and on Climate and Human Health formed toxins in fish. The emphasis was on A conference organized by PASB/WHO by WHO, the World Meteorological Or- work conducted in or relevant to the examined such issues as climate variability ganization, and the United Nations En- Caribbean basin. Some presentations vironment Program. discussed ecological effects that are and change, vulnerability of the health unique to the Caribbean, focusing on an system to climate variability and Most of the participants were from the episode of massive contamination of the change, and links between climate Caribbean, although representatives from sea linked to river outflows from South and human health. elsewhere in the Region and the world America, as well as the annual atmos- also attended. The conference drew rep- pheric transport of African dust across resentatives from Anguilla, Antigua and the Atlantic to the Caribbean. The poli- Barbuda, Australia, Bahamas, Barbados, cies and strategies for adaptation to cli- Belize, Bermuda, British Virgin Islands, mate variability and change covered a Canada, Colombia, Cuba, Dominica, Do- broad range of topics, from the control minican Republic, Grenada, Haiti, Ja- of specific diseases to general communi- maica, Kenya, Mexico, Netherlands An- cation strategies on climate and health. tilles, New Zealand, Panama, Puerto Rico, Saint Kitts and Nevis, Saint Lucia, During the workshop portion of the Saint Vincent and the Grenadines, event, 39 participants from the Region Samoa, Suriname, Trinidad and Tobago, came together, including representatives United Kingdom of Great Britain and of the public health, climate/weather,

79 Annual Report of the Director – 2003 Pan American Health Organization

and environmental sectors, mainly from ning for public health services in the Caribbean islands and Caribbean Com- countries. munity countries. The countries and territories represented were Anguilla, Antigua and Barbuda, Bahamas, Belize, British Virgin Islands, Cuba, Dominica, Health and Dominican Republic, Grenada, Haiti, Jamaica, Netherlands Antilles, Saint sustainable Kitts and Nevis, Saint Lucia, Saint Vin- cent and the Grenadines, Suriname, and development Trinidad and Tobago. As a way to contribute toward institu- Work groups, facilitators, and resource tional strengthening, the Latin Ameri- people discussed issues of awareness, can Toxicology Network; national net- use of data, roles of health and climate works in Argentina, Brazil, Chile, and professionals, and needed institutional Mexico; and the Workers’ Health Net- linkages. They reached consensus on work, were consolidated. The subthe- 22 recommendations for future work matic network on persistent organic on climate and health in the Region. contaminants and the Occupational Recommendations generally fall into Health Laboratories Network were the categories of strategies for enhancing established. awareness about the effects of climate change, more effective use of data, and The CEPIS/GTZ project designed to mechanisms for strengthening related harmonize records of poisoning cases institutions. and the project on chemical emergencies conducted with São Paolo’s CETESB As a result of the conference and (Brazil), a PAHO collaborating center on workshop, health scientists, practition- chemical disasters, also got under way in ers, and officials were informed about 2002. The Peru/Ecuador and Colombia/ the impact of climate variability and El Salvador technical cooperation proj- long-term change in the Caribbean; sec- ect on surveillance systems for pesticide tors relevant to health—water resources, poisonings continued to operate. agriculture, and fisheries—were brought on board; strategies in coastal zone Finally, the following tools were com- management related to sewage disposal pleted: a virtual library on health and and other health issues were introduced; environment-toxicology; a virtual library joint interdisciplinary research projects on health and environment-workers’ were fostered among local participants health; electronic libraries on pesti- and partnerships were established be- cides for household use; eight self- tween scientists from developed and de- instructional courses published on com- veloping nations; and global, regional, pact disc, which are being accredited by and national climate information was several universities; a glossary of health promoted and incorporated into plan- and environmental terms; a registry of

80 Strategic and Programmatic Orientations, 1999–2002

toxicology professionals who belong to related to drinking water and sanitation, the Toxicology Network of Latin Amer- solid waste management, and pollution ica and the Caribbean (known by its prevention and control, using health and Spanish acronym, RETOXLAC), which social indicators obtained from various will mobilize resources; and a registry of sources, including household surveys. toxicological centers with an expanded directory. SISAM also will cover three broad fields of action: drinking water and sanitation; solid waste; and the prevention and control of air, water, and soil pollu- Inter-American tion. To date, the drinking water and sanitation module has been put in place Environmental in Cuba, Honduras, and Panama, where the system’s efficiency and effectiveness Sanitation will be pilot-tested. The SISAM water and sanitation module provides govern- Information System ment and business entities, and international organizations, with information In 2002, PASB developed the Inter- on institutions and agencies associated American Environmental Sanitation In- with the sector, as well as with informa- formation System (known by its Spanish tion on the quality of drinking water acronym, SISAM), a dynamic support and sanitation services. information system for the countries that covers basic institutional and quality- Workmen process recyclable materials of-service aspects and facilitates the Environmental at a solid waste collection point. The coordination of sectorial initiatives. The system, which can be accessed on the Services: Regional Regional Assessment of Solid Waste is CEPIS website (www.cepis.osp-oms.org), designed to collect information on the will help national institutions and agen- Assessment of Solid status and prospects of urban cleanup cies to expand sectorial information based services in the countries. on need. Waste

SISAM directly contributes to the fol- The conceptual design for the 2002 low up of the United Nations Millen- regional assessment of solid waste man- nium Development Goals by providing agement services was completed. The organized and reliable regional informa- model and its implementation strategy tion on the coverage and quality of were discussed and adjusted during re- drinking water and sanitation services, gional seminars at which most of the as well as other key aspects for the sec- countries of the Region were repre- tor. SISAM also will promote the cre- sented. The overall objective of this pio- ation of national sectoral information neering exercise is to gather information systems in the countries, and will make on the current status and future pros- it possible to cross-check information pects of urban cleanup services in the

81 Annual Report of the Director – 2003 Pan American Health Organization

countries, thereby facilitating the estab- National networks of environmental lishment of policies, plans, and pro- laboratories were established in Argen- grams for improving those services and tina, the Dominican Republic, El Sal- reducing the adverse effects on people’s vador, Guatemala, Honduras, Mexico, health and the environment. and Nicaragua.

The assessment is being carried out A laboratory portal was developed on under the direction of national groups in the CEPIS website. The portal allows each of the countries. These groups are network members to interact with one composed of public and private institu- another and disseminates information of tions, NGOs, and professional associa- interest to the environmental laborato- tions. PAHO/WHO Country Offices sup- ries. In 2002, PASB signed an accredita- ported the work of each national group, tion agreement with the Canadian Asso- and the groups also received technical ciation for Environmental Analytical cooperation from CEPIS and PASB. Laboratories and the Standards Council of Canada, which four laboratories already have endorsed. A patent was obtained for a product that removes arsenic National from drinking water in remote communities, and advisory assistance and tech- Laboratories nical cooperation were provided on this matter to Argentina, Mexico, Nicaragua, As a way to promote and coordinate and Peru (municipio of Ilo); the CEPIS activities for developing the capabilities laboratory is self-sufficient, with im- and enhancing the quality of environ- proved capability to test human and en- An environmental health project in mental health laboratories, training and vironmental samples for parasites. indigenous communities is now fully development projects were carried out operational in 15 countries. The project for staff of environmental and health will benefit families such as this laboratories in Belize, Bolivia, Colombia, Populations at Risk Guatemalan father and child. Costa Rica, the Dominican Republic, El Salvador, Guatemala, Honduras, Mexico, Nicaragua, Panama, and Uruguay. Four- Indigenous Communities teen environmental laboratories in the The acceptance of the environmental Region received technical assistance. health project in indigenous communities that began in 2002, has far exceeded A regional network of laboratories in expectations. The project is now fully Latin America and the Caribbean was operational at the regional level and in consolidated to provide training and 15 participating countries. National compare environmental samples. The working groups executed demonstration network includes a database of the lab- projects in Bolivia, Colombia, Ecuador, oratories. This project was partially Guatemala, Peru, and Venezuela; these funded by the United States Centers for countries are pooling efforts and, con- Disease Control and Prevention (CDC). sequently, integrating the financial

82 Strategic and Programmatic Orientations, 1999–2002

ARGENTINA Improves an Indigenous Community’s Quality of Life Late in 2001, a pilot project was launched to improve the quality of life of indigenous peoples in Argentina’s Chaco region—the Chorote community was selected for the project. The Chorote community of Misión Lapacho Uno has a population of more than 300 and is located three kilometers from Tartagal, in the north of Salta Province. It had a high rate of gastrointestinal and lung ailments, and its inhabitants were exposed to vector-borne diseases such as Chagas’ disease, malaria, dengue, and Hantavirus infections. The community’s poor health conditions were due, in large part, to inadequate housing, lack of latrines, insufficient water supply, and lack of an adequate place in which to cook and prepare food. The Chorotes cooked their food outdoors, using a handful of logs for fuel. Persons in charge of food preparation—mainly women—often had to shift the location of the cooking area, in search of a little shade. In order to help correct this situation, which affected all of the Chorote community’s 21 family groups, it was decided to build three water storage tanks with a capacity of 5,000 liters each, three areas to wash clothes, and bathroom facilities. In addition, a model home that the community could use as a sewing and handicraft workshop was constructed, 21 cooking areas were set up for hygienic food preparation, and 21 solar ovens and 21 latrines that convert waste to fertilizer were installed. In mid-2001 UNICEF’s office in Argentina joined in, providing materials for constructing these installations. Each family group participated in the construction of its own cooking area and latrine. Construction began in 2001, and in December of that year, Dr. Mirta Roses, then Assistant Director of PAHO, visited the Chorote village, learning first-hand of the community’s needs while assessing the progress of the planned activities. Subsequently, at the community’s request and with the support of the Ministry of Health of Salta Province, the project was expanded and community women were offered courses in sewing and in nutrition and cooking, so they could make their own and their children’s clothing and prepare more nutritious meals. In September 2002, the Pan American Institute for Food Protection and Zoonoses added its support, providing instruction for the safe use of cooking areas and latrines, as well as educational material on hygienic food-handlling. On December 18, 2002, the new facilities were inaugurated with a ceremony in which the entire Chorote community participated, as did leaders of other indigenous ethnic groups, the Governor of Salta Province, officials from Tartagal, and representative of Argentina’s Ministry of Health, the In- digenous Provincial Institute of Salta, the National Institute for Farming and Livestock Technology, PAHO/WHO, UNICEF, Bolivia’s Sumajhuasi Foundation, and the Padre Ernesto Martearena NGO.

83 Annual Report of the Director – 2003 Pan American Health Organization

contributions from the members of the Guatemala, Honduras, and Nicaragua), group. beginning in August 2002 with funding from the Swedish International Devel- Eighteen demonstration projects are opment Authority (SIDA). To date, na- under way, involving the preparation of tional teams are organizing and training training and educational materials and local teams at the pilot sites where the of a database. Argentina, Brazil, Costa validation exercise is being carried out, Rica, Chile, El Salvador, Honduras, in accordance with the methodology Mexico, Nicaragua, and Panama are proposed in the tool-kit. participating, but they are not executing demonstration projects. Each country These activities have been carried out has a national working group comprised through the consensus and participation of institutions involved in development of governmental, private, academic, and of the indigenous population; these form NGO sectors. They have helped to con- a network with 95 professionals from 65 solidate existing national health and institutions. safety commissions in the countries. In addition, this project helped to raise awareness among businesspeople and Workers’ Health managers, and influenced the methodol- In Central America, PASB designed a ogy for evaluating the cost-benefit of in- “tool-kit to foster healthy work environ- vesting in workers’ safety and health. ments” in the economy’s formal sector, as practical support for the Strategy to ILO contributed materials to the tool- Promote Healthy Workplaces in Latin kit that will enhance that organization’s America and the Caribbean. To this end, opportunities to send a message to all A PASB effort in Central America has a team of consultants is working to im- the involved countries about the possi- helped to put in place such activities as plement the strategy in Brazil’s informal bility of planning joint actions that in- hygiene and safety measures, sector of the economy. crease the efficiency of those already occupational medicine efforts, and being carried out in the Region, and so general medical care for workers. The tool-kit promotes various scattered further the cause of creating healthy efforts that have been partially used to workplaces. implement hygiene and safety activities, occupational medicine efforts, cost- benefit analyses on productivity, general medical care, and other areas. As such, it Healthy seeks to generate holistic processes that integrate various approaches with a Environments human development perspective, and to reinforce the leadership role of those involved in the workplaces. Citizen Participation PASB cooperated in preparing the This strategy underwent a validation Inter-American Water Day (IAWD) by process in Central America (El Salvador, developing and distributing information

84 Strategic and Programmatic Orientations, 1999–2002

to the countries to promote national working groups. It also developed the IAWD portal (http://www.cepis.opsms. Health org/bvsadiaa/e/home.html), with reference documents from previous years, ex- Promotion periences from the countries, and links to the other participants in the IADW initiative. and Disease

Through CEPIS, PASB supported Prevention health-promoting schools as an environmental health strategy, highlighting the creation of healthy environments. In Lifestyle Changes Peru, the PAHO Country Office is part of the Multisectoral Committee of Health and Obesity Promoting Schools, and it has encouraged the signing of the Cooperation Agreement Environmental and lifestyle changes by the ministries of health and the min- that have occurred in the last 50 years istries of education to strengthen the are responsible for the epidemic emer- strategy at the national level. gence of obesity throughout the Ameri- cas. Increasing obesity rates are now observed in several of the Region’s coun- Disaster Prevention in tries, affecting persons of all social and Water and Sanitation cultural backgrounds. The alarming rise in obesity is partly due to an increase in Infrastructures more sedentary occupations, particularly The Regional Course on Disaster Miti- among urban dwellers; a greater reliance gation in Drinking Water and Sanitation on motorized transportation; longer tele- Systems was held in 2002, with the par- vision viewing; and ubiquitous labor sav- ticipation of 16 countries of the Region. ing devices that favor physical inactivity. A CD-ROM with technical and training Some key environmental changes such as material was developed for this course. the rapid pace of urbanization, economic New technical material was also devel- growth, and more efficient agricultural oped and material was updated on seis- production also are factors. Together, mic design of water systems and design these factors have made possible what criteria for treatment plants in the face for was unattainable for many cen- of natural threats. This spurred univer- turies—year-round food availability at sities in Guatemala, Honduras, Nica- affordable prices for larger segments of ragua, and Peru to include disaster pre- the population. vention in their sanitary engineering curricula. Treatment approaches for obesity have shown only modest results so far, and are unlikely to halt the epidemic. They

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BAHAMAS Fights Obesity Among its Adolescents PASB technical assistance supported the Bahamas Ministry of Health in an effort to develop standards, norms, and policies to strengthen its adolescent health program. During 2002, PASB provided support for a summer camp for 125 students to teach them about healthy lifestyles and healthy choices regarding such issues as better nutrition, delaying the onset of sexual activity, reducing al- cohol intake and tobacco use. In addition, lectures, cultural demonstrations/presentations, historic educational tours, craft and job training were part of an effort targeting more than 200 children and adolescents. A cross-section of students from both private and public schools and adolescent children participated. In 2002, The Ministry of Health’s Public Health Nutrition Unit, with PASB support, coordinated a special summer camp for extremely obese junior high-school students and their parents. Camp sessions oriented students on how to make lifestyle changes through diet and exercise, and taught them how to prepare low fat meals. The students will be monitored throughout 2003.

are not only technically unfeasible but transformed their urban landscapes, en- also unrealistic, given the extraordinary hancing pedestrian activities. financial resources that might be required even for developed countries in the Region. Therefore, preventive and health promotion strategies are most Community Mental likely to succeed at the population level. Public health’s role in the Americas Health Services should be to make healthy choices be the easiest choices, and the objective over An assessment of the delivery of men- the next decade is to bring about key be- tal health services in Latin America and havioral changes at the population level. the Caribbean that PASB conducted in 2001, showed that in most countries tra- To commemorate World Health Day, ditional psychiatric hospitals remain as whose motto in 2002 was “Move for the centerpiece of their mental health Health,” PASB organized a regional con- systems. Moreover, despite advances test to award prizes to small cities in the made in formulating mental health poli- Americas that are setting an example of cies in the 1990s, the implementation active living by improving recreational of mental health services reform is still areas and protecting public spaces. More very incomplete. than 150 municipalities took part, attest- ing to the great interest that the issue has As a way to change this situation, in awakened in the Americas. Loja, Ecua- 2002 PASB embarked on a comprehen- dor; Surco, Peru; and Balcarce, Argentina sive strategy to support the countries de- received awards. Bogotá, Colombia, and velop community-based mental health Curitiba, Brazil, also have significantly services. This approach includes building

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The CARIBBEAN PROGRAM COORDINATION Fights for Mental Health Care The Caribbean Program Coordination (CPC) engaged in many and varied activities designed to improve mental health care in the countries served by the office. At the subregional level, the first draft of a Mental Health Strategic Plan was presented to the Caucus of CARICOM Ministers Responsible for Health. CPC’s technical cooperation with the countries under its jurisdiction included the following activities:

• A technical-cooperation-among-countries project in Barbados and Saint Lucia seeks to shift mental health care away from institutional settings and into the community. • With PASB support, mental health legislation was updated in Antigua and Barbuda, Barbados, Grenada, Saint Lucia, and Saint Kitts and Nevis. • Police and prison officers in Barbados, Saint Lucia, and Montserrat received sensitivity training regarding mental health issues. • Barbados and Saint Lucia received support for their participation in the WHO/PASB Mental Health Policy Project. • The CPC office provided technical cooperation for the development of a mental health plan in Montserrat. • Mental health reforms in Barbados and Saint Lucia were reviewed in a subregional mental health meeting, which also discussed whether the methodology used in these two countries was applicable elsewhere in the Caribbean. • In Barbados and Saint Lucia, the CPC office, working with PASB, held a workshop, “The Human Rights and Fundamental Freedom of Persons with Mental Disabilities and their Fam- ilies,” to sensitize stakeholders about issues related to the human rights and basic freedoms of persons with mental disorders and their families. • In Dominica, the CPC office helped launch a mental health campaign aimed at health workers and provided assistance to train primary health care staff. • In Grenada, a curriculum was developed and disseminated for the in-service education of primary health care staff on how to recognize and begin to manage common mental disorders; a training-of-trainers program on the use of that curriculum also was carried out. It is hoped that the curriculum will be used throughout the subregion. • Saint Vincent and the Grenadines received support for drafting a mental health plan aimed at improving mental health care and facilitating promotion and prevention activities. capabilities in planning and management oping research and disseminating guide- of mental health services, training pro- lines, and implementing best practices. fessionals and community members, providing technical support to countries for In cooperation with the Government of implementing mental health plans, devel- Emilia Romagna Region (Italy), PASB

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organized a course on planning and volves the development of a network for managing mental health services for of- research on mental health with the par- ficers from Latin American ministries of ticipation of Latin American, Canadian, health. An advisory group was created and United States centers. The network to provide technical support to countries is developing training activities and pro- developing new community services, moting studies to obtain data that could and training in the use of WHO modules foster the development of cost-effective on mental health policy and in plan de- mental health services in the Region. velopment was provided.

In 2002 PASB continued to support re- Empowering forms to mental health services in Barba- dos, Brazil, Chile, Guatemala, El Sal- Population Groups vador, Mexico, Paraguay, Peru, and Saint Lucia. Projects in this regard also were started in Argentina, Bolivia, Ecuador, Adolescents and Youths and Nicaragua. With PASB support, a Adolescents (10 to 19 years old) and meeting to discuss mental health reforms youths (15 to 24 years old) in the Re- in the Caribbean was held in Barbados; gion are a heterogeneous population. To in-depth discussions led to potential col- improve the health of these groups, laborative projects in this area. PASB has pioneered the development of health policies and legislation, the de- Several countries are implementing in- sign of distance education, the establish- novative community mental health ser- ment of networks and alliances, and To improve the health of adolescents vices. Some examples include the devel- support for health services. and youths, PASB has pioneered the opment of a program to treat depression development of health policies and at the primary care level in Chile, the Drafting of youth-related legislation legislation for these groups, the design deinstitutionalization of psychiatric pa- was encouraged in Honduras and Ni- of distance education, the establishment tients in Brazil and Mexico, the downsiz- caragua, and in El Salvador, citizen con- of networks and alliances, and support ing of the psychiatric hospital and the sultations were held on youth legisla- for the health services. development of community-based mention. These three countries, along with tal health projects in Barbados, and the Belize and Guatemala, have explicit na- promotion of community programs in tional policies on adolescents that in- Guatemala and El Salvador. clude sexual and reproductive health. In addition, the five countries have To ensure that the new community established intersectorial committees on services will be monitored and evalu- adolescents with the participation of ated, PASB launched two initiatives. government organizations, NGOs, inter- The first involves a project to develop national cooperation agencies, and min- indicators and methodologies for evalu- istries of education. All except Belize ating mental health reforms in Barba- have published and disseminated a doc- dos, Ecuador, and Saint Lucia; this proj- ument analyzing laws and regulations ect was supported by the Montreal on adolescents and youths. Some 100 Collaborating Center. The second in- professionals have been trained in the

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EL SALVADOR Empowers and Trains At-risk Population Groups Adolescents in El Salvador have many serious unmet needs. As a way to provide training for this population group, the Bureau cooperated in designing the Interagency Program for the Empower- ment of Adolescent Girls and in managing its funds, with the support of the United Nations Inter- agency Gender Working Group (IGWG). The program deals with the needs of the most vulnerable adolescents in terms of factors such as health, entry into the world of work, participation at decision making levels, education, and violence prevention. PASB also cooperated in consolidating organized groups of adolescents and youths. For example, it promoted work for adolescents and youths in the municipio of El Paisnal, thus helping to improve food and nutritional safety and decrease levels of violence. The Bureau also cooperated in the design and dissemination of the National Plan to Prevent and Respond to Family Violence, which has a strong intersectoral and community participation. Part of this plan involved promoting local groups’ involvement in the care of women, boys, and girls who had been victims of family violence. These initiatives, along with the interventions related to the health sector reform process, have helped improve the detection of and response to family violence in all the sexual and reproductive health services of the country’s 28 basic comprehensive health systems. All these activities were strengthened by the incorporation of the gender perspective. In addition to the work with the groups, health indicators that demonstrate the gender inequities in health and measure progress in achieving equity, reducing gender disparities in health, and planning timely interventions were validated. This work was accomplished with the participation of 13 national governmental and non-governmental institutions. drafting of public policy; 350 youth or- Brazil, have trained many health pro- ganizations, NGOs, 120 government fessionals. Johns Hopkins University organizations, 125 legislators, and more (U.S.A.), in cooperation with the Bureau, than 100 community leaders receive ad- designed a Spanish-language CD-ROM vocacy notifications issued by the inter- to train first level health care providers in sectorial committees on adolescence. the sexual and reproductive health of adolescents. PASB also has played an important role in developing the countries’ capabilities The Bureau also designed and ex- to train professionals, who currently lack panded the ADOLEC/BIREME project experience, in adolescent health at the (http://www.adolec.org). This regional undergraduate and graduate levels and Web page offers those interested in ado- in the services. It worked with three uni- lescent health access to reports, newspa- versities to design and deliver distance per articles, and the results of research courses. The University of Monterrey, and experiments through its virtual Mexico, the Catholic University of Chile, health library. Brazil, Costa Rica, Hon- and the University of Río de Janeiro, duras, Mexico, and Nicaragua have their

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own Web pages with interactive forums participated in establishing the Intera- for youths. gency Working Group on Aging, which promotes monitoring of the agreements In October 2002, PASB supported the reached at the World Assembly on First Virtual Conference on Adolescence, Aging, held in 2002 in Madrid. The In- held over the Internet from Guadalajara, ternational Plan of Action approved in Mexico. For the conference’s 14 days, the Madrid Summit by the United Na- nearly 1,000 specialists in adolescent tions Member States is complemented in health saw and heard presentations on the Region by the Policy Framework on the Internet, participated in virtual Active Aging and by a protocol for the courses, and shared lessons learned in execution and evaluation of comprehen- various forums. sive programs that support older adults. In collaboration with regional experts, PASB is improving the lives of adoles- indicators for monitoring and evaluating cents through an innovative approach: a priorities in the area of health and aging project that engages adolescent males in were developed. To initiate implemen- an activity they enjoy, playing soccer. tation of the International Plan of Ac- The goal is to promote positive health tion, the countries were supported in behaviors and gender equity in preado- evaluating and promulgating regu- lescent males (ages 8 to 12 years) by de- lations for laws and national plans to veloping, testing, and validating a train- guarantee older adults’ right to health. ing curriculum for soccer coaches. As part of the effort to improve older PASB is helping to create a guide to Since 2002, PASB has been supporting adults’ access to primary care, PASB cre- the countries in the development of proj- ated a network of experts to develop a provide health personnel with essential ects and models to prevent HIV/AIDS clinical guide to primary care for older tools for evaluating older persons’ health among adolescents. A network of more adults. The guide’s objective is to provide problems, identifying risk factors for than 500 specialists has been estab- health personnel with essential tools for loss of function and for disability, and lished; they periodically receive advo- evaluating older persons’ health prob- establishing comprehensive primary cacy notices on AIDS and youths, as well lems, identifying risk factors for loss of care programs that address these as a quarterly news bulletin on the sub- function and disability, and establishing persons’ health. ject. A model for changing behavior in comprehensive primary care programs young people was developed and dis- that address the major problems associ- seminated; it will contribute to the for- ated with older adults’ health. The net- mulation and evaluation of interven- work members who validated the guide tions aimed at adolescents and youths. are experts from Chile, Costa Rica, Cuba, El Salvador, and Mexico; they have the support of the Latin American The Elderly Academy for the Medicine of Aging The fact that people are now living (known by its Spanish acronym, ALMA). longer lives poses a challenge in the 21st century. In almost all the countries of PASB and ALMA spearheaded the ef- the Region, life expectancy at birth in- fort to train teachers in geriatrics in the creased by 20 years during the last 50 Region’s medical schools and promoted years of the 20th century. PASB actively ongoing dialogue between geriatric spe-

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HEALTH CANADA and MEXICO’S Ministry of Health Work for the Mexican Elderly The Ministries of Health of Canada and Mexico joined hands to improve the health and well-being of seniors in Mexico. Both entities developed a joint plan of action, which focused on four main areas:

• developing policy and program recommendations for Mexico, based on analyses of the country’s data for the “Health, Well-being and Aging in Seven Urban Centres of Latin America and the Caribbean” (SABE) survey; • developing policies that help both countries plan for and assess the continuing care of seniors and an aging population; • sharing knowledge on healthy-aging issues, particularly nutrition and dementia; • sharing information on long-term and continuing care models, including training and educational models for professionals and para-professionals, with a view to building capacity to develop innovative programs and services for seniors.

The project responded to a joint memorandum of understanding on health matters signed by the governments of Canada and Mexico in 1999. A coordinating committee consisting of representatives from Health Canada’s Division of Aging and Seniors, Mexico’s Ministry of Health, and the Pan American Health Organization oversaw the project. In October of 2002 this project culminated in a joint workshop in Ottawa, October 10–12, 2002. The result of this conference was a Health Canada/PAHO/Ministry of Health of Mexico co-publication entitled “A Guide for the Development of a Comprehensive System of Support to Promote Active Aging.”

cialists and the public health decision lished the Regional Guide for Promoting making bodies. Both entities have the Physical Activity, which will help to ac- support of the Merck Institute of Aging knowledge the importance of physical and Health, and Brazil, Chile, Columbia, activity for older people and will provide Costa Rica, Cuba, Mexico, and Uruguay a conceptual framework for physical ac- are participating in the initial phase. The tivity programs for older persons. ongoing development of training materials and programs on aging is a multidisciplinary and Regional effort with important contributions from doctors, nurses, The “Health and health educators. Promotion Forum A sedentary lifestyle and malnutrition are the leading risk factors for disease of the Americas” and disability in advanced age. There- fore, PASB, in collaboration with a The “Health Promotion Forum of the group of experts from the Region, pub- Americas,” held in Santiago, Chile, in

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October 2002, was one of the most im- public health professionals, community portant gatherings of its kind in Latin leaders, and NGO representatives from America. The meeting brought together Argentina, Aruba, Barbados, Belize, Bo- more than 600 participants from the Re- livia, Brazil, Canada, Chile, Colombia, gion’s countries to analyze progress Costa Rica, Cuba, Dominican Repub- made in the health promotion commit- lic, Ecuador, El Salvador, Guatemala, ments adopted in the Mexico Declara- Guyana, Haiti, Honduras, Jamaica, tion (2000). Participants included may- Mexico, Nicaragua, Panama, Paraguay, ors and other local government officials, Peru, Puerto Rico, Suriname, Trinidad ministers of health and of other sectors, and Tobago, the United States of Amer-

CUBA Addresses the Care of Specific Population Groups and the Creation of Healthy Spaces The National Program for the Comprehensive Care of Adolescents’ Health has been a valuable tool for integrating PAHO cooperation within the framework of broad intersectorial participation. The program includes care targeted to adolescents in the health services, the training of health personnel to raise the quality of care, and the training of adolescents as health promoters. Community and school projects have been implemented in various areas considered as priorities by adolescents. The projects, which enjoy the strong support of the local governments and social institutions and organizations, have yielded excellent results. Cuba, with PASB’s cooperation, has been a member of the Latin American Network of Healthy Municipios and Communities since 1997. At this time, 52% of the country’s municipios are part of the National Network and are working in various arenas—communities, schools, universities, hospitals, workplaces, marketplaces, penitentiaries, and agricultural cooperatives—thanks to policies that enhance the community’s and the various sectors’ decision-making and managerial capacities. The Network of Schools for Health includes 987 schools and 22 universities that implement projects aimed at the comprehensive development of children, adolescents, and youths and the restora- tion of values, self-esteem, and individual and social responsibility. The Bureau worked with the education sector to finalize the Master Plan for Health Promotion and Education. Some 42% of older adults participate in the “Grandparents’ Circles,” taking part in physical, recreational, and cultural activities. The number of “grandparents’ houses”—community institutions that provide comprehensive care to older adults while enabling them to retain their family ties—has increased. Care for adolescents and older adults, who are the target groups chosen by the localities in the Municipal Development Projects, has made it possible to diversify and expand the technical cooperation provided by the Bureau.

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ica, Uruguay, and Venezuela. Partici- pants from Australia, Spain, Sweden, Promoting and Switzerland also attended. Healthy Spaces Participants identified several challenges and future prospects for health PASB’s programs provided input to the promotion in the Region. First, the preparation of the technical guidelines health sector must embrace health pro- and summaries in the “Mayors Guide to motion as a mission and as a priority. Health Promotion and Quality of Life.” Second, while health promotion con- These guidelines were reviewed with cepts and strategies are fairly well un- groups of mayors in Brazil, Costa Rica, derstood and implemented, discussions Cuba, Ecuador, Mexico, and Peru. at the policy level remain weak and need to be fostered and strengthened through In addition, PASB, with support from strong leadership and clear vision. In the Kellogg Foundation, produced an in- addition, the countries’ capabilities to novative local strategic planning tool— develop health promotion plans of ac- the “Healthy Municipalities and Commu- tion that include clear targets should be nities: Mayors’ Kit for Promoting Qual- made a priority; citizen participation ity of Life.” The kit gives mayors and must be fostered and intersectoral al- city planners the wherewithal to create liances and partnerships with the pri- healthy environments, and has been pub- vate sector and universities must be lished in English, Spanish, and Portu- forged; and all levels of the health sys- guese. Dr. George Alleyne, then-Director tems and services must be strengthened. of PAHO, and Dr. Francisco Tancredi, Director of the Kellogg Foundation’s Pro- Throughout the year, consultants and gram for Latin America and the Carib- With support from the Kellogg regional advisors supported intersectoral bean, officially launched the kit at the Foundation, PASB produced an country teams in the preparation of Health Promotion Forum’s inaugural innovative planning tool for mayors ceremony, and a copy of the kit was made country reports that summarized and and city planners to help them set up available to all participants. One session reviewed the progress made toward healthy spaces. these commitments. The Bureau sup- was devoted to giving mayors an orienta- ported countries in preparing their re- tion on how to use the kit. At special ses- ports—27 countries presented their sions, mayors presented and reflected on progress reports and outlined their fu- their experiences building healthy mu- ture perspectives. Reports showed sig- nicipalities and communities. At other nificant progress since the Mexico Dec- sessions, mayors received guidance on laration and since PAHO’s Directing such issues as how to use Geographic In- Council adopted the pertinent Resolu- formation Systems and strengthen net- tion (DC 43/14) in 2001. works of healthy municipalities and communities. To date, 24% of the Region’s countries have national networks of healthy municipalities or communities. During the Forum mayors committed themselves to revive and strengthen the

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“Regional Network of Healthy Munici- • Support for the development and palities and Communities.” strengthening of healthy communities and health promoting schools The kit was pilot-tested in Chile with a as part of the VIDA Chile national group of mayors from Brazil, Canada, plan of action. In addition, PASB Costa Rica, Ecuador, El Salvador, and fostered the exchange of experiences Mexico. Four municipalities have re- with other countries in the Region— ceived recognition for their efforts in cre- with Canada, in the context of the ating healthy environments—Balcarce, CIDA-funded project to build and Argentina; Surrey, Canada; Loja, Ecua- strengthen capacity in health promo- dor; and Surco, Peru. The awards were tion among the Region’s countries, given after a contest sponsored by PASB with El Salvador and with Argentina and CDC as part of World Health Day. in preparing a technical cooperation Dr. George Alleyne and Dr. David Mc- among countries project. Queen, Director of Global Health Pro- • Support to Brazil, Honduras, and motion at the CDC presented the awards. El Salvador in the development of their health promotion national pol- Two other important health promotion icy and plans of action. documents were prepared and reviewed • Support to Ecuador for the imple- by a group of experts from several orga- mentation of healthy municipalities nizations and institutions. The “Tool in the context of the Loja Healthy Kit for the Participatory Evaluation of Spaces Project and the USAID- Health Promotion at the Local Level” funded “Making Cities Work” proj- contains guidelines for evaluating healthy ect, which focused on strengthening municipalities and communities. “Rec- the capacities of local government A young girl plants trees to enhance her ommendations for Policymakers” exam- to adequately respond to municipal school’s healthy space. According to a ines how to work with decision makers needs. survey, most Latin American countries and policy makers to ensure that evalua- have established health-promoting tion of healthy municipalities and com- schools to some degree or another. munities and of health promotion in general is a priority and given appropriate support. Health-Promoting

The following highlights the year’s im- Schools portant direct technical cooperation and support efforts designed to strengthen Educational systems in Member States country efforts in developing their na- have undergone structural reforms, re- tional health promotion plans of action sulting in decentralization, greater com- and to position health promotion in the munity involvement, increased school national policy agenda: autonomy, and curriculi changes that have incorporated such subjects as health education and health promotion. Taking advantage of the opportunity of-

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fered by these changes, PASB launched health programs and activities in the Re- the “Health Promoting Schools Regional gion. This document, which has been re- Initiative” in 1995, as a way to create, viewed and validated by a multidiscipli- foster, and maintain healthy and sup- nary and multisectoral panel of school portive physical and psychosocial school health experts, will help hone PASB’s environments. The initiative is designed support to Member States as they further to strengthen comprehensive school develop and integrate health-promoting health programs to facilitate human schools. growth and sustainable development, including the adoption and maintenance In 2002, PASB entered into important of healthy lifestyles by students and the multisectoral and multidisciplinary al- school community at large. liances to further its work in health promoting schools. For example, the Bu- Some initiative accomplishments in reau signed a collaborative agreement 2002 deserve mention. First, the Third to strengthen health promoting schools Meeting of the Latin American Network with UNESCO in October. The agree- of Health-promoting Schools in Quito, ment highlights the importance of re- Ecuador, in September. Every Latin search to assess the process and impact American country except for Mexico and of different components of the initiative, Argentina participated, exchanging infor- especially of life skills training. mation and materials about the design and implementation of comprehensive During 2002, and with PASB’s sup- school health programs and activities. In port, several countries developed and addition, the analysis of data collected started implementation of healthy poli- through a Regional health promotion cies in their health-promoting schools, survey is almost complete, and results including schools free from smoke, vio- will soon be published. Results show that lence, and with adequate space for phys- most Latin American countries have ical education. Countries developed ac- already established health-promoting tion plans for health promoting schools schools to one extent or another, and also at the preschool, primary, and secondary- have established intersectoral and in- school levels. Several countries also de- terinstitutional committees for develop- veloped plans of action to strengthen ing integrated school health programs. health promotion and health education PASB also collaborated with INCAP to in their university programs. Universities publish “Escuelas Promotoras de la in the Region are developing and imple- Salud: La Experiencia Centroameri- menting strategies to promote health cana,” documenting the development of activities where students and teachers integrated school health programs and work, as well as in teaching curriculi and activities in seven Central American materials. countries. Finally, the “Regional Health- Promoting Schools Plan of Action, Universities in the Region, such as the 2003–2012,” was developed, taking into Institute of Nutrition and Food Technol- account the status and trends of school ogy (INTA), the Chilean Catholic Univer-

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sity, Universidad del Valle in Colombia, materials include examples of innovative and University of São Paulo in Brazil, de- experiences in countries such as The veloped on-site and distance courses that United States of America and Canada. helped to significantly strengthen health promotion capabilities in several coun- Third, it developed and published a tries, including Brazil, Colombia, Cuba, model and guidelines for the writing of Ecuador, and El Salvador. tobacco control legislation. The model, translated into several languages, ex- plains why the regulation of tobacco products is important, what types of Control of legislation are and are not effective, and how to draw up and enforce the legisla- Tobacco Use tion. This document is intended to help the PAHO Member States adopt effec- In 2002, PASB achieved five basic ob- tive policies for the fight against tobacco jectives in the control of tobacco use. and to provide valuable background in- First, it facilitated and energized the dis- formation on tobacco legislation. cussion and negotiation of the Frame- work Convention on Tobacco Control Fourth, for the first time information (FCTC). During the year, funds and was available on most of the countries of As part of its effort to help Member technical cooperation were mobilized to the Americas, as a result of the Global States fight against tobacco, PASB support two regional meetings to discuss Youth Tobacco Survey (GYTS), a world- the FCTC text and support the partici- wide surveillance system of tobacco use, published guidelines for writing tobacco pation of the countries of the Americas implemented in cooperation with the control legislation. They include an in two meetings of the Intergovernmen- Office on Smoking and Health of the explanation as to why the regulation tal Negotiating Body in Geneva, and in U. S. Centers for Disease Control and of tobacco products is important, an international meeting on illegal trade Prevention (CDC). GYTS collects in- which sorts of legislations work and in tobacco products co-sponsored by the formation on the prevalence of tobacco which do not, and how to draw up Government of the United States. use, exposure to environmental tobacco and enforce laws. smoke, exposure to the marketing tech- Second, it consolidated the “Smoke niques of tobacco advertising, and edu- Free Americas” initiative launched in cational activities in educational centers 2001. Seven countries have begun to for youths aged 13 to 15. create smoke-free spaces, that include the establishment of a nicotine environmen- Finally, PASB prepared and published tal surveillance system to monitor the ef- a report revealing that transnational to- fectiveness of those actions. Argentina, bacco companies have conducted delib- Brazil, Chile, Costa Rica, Paraguay, Peru, erately misleading campaigns over the and Uruguay participate in this system, past 10 years in Latin America and the the first multinational system of its type. Caribbean, designed to delay or evade Advocacy and training materials have restrictions on tobacco use and limita- been developed to ensure the effective tions on its marketing. The report, implementation of this initiative; these whose objective is to alert the govern-

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ments and civil society to the sorts of ob- Some of the Region’s countries have re- stacles they may encounter in effectively cently introduced important changes in combating smoking, was the result of a their policies and legislation that deal review of internal tobacco company doc- with sexual and reproductive health (Ar- uments, principally those of Philip Mor- gentina, Columbia, and Uruguay), and ris and British American Tobacco, which changes are under review in Barbados, Ja- together control the largest market share maica, and Trinidad and Tobago. These in tobacco in Latin America and the changes notwithstanding, the prevalence Caribbean. of use of modern contraceptives is still below 70% in most Latin American and Caribbean countries (Figure 10).

Maternal Health With regard to high-quality family planning services, two WHO manuals In 2002, PASB placed emphasis on en- were translated and adapted: “Improv- couraging legislative changes in sexual ing access to high-quality family plan- and reproductive health, particularly in- ning care” and “Selected recommended dividual rights; promoting the use of practices for contraceptive use.” Techni- modern contraceptives; adopting public cal recommendations also were made for policies; and embarking programmatic modifying the WHO document “Safe activities to decrease maternal mortality abortion, technical and policy guide for and improve perinatal health. health systems.”

FIGURE 10. Prevalence of contraceptive use, Region of The Americas, 2000.

40 Percentage

0 North Mexico Central Latin Non-Latin Andean Brazil Southern America America Caribbean Caribbean Area Cone

Costa Rica 65% Cuba 82% Colombia 59% Uruguay 84% Guatemala 27% Haiti 13% Bolivia 31% Paraguay 41%

Source: PAHO, Basic Indicators, 2002.

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FIGURE 11. Potential for reducing maternal mortality in Latin America and the Caribbean, countries with more than 2.5 million population, 2002.

Possible, reference Uruguay, Maternal mortality Desirable, reference Canada, 11.1 per 10,000 per 10,000 2.4 per 10,000

Chile 22.7 Cuba 33.9 Argentina 35 Costa Rica 35.3 Brazil 55.8 Venezuela 60.1 Panama 60.7 El Salvador 63.4 Mexico 83.6 Nicaragua 87 Ecuador 91.7 Colombia 91.7 Guatemala 98.1 Jamaica 106.2 Honduras 108 Paraguay 114.4 Peru 185 Bolivia 390 Haiti 523

100 75 50 25 25 50 75 100 Reduction potential (%) Reduction potential (%)

Source: PAHO, Basic Indicators, 2002.

Maternal mortality continues to pose a Mortality, the Bureau prepared a docu- challenge to public health in the Region. ment on the strategic consensus for the In 2002 the Bureau, at the request of reduction of maternal mortality, which PAHO Member States, developed a new the countries have been consulted about regional strategy to decrease maternal and have discussed. morbidity and mortality. Two resolu- tions were adopted at the 26th Pan PASB continues to work to ensure that American Sanitary Conference, at which men participate in matters relating to all the Member States committed them- sexual and reproductive health, espe- selves to reduce maternal mortality by cially in the seven Central American 75% by 2015, as compared to 1990 lev- countries, where research will look at in- els, and to ensure skilled care at delivery. volving men in health care. The pilot test has already been conducted and The reducible gap in maternal mortal- data collection will begin in 2003. ity for all the countries of the Americas, as compared with Canada’s maternal To foster the national plans and pro- mortality rate, which is the lowest in the grams, it was established that all re- Americas, is approximately 90%, and search on sexual and reproductive compared with that of Uruguay, it is health funded or supported by interna- around 85% (Figure 11). tional organizations would have a dissemination plan targeted at program Working with the Interagency Work- managers, ministers of health, political ing Group for the Reduction of Maternal leaders, and the general public.

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PASB completed case studies in five Latin American and Caribbean countries to strengthen health promotion in Health in the areas of children’s health, adolescent health, reduction of maternal mortality, Human aging, and healthy spaces.

To strengthen the epidemiological sur- Development veillance systems for maternal and perinatal morbidity and mortality, support was provided for the introduction of a Health in Economic perinatal computerized information system in the Caribbean countries, and the and Social perinatal clinical history was updated. While mortality due to perinatal con- Development ditions represents more than 60% of in- fant mortality, it has experienced the In consultation with ALADI, UNC- greatest relative decline in the last 20 TAD, WTO, IDB, and WHO, criteria years (34%), compared with the other were formulated in 2002 for the prepa- major groups of causes. ration of a database on international trade in health goods and services in the Among technical cooperation activities Region. This tool will be essential for carried out by the Latin American Center negotiating commercial agreements at for Perinatology and Human Develop- the global, Regional, subregional, and ment, special emphasis was given to sup- bilateral levels, and for formulating na- porting 17 countries in improving the tional policies in fiscal and regulatory quality and use of maternal-perinatal in- spheres that take health sector priorities formation, training national experts to into account. Cooperation with Canada make test-based medical decisions tests, helped establish a network of health and and strengthening the network of asso- trade researchers who will study the im- ciated centers for the dissemination of plications of the General Agreement on the perinatal computerized information Tariffs and Trade (GATT) for the health system. sector in the Region. A report also was completed on trade negotiations related The Center’s web page was finalized to health services, and, in cooperation and the Library on Perinatal Maternal with WHO, a book on trade in health Reproductive Health was launched, services, based on an international which improves the dissemination of in- workshop held in 1999, was published. formation and fosters ongoing contacts with institutions and persons associated Progress was made in discussions with this area of work. among national statistical and census offices and statistical units in the ministries of health with respect to the ethnic and racial breakdown of persons and

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and populations in the data and statis- gion’s countries. The legislation database tics produced by the health sector and (Leyes), which contained 11,600 records by other sectors that are relevant to by the end of 2002, was updated. Its dis- health. A publication on this issue was semination through the virtual health prepared, based on the results and con- library/legislation accounts for its grow- clusions of a workshop held in Quito, ing use as a reference source by govern- Ecuador, with the participation of na- ments, legislatures, and civil-society or- tional statistical and census offices, min- ganizations interested in health, as well as istries of health, and representatives of the health sector’s public and private of- interested NGOs. National initiatives ficers, professionals, researchers, and in- were promoted to reduce health institutions. As part of this effort, Mexico, equities based on ethnicity and race, as in cooperation with the Inter-American a followup of the World Conference Center for Social Security Studies, held against Racism, Racial Discrimination, the IX Course-Workshop on Health Leg- Xenophobia and Related Intolerance, islation, which had 40 participants from held in Durban, South Africa in 2001. 18 countries of the Region. PASB participated in the followup meeting to the Conference, sponsored by the A database on household surveys of Government of Mexico and the United interest to health was updated and dis- Nations High Commissioner for Human seminated on the Internet. By the end of Rights. This work is supported by an in- 2002, it contained general characteris- teragency coordination in which IDB, tics and sources of access to 110 surveys the World Bank, the Inter-American Di- on living conditions, demographics, and alogue, the Ford Foundation, the Inter- health carried out in the Region. Coop- American Foundation, and PAHO par- eration with WHO to implement the ticipate. It coordinates the activities of World Health Survey in the Region also As a follow-up to the 2001 World participating institutions in support of intensified. In its first phase, this survey Conference against Racism, Racial governmental and civil-society initia- is being carried out in eight countries Discrimination, Xenophobia, and Related tives whose goal is to reduce ethnicity- (Brazil, Chile, the Dominican Republic, Intolerance, the countries launched based inequities in the Region. Ecuador, Guatemala, Mexico, Paraguay, initiatives to reduce health inequities and Uruguay). Experts from these coun- based on ethnicity and race. In cooperation with IDB, the systematic tries participated in a training and coor- evaluation of health legislation in dination workshop at the Institute of 24 of the Region’s countries was com- Public Health in Cuernavaca, Mexico. pleted. The evaluation covered seven Collaboration continued with MECOVI, areas relevant to health for those popula- an initiative for improving living conditions—drugs, insurance, certification and tions surveys, promoted by ECLAC, accreditation, the environment, food pro- IDB, and the World Bank to improve the tection, occupational health and safety, design of health-related modules and and blood banks and transfusion ser- promote wider use of the results of these vices. The evaluation showed the level of surveys by health authorities, profes- development of health legislation in par- sionals, and researchers. ticipating countries and areas. The evaluation’s report will be a key tool for In addition to increasing the countries’ strengthening health legislation in the Re- capabilities to identify and monitor

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health inequities, the aforementioned ac- sis of PASB’s technical cooperation strat- tivities are also intended to support the egy for research, known by its Span- development and assessment of national ish acronym, DECIDES (Democratizing policies to reduce those inequities. These Knowledge and Information for the Right issues were addressed at the workshop on to Health). This strategy was designed to policies for equity in health and social se- help overcome some of the major prob- curity, held with CIESS in Mexico in lems observed in the organization of sci- March 2002, and the seminar on policy entific activity in health in the Region, tools for equity in health, held in Toronto such as limited participation in the estab- in June 2002 with the Government of lishment of research agendas, low utiliza- Canada, the University of Toronto, and tion of research results in health policies the International Society for Equity in and programs, weak cooperation and Health. In 2002, PASB’s cooperation with weak exchange of researchers among WHO in the field of health and poverty countries of Latin America and Carib- reduction was the subject of a seminar bean, and unequal access to health held in Crete, Greece, and an interre- knowledge and information. gional consultation held in Gaborone, Botswana. Health and poverty reduction VLH/S&H is taking advantage of the initiatives also were implemented, espe- opportunities opened up by new com- cially among the heavily indebted poor munication and information technology countries (HIPC) initiative. to increasingly position itself as an integral part of the management of scientific activity in health based on information and scientific proof, as well as on the The Virtual Health active participation of various actors associated with this activity. In short, Library and the VLH/S&H promotes the strengthening of scientific activity in health and ce- Network of National menting its relationships with the vari- Councils for Science ous sectors of society. VLH/S&H has a decentralized organi- and Technology zation that functions through networks of national and international science and Noteworthy among the Bureau’s co- technology organizations, scientific and operation activities in 2002, is the im- technical units of the ministries of health, plementation of the Virtual Library in and other institutions in the Region. One Science and Health (VLH/S&H). The of these networks, the International Net- virtual library was officially launched work of Information and Knowledge during the VI Regional Congress on Sources for the Management of Science, Health Sciences Information in Puebla, Technology, and Innovation (ScienTI Mexico, in May 2003. Network), currently comprises 10 national science and technology organiza- VLH/S&H supports the management tions in Latin America and Portugal, four of scientific activity in health on the ba- international science and technology

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ARGENTINA Establishes the Virtual Health Library Since the issuance of the San José Declaration in 1998, the PAHO/WHO Country Office in Argentina has been providing technical cooperation for the establishment of the Virtual Health Library (VHL)- Argentina Branch, at: http://www.bvs.org.ar. Some 70 institutions from all parts of the country are participating in this project. Together they form the National Health Sciences Information Network (known by its Spanish acronym, RENICS). Its three principal resources are the National Health Sciences References database (known by its Spanish acronym, BINACIS), with 40,000 bibliographic records of the country’s documents; the Col- lective Catalogue of Periodic Publications, which includes the collections of cooperating libraries; and the Combined Databases of the RENICS Cooperating Centers (known by its Spanish acronym, UNISALUD), which includes all the libraries’ databases, with a total of 80,000 bibliographic records. The Documentation Center of the Inter-American Association of Sanitary and Environmental En- gineering (AIDIS)-Argentina coordinates the Virtual Library on Health and Environment of Ar- gentina, in which 20 cooperating centers within the country participate. The site is on the CEPIS server: http://www.cepis.org.pe/argentina/E/home.html. This library gathers many sources of information for those interested in the evaluation and control of environmental risk factors that affect the health of the population. It uses CEPIS methodological tools for recording, quality control, and dissemination of these sources. Included are database manuals, guides, and the health and environment thesaurus in five languages. In addition to offering access to 5,000 full-text documents, the site provides information on on-site, distance, and virtual training and education resources. It also provides information about various types of meetings, access to environmental indicators, legislative databases, discussion lists, information locators, educational material, news, journals, and the bibliographic database for the CEPIS journal collection. The Virtual Library on Toxicology provides access to more than 20 databases on chemical substances. With PAHO’s cooperation, databases containing sectoral information are being created, and the Global Evaluation of Drinking Water and Sanitation, which includes statistical information on every country in the Americas and information by groups of countries, has been initiated. Also, work is in progress on the Inter-American Environmental Sanitation Information System (known by its Spanish acronym, SISAM). PAHO/WHO’s Country Office in Argentina also is cooperating in the establishment of Argentina’s Virtual Library on Adolescence and Youth (http://maestria.rec.uba.ar/NUEVA/home.htm), a project that began in 2001. Technical coordination is the responsibility of the Documentation Center for the Master’s Degree in Public Health of the University of Buenos Aires. The databases of the participating institutions were converted to standardized Latin American Health Sciences Literature Data- base (LILACS) formats for incorporation into this library, which also has directories in keeping with the VHL model. At this time, compilation, processing, classification, and standardization in accordance with BIREME methodology is under way. The hope is that this resource will be enriched, in the future, through the addition of other products and services.

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organizations, and three groups that de- from the health sector, women’s bureaus, velop information science technology. statistical offices, and women’s organizations to strengthen their capacity to con- These institutions collaborate with duct and apply the results of gender VLH/S&H by providing indicators and analysis. PASB has developed a strategy data on projects, researchers, and scien- for the application of basic gender and tific and technology entities of the Re- health indicators that: sensitizes decision- gion. A database of resumes in stan- makers to the importance of gender dardized electronic format is the first analysis, conducts a technical review and product of this collaboration. In Decem- adaptation of PASB’s basic health and ber 2002, the first coordination meeting gender indicators with counterparts, fa- of the ScienTI Network was held in Flo- cilitates training for producting and ap- rianopolis, Brazil to assess the progress plying gender and health statistics, and of implementation and the planning of leads to the production and publication future actions; it was attended by repre- of national health-and-gender equity sit- sentatives of all its members. uation profiles. Five Central American countries have begun their profiles; in Chile and Peru, the process is tied to Reducing Gender monitoring sector reform policies. One of the main goals of these situa- Inequities in Health tion analyses is to provide information and improve policies that have differen- PASB has earmarked the production tial effects on the health of men and of health information that considers women, such as many of the countries’ gender issues as one of its highest prior- health sector reform policies. There is ities. A resolution adopted by the 26th evidence that some health care and Pan American Sanitary Conference in financing models promoted by these 2002, urges Member States to include processes may further marginalize the gender analysis in their policy-making. poor, the elderly, some ethnic groups, The Bureau now has an expert who col- and especially women. In most countries laborates with countries to develop gen- women’s organizations and other stake- der and health indicators and tools for holders are often excluded from defining their analysis. health sector reform policies or monitoring their outcomes. Strengthening National Capacity to Carry Out Strategy for Reducing Gender and Health Gender Equities within Analysis Health Sector Reform The Bureau has worked with national PASB and its national counterparts users and producers of health statistics have developed a strategy to identify

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and address these inequities. Compo- health and gender issues (i.e., “Traffick- nents of this strategy include the devel- ing of Women for Sexual Exploitation,” opment of information on gender and “Gender and HIV/AIDS in the Ameri- health inequities and their relation to cas,” “Gender Equity in Health); a list- health policies; the dissemination of this serv ([email protected]) that dis- information to health and other sectors seminates information about websites, and to civil society, and the inclusion of publications, conferences, and training these informed stakeholders in the for- to more than 1,000 subscribers; a virtual mulation of better policies and the mon- information center on women, gender, itoring of their implementation and ef- health, and development that includes fect on the health of women and men. an information portal and a virtual li- The Bureau has developed several work- brary; a gender and health training data- ing and conceptual papers on gender, re- base; and a virtual learning center. (http:// productive health, and health sector re- genero.bvsalud.org). forms to help implement the strategy.

The “Gender Equity and Health Sec- Addressing Gender- tror Reforms” project was launched in Chile in 2001 and in Peru in 2002. It fo- based Violence cuses on the participation of civil society The Nordic countries’ original support in the analysis and monitoring of new for the domestic violence project in Cen- health policies. In Chile, PASB’s team tral America came to a close in 2002; Bo- working on the project was instrumental livia and Ecuador continued to receive in supporting an intersectoral gender support for their projects from the gov- advisory committee that the Minister of ernment of the Netherlands. The govern- A sign denouncing domestic violence Health convened to assure that gender is ments of Sweden and Norway renewed serves as a backdrop for women waiting taken into consideration throughout the their support for the Central American in line at a health center. PASB has reform process. The advisory committee countries during the year, expanding mobilized the health sector to address also issued a strategy paper that was their support to include other issues. The gender-based violence and the Regional, presented to the National Health Sector results of the evaluation of the Central national, and community levels. Reform Commission and that was de- America project were shared with na- bated with civil society. tional counterparts, in an effort to repli- cate successes and identify challenges. To One of PASB’s key objectives is to date, PASB’s efforts to mobilize the health provide information, training materials, sector to address gender-based violence and communication and learning chan- has resulted in achievements at the Re- nels to its network of focal points and gional, national, and community levels. counterparts. For example, the Bureau put in place a multifaceted GenSalud • At the regional level, PASB held information strategy, which includes the “Symposium 2001: Gender Vio- access to information and publications lence, Health, and Rights in the via PAHO’s website (www.paho.org/ Americas,” which brought together genderandhealth), offering advocacy more than 100 participants from packets and monthly fact sheets on governmental and NGO sectors

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SAINT LUCIA and Gender Health In 1998, St. Lucia’s Minister of Health, Human Services, Family Affairs and Gender Relations expressed interest in learning about Canada’s support services for family violence and violence against women. Since then, the two countries have been involved in a series of exchanges involving professionals, which has led to Saint Lucia’s development of domestic violence policies, including the country’s first shelter for abused women. In addition to partnering with Health Canada, Saint Lucia also joined hands with the Manitoba Ministry of Family Service and Housing. The latter is providing expertise on policy development, program assessment, shelter design and operation, and strategic planninc to deal with violence against women. One of the highlights in this initiative in 2002 involved a Saint Lucia delegation that travelled to Winnipeg, Canada, to view existing programs related to men’s health and positive behaviours; and to review policies and identify programs that would be helpful to Saint Lucia’s plan to work towards the elimination of violence against women.

(http://www.paho.org/english/hdp/ 10 countries; a prevalence study on hdw/symposium2001.htm); pro- gender-based violence and the role moted exchanges between coun- of men in promoting violence was tries; advocated the prevention of conducted in Bolivia; and a knowl- gender-based violence; and con- edge, attitudes, and practice study ducted a participatory evaluation of was conducted in Peru. In addition, Central American project. gender-based violence prevention • At the national level, the Bureau campaigns were carried out in 10 established multisectoral coalitions countries. Finally, the study of vio- in 10 countries to advocate for leg- lence was included in primary islation and policies in this regard— school curricula in Belize and Peru, legislation was passed in all 10, and in college curricula in public monitoring bodies were set up in 6, health and nursing schools and po- and gender-based violence was in- lice academies in Central American corporated in health sector reform countries. processes in 5. Tools (norms and • At the community level, more protocols in 10 countries, surveil- than 200 community networks were lance systems in 5, and training formed, comprising of health, edu- modules in 10) were developed and cation, and judicial sectors, police, put in operation; more than 15,000 churches, community leaders and representatives from health and women’s organizations. In addition, other sectors were trained each community-support groups were year. Community assessment of trained and are functioning in eight women and providers was carried countries—more than 390 of these out in more than 20 communities in are in Central America.

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