Paho Coll Od 234

PAHO COLL OD 234

Ial:ui Published also in Spanish with the title: Informe del Director: Cuadrienal 1986-1989, Anual 1989 ISBN 92 75 37234 9

ISBN 92 75 17234 X

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Report of the Director Quadrennial 1986-1989 Annual 1989

Official Document No. 234

PAN AMERICAN HEALTH ORGANIZATION Pan American Sanitary Bureau · Regional Office of the WORLD HEALTH ORGANIZATION 525 Twenty-third Street, N.W. Washington, D.C. 20037, U.S.A. TO THE MEMBER COUNTRIES OF THE PAN AMERICAN HEALTH ORGANIZATION

In accordance with the Constitution of the Pan American Health Organi- zation, I have the honor to submit the 1986-1989 quadrennial and 1989 annual report on technical cooperation activities of the Pan American Sani- tary Bureau, Regional Office of the World Health Organization. Within the context of regional health-for-all strategies and of policies set by the Pan American Health Organization's Governing Bodies, the report analyzes the salient activities in the Organization's technical cooperation program during the quadrennium. This report is complemented by other documents that are also submitted for the consideration of the XXIII Pan American Sanitary Conference: Health Conditions in the Americas (1990 edition) and the Financial Report of the Director and Report of the External Auditor, 1988-1989. This report has been produced with the same structure as the biennial Program Budgets in order to facilitate the analysis of the activities carried out by the Organization. Respectfully,

Carlyle Guerra de Macedo Director CONTENTS

PAN AMERICAN HEALTH ORGANIZATION: HISTORY AND STRUCTURE ..... vii

INTRODUCTION ...... xi

1. GOVERNING BODIES ...... 1

Pan American Sanitary Conference ...... 1 Directing Council ...... 2 Executive Committee ...... 4

II. GENERAL PROGRAM DEVELOPMENT AND MANAGEMENT ...... 5

Executive Management ...... 5 Regional Director's Development Program ...... 5 General Program Development ...... 5 External Coordination for Health and Social Development ...... 6 Information Coordination ...... 7

III. HEALTH SYSTEMS INFRASTRUCTURE ...... 9

Introduction ...... 9 Managerial Process for National Health Development ...... 10 Technical Cooperation among Countries and Projects at the Country Level ...... 11 Health Situation and Trend Assessment ...... 1...... 11 Health Policies Development ...... 14 Organization of Health Services Based on Primary Health Care ...... 17 Health Services Development ...... 17 Essential Drugs and Vaccines ...... 21 Oral Health ...... 23 Clinical, Laboratory, and Radiological Technology for Health Services ...... 26 Health Education and Community Participation ...... 28 Women, Health, and Development ...... 30 Emergency Preparedness and Disaster Relief Coordination ...... 31 Human Resources Development ...... 36 Policy and Coordination ...... 37 Human Resources Administration ...... 38 Human Resources Training ...... 38 Health Information Support ...... 39 Official and Technical Publications ...... 39 Scientific and Technical Information ...... 39 Information and Public Affairs ...... 43 Research Promotion and Development ...... 45

IV. HEALTH PROGRAMS DEVELOPMENT ...... 48

Introduction ...... 48 Food and Nutrition ...... 49 iv Report of the Director

Environmental Health ...... 51 Maternal and Child Health, Including Family Planning ...... 55 Communicable Diseases ...... 61 Acquired Immunodeficiency Syndrome (AIDS) ...... 63 Health of Adults ...... 67 Veterinary Public Health ...... 68

V. ADMINISTRATION ...... 75

Budget and Finance ...... 75 General Services and Headquarters Operating Expenses ...... 76 Personnel ...... 77 Procurement ...... 78

VI. PAHO/WHO TECHNICAL COOPERATION AT SUBREGIONAL AND COUNTRY LEVELS ...... 79

Introduction ...... 79

Caribbean Area ...... 80

Caribbean Cooperation in Health ...... 80

Antigua and Barbuda ...... 81 Bahamas ...... 82 Barbados ...... 85 Bermuda ...... 86 British West Indies ...... 87 Cayman Islands ...... 87 Cuba ...... 88 Dominica ...... 90 Dominican Republic ...... 91 French Antilles and French Guiana ...... 93 Grenada ...... 94 Guyana ...... 95 Haiti ...... 97 Jamaica ...... 99 Netherlands Antilles and Aruba ...... 100 Saint Kitts and Nevis ...... 101 Saint Lucia ...... 101 Saint Vincent and the Grenadines ...... 102 Suriname ...... 103 Trinidad and Tobago ...... 104 Turks and Caicos Islands ...... 107

Central America ...... 107

Plan for Priority Health Needs in Central America ...... 107

Belize ...... 1...... 110 Costa Rica ...... 111 Contents v

El Salvador ...... 113 Guatemala ...... 114 Honduras ...... 116 Nicaragua ...... 117 Panama ...... 119

South America ...... 121

Andean Cooperation in Health ...... 121

Bolivia ...... 122 Colombia ...... 124 Ecuador ...... 126 Peru ...... 128 Venezuela ...... 130

Southern Cone Health Initiative ...... 132

Argentina ...... 133 Brazil ...... 135 Chile ...... 137 Paraguay ...... 138 Uruguay ...... 139

North America ...... 140

Canada ...... 140 Mexico ...... 142 PAHO/WHO Field Office, El Paso, Texas ...... 144 United States of America ...... 145

Index ...... 148

SPECIAL REPORTS

Local Health Systems ...... 19 Regional Program on Women, Health, and Development ...... 32 Health and Communications Technology ...... 44 The Eradication of Poliomyelitis ...... 56 AIDS ...... 64 Elimination of Urban Rabies in Latin America ...... 72 The Right to Health in the Americas: A Comparative Constitutional Study ...... 84 t

-, 1 PAN AMERICAN HEALTH ORGANIZATION: HISTORY AND STRUCTURE

The Pan American Sanitary Bureau (PASB) is the executive arm of the Pan American Health Organization (PAHO); at the same time, it serves as the Regional Office of the World Health Organization for the Americas.

Origin: The Pan American Sanitary Bureau had its origin in a resolution of the Second International Conference of American States (Mexico, January 1902) recommending that "a general convention of representatives of the health organizations of the different American republics" be convened. That convention met in Washington, D.C., on 2-4 December 1902 and established a permanent directing council-the International Sanitary Bureau-which was the predecessor of the current Pan American Health Organization. The Fifth International Conference of American States (Santiago, Chile, 25 March-3 May 1923) changed the name of the International Sanitary Conferences and of the International Sanitary Bureau to Pan American Sanitary Conferences and Pan American Sanitary Bureau, respectively. In 1924, the Pan American Sanitary Code, signed in Havana and ratified by the governments of the 21 American republics, assigned broader functions and responsibilities to the Bureau as the central coordinating agency for international health activities in the Americas. The XII Pan American Sanitary Conference (Caracas, 1947) adopted a reorganization plan whereby the Bureau became the executive agency of the Pan American Sanitary Organization, the Constitution of which was officially approved by the Directing Council at its first meeting in Buenos Aires later that year. In 1949, the Pan American Sanitary Organization and the World Health Organization agreed that the Pan American Sanitary Bureau would serve as the Regional Office of the World Health Organization for the Americas. In 1950, the Pan American Sanitary Organi- zation was recognized as a specialized inter-American organization with full autonomy in the accomplishment of its purposes. Thus, the Organization became a component of both the United Nations and the inter-American systems. The XV Pan American Sanitary Conference (San Juan, Puerto Rico, 1958) changed the name of the Pan American Sanitary Organization to the Pan American Health Organi- zation. The name of the Pan A-merican Sanitary Bureau remained unchanged.

Fundamental Purposes: The fundamental purposes of the Pan American Health Organization are to promote and coordinate the efforts of the countries of the Region of the Americas to combat disease, lengthen life, and promote the physical and mental health of the people.

Structure: The Pan American Health Organization comprises the following: The Pan American Sanitary Conference-its supreme governing body in which all the Member Governments are represented-meets every four years, defines the Organiza- tion's general policies, serves as a forum on public health matters, and elects the Director of the Pan American Sanitary Bureau. In 1986, the XXII Pan American Sanitary Conference reviewed and approved the "Orientation and Program Priorities of the Pan American Health Organization during the Quadrennium 1987-1990," which initiated a new mechanism to strengthen the coordination of activities and orient the work of the Organization.

vii viii Report of the Director viii Report of the Director The Directing Council-consisting of one representative of each Member Govern- ment-meets once a year and acts on behalf of the Conference in years when that body does not meet. It reviews and approves the Organization's program and budget. The Executive Committee-composed of representatives of nine Member Govern- ments elected by the Conference or the Council for staggered three-year terms-meets twice yearly to consider technical and administrative matters, including the program and budget, and submits its recommendations to the Conference or Council. The Subcommittee on Planning and Programming of the Executive Committee was reorganized in 1984 to enhance the participation of the governments in programming the Organization's activities. It is made up of delegates from seven countries, meets twice yearly, and reports directly to the Executive Committee. The Pan American Sanitary Bureau, which acts as the Executive Secretariat and is headed by the Director, carries out the directives of the Governing Bodies.

Budget: The Organization has a biennial budget made up of quotas from Member Countries of the Pan American Health Organization, the World Health Organization allocation for the Regional Office of the Americas, and extrabudgetary funds. Disbursements during the 1986-1987 biennium were $US243,000,000, of which over 42% ($US102,200,000) were from PAHO Member Countries, 22% ($US54,000,000) were from WHO, and 36% ($US86,800,000) were from extrabudgetary sources. During the 1988-1989 biennium disbursements rose to $US311,000,000, of which roughly 38% ($US117,500,000) were from PAHO Member Country funds, 19% ($US58,000,000) were from WHO, and 43% ($US135,500,000) were from extrabudgetary sources.

Member Governments: Antigua and Barbuda Dominica Panama Argentina Dominican Republic Paraguay Bahamas Ecuador Peru Barbados El Salvador St. Kitts and Nevis Belize Grenada Saint Lucia Bolivia Guatemala St. Vincent and the Brazil Guyana Grenadines Canada Haiti Suriname Chile Honduras Trinidad and Tobago Colombia Jamaica United States of America Costa Rica Mexico Uruguay Cuba Nicaragua Venezuela

Participating Governments: France, Kingdom of the Netherlands, and United Kingdom of Great Britain and Northern Ireland

Observers: Portugal and Spain PAHO: History and Structure ix PAHO: History and Structure ix PAHO/WHO Country Representations: Argentina Belize Jamaica Bahamas Bolivia (Also directly served by this Barbados Brazil Representation: Bermuda, (Also directly served by this Chile Cayman Islands, Turks and Representation: Antigua and Colombia Caicos Islands) Barbuda, Dominica, Costa Rica Mexico Grenada, St. Kitts and Cuba Nicaragua Nevis, Saint Lucia, St. Vin- Dominican Republic Panama cent and the Grenadines. Ecuador Paraguay Eastern Caribbean: Anguilla, El Salvador Peru British Virgin Islands, Mont- Guatemala Suriname serrat. French Antilles: Gua- Guyana Trinidad and Tobago deloupe, Martinique, St. Haiti Uruguay Martin and St. Bartholomew, Honduras Venezuela French Guiana) (Also directly served by this Representation: Netherlands Antilles) PAHO/WHO Field Office, El Paso, Texas, U.S.A. English-speaking Caribbean Program Coordination, Barbados

Central Office Washington, D.C., U.S.A.

PAHO/WHO Regional and Subregional Centers, Institutes, and Programs Latin American Center on Health Sciences Information (BIREME), Brazil Caribbean Epidemiology Center (CAREC), Trinidad Pan American Zoonoses Center (CEPANZO), Argentina Pan American Center for Sanitary Engineering and Environmental Sciences (CEPIS), Peru Caribbean Food and Nutrition Institute (CFNI), Jamaica Latin American Center for Perinatology and Human Development (CLAP), Uruguay Pan American Center for Human Ecology and Health (ECO), Mexico Institute of Nutrition of Central America and Panama (INCAP), Guatemala Pan American Foot-and-Mouth Disease Center (PANAFTOSA), Brazil Health Training Program for Central America and Panama (PASCAP), Costa Rica i s - a i¿t,

*tumh INTRODUCTION

The 1980s has been the most pivotal nomic deterioration and the detection of its decade since the Second World War in terms effects, many of the consequences in health of social and economic development policies. may not yet be fully apparent. By the end of 1989, the world's political and Faced with the surrounding economic economic conditions that had been taken deterioration, the Region's health ministries for granted since the 1940s had been irre- concentrated much of their effort toward versibly altered. reforming the deployment of resources in The economic contraction in the devel- order to maximize coverage of preventive oped countries of the West rippled through services. The challenge was sizable and the developing countries in the form of demanded great perseverance from health shrinking markets, mounting inflation, and personnel during the 1986-1989 period. Yet, stringent loan policies. Debt-ridden govern- despite seemingly insurmountable odds, they ments in the Region halted development successfully protected past gains and, in projects and slashed social spending. The cri- some instances, even achieved significant sis also had deep repercussions in the democ- improvements in key health indicators. ratization process that was taking place at the time. Even in the prosperous industrial- ized areas of the Americas, unprecedented The Regional Economy affluence, space-age technology, and extraor- dinary medical and scientific breakthroughs Economic reports on the developing vied for headlines alongside urban homeless- countries in the Americas paint a picture of ness, environmental hazards, massive fiscal setbacks or stagnation for most of the deficits, drug addiction, violence, and decade. The last quadrennium was no excep- AIDS. tion: as many development projects ground For the vast majority of the people of to a halt, inflation and the foreign debt bur- Latin America and the Caribbean, the 1980s den grew in tandem with the population in became the "lost decade," a term coined by need of public services. banks and international development orga- The governments, including several new nizations to sum up the dashed hopes and civilian and democratic administrations that the erosion of gains in infrastructure, indus- inherited enormous problems, tackled the try, and health that had been achieved over foreign debt crisis within the framework of the past 30 years.' harsh formulas prescribed by international The protracted economic crisis shook lenders. Debt repayment plans called for the foundations of prevailing development export increases, import cuts, and sharp models and seriously jeopardized the role of reductions in public spending. the State in providing for the welfare of its Efforts to expand the volume of exports citizens. The social services sector-including yielded dramatic results. Yet, the expected public health-was particularly hard hit. increase in earnings was virtually nullified by Moreover, since there is a lag between eco- the falling prices of export commodities. In fact, although export volume for the Region increased a remarkable 35% from 1981 to ' Economic and Social Progress in Latin America, Inter- 1988, balance sheets showed that countries American Development Bank, Washington, D.C., 1988. were treading water: total income from

xi xii Report of the Director xii Report of the Director exports remained unchanged or actually 17 countries studied by the Economic Com- dropped, 2 and 40% of those earnings went to mission for Latin America and the Carib- finance the debt service. bean (ECLAC). Food imports declined and Fiscal policies, credit shortages, and consumer food prices spiraled upwards, monetary devaluations sharply curtailed while governments slashed food subsidies. imports, and national production of substi- tutes-for which start-up imports and a stable investment climate would have been Effects on the Health Sector necessary-did not replace them. Instead, the investment-to-GDP ratio in Latin Amer- Ever-tightening resources make public ica and the Caribbean was the lowest of all planning difficult-including in the health the regions with the exception of Africa. As sector. Although the budget percentages a result, obsolescence and decapitalization allocated to health ministries generally did ruled the day, and the health sector was not not change much for the Region as a whole, spared.3 they were severely reduced in more than a Economic adjustment policies were dozen countries. 7 Moreover, the real value of imposed at great social cost: in 1980, 30% of the resources declined yearly across the the population was poor, whereas in 1989, board, as did total government social expen- an estimated 40% of the Region's popula- ditures. Consequently, less money was avail- tion-170 million people-lived in poverty. able to maintain and stock public health Half of the poor had incomes too meager to programs, clinics, and hospitals. Health buy enough food. workers' real wages dropped; scarce funds The cumulative regional trend was dis- made it difficult to cover the rising cost of couraging. With some notable exceptions, critical imports like vaccines, equipment, per capita availability of goods and services and pharmaceuticals; 8 and investments for in 1987 was only 87.5% of that existing in maintaining or improving equipment and 1980.4 With a gross domestic product growth health facilities plummeted. rate of 1.4% over the decade, Latin America Maintaining existing levels of services and the Caribbean lagged behind the rest of was difficult, and expanding programs, the world's regions, which, except for sub- almost unthinkable. Yet, expansion was Saharan Africa, had growth rates of at least called for: the natural population growth 5 2.5%. increased the number of people requiring The low economic growth rate caused services; in addition, more than 150 million unemployment and underemployment to people who were unemployed or had lower rise, while inflationary pressure, fueled disposable incomes were not covered by partly by monetary expansion to finance social security, nor could they afford private public deficits, was increasingly felt in many care. countries.6 In several, notably Argentina, If circumstances remain as they are, in Brazil, Nicaragua, and Peru, inflation soared the year 2000, only 10 years from now, out of control, placing scarce products out of almost half the population of the Region- the average person's reach. Simultaneously, some 250 million people-will lack regular per capita food availability dropped in 13 of access to health services. If the governments

2 Ibid. 7 IDB, op. cit. 3 The World Bank Annual Report, World Bank, Washing- 8 P. Musgrove (ed.), "Economic Crisis and Health: The ton, D.C., 1989. Experience of Five Latin American Countries," Document 4 IDB, op. cit. CD34/24, Annex II, prepared for the XXXIV Meeting of World Bank, op. cit. the PAHO Directing Council, Washington, D.C., Septem- 6 IDB, op. cit. ber 1989. Introduction xiii Introduction xiii are to meet their goal of providing equal Although the health sector can do little access to health care for all of their people, to solve poverty itself, it deals daily with pov- they will have to double their coverage in erty's consequences. Almost 700,000 people, the coming decade, precisely when they are most of them children, die each year from least able to do so. diseases that would be wholly preventable if these persons had clean water, enough food, and access to simple, inexpensive vaccines Health Trends and early, basic preventive and curative care. Gastroenteritis and diarrheal diseases alone Daunting as the task of doubling the are linked to 200,000 of these deaths. No coverage may be, the health sector's chal- expensive new pharmaceuticals need be lenges go well beyond the sheer number of developed; the technology already is there. persons to be served. The problem is how to provide access to One of the reasons that public health existing services and technology and how to services have been taxed by increased obtain the political commitment and fund- demand has been the demographic shift ing support to expand effectively and effi- from rural to urban centers that has resulted ciently in times of crisis. from preceding development policies. The Another change also has made itself felt economically active population is now con- in the demands on health services. Gradu- centrated in the cities, where the jobs and ally but steadily, the population of Latin services are based. By this century's close, it America and the Caribbean is aging. Pro- is expected that more than 75% of the longed life expectancy is a sign of significant Region's population will live in urban set- achievement by the Region, but that very tings, and that half of that urban population success also means that public health and will be concentrated in 15 cities of more than medical services must adapt to the increasing four million people each. prevalence of chronic diseases that were This radical shift brings with it a change once the province of the wealthy who could in health profile, for what is termed urban- afford private care. This implies new train- ization is actually fast-growing rings of pov- ing, epidemiologic studies, more complex erty surrounding major cities. The residents services, and public information activities- of these poverty belts live in squalor, in all of which require funding. unplanned and overcrowded settlements with no basic services such as water, sanitation, vector control, and health clinics. They The Work of the Organization During are beset by the problems typical of impover- the Quadrennium ished urban concentrations: low infant birth weight, abandoned children, environmental One of the principal tenets on which the hazards, drug abuse, malnutrition, and a Organization's activities are based is that host of other diseases stemming from inade- universal access to health services should be quate income and services. seen and acted upon as a fundamental right Economic conditions in rural areas have of every citizen, whose well-being should be not improved either. According to ECLAC, the very purpose of national development agricultural real wages fell steadily in 16 policies. countries studied. Simultaneously, the criti- Putting these principles into practice, cal demand for services in urban areas, cou- especially during an economic crisis, calls for pled with resource and personnel shortages, unflagging efforts to preserve existing pro- meant that most health programs did not grams while discovering creative ways to make major inroads in reaching dispersed achieve the goal of equity. Part of the strat- agricultural population groups. egy is to obtain the political resolve at the xiv Report of the Director xiv Report of the Director

national and local levels to make the neces- flexible enough in scope to serve specific sary changes and increase financing for community needs. This approach also seeks health programs. The health sector itself to decentralize decisions about how must also find ways of making more efficient resources and services are managed in order use of the resources it already has in hand. to establish responsibility and accountability At the request of its Member Govern- at the local level; in other words, it sets up a ments, PAHO marshaled its resources to level of local authority that is lacking in emphasize a several-pronged strategy over highly centralized systems. Given that social the quadrennium: while tackling the com- participation is critical for this approach to plex organizational reforms needed to work, democratization is both a key to its increase the efficiency and scope of the deliv- success and a byproduct of its implemen- ery of basic health services, the Organization tation. spearheaded the mobilization of national, The vulnerable groups that have been subregional, and external resources for spe- singled out for special efforts include chil- cific projects that are achievable in the dren, pregnant women, the very poor, and shorter term. A chief approach toward the elderly, as well as adolescents who are accomplishing the mobilization of resources exposed to the additional risks of violence was the identification of priority programs of and drug abuse in periurban settlements. common interest to groups of countries, Among these groups, children received spe- which translated into intensified coopera- cial attention through programs for immuni- tion in jointly chosen fields and better coor- zation, control of diarrheal diseases and dination among national-level institutions acute respiratory infections, and monitoring and organizations. of growth and development. If the campaign to eradicate the wild poliovirus by the end of 1990 is successful-and evaluation results Transformation of National Health indicate that this target will be met-the Systems Region will be the first in the world to have done so. Inroads also have been made The core of PAHO's quadrennial strat- against measles, another serious and pre- egy to promote the transformation of exist- ventable childhood disease; the Caribbean, ing national health systems was set out in Canada, Costa Rica, Cuba, and the United the "Orientation and Program Priorities for States have set 1995 as the target date for PAHO during the Quadrennium 1987- eliminating its indigenous spread. 1990." Adopted in 1986, this document The effort to harness knowledge by pro- addressed institutional obstacles-many of moting a greater availability and better use which are the product of excessive centrali- of information includes researching, analyz- zation-that hinder the expansion of health ing, and disseminating information. Further- services' delivery. The programming priori- more, the Organization boosted its public ties established were to develop the health information efforts through video and service infrastructure with emphasis on pri- broadcast technology to make succinct, visu- mary health care, to provide responses to ally immediate health information available priority health problems present in vulnera- to the public at large. It is hoped that a bet- ble groups, and to administer the knowledge ter-informed public will change its behavior required to carry out the former. in the pursuit of health. Likewise, a well- The key to the first priority was the informed population is better able to break move to develop and strengthen local health the barrier of silence and exercise its demo- systems. Local health systems should pro- cratic rights in demanding appropriate vide comprehensive primary services that are health services where it lives. Introduction xv Introduction xv

Where the Region Stands Organization as a catalyst for regional health development policies. The main approach during 1986-1989 Regarding the development of health was to target concrete, achievable goals service infrastructures, several health minis- while tackling the more difficult process of tries established operational agreements with transforming the structures of health care social security institutes to reduce the dupli- delivery systems. In addition to guaranteeing cation of services and provide coverage tangible progress, this approach capitalizes where neither had done so before. Progress on specific accomplishments to maintain also was made in the complex task of estab- momentum and morale. There were a num- lishing epidemiologic profiles on which to ber of accomplishments that would be grati- base preventive interventions and local fying even in the best of times; they are health systems. Most governments also particularly noteworthy given the crisis envi- advanced in determining health manpower ronment in which they were realized. needs and, with PAHO/WHO's coopera- Among PAHO Member Governments' tion, in implementing appropriate training most significant gains is the fact that they programs. conceived of and cooperated in carrying out In order to combat priority health prob- a common health strategy-an achievement lems among vulnerable groups, most Mem- in its own right, since crises often bring ber Governments improved their vac- about competition for resources. The adop- cination coverage of children under one year tion of the "Orientation and Program of age; lowered infant mortality due to diar- Priorities" as a framework for health devel- rheal diseases, acute respiratory infections, opment was linked to the subregional initia- and poor perinatal care; and significantly tives for coordinated solutions to problems. decreased the incidence of urban rabies. The Plan for Priority Health Needs in Cen- Achievements in overall nutrition were less tral America has achieved substantial suc- marked, largely because of the economic sit- cess in obtaining financial support due to uation. However, notable improvements international concern about the subregion's were made in addressing specific nutritional critical situation and the consonant enthu- problems, such as endemic goiter, for which siasm for the initiative's strategic motto, targeted health interventions are possible. "Health as a Bridge for Peace." The other The health service areas that were most initiatives made progress in some of their affected by the economic crisis were hospital- target areas, and will continue to be major based care, water and sanitation services, vehicles for PAHO/WHO's technical and vector control, areas for which supplies cooperation. and equipment that are often imported rep- An important indicator of the Organiza- resent expensive recurrent costs. The lack of tion's achievements during the quadren- funds also curtailed the construction and nium is the vote of confidence expressed by maintenance of large facilities for hospital the sizable external funding that was care and for water and sewage treatment. received over the period. By the close of the Significant challenges will continue to quadrennium, the extrabudgetary contribu- face the Region's health sector over the com- tions to PAHO's health programs came close ing decade: health hazards from increasing to matching the combined contributions to exposure to environmental contaminants, a the PAHO and regional WHO regular pro- continual struggle to guarantee universal gram budgets. Raising funds of that magni- access to health services, the persistent prob- tude at a time when many international lem of controlling preventable diseases that programs face cutbacks testifies to the inter- still take an unnecessary toll in morbidity national community's confidence in the and mortality, the growing problem of meet- xvi Report of the Director ing the health needs of the elderly, and the implications of a changing world and their increasing impact from the abuse of alcohol, impact on the environment, and should tobacco, and illicit drugs. redefine the role of the State in the provision As the following chapters will make of social services. clear, the Region has shown that much can The health sector's progress hinges, to a be done even in the worst of times. Yet, none significant extent, on the outcome of of these areas fall within the health sector's national development decisions. Yet, in for- sole purview. The challenge of crafting via- warding its goals of safeguarding the health ble new development policies is now on the of the population and obtaining universal, table for the countries of the Americas. Such equitable access to services, the health sector development policies will have to include is simultaneously contributing toward the participatory democracy, must consider the larger purpose of national development. CHAPTER I

GOVERNING BODIES

Three Governing Bodies guide the work period provide guidelines for national and of the Pan American Health Organization. regional programs and reflect the chief con- The Pan American Sanitary Conference, cerns of Member Governments regarding PAHO's supreme governing body, is com- the status of public health in the Region. posed of a representative from each Member Government and meets every four years. It elects the Director of the Pan American San- PAN AMERICAN SANITARY itary Bureau, defines PAHO's general poli- CONFERENCE cies, and serves as the main forum in which the governments debate major public health The XXII Pan American Sanitary Con- issues. ference (XXXVIII Meeting of the WHO The Directing Council, too, is made up Regional Committee for the Americas) was of one representative of each Member Gov- held at PAHO/WHO's Washington, D.C., ernment and meets yearly during the three headquarters in 1986. Member Govern- intervening years that the Conference does ments elected Dr. Carlyle Guerra de Macedo not. The Council reviews and approves the to a second four-year term as Director to budget for PAHO's programs and matters of start in 1987 (Resolution II). importance to the Organization and its Noteworthy among Conference resolu- Member Governments. tions was one approving the document "Ori- The Executive Committee is constituted entation and Program Priorities for PAHO by representatives from nine Member Gov- during the Quadrennium 1987-1990" (Reso- ernments elected by the Conference or the lution XXI), which set the basic four-year Council for staggered three-year terms. The program guidelines for the Organization and Committee meets twice yearly to review its Secretariat. The resolution further technical and administrative matters and requested that special attention be given to submits its recommendations to the Council the following: strengthening health services or Conference; it also drafts the agendas for infrastructures; developing the health sec- their meetings. tor's financial analysis and resource manage- By agreement with the World Health ment capabilities; improving national health Organization, the Conference and the information systems; and defining the roles Council also serve as the World Health of health workers, recognizing the impor- Organization's Regional Committee for the tance of community participation and inte- Americas. grating health manpower education and In the course of their regular meetings training. during the quadrennium, each of the Gov- The Conference endorsed the initiative erning Bodies of PAHO passes a set of reso- "Caribbean Cooperation in Health" (Reso- lutions recommending actions to Member lution XI) that PAHO, the Caribbean Com- Governments and the Director of PASB. munity (CARICOM), and the Conference The main resolutions adopted during the of Ministers Responsible for Health in the

1 2 Report of the Director 2 Report of the Director Caribbean developed jointly. The Confer- attracting more extrabudgetary resources, ence also supported the "Joint Plan of the Organization kept its budgetary Action for the Andean Subregion" (Resolu- increases at modest levels, particularly com- tion XXII) designed by the Organization and pared to other international agencies. the Hipólito Unanue Agreement, in which the mobilization of resources for priority areas was emphasized. Quota Contributions

The status of Member Countries' quota DIRECTING COUNCIL contributions was a matter of grave concern for PAHO's Governing Bodies. As a result of During the quadrennium, the Directing the prolonged economic and debt crises, Council held three meetings: XXXII (1987), some governments did not meet their inter- XXXIII (1988), and XXXIV (1989). Resolu- national treaty obligation to pay yearly tion XV adopted at the XXXIII Meeting of membership quotas. Over the quadrennium, the Directing Council was one of the Coun- the Governing Bodies noted a disturbing cil's strongest actions to ensure implementa- increase in the number of PAHO Member tion of the Organization's priority to Governments that were in arrears. strengthen health systems infrastructures. Consequently, the Governing Bodies Stating its conviction that the challenge of considered applying Article 6.B of the improving the health of most needy popula- PAHO Constitution, which requires sus- tion groups should be met despite the pending the voting privileges of a Member Region's economic crisis, the Council called Government that falls in arrears in an on Member Governments to redouble their amount exceeding the sum of its annual quo- efforts to define policies, strategies, pro- tas for two full years. Several resolutions grams, and activities toward developing local voiced the Council's concern that this sanc- health systems. The Resolution placed spe- tion might be called for. In 1989, the Council cial emphasis on the adequate allocation of requested that the Director notify two Mem- resources and on administrative decentral- ber Governments that their voting privileges ization as ways to strengthen the operating would be suspended unless their payment- capacity of local systems. The Director, plan requirements were fulfilled by the open- meanwhile, was requested to undertake a ing of the XXIII Pan American Sanitary wide range of activities in this area, includ- Conference in 1990. The Council, however, ing technical cooperation, information dis- also commended those governments that semination, evaluation, and program had made impressive efforts to meet their support of national efforts. back obligations to PAHO.

Program Budget Subregional Initiatives

In 1987, at its XXXII Meeting, As noted above, the XXII Pan American the Directing Council appropriated Sanitary Conference endorsed PAHO subre- $US 138,806,000 to support PAHO programs gional initiatives in the Caribbean and in during the 1988-1989 biennium (Resolution the Andean Region. At its XXXIII Meeting, II). At its XXXIV Meeting in 1989, the the Council adopted Resolution X, endors- Council appropriated $US145,599,550 for ing the guidelines and strategies jointly the 1990-1991 budget period. By increasing developed by the countries of the Andean the efficiency and effectiveness of its opera- Subregion and instructing the Director to tions, managing its resources carefully, and collaborate with the Andean countries in Governing Bodies 3 mobilizing international support for this drennium, the Council adopted resolutions joint endeavor. reflecting its concern regarding this issue, and its desire that substantial improvements be achieved in this regard. Disease Prevention and Control

The Governing Bodies adopted several Disasters and Emergency resolutions which promoted concerted cam- Preparedness paigns to prevent, control, or eradicate certain infectious diseases and to increase Each year, the Region of the Americas awareness regarding substance abuse and suffers damages from hurricanes, earth- other behavior resulting in ill health. The quakes, volcanic eruptions, floods, droughts, campaign to eradicate the indigenous trans- and armed conflicts. Since the mid-1970s, mission of the wild poliovirus from the PAHO has pioneered disaster preparedness Americas by 1990 was the subject of several in the world. Resolution X adopted at the resolutions of the Directing Council. The XXXII Meeting of the Directing Council Council also approved resolutions calling for (1987) focused on the technical aspects of prompt measures in response to the growing disasters and health, and Resolution VI problem of AIDS, for which program the adopted at the Council's XXXIV Meeting Organization received increased financial addressed the effects of Hurricane Hugo and support. The need to strengthen malaria commended the Director for the Organiza- control programs and the observed spread of tion's response to emergency situations in Aedes albopictus in certain areas of the Re- the countries. gion prompted the Directing Council to ap- prove resolutions that also underscored the need to control or eradicate Aedes aegypti. Additional Issues Tobacco and drug abuse received growing attention from the PAHO Governing The implications of the "lost decade" for Bodies. At its XXXIII Meeting, the Directing health programs in Latin America and the Council approved Resolution XVIII, pro- Caribbean were considered at every meeting moting drug abuse prevention, and Resolu- of the Governing Bodies throughout the tion XXII, encouraging the fight against 1980s. At its XXXIV Meeting in 1989, the tobacco use. Similarly, at its XXXIV Meet- Directing Council, in Resolution XV, under- ing, the Council approved the Regional Plan scored the importance of PAHO's ongoing of Action for the Prevention and Control of study of the repercussions that the economic the Use of Tobacco (Resolution XII), as well crisis has had on health conditions in the as Resolution XIV on the fight against drug Region. addiction, drug abuse, and drug trafficking. Resolution XIII adopted at the XXXIII Meeting of the Directing Council (1988) requested that before the end of 1990, Mem- Women, Health, and Development ber Governments set national goals to reduce maternal mortality by the year 2000, The Governing Bodies of PAHO have and that those countries registering more noted repeatedly the injustices and waste of than five maternal deaths per 10,000 potential resources that arise when women recorded live births set the goal of reducing are denied full partnership, with equal rights that mortality rate by at least 50%. and equal access, in all areas of the struggle During its XXXIII Meeting, the Direct- for human and national development. In ing Council also addressed the Organiza- each of its meetings throughout the qua- tion's policy and lines of action in regard to 4 Report of the Director 4 Report of the Director

food and nutrition (Resolution XVI). Recog- to the Directing Council and the Pan Ameri- nizing the persistence of serious food and can Sanitary Conference for final consider- nutrition problems in the Region, the Coun- ation and action, the Executive Committee cil urged Member Governments to reviewed a variety of matters regarding the strengthen multisectoral policies and strate- Organization's management, including sev- gies for improving nutritional status, particu- eral amendments to the Staff Rules of the larly among low-income populations and Pan American Sanitary Bureau, progress groups at high biological risk. Seven aspects reports on the implementation of the newly of the Organization's technical cooperation created system for hiring personnel under were emphasized, including planning, exe- local conditions of employment, actions cuting, and evaluating food and nutrition required for administration of the building strategies; nutritional surveillance; food dis- fund, and recommendations concerning the tribution; and the control of iodine, iron, content of the fellowships program. The and vitamin A deficiencies. Committee also took action on the reports of its Subcommittee on Planning and Pro- gramming; its Subcommittee on Women, EXECUTIVE COMMITTEE Health, and Development; and its Standing Subcommittee on Inter-American Nongov- In addition to analyzing technical and ernmental Organizations in Official Rela- policy issues and making recommendations tions with PAHO. CHAPTER II

GENERAL PROGRAM DEVELOPMENT AND MANAGEMENT

EXECUTIVE MANAGEMENT tor of PASB the flexibility to finance special activities in priority areas in which timing is PAHO Executive Management provides of the essence and for which budgetary allo- leadership to the Organization and guidance cations could not be foreseen. Because of the to its Secretariat. Organization leadership shortfall in financial contributions to the entails monitoring programs to ensure that Organization, the Director reduced by 36%, they are regularly updated to meet the needs or $US1,947,000, the amount originally of the countries they serve and to keep pace approved for this purpose by the Governing with developments in health technologies Bodies for the period 1986-1989. and methods. In guiding the Organization's The Director used the remaining funds Secretariat, Executive Management has the to respond to unanticipated problems in the tasks of fostering dialogue and cooperation health sectors of Member Countries; to take among multilateral, bilateral, and private advantage of new opportunities for or pro- agencies active in the health field, and of mote approaches to technical cooperation; promoting international and national com- to support innovative concepts, approaches, mitment to improve health in the Region. or technology in health; and to promote, Maintaining the Organization on a coordinate, or accelerate initiatives. sound financial footing is a critical Executive In this period, almost 62% of these Management responsibility that involves remaining funds were used for the first two close monitoring of the Organization's finan- purposes, including the provision of special cial status. This scrutiny was especially nec- support to several countries ravaged by the essary during the 1986-1989 quadrennium, effects of hurricanes Gilbert and Joan. Of the in which serious budgetary deficits and balance, most was devoted to specific activi- erratic payment of quota contributions were ties of an urgent nature related to the initia- matters of constant concern. The new pro- tion and execution of the Organization's gramming and financial systems that have regional and subregional initiatives. been introduced over the past four years have enabled management to protect the programs, activities, and strategic approach GENERAL PROGRAM of the Organization during the 1980s. DEVELOPMENT

During the 1986-1989 quadrennium, REGIONAL DIRECTOR'S significant headway was made along various DEVELOPMENT PROGRAM lines of general program development to improve administrative management, increase The Regional Director's Development the Organization's efficiency and effective- Program is a fund that is allocated in the ness, and ensure the Pan American Sanitary budget with the purpose of giving the Direc- Bureau's capacity to respond to changing

5 6 Report of the Director 6 Report of the Director

conditions in the countries and to the man- Program Budget (APB) plan and a four- dates of the Governing Bodies, as contained month work plan (PTC). Microcomputer- in the document "Orientation and Program based systems are now used to prepare each Priorities for PAHO during the Quadren- unit's APB and PTC, which are then incor- nium 1987-1990." Special attention was porated in a single, Organization-wide data devoted to the improvement and automa- base on the mainframe computer. tion of the American Region Planning, Pro- As part of the general program manage- gramming, Monitoring, and Evaluation ment process, joint evaluations of PAHO/ System (AMPES), the joint PAHO/WHO- WHO's technical cooperation were held in national government reviews of technical most of the countries of the Region. The cooperation activities in each country, the meetings sought to refine the orientation of development of the Organization's staff, and technical cooperation programs in each the strengthening of its Country Represen- country and to increase the efficiency with tations. which PAHO/WHO resources are used. As part of the AMPES process, consulta- Regarding the development of PAHO/ tions were held at the country level in 1986 WHO staff, top priority was given to staff and 1988 to draw up the general program training at all levels and to effective use of budgets for 1988-1989 and 1990-1991, training resources and other support respectively, which include PAHO/WHO mechanisms. technical cooperation activities during those Activities designed to strengthen periods. PAHO/WHO Country Offices are discussed In addition to streamlining AMPES pro- in Chapter III of this report, under the sec- cedures, evaluation of PAHO/WHO's pro- tion "Managerial Process for National grams was incorporated into the system, as Health Development." were mechanisms that permit activities in progress to be adjusted according to the availability of human and financial EXTERNAL COORDINATION FOR resources. Overall, greater decentralization HEALTH AND SOCIAL was sought, which in turn required each DEVELOPMENT organizational unit to have the appropriate managerial infrastructure, while the Organi- PAHO/WHO's intensive effort to mobi- zation maintained a centralized system to set lize external financing for health projects has policies and priority programs. achieved dramatic progress in the last four Efforts also focused on improving the years. In 1989, extrabudgetary funds reached Program Budget and Monitoring and Evalu- all-time highs, amounting to more than 40% ation Subsystems by establishing the prac- of the Organization's total spending. tice of specifying the results that each As a result of its work to mobilize exter- program hoped each of its projects would nal resources, PAHO/WHO's relationship achieve. The description of expected results with major external funding sources that are then serves as the basis for monitoring and active in the Region was strengthened dur- evaluating programs. ing the quadrennium. Annual meetings were Work done to improve the short-term held with multilateral organizations such as phase of AMPES was geared toward creating the World Bank, the Inter-American Devel- an integrated management information sys- opment Bank (IDB), the United Nations tem, which will be refined over the course of Development Program (UNDP), the United the coming quadrennium. In this domain, Nations Children's Fund (UNICEF), and progress was made in defining and program- the United Nations Population Fund ming an automated system to produce and (UNFPA). assemble a PAHO/WHO Annual Operating PAHO/WHO also developed a network General. Program Development and Management 7 GeneralDevelopment Progra ad Management

of contacts with contributors to PAHO's lizing resources and updated directories of subregional initiatives (Plan for Priority major official and nongovernmental funding Health Needs in Central America, Andean sources active in the Region. To further sup- Cooperation in Health, Caribbean Coopera- port Member Countries, PAHO/WHO tion in Health) and to special priority organized seminars and workshops on finan- projects and programs (women, health, and cial mobilization techniques that were development; polio eradication; and AIDS attended by officials in charge of interna- prevention and control). In support of the tional cooperation in the Central American initiatives in Central America and the countries, representatives of 11 Eastern Caribbean, the Organization formed delega- Caribbean countries, PAHO/WHO resident tions of national and PAHO/WHO officials fellows, and participants from the Andean to seek potential financial backers in North countries, Argentina, Guyana, Saint Lucia, America and Europe. and Trinidad and Tobago. The main external financing sources for health projects were the multilateral lending institutions (IDB, World Bank), the Euro- INFORMATION COORDINATION pean Economic Community (EEC), and the governments of Canada, Denmark, the Fed- During the 1986-1989 quadrennium, eral Republic of Germany, Finland, France, information requirements and capabilities Italy, Japan, the Kingdom of the Nether- changed substantially, as did plans to accom- lands, Norway, Sweden, the United King- modate them. The Office of Information dom, and the United States. In addition to Coordination made progress in consolidat- WHO, other agencies in the United Nations ing the information processing resources of system, such as UNDP, UNFPA, and the Organization at Headquarters. The over- UNICEF, provided significant support, as all computational capacity was increased by did nongovernmental sources, including the upgrading the mainframe computer and the W. K. Kellogg' Foundation, the Carnegie word processing capability and by adding a Corporation of New York, and Rotary minicomputer and a set of microcomputers. International. The introduction of compact disk, read- The Organization participated in two only memory (CD-ROM) technology al- major meetings designed to mobilize lowed large amounts of bibliographic infor- resources for the Region and to improve the mation to be made available to installations coordination of international cooperation in in a number of countries at very low cost. health projects at the country and subre- During the quadrennium this project was gional levels. In 1988, PAHO/WHO and the prototyped, placed in operation, and trans- Government of Spain cosponsored the II ferred to BIREME. Madrid Conference on Central America in Completion of the Financial Manage- support of the plan known as "Health, a ment System (FMS) remained the highest Bridge for Peace," which was attended by priority within the applications development representatives of more than 35 govern- area. The Office of Information Coordina- ments and nongovernmental agencies. In tion worked closely with the Budget and 1989, the Government of Italy and PAHO/ Finance and Accounts units to define and WHO cosponsored a Ministerial Conference program the system. The "Budget" module on Italian Cooperation in Health in Latin of the FMS was completed, as were the America and the Caribbean, at which 22 "Expenditure Accounting" and "General ministers of health of the Region were Ledger" modules. They are now in operation present. and require only minor modifications. These PAHO/WHO continued to prepare, modules were designed to interface with publish, and distribute guidelines for mobi- each other and other PAHO systems, and 8 Report of the Director work will continue on these interdependen- An electronic mail capability was nearly cies in the next period. ready for use at the end of the quadrennium. In 1989 linkage was established between Once installed, it will allow users of the the Field Financial Management System WANG systems within PAHO/WHO to (FFMS), which is being used in several loca- communicate easily with offices and institutions, and the Headquarters FMS. This tions outside Headquarters. This application allows transactions occurring in the field to employs techniques and programming that be quickly reflected at Headquarters. were developed by another United Nations The Human Resources System's initial agency. data base, containing curricula vitae of pro- The introduction of a large number of spective employees, was made available to microcomputers and the need to share infor- users of PAHO's on-line system. Additional mation led to the Organization's decision to capabilities and linkages were developed as install a Headquarters-wide local area net- resources allowed, but completion of the sys- work (LAN). Work on this project began in tem is expected to take several years. 1989. CHAPTER III

HEALTH SYSTEMS INFRASTRUCTURE

INTRODUCTION the countries of the Region agreed that the health sector should be reorganized by devel- The Health Systems Infrastructure Area oping local health systems. The Health Ser- was reorganized in 1986 to bring together vices Development Program was made the Health Services Development, Health responsible for coordinating this strategy, Policies Development, Human Resources and the entire group of programs making up Development, Scientific and Technical the Health Systems Infrastructure Area was Health Information, and Health Situation oriented accordingly. Personnel requirement and Trend Assessment programs. The Area's profiles and training programs sponsored by programs concentrated on designing strate- the Human Resources Development Pro- gies for delivering integrated, interprogram- gram focused on developing the cadre of matic technical cooperation to Member health care workers needed to make possible Governments. universal access to decentralized primary The economic and social crisis in the care services. The Health Policies Develop- Region, the sustained democratization ment Program concentrated on the areas of process, the governments' need to reformu- planning, financing, and health technology late development strategies, and the process innovations. A major part of the Health Sit- of modernizing the role of the State were all uation and Trend Assessment Program's factors that influenced attempts to reform effort was lent to developing applied epide- the delivery of health services during the miologic methods that would both improve quadrennium. Within the health sector national analytic capabilities and incorpo- itself, past attempts to achieve equity of rate epidemiologists into policy making. The access by simply increasing the number of Scientific and Technical Health Information existing services proved infeasible. As a Program provided support to all of these result, health sector leaders were largely sup- activities, as well as those of other technical portive of the Area's integrated approach, in programs not included in the Area, by which the quality and efficiency of services, selecting, publishing, and distributing infor- as well as their managerial reform, were mation vital to the democratization of given top consideration. knowledge that goes hand in hand with the The Area's programs hence conducted establishment of effective local health their technical cooperation activities guided systems. by the strategies of decentralizing manage- To foster cooperation with other sectors ment and promoting local health systems, whose work has a bearing on health, the coordinating information gathering and Area identified key institutions with which intervention methods with other sectors, to undertake joint projects. Notable among improving the management of information, these undertakings was the University and and recognizing and incorporating multi- Health in Latin America and the Caribbean causal analysis in the design of health for the Twenty-first Century (USALC-XXI) projects. project, in which the universities of Latin In adopting Resolution XV of the America and the Caribbean and the Union XXXIII Meeting of the Directing Council, of Latin American Universities participated

9 10 Report of the Director

in reviewing the solutions that such disci- improve their health systems' coverage using plines as economics, political science, engi- the strategy of networks of local health sys- neering, and environmental sciences could tems. Some of them made concrete technical offer to health problems. and legislative progress in carrying out these The Area also pursued increased collab- policies. oration between the health sector and the social security sector, which, as a major financer and provider of health services, is MANAGERIAL PROCESS FOR an indispensable participant in the reform of NATIONAL HEALTH services and the extension of coverage. The DEVELOPMENT Area's programs also sponsored meetings to obtain the participation in health projects of During the quadrennium, most of the such organized groups as labor unions, medi- countries of the Region made progress in cal associations, and political parties. reorienting technical cooperation activities The management of information was toward building health system infrastruc- critical in all of these endeavors. There was a tures and health services aimed at fulfilling vast increase in the quality and quantity of the requirements of high-risk priority information and expertise in the Region over groups. PAHO/WHO cooperated in these the quadrennium. It was therefore necessary efforts and in assessing the progress achieved to identify new information gaps and deter- toward the goal of universal primary health mine how the Area could fill them. The care by the year 2000. Areas of focus needs that came to light were related to included the analysis and management of administrative and epidemiologic methodol- the political dimensions of health and the ogy. Thus, the production and distribution institutional organization of health systems, of documentation on strategies toward the with special emphasis on forging relations efficient planning and management of ser- with social security institutions and the pri- vices was an area that received attention vate sector. from all of the programs. Their efforts A key element of PAHO/WHO's coop- resulted in numerous scientific and technical eration was its improvement of the organiza- publications issued in Spanish, English, tion and administration of the Country French, and Portuguese. Several of them- Offices, which are responsible for coordinat- most notably The Challenge of Epidemiology, ing PAHO/WHO technical cooperation to AIDS: Profile of an Epidemic, and Recomenda- national programs. The procedures for for- ciones de la Comisión Internacional de Protec- mulating technical cooperation programs ción Radiológica-had an even greater impact were made more efficient by the introduc- than had been foreseen. tion of automated systems in all Country The development and extension of Offices to facilitate project planning, information network systems and technolo- programming, and execution. In many gies (LILACS/CD-ROM and BITNET) were Country Offices, the staff profile was modi- also very well received. Based on PAHO/ fied to better accommodate national WHO's own data base and acquired data, requirements. and aided by the development of MicroISIS PAHO/WHO staff members were given software, the information network systems training in administrative and technical mat- contributed greatly to the availability and ters to improve their proficiency. Special coordination of information in the emphasis was also placed on improving countries. administrative services, communications, The majority of the countries in which and secretarial support, and on decentraliz- an analysis had been carried out by the end ing the administrative control of fellowships, of the quadrennium expressed willingness to seminars, and courses. Health Systems Infrastructure 11

Documentation centers were bolstered tion that would facilitate technical to increase the availability and timeliness of cooperation undertakings between its Mem- much-needed information. The documenta- ber Governments. It also conducted multi- tion centers made available periodical sub- national meetings, workshops, and seminars scriptions, book purchases, and photo- and awarded fellowships to national officials copies of scientific articles, and provided so that they could observe cooperation pro- such assistance as bibliography preparation, grams in progress. advisory services, and staff training. The Central American, Caribbean, The physical infrastructure was up- Andean Area, and Southern Cone initia- graded by seeking new buildings for Coun- tives provided a framework in which pro- try Offices or remodeling the facilities in grams and activities related to joint health use. problems could be more easily established. As computers were gradually intro- With the Organization's participation, the duced, so was the field financial manage- Latin American Economic System (SELA) ment system, which was operational in Meeting in 1989 chose the health sector to several Country Offices and Centers by the promote programming and negotiation end of 1989. The system is designed to meetings on technical cooperation among improve the reliability of budgetary and developing countries in the field of health. financial/accounting information and to Although the results have been slow to reduce the workload involved in processing accrue because of the lack of tradition in this information at Headquarters. such ventures, programs such as those that were forged between Mexico and the United States, between Mexico and Belize, and TECHNICAL COOPERATION among participants in the Central American AMONG COUNTRIES AND and Caribbean initiatives were auspicious PROJECTS AT THE COUNTRY beginnings. LEVEL

Technical cooperation among develop- HEALTH SITUATION AND TREND ing countries is one of the most useful means ASSESSMENT of promoting the coordination of efforts by the Organization's Member Countries, while The Health Situation and Trend Assess- ensuring that they benefit from each other's ment Program was created in 1986 in experiences in handling common health response to the need for strengthening and problems. During the 1986-1989 period, the expanding the practice of epidemiology in Organization promoted such technical coop- the countries of the Region, in view of the eration in the form of the sharing of man- major epidemiologic changes observed in power, expertise, and financial resources and Latin America and the Caribbean. Along the development of joint projects. The areas with the persistence of diseases typical of in which such efforts were concentrated were poverty and underdevelopment, there has promoting health research and technology been a rise in health problems common to development, designing systems to ensure developed nations, such as diseases of the the availability of critical supplies and equip- elderly, environmental contamination, and ment, coordinating interventions for health accidents and violence. The protracted eco- problems common to several countries, and nomic crisis made an epidemiologic assess- sharing human resources development ment of needs even more critical, as health projects. sectors sought a sound basis on which to During the quadrennium, the Organiza- determine how to best deploy their tion gathered and disseminated documenta- resources. 11 RPeport oftle Director

The aims of the Program are geared of the organization and functions of epidemi- toward generating and utilizing knowledge ology units in light of ongoing decentraliza- related to the assessment of the health status tion processes. Particular efforts were of the population, its determinants, and devoted to improving the utilization of epi- trends, in order to contribute to the defini- demiologic concepts, principles, and meth- tion of priorities and the formulation of ods to perform analysis of the health health policies and strategies for interven- situation and trends and surveillance of old tion. An additional goal is the evaluation of and new health problems. Cooperation was the impact of these policies and strategies, provided for the identification of training and of health interventions in particular, so needs in epidemiology and related disciplines that they may be adjusted or redesigned as and for the formulation of strategies to necessary. These objectives include enhanc- address those needs, especially in regard to ing the availability, quality, and timeliness of training in and for the health services. suitable data and the promotion of their Priority attention was also given to stim- appropriate utilization for ongoing analyses ulating and supporting epidemiologic as well as for special research projects. The research and the discussion and dissemina- Program's work, as set out in its 1984-1989 tion of research results. To facilitate these medium-term program, was carried out by discussions, scientific meetings were sup- staff at Headquarters, in several countries, ported in several countries. At the present and at the Caribbean Epidemiology Center time, this sort of meeting represents the best (CAREC). available mechanism for consolidating the In the understanding that epidemiology practice of epidemiology and promoting the is one of the public health disciplines that is utilization of epidemiologic knowledge as key to the achievement of the objectives input for policy formulation and health ser- stated above, the Program supported vices organization and evaluation. national meetings convened to review and In addition, regional initiatives were refocus the practice of epidemiology, to for- devised to promote research, support train- mulate recommendations for its expansion ing, and enhance the dissemination of tech- and strengthening, and to revise the ensuing nical information. implications for training and the generation The Program's main efforts regarding of knowledge. This effort has been carried the generation of knowledge were geared out in almost all the countries of the Region. toward promotion and support of research Several countries, including Argentina, Bra- projects on health profiles. Individual zil, and Venezuela, created national commis- research projects were designed to systema- sions on epidemiology to follow up on these tize procedures traditionally used to analyze meetings' recommendations, with special mortality data and to gain experience with attention to requirements of local health ser- some infrequently used procedures, such as vices. The conclusions and recommenda- years of life lost prematurely. PAHO/WHO tions of these meetings have contributed to Headquarters and field personnel worked the preparation of national plans of action to with national researchers to carry out the strengthen the practice of epidemiology and, studies. Of the eleven projects begun in in turn, have served as input for the ongoing 1985, nine were completed, while the other adjustment of the Program's technical two continued. A major meeting was held in cooperation. 1988 in Washington, D.C., to summarize the Emphasis has been placed on direct results of this two-year effort to study mor- technical cooperation with Member Gov- tality. The conclusions of the meeting were ernments for strengthening the practice of distributed Region-wide and had major epidemiology in the health services, includ- impact on mortality analyses. ing the revision, expansion, and adjustment A second line of epidemiologic research Health Systems Infrastructure 13 has been promoted to enhance the under- and attended by representatives of epidemi- standing of the epidemiologic transition and ology training centers in Latin America and its relationship to the socioeconomic condi- the Caribbean, agreed on the need to tions of different geographically defined develop a conceptual framework for the population groups, in order to facilitate determination of health phenomena that health services planning and evaluation. incorporates the relationship between bio- Along this line, in August 1989 a meeting logical and social processes. It was also was held in Brasilia at which senior research- widely agreed that all aspects of the field of ers from 10 countries discussed appropriate epidemiology should be considered, includ- methods and approaches for studying the ing studies of the health situation, epidemio- relationship between health and overall liv- logic surveillance, research on causes, and ing conditions. service evaluation. Special mention was Training in epidemiology cannot be made of the need to emphasize the applica- developed in isolation from its practice in tion of epidemiologic thinking in an integral the health services. Moreover, by integrating approach to public health and to avoid the teaching of epidemiology with the provi- reducing epidemiology to a simple technique sion of services, a pattern of practice that has for validating hypotheses that are formu- been largely unresponsive to changes in the lated on the basis of individual clinical health requirements of the population would approaches. be gradually transformed. Faculty from pub- The Program participated in program- lic health schools in Medellín, Mexico City, ming, carrying out, and evaluating a 10- and Rio de Janeiro met in San José, Costa week course in epidemiology for the Rica, in July 1986 to discuss a proposal call- countries of the Central American Isthmus, ing for the development and adoption of a which has been held annually since 1987 in training model in which a work-study strat- San José, Costa Rica, in collaboration with egy would accomplish the twofold objective the Government of Spain. of transforming epidemiology's practice and The Program further promoted research training. Through the cooperation of the and training through the wide dissemination Latin American and Caribbean Association of information. This effort centered around for Education in Public Health (ALAESP) quarterly publication of the Epidemiological and the United States Association of Bulletin, with current pressruns of 4,000 in Schools of Public Health (ASPH), an initia- English and 8,500 in Spanish. In addition, tive was completed, in collaboration with bibliographies and other reference materials the Human Resources Development Pro- on epidemiology and health statistics were gram, to address the need for leadership in assembled and made available to countries, the health sector and the complexity of the and special-purpose documents were pro- decisions undertaken by health workers. duced and distributed, including reports on Within this context, a meeting was held in technical meetings. Caracas in 1987 with participants from vari- In response to the growing demand for ous institutions, including schools of public technical information in the countries, health in the United States. The meeting PAHO/WHO increased the dissemination dealt with improving national health care of epidemiologic and statistical information. information systems and the need to A first step in the Program's project to col- strengthen epidemiologic training and lect, analyze, organize, and distribute biblio- research in schools of public health. graphic information on epidemiology and In Taxco, Mexico, in November 1987, a related material was the publication of the meeting jointly organized by ALAESP, book The Challenge of Epidemiology, Issues ASPH, the United States Centers for Dis- and Selected Readings in 1988. ease Control (CDC), and PAHO/WHO, Specific reports on technical meetings 14 Report of the Director 14 Report of the Director

were produced and distributed, such as the have been circulated, and essentially all of ones generated by the ALAESP meeting in the suggestions of the Region of the Ameri- Taxco, Mexico, and the meeting on Guide- cas have been taken into account in the lat- lines and Procedures for Mortality Analysis est drafts. The preparation of the Spanish in Washington, D.C. version of the 10th revision was initiated in In the area of health information, the parallel and is presently well advanced, and Program maintained a data base on mortal- field trials of the index are under way. In ity, population, and reported cases of dis- addition, trials of the different drafts and eases subject to the International Health studies of comparability between ICD-9 and Regulations, and incorporated population ICD-10 (bridging studies) were carried out. data obtained through an agreement with The third line of work concerned the the Latin American Center on Demography improvement in basic data that are oriented (CELADE). Data were collected from Mem- especially toward improvement of the instru- ber Countries and processed for publication ments used, above all those dealing with in the World Health Statistics Annual. The mortality. Program responded to external and internal The fourth line of work was the investi- requests for information from PAHO techni- gation of new or alternative methods for the cal units, the IDB, the United States Congress, collection and analysis of data. Regarding newspapers, researchers, and Member data collection, nonconventional methods Governments. were investigated for their utility in provid- The Program also coordinated an inter- ing simplified epidemiologic surveillance, disciplinary working group with other improving vital statistics, and addressing the PAHO/WHO programs to prepare the 1990 perceived needs of communities, as well as edition of Health Conditions in the Americas, for the validation of information, as was sup- in which the Organization and its Member ported by the Revision Conference for ICD- Countries present detailed statistical analy- 10 held in Geneva in 1989. With regard to ses of the major health trends in the Region. alternative methods of analysis, studies were A special project within the Health Situ- carried out on multiple cause analysis and ation and Trend Assessment Program has the search for new indicators. been the International Classification of Dis- eases (ICD), which involved several lines of work. The first concerned the promotion of HEALTH POLICIES DEVELOPMENT ICD in a comprehensive manner, taking into account its instruments and its uses. The The Health Policies Development Pro- main strategy was the strengthening of a net- gram was created at the start of the quadren- work of national centers. The work of these nium to lend technical cooperation in the centers concerned the utilization of ICD and development of health systems infrastruc- the generation of information to reinforce ture. Its purpose is to foster a comprehensive vital and health statistics. The network of and integrated approach to analyzing and centers and related institutions was developing health policies. expanded with the incorporation of Cuba, The Program emphasized developing and discussions were initiated toward estab- and strengthening the capacity of national lishing centers in the English-speaking health sectors to interact with all those sec- Caribbean and in Central America. tors that have a bearing on health policies The second line of work concerned the and at the same time improving coordina- next revision of ICD, its family of classification among agencies providing health ser- tions, and other classifications related to vices in order to achieve greater effec- health. Successive drafts of the 10th revision tiveness. It stressed the need to make health Health Systems Infrastructure 15 Health Systems Infrastructure 15 planning consonant with national developments in negotiating projects with interna- ment policies and to enhance the effective- tional or bilateral funding agencies. ness of national legislation regarding the The Program developed a technical rights and duties of the State, individuals, capacity in the area of public health legisla- and private institutions in promoting, pro- tion, a service that expanded greatly due to tecting, and restoring health. Other areas of the interest of national health authorities. In Program concern were analyzing the rela- cooperation with the Library of Congress in tionship between a country's economy and the United States, BIREME, and the Faculty its health conditions, increasing efficiency of Law of the University of the West Indies, and equity in the economic and financial the Program created the LEYES data base, management of health services, and promot- which contains summaries of the health leg- ing the development of health technology, islation of the countries of Latin America while increasing its accessibility and and the Caribbean. Incorporated in effectiveness. LILACS/BIREME's MicroISIS system, this Given the nature of the Program, it data base served as a reference source for worked closely with social security agencies countries that were reforming their health and other governmental and private institu- legislation. tions in addition to the health ministries. The Program also provided specialized Other PAHO/WHO Regional Programs technical support in applying economic and collaborated on activities related to their financial analyses to health problems and areas of work, as did other international services. This support was useful in the insti- organizations. tution of a national health insurance plan in In collaboration with the Human Trinidad and Tobago, the implementation of Resources Development Program, work was food and nutrition programs in Brazil, and carried out with the governments of Argen- cost-effectiveness analyses of the campaign tina, Brazil, Colombia, Mexico, Peru, and to eradicate wild poliovirus in Central Venezuela to strengthen the operational and America. leadership capacity of their health sectors The formation and maintenance of and to reform their national health systems national groups specializing in the develop- through dialogue with social security in- ment of health technology was a primary stitutes, the private sector, universities, concern of the Program. Such groups were parliaments, labor organizations, and organized in the ministries of health, social communities. security agencies, and universities of Argen- In Central America, the workers' health tina, Brazil, Colombia, Costa Rica, Cuba, component of PAHO/WHO's Environmen- Mexico, and Uruguay. Toward the end of tal Health Program cooperated in a project the quadrennium the Program began similar to expand workers' health services provided projects in other countries. by the ministries of health and the social With support from political science cen- security institutes by supporting coordina- ters in the Region, a preliminary survey was tion efforts between those entities. completed in 15 countries to determine their The governments of Brazil, Guatemala, health policy agendas, identify principal pro- Honduras, Jamaica, Mexico, Paraguay, and tagonists and their positions, and assess the Peru received the Program's assistance in capacity for health policy research and strengthening their ability to draft, carry teaching. The information gathered will be out, and evaluate health policies, plans, pro- used to establish follow-up activities in these grams, and projects. In general, such cooper- countries and guide the expansion of similar ation entailed providing support to national studies to others. groups, developing information systems for The Program systematized a methodol- planning purposes, and assisting the govern- ogy for formulating, implementing, and eval- 16 Report of the Director

uating projects, areas in which many ning with emphasis on health that was held countries required cooperation as they in Buenos Aires in 1987 and 1989. Similar sought to improve project management. topics were covered in the Seminar on Insti- The Program also promoted, in collabo- tutional Aspects in Formulating, Implement- ration with the Health Services Develop- ing, and Evaluating Health Policies, which ment Program, the design, modeling, and the Program conducted in San José, Costa application of automated information sys- Rica, in 1987, in cooperation with the Latin tems on health equipment. In cooperation American Development Administration with the Health of Adults Program, a con- Center (CLAD) and ECLAC's Latin Ameri- sensus conference was held that produced can Institute for Social and Economic Plan- recommendations on the use of technologi- ning. Sixteen countries participated. cal options for managing chronic renal in- The material the Program has gathered sufficiency and served as a model for re- and systematized on health development viewing complex issues surrounding other projects was presented at five intercountry technologies. seminars. The training package consisted of The Program's research activities center texts, exercises, computer programs, audiovi- on two of the priority areas of PAHO/ sual aids, and teaching guides, and should be WHO's Research Grants Program (health available for wide distribution starting in financing and technological development 1990. In addition, health planning courses process in health) for which it has direct offered by national educational institutions responsibility. It also provides support to the were supported in Brazil, Jamaica, Mexico, area of health policy process, which is the Nicaragua, and Venezuela, and the World responsibility of the Office of Analysis and Bank Economic Development Institute col- Strategic Planning Coordination. laborated on two seminars on health eco- The implications for health policies of nomics and financing, held in Brasilia (1987) the return to a democratic form of govern- and Barbados (1989). ment during an economic crisis were In view of the health sector's relative explored through a comparative research inexperience with many of the subjects project begun in Argentina, Brazil, and Uru- addressed by the Program, more than a guay, which have recently gone through that dozen reference texts were produced to transition. The IDB cooperated in another increase knowledge of the theories and comparative research project in Brazil, Ecua- methods involved. A series of articles and dor, Honduras, Mexico, and Uruguay that four texts on health economics and financ- explored the impact of the economic crisis ing were published, as was a book on meth- on health conditions and services. The Pro- odologies for evaluating health technologies. gram supported a similar study in the Carib- Publication was begun of a Spanish edition bean, conducted by the Institute of of the Bulletin of the International Society for Socioeconomic Studies of the University of Evaluation of Health Technology. the West Indies, as well as studies of sectoral The Program has carried out regular financing that were undertaken in Argen- evaluations of its activities. Its impact is hard tina, Brazil, Mexico, and Peru. to assess at this early stage, however, espe- The Program engaged in numerous cially since it acts in coordination with so training activities, including drawing up a many other programs and institutions. training plan on technologic development Although the economic crisis during the sec- that was put into practice in several coun- ond half of the 1980s bore witness to the tries. In cooperation with the OAS Center prudence of the Program's proposals to for Economic and Social Development reform traditional planning methods, resis- Research, the Program sponsored an inter- tance was encountered from those who American course on social policy and plan- underestimate the weight of the socioeco- Health Systems Infrastructure 17 nomic and political components of health above all, with technical information and problems and interventions to solve them. training to enable the staff to carry out most Many health professionals and authorities of the activities of direct cooperation. also were reluctant to accept the participation of other sectors in the design of health interventions. ORGANIZATION OF HEALTH Nonetheless, over the quadrennium SERVICES BASED ON PRIMARY there was a marked increase in interest on HEALTH CARE the part of authorities, specialists, teachers, and researchers in subjects related to health Health Services Development policy analysis and development. This same kind of interest also began to emerge in PAHO/WHO received two mandates other development sectors, especially among from its Governing Bodies that emphasized those active in health projects. Interest was the need for reorganization of health services expressed not only in discourse but also in by the Member Governments. Resolution the actions of governments, in training pro- XXI of the XXII Pan American Sanitary grams for health workers, and in the Conference (1986) approved the Organiza- research areas assigned priority by the coun- tion's programming priorities for 1987-1990, tries. The receptivity in the countries toward establishing the need to develop the health the proposals drawn up and activities carried infrastructure as a fundamental component out by the Program is another indicator of in the application of the strategy of primary the positive results that have been achieved. care. Resolution XV of the XXXIII Meeting The linkage between health and social secu- of the Directing Council (1988) recognized rity institutions, the documentation system "the urgent need to accelerate the transfor- on health legislation, the approaches to mation of the national health systems" and managing development projects, the pro- requested the Director of PASB to support posals for strategic and situational planning, the processes of decentralization and devel- the application of economic analysis to opment of local health systems in the health problems, and the sector's approaches countries. to technology management are all examples Having identified the development of of progress made. Another indicator is the local health systems as the most suitable high demand at the end of the quadrennium means of attaining universal primary care, for repetition of the courses sponsored by the Organization entrusted the Health Ser- the Program. vices Development Program with carrying Finally, it is notable that most of the out activities in support of that policy. The publications supported by the Program were Program's main objective was to promote already out of print by 1989. Moreover, the and support national efforts to establish net- training modules on development projects, works of local health systems that are although they were still in the prototype responsive to the specific needs of the com- stage, were reproduced several times in munities they serve. response to specific requests from Regional To that end, the Organization held con- Programs and PAHO/WHO Representa- sultations with national health leaders and tives' Offices. drafted Document CD33/14, which pro- Requests from Member Governments posed a framework for the development of for cooperation in analyzing and developing local health systems. During 1988 and 1989, policies greatly exceed the Program's ability information was gathered on the results of to respond at the regional level. It therefore on-going experiments in the establishment adopted a policy of supporting the PAHO/ of local health systems in a number of coun- WHO Representations with personnel and, tries. Five subregional meetings were held in 18 Report of the Direíctor 18 Report of the Director

which 360 representatives from 35 Member tion with the Central American Institute for Countries took part, sharing experiences Business Administration (INCAE), with and contributing new concepts and which training and research activities were methodologies. conducted. To foster a Region-wide debate on the Health care in major urban centers con- ideas discussed and methods to put them tinued to be a cause for concern in the into effect, the documents and conclusions Region, and efforts to provide it merited of these meetings were published and distrib- high priority. In cooperation with Rio de uted to the countries (15,000 copies in Span- Janeiro State, Brazil, the Program conducted ish, 5,000 in English). In addition, the book a meeting on the subject that was attended Primary Health Care and Local Health Systems by health care authorities from large metro- in the Caribbean was published for the politan areas in the Americas and Europe. English-speaking Caribbean. Participants stressed the need to decentralize The Program decided to emphasize a few health care in large cities by creating local, areas critical to the development of local neighborhood-based health systems geared health systems, with the aim of hastening toward health promotion and comprehen- the reorganization process. These areas were sive primary care. The approach recom- social participation, local strategic program- mended is in accord with the concept of ming, decentralization, and pharmaceutical developing healthy cities by coordinating supply systems. the efforts of all segments of civil society and Two expert meetings were organized to government to create a more humane discuss social participation. They defined a habitat. program of cooperation with 17 countries to Regarding the role of hospitals, the Pro- conduct surveys to assess the existing degree gram sponsored a meeting in Buenos Aires, of social participation. Subsequent meet- Argentina, of the directors of 50 hospitals in ings-one for Latin America and one for the the Region to analyze the participation of Caribbean-issued recommendations to hospitals in the development of local health guide the development of local health sys- system service networks. The Program also tems and the technical cooperation offered coordinated a meeting on hospital evalua- by the Organization and other agencies tion and accreditation with the Joint Com- active in health. Spain and UNDP, as part of mission on Health Services Accreditation, its management capacity development American Medical Association, American project, cooperated in a number of consul- Hospital Association, and the governments tant group meetings. of Argentina, Brazil, Colombia, Costa Rica, Since the proposal for developing health Cuba, Mexico, Peru, the United States, services based on the primary care strategy Venezuela, and the Caribbean countries. requires interdisciplinary and interprogram- A meeting of specialists in hospital matic action, which in turn necessitates design and maintenance was held in coordination among international agencies, Havana, Cuba. In this same country, evalua- the Program organized a consultative meet- tion of the quality of local health systems has ing on "Decentralization of the State and begun, using methodologies that may be Social Services," in cooperation with the applied by the Program to future coopera- Latin American and Caribbean Institute for tion efforts. Economic and Social Planning, UNESCO's The subject of hospital infections was Regional Office for Education in Latin also analyzed at the regional level, since this America and the Caribbean, ECLAC, problem has a relationship to both the qual- UNDP, and the United Nations Center for ity and increased cost of care. A meeting Human Settlements. Another step toward organized with the cooperation of 10 United intersectoral coordination involved coopera- States universities, Latin American and LOCAL HEALTH SYSTEMS

During the 1980s, the health sectors of most of the countries d the Americas became acutely aware that their own highly centralized structures-set up in a different era-were inadequate to accomplish their goal of providing universal access to primary health care, and often were a hindrance. How to reform these structures to make them more responsive, flexible, and efficient was a pressing concern at the outset of the 1986-1989 quadrennium. When the Ministers of Health met at the XXII Pan American Sanitary Conference in September 1986, they called on the Director to give "spcial attention to strengthenrng health services infrastru ctures." The next two years were marked by a concerted effort on the part of national health authorities and PAHO/WHO staff to study the feasibility of and draw up guidelines for developing and strengthening local health systems, An important outcome of that effort was the drafting of the document "Development and Strengthening of Local Health Systems," in which the main conepts and rationale for national networks of local health systems were elaborated and which was adopted in September 1988 by the XXXIII Meeting of the PAHO Directing Council. The Council proclaimed the "urgent need to accelerate the transformtation of national health systems' and called on the Organization to support the countries by, among other things, encouraging "exchanges of experiences between countries . . on advances in the development of local health systems.. ." (Resolution XV). Emergence of the concept of local health systems coincided, not surprisingly, with the increasing political democratization under way in many countries of the Region. A main approach of local health systems-to decentralize the management of health services-both relies on and promotes the active participation of the community. Administrative decentralization affords local health systems the flexibility to address the specific needs of the community they serve. By assigning to each of the local health systems responsibility for delivering health services to a given population within a dearly defined geographic jurisdiction, that system can be held accountable more easily for the efficiency and quality of those services. Another objective of local health systems is to integrare health programs, thereby providing comprehensive health care at each level. Simultaneously, the assignment of specific geographic areas of responsibility to local health systems expedítes the coordination of efforts with other sectors and agencies whose actions have a bearing on health programs. This coordination aims to make efficient use of all the resources available in a given area, avoiding duplication of efforts and permitting gaps in coverage to be detected more readily. A good managemtent measure in any event, intersectoral coordination is especially important when economic conditions require that optimal use be made of all the resources that can be tapped. In accordance with Resolution XV, subregional workshops were held at which participants from the countries discussed concrete measures, including financial, legal, and technical requirements, for developing local health systems. By the end of the decade, the Region had moved from recognizing that something had to be done to transform the health sector infrastructure to devising working definitions of local health systems for most of the countries. The groundwork has thus been laid to actually put those systems into effect throughout the Region during the last decade of the century.

19 20 Report of the Director

Caribbean countries, and specialized centers training events; technical and financial sup- formulated recommendations and a plan of port for the organization of local health sys- work to be conducted jointly by the coun- tems, management information systems, and tries and PAHO/WHO. decentralization; and the production of Technical guides for analyzing the devel- teaching materials. opment of installed hospital capacity were The first phase of the project "Strength- finalized and will be published in coopera- ening and Development of Engineering and tion with the research center on physical Maintenance Services in Health Facilities" resources in health of the University of for the Central American subregion was Buenos Aires, the National Hospital Fund of completed at a cost of $US3.5 million. It was Colombia, and the University of Campinhas conducted in coordination with national (Brazil). maintenance projects in Belize, Guatemala, The role of nursing in the provision of and Nicaragua. Each of the subregion's health services and in improving hospital countries put into operation a model hospi- care was also a matter of concern during the tal for which a Master Program for Adminis- quadrennium. Cooperative activities were tering Engineering and Maintenance carried out through an agreement with the Services was designed. Technical documen- Pan American Federation of Nursing Profes- tation centers were organized in each of the sionals (FEPPEN), a nongovernmental orga- subregion's countries, and approximately nization in official relations with 1,100 officials were trained in nine subre- PAHO/WHO. gional and national courses on priority top- The Program also supported national ics in the area of maintenance. Eleven health service reform efforts by developing technical manuals were prepared to allow for proposals to be presented to funding agen- follow-up and support of maintenance tasks, cies, such as IDB and the World Bank. and spare parts, tools, vehicles, microcompu- Another subject of priority interest ters, and technical books were acquired for a related to the development of local primary price of $US1.4 million. Joint purchase of health care services was pharmaceutical sup- these materials resulted in savings of approx- ply. A consultative document was prepared imately 20%. and a meeting was held at Quito, Ecuador, In the area of research and the manage- in which most of the Region's countries took ment of knowledge, the experience gained part. The need to ensure greater availability through technical cooperation activities of basic drugs was reiterated. It was con- made it possible for the Organization to cluded that to design effective drug policies, compile ample reference materials and case local health services systems must be able to histories, which will be published in Spanish carry out epidemiologic analyses, program in the PAHO Scientific Publications Series their own activities, and decide their own as "Local Health Systems: Concepts, Meth- intervention priorities. ods, Experiences." The UNDP-financed management Evaluations of ongoing decentralization capacity development project for Central and local health system development efforts America completed its first phase, and its in Brazil (Niteroi), Colombia (Cali), and significant contributions to national efforts Mexico (Monterrey) were carried out in were recognized in an external evaluation cooperation with the W. K. Kellogg Founda- conducted by UNDP. The activities carried tion. Likewise, in cooperation with WHO, out included design of minicomputer meth- studies were begun of local experiences in odologies and programs for the development Brazil, Chile, Ecuador, Guatemala, and of managerial capacity; promotion of wom- Jamaica. en's leadership in health administration (a The Program increased its support of joint effort with INCAE); seven subregional health services research in an effort to help Health Systems Infrastructure 21 countries obtain a current profile of prob- Practically all of them had passed corres- lems associated with quality of care, effi- ponding legal measures to support the decen- ciency, equity, and productivity of services. tralization process. Fifteen countries had Two consultative meetings, in which eight revised their health care models and 12 oth- countries participated, were held to deter- ers were contemplating doing so at the end mine ways of reinforcing health services of 1989. Most countries had concrete work- research, particularly the gathering of infor- ing definitions of local health systems, which mation on the modes of operation of local was evidence of the governments' political health systems. In one of the recommenda- commitment to establish them and rein- tions from these meetings, the need for forced the need for PAHO/WHO to con- investigators to exchange information about tinue to support their work in this area. the findings of ongoing research or projects was stressed. To this end, the Program began joint publication with WHO, the Rockefeller Essential Drugs and Vaccines Foundation, and the Health Services Research Foundation of the United States of The objective of the Essential Drugs and the thrice-yearly Health Services Research Bul- Vaccines Program is to support the develop- letin. Production of a series of educational ment of health services through activities modules on conducting health services that improve the availability, quality, and research also was begun with IDRC (Can- utilization of essential drugs and vaccines. ada) and WHO, and a compilation of scien- The Program was most active in the tific articles on the subject was started. It will Central American Isthmus, where human be published in book form as part of the and financial resources were mobilized PAHO Scientific Publications Series. through the Plan for Priority Health Needs. One of the main objectives of the reor- The Central American health ministries ganization of the health sector by decentral- agreed to specific subregional projects on izing its administrative management and pharmaceutical policies, drug regulation and establishing local health systems is to make quality control, supply systems, the produc- use of all resources available for health care tion of essential drugs, and the establish- within a given geographic area. Accomplish- ment of joint purchasing mechanisms. ing this goal entails building operational Numerous activities have been carried out as relationships between autonomous entities, part of annual work programs approved by especially health ministries and social secu- the national coordinators in the participat- rity agencies, a process that was a focus of ing countries, including direct technical Program cooperation with the countries. An cooperation, national and subregional work- important example of this kind of activity shops and courses, improvements in the was seen in Costa Rica, where joint pro- infrastructure of hospital and health center gramming in local health systems com- pharmacies and warehouses, provision of menced. This country's experience made supplies and equipment, and preparation of possible the formulation of a cooperation documents and technical guides. agreement between PAHO/WHO and IDB The joint purchasing of pharmaceuticals in support of the project. through the Essential Drugs Revolving Fund The effectiveness of the Program was for Central America made it possible to evaluated by means of an analysis of progress import these products at favorable prices. in health services development in all coun- Nevertheless, the fund's impact was dimin- tries of Latin America and the Caribbean. ished by the severe economic crisis affecting Approximately 80% expressed their determi- the subregion, the difficulties the countries nation to make revisions tending toward experienced in making foreign exchange decentralization of management systems. reimbursements to the revolving fund, and 22 Report of the Director the opposition of the local pharmaceutical courses in several countries on cold chain industry in some countries. All these factors management for the vaccines used in the led to a marked drop in purchase volume in Expanded Program on Immunization (EPI). 1988. Therefore, in 1989 a study was Several countries made advances in leg- launched on reorienting the fund toward islation governing blood transfusion ser- acquiring raw materials for national pro- vices, and others held courses on blood bank ducers in order to stimulate subregional pro- laboratory work. The United Kingdom's duction. The Central American Economic Overseas Development Agency collaborated Integration Bank will participate in this in courses held in the English-speaking endeavor to facilitate payments. Caribbean. In the Andean Subregion, the Program In support of the reorientation and reor- concentrated on Bolivia, Colombia, and ganization of health services, one of the Ecuador. With the collaboration of WHO's main objectives of the Program's technical Essential Drugs Action Program, prepara- cooperation during the quadrennium was to tory technical cooperation was carried out promote the development of modern phar- and projects were designed to develop and maceutical services, in which pharmacies strengthen national drug programs, includ- are active members of the health team. ing such aspects as pharmaceutical policies, These services aim to rationalize the supply regulation, quality control, production, and and use of drugs and improve the quality of drug supply systems. drug therapy by educating professionals and The Program's development within the patients. Southern Cone Health Initiative was Other activities of note were the regional delayed by external factors. In recognition of courses on hospital pharmacy administra- the slight progress made, national authori- tion conducted in 1987 and 1988 in Costa ties adjusted the schedules of joint projects at Rica in collaboration with national institu- a meeting of technical groups in October tions, the publication of the practical hand- 1989. Agreements were reactivated with books Bases for the Development and Sanitary regard to projects in public health legislation Improvement of Hospital Pharmaciesand Man- and regulation; exchange of information ual of Hospital Pharmacy Administration, and about pharmaceutical products and chemi- the projects under way in several Central cals; promotion of the exchange of immuno- American hospitals. The updating of drug biologicals, blood derivatives, and devices lists and preparation of therapeutic formula- required for blood transfusion; a data bank ries for health-sector institutions in Andean on installed capacity for specialized analyses; and Central American countries also and studies on drug utilization. received support. To ensure that the vaccines acquired for Drug information centers, which are countries in the Region through the important elements of pharmaceutical ser- Expanded Program on Immunization vices, began operation in the Central Ameri- Revolving Fund met international specifica- can and Andean countries and in the tions, the Program collaborated in quality Dominican Republic. The centers' effective- control procedures. PAHO/WHO's refer- ness was hampered by a shortage of full-time ence laboratories in Argentina (CEPANZO), professional staff. the United States (Center for Biologics Eval- The Latin American Network of Drug uation and Review, FDA), and Mexico Quality Control Laboratories, established (National Institute of Virology) analyzed with PAHO/WHO support in 1984, became vaccines when necessary. The Program also a major instrument for developing national provided technical support for the produc- laboratories through cooperation, information and quality control of biologicals in the tion exchange, and standardization of norms countries that manufacture them, and gave and procedures. Among the activities car- Health Systems Infrastructure 23 Health Systems Infrastructure 23 ried out in support of national laboratories care coverage and dental disease prevention were meetings of laboratory directors, at efforts. The Program provided technical which the network's biennial program was cooperation to 26 countries in reducing oral defined; updates of the bibliographic health problems. This collaboration ranged resources of member institutions; prepara- from advisory services for the development tion of a training program and teaching of dental care systems and establishment of materials on laboratory administration; pub- institutions for teaching oral health to initia- lication of Standards of Good Laboratory Prac- tion of infection control and educational tice; preparation of regional pharmaceutical programs regarding oral manifestations of reference standards; and establishment of an HIV infections. external quality control program. This last Epidemiologic surveys indicate that project was supported by the U.S. Food and dental caries and periodontal diseases are Drug Administration (FDA). Despite these prevalent in the Region. In many countries positive efforts, many of the laboratories still the prevalence of dental caries is still almost have not developed national monitoring and double the target level established by WHO control programs of marketed pharmaceuti- for the year 2000, and there is evidence of cal products, due in part to the poorly the extensive occurrence of periodontal dis- defined role of laboratories in the health ease in children. Whereas the incidence of sector. dental caries decreased significantly in the Another of the Program's activities developed countries, such a trend was not aimed at upgrading the quality of pharma- recorded in the developing countries of the ceutical services is the provision of training Americas except in those locations where courses on good manufacturing practices fluorides have been used extensively and and quality assurance for professionals in continuously. The high prevalence, com- industry, universities, and government. Six pared to other WHO Regions, of oral cancer countries have held such courses using (particularly in Brazil, where it is estimated audiovisual material prepared by the Pro- to represent 20% of all cancers) was a cause gram, and have benefited from the coopera- of concern, as was the recent recognition of tion of an expert on assignment from the significant oral lesions and conditions associ- FDA. ated with HIV infection. Estimates of the In summary, the Essential Drugs and population in need of orthodontic treatment Vaccines Program significantly expanded its were as high as 60% of children in some range of activities during the quadrennium countries. to encompass the various aspects of this sec- A major focus of the Program was to tor, including pharmaceutical policy, pro- prevent dental caries, especially among chil- duction, supply systems, quality control and dren and adolescents. Programs that sup- regulation, pharmacologic information, and plied systemic fluorides by fluoridating water training. Promoting the development of or salt were promoted, and other possible pharmaceutical services within the frame- vehicles for fluoride, such as milk, were stud- work of local health systems was a priority ied. Major advances were made in Brazil, activity. which fluoridated water supplies in Rio de Janeiro and Sao Paulo; in Venezuela, where 70% of the population now drinks fluori- Oral Health dated water; in Argentina, which decided to fluoridate water supplies in the city of The Oral Health Program's chief activity Buenos Aires; and in Guatemala, which during the quadrennium was to promote the decided to do the same in Guatemala City. integration of oral health services with other Salt fluoridation programs commenced health services and the extension of dental in Costa Rica and Jamaica, making the bene- 24 Report of the Director fits of fluoride available nationwide at a tries, Guyana, and Suriname had organized nominal cost (less than $USO.01 per capita dental programs for children, utilizing auxil- per year), which, in the case of Jamaica, was iaries trained in dental auxiliary schools absorbed in the cost of the product. Similar established in Jamaica, Guyana, Suriname, programs were being initiated in Colombia, and Trinidad and Tobago. Mexico, and Peru at the close of the qua- Local service programs in Chile, Mex- drennium. These programs evolved from the ico, and Venezuela demonstrated the eco- collaborative efforts of PAHO/WHO, which nomic viability of providing comprehensive lent technical and financial support, and the primary oral health care in communities governmental and private sectors in each with limited public and private resources. country. In Costa Rica, Mexico, and Peru, Cuba introduced "family dentists," who the W. K. Kellogg Foundation provided have responsibility for preventive, primary, additional support. and comprehensive oral health care in spe- The potential of salt fluoridation to cific geographic zones. reach the entire population of a country at a The need for basic information on oral cost low enough to be absorbed by govern- health status and the availability of national mental agencies or salt producers was the resources to carry out programs received basis for resolutions adopted by the Minis- attention during the quadrennium. The Pro- ters responsible for health in the English- gram initiated a survey to obtain that infor- speaking Caribbean. The production of mation and to identify areas in which fluoridated table salt in Jamaica has now collaboration between countries could be made this product available to the Carib- improved. It also developed a series of indi- bean countries. Another benefit is that the cators that all countries can use to assess fluoridation and the iodization of salt can be their populations' oral health status. Agree- done simultaneously, thus combating dental ments were made to take advantage of the caries and endemic goiter at the same time. subregional initiatives to pool resources for In Bermuda, a program of multiple fluo- the development of oral health activities. ride treatments to prevent dental caries in Components of oral health were integrated schoolchildren was conducted by the into the maternal and child health, nutri- PAHO/WHO Program and the Ministry of tion, equipment maintenance, and AIDS Health with initial support from the W. K. programs. Kellogg Foundation. The incidence of dental It became evident during the 1986-1989 caries was reduced by over 80% after 11 period that the ratio of dentists to popula- years. tion in many countries was approaching that The need to incorporate oral health ser- of developed nations, and that government vices into local health systems was addressed health systems' capacity to absorb profes- within PAHO/WHO by including the Pro- sional dental personnel was becoming lim- gram in the planning of activities conducted ited. A review that compared the increase in by the Health Services Development Pro- professional dental human resources to gram. In Member Countries, the Oral national population growth in 12 countries Health Program collaborated to improve the between 1961 and 1984 clearly indicated the efficiency and efficacy of oral health care need to make better use of such resources, delivery systems by coordinating teaching especially in underserved areas. programs with oral health care services for The availability and dissemination of underserved populations and promoting the information, meanwhile, were enhanced by use of professional, auxiliary, and commu- linking the resources of the library of the nity personnel. By the end of 1989 virtually Argentina Dental Association and those of all the English-speaking Caribbean coun- the dental school of the University of Sáo Health Systems Infrastructure 25 Health Systems Infrastructure 25 Paulo with BIREME. The arrangement now created for the purpose of enabling Spanish- permits access to Spanish and Portuguese speaking dental professionals from North language bibliographic information in virtu- America and Latin America to exchange ally every country in the Region. The elec- experiences. tronic communication network will be Two major international meetings were extended to include dental information cen- held with the International Dental Federa- ters in Canada and the United States. tion (FDI), the chief nongovernmental orga- The Program endeavored to involve the nization that collaborates with WHO/ nongovernmental sector in building oral PAHO in oral health. On both occasions, health programs. Assistance was provided to Chief Dental Officers from the Region and the Organization of Faculties, Schools, and the deans of dental schools met to coordi- Departments of Dentistry of the Union of nate the activities of the educational and Latin American Universities (OFEDO/ service sectors. The Program and FDI con- UDUAL) to enhance its role as a regional ducted two surveys to provide information entity uniting dental educational institu- on areas for future activities in the tions in North and South America. A spe- Americas. cific agreement of collaboration was signed To stimulate the development of between OFEDO/UDUAL and the Ameri- research and the use of appropriate technol- can Association of Dental Schools. ogy, two workshops were held from which OFEDO/UDUAL conducted five technical documents were issued that outlined areas commission meetings and two congresses. It for activity and support needs in the forth- also held a meeting in Ecuador attended by coming period. The development of appro- representatives of 36 dental schools and the priate technology has been most notable associations of schools of medicine and nurs- with regard to dental equipment, which 17 ing. The Program collaborated with countries now produce or assemble. OFEDO/UDUAL in conducting a prospec- In the area of traditional medicine, tive analysis of dental education. investigations were carried out regarding the Evidence of the new approach that inte- use of local substances for oral hygiene, pain grates training with service was seen in El relief, and infection control. Active compo- Salvador and Uruguay (where an estimated nents of these remedies were analyzed to 50% of student time will be spent in commu- confirm their bacteriocidal or bacteriostatic nity settings) and in the growth of commu- effects. nity-based programs in Argentina, Costa The Program collaborated with the Rica, Mexico, Peru, and Venezuela. PAHO/WHO AIDS Program, the U.S. The Program also participated in the National Institutes of Health, the Centers design and development of curricula and in for Disease Control, and the WHO Collabo- the establishment of training programs for rating Center on Oral Manifestations of dental professionals at the Universidad HIV Infection in preparing informational Complutense in Madrid. Staff and faculty materials and courses on the oral health from that school participated in Spanish-lan- effects of HIV infection. Oral lesions can be guage courses in the United States and other an important indicator of the health status countries of the Region, and in a traveling of individuals infected with HIV, and oral seminar that enabled those responsible for health care personnel can play a role in producing curriculum changes to observe treatment regimens. the new dental curricula adopted in Spanish- Other achievements supported by the speaking countries of the Americas. Program included the completion of epide- An International Center at the Faculty miologic and oral health status studies in of Dentistry, University of Puerto Rico, was Brazil and Ecuador, the establishment of 26 Report of the Director

Divisions of Oral Health in both countries, their capacity as diagnostic centers and in and the completion of the first dental school their new roles as referral centers for infec- for the English-speaking Caribbean in Trini- tious diseases of public health impact and for dad and Tobago. In Ecuador, the creation of clinical, hospital-based health laboratory an institute for the development of research services. in oral health led to the establishment in In 1986, all Member Countries were rep- Quito of the WHO Collaborating Center in resented in a regional meeting to promote Oral Health. the production and quality control of diag- Other WHO Regions, particularly nostic reagents. Simultaneously, four Latin Europe and the Western Pacific, expressed American institutions-Adolfo Lutz and interest in the experiences and developments Oswaldo Cruz in Brazil, Instituto de Salud in the Americas with respect to dental edu- Pública of Chile, and Gerencia General de cation, prevention, the use of technology, Biológicos y Reactivos of Mexico-estab- and the combination of teaching with ser- lished an exchange network to distribute vice and research. reagents to 19 countries. Argentina, Cuba, and Spain also participated informally with their reagent-producing institutes. In 1989, Clinical, Laboratory, and Radiological Brazil, Chile, Cuba, and Mexico received Technology for Health Services support in developing a UNDP-funded project for production of viral reagents. In 1986, 23 countries were participating in qual- Laboratory Services ity assessment schemes for clinical chemistry, hematology, blood grouping, microbiology, As national health systems were reorga- and parasitology. By 1989, 29 countries were nized to facilitate the establishment of local enrolled in at least one of the external qual- health systems, laboratory services were ity assessment schemes, which also included expanded and adapted accordingly. PAHO/ syphilis testing (VDRL) and human WHO convened a task force and funded a immunodeficiency virus (HIV) testing. Since field study to evaluate the most effective and 1986, PAHO/WHO has promoted labora- simple laboratory tests needed to support tory testing for HIV of blood for transfu- primary health care. The Organization also sions. Subregional meetings in South promoted the establishment of national lab- America and Central America and a oratory network systems that are based on Regional Meeting on New Technologies for referral services. Fourteen countries (Brazil, HIV Detection in the Dominican Republic Chile, Colombia, Costa Rica, Cuba, Domin- were held in 1989. The meetings brought ican Republic, Ecuador, El Salvador, together the directors of public health and Grenada, Guatemala, Mexico, Peru, Uru- blood bank laboratories and research scien- guay, and Venezuela) have initiated such tists to review state-of-the-art testing for HIV national laboratory networks. To support infections and to recommend approaches the laboratories, PAHO/WHO trained per- that individual countries should adopt sonnel and provided assistance to national according to their epidemiologic situation. workshops in laboratory administration and Given that laboratory work implies management and in specialties such as exposure to biological, chemical, and physi- immunology, clinical chemistry, virology, cal agents, the program supported the pro- food bacteriology, enteric bacteriology, and duction of biosafety documents and acute respiratory infections. cosponsored workshops on the subject. The Organization supported national Argentina, Chile, Costa Rica, and the public health laboratories and institutes in Dominican Republic published biosafety Health Systems Infrastructure 27 documents for their laboratory networks, Peru, and Venezuela to review their radio- and PAHO/WHO distributed the "National logical programs on equipment and safety. A Committee for Clinical Laboratory Stan- practical course in Spanish on radiotherapy dards (US) Guidelines for the Protection of dosimetry was directed and organized in San Laboratory Workers from Infectious Diseases Antonio, Texas, USA, for Latin American Transmitted by Blood, Body Fluids, and Tis- medical physicists, and a video of the course sues" to all the countries of the Region. was produced to help improve the quality Information exchange was promoted and effectiveness of the Region's radiation through the distribution of more than 2,400 therapy. Lectures were presented at seminars technical documents to national health in diagnostic radiology in Argentina, Brazil, authorities and 51 institutions in 19 Costa Rica, Mexico, and Venezuela; in countries. radiotherapy, in Peru; in medical physics, in The need to train laboratory personnel Argentina and Brazil; and in radiation pro- in new technologies created a greater tection, in Mexico, Chile, and Peru. Close demand for PAHO/WHO assistance. cooperation was established with the WHO/ Increased funds from granting agencies were IAEA Secondary Standards Dosimetry Lab- sought for this purpose. National investment oratories (SSDL) in Argentina, Brazil, Chile, in equipment maintenance and local produc- Mexico, and Venezuela, and with the three tion of quality control reagents were pro- WHO Collaborating Centers for Radiation moted as measures to reduce laboratory Emergencies in Argentina, Brazil, and the expenditures on imported supplies. United States. The PAHO Spanish translation of the recommendations of the Inter- Radiological Technology national Commission on Radiological Pro- tection was edited (PAHO Scientific Publica- Cooperation in radiological technology tion No. 497, 1986), and radiological health for health services encompasses activities publications, especially those of PAHO, were related to diagnostic imaging, radiation ther- distributed. apy, nuclear medicine, and radiation protec- In 1987 a serious contamination acci- tion. Use of the WHO-designed simplified dent occurred in Goiania, Brazil, resulting in radiography unit known as the Basic Radiol- the death of four persons. In the aftermath ogy System (BRS), which can cover more of this accident, the WHO Collaborating than 80% of all needs for radiological exami- Center on Radiation Emergencies in Brazil nations, was promoted, especially in local played a prominent role. In 1989 two other health systems. Despite the completion of radiation accidents were investigated. The very encouraging evaluations of the BRS first one, in February 1989, involved a units in Chile and Colombia in 1986, only cobalt-60 industrial irradiator in El Salva- about 25 units have been installed in the dor, where one person died and another had Region. Another significant project, with a both legs amputated. The second accident potential impact on cancer cures, was the occurred in Bolivia in September of that year WHO/International Atomic Energy Agency and involved an industrial gammagraphic (IAEA) postal dosimetry intercomparison source of iridium-192; two persons suffered for high energy radiotherapy units, which hand injuries. In both cases, medical between 1988 and 1989 alone verified the assistance was secured through the WHO calibration of over 200 cobalt units and lin- Collaborating Centers for Radiation Emer- ear accelerators. gencies in Argentina and the U.S.A. Techni- Visits were made to Argentina, Barba- cal assistance was also provided in 1989 after dos, Belize, Brazil, Chile, Costa Rica, Cuba, two minor radiation incidents-one in the Haiti, Mexico, the Netherlands Antilles, Dominican Republic and the other one in 28 Report of the Director

Trinidad-which both involved brachy- nomic, and physical environments. It also therapy sources and did not require medical stressed the need to develop personal and treatment. These events have demonstrated advocacy skills among participating popula- the need to strengthen radiation safety legis- tion groups. lation in the countries of the Region. In February 1988, 49 spokesmen from 11 countries in the Americas participated in a technical meeting held in Washington, D.C., Health Education and Community to define priorities in health promotion, edu- Participation cation, and community participation. The meeting recommended that health promo- Local health services based on primary tion and education; community action, health care operate within the context in mobilization, and participation; self-care; which the population lives and works. As a appropriate communication strategies; and way to promote healthier lifestyles, the skill development continue to be stressed. In Health Education and Community Partici- August of the same year, PAHO/WHO pro- pation Program assisted ministries of health vided leadership and expertise for the XIII in developing public information, health Global Conference on Health Education, promotion, education, and community par- cosponsored by the International Union for ticipation projects. These projects aim at Health Education, PAHO, and WHO, and motivating and enabling individuals, fami- held in Houston, Texas. The meeting's 1,500 lies, and communities to protect their participants from 111 countries reiterated health, prevent disease, make good use of that health is intricately tied to the multiple existing health services, and take an active social and political factors that affect devel- part in planning and developing improved opment, and that countries should reorient community health care activities. Emphasis health and education services to better was placed on situational analyses, planning, respond to these influences. Given the diver- implementation, monitoring, and evaluation sity of countries and experiences that were at the local level to reorganize existing ser- represented, participants also urged that vices for greater flexibility and administra- health workers "think globally and act tive accountability to the communities locally" to better coalesce the forces neces- served. Simultaneously, the promotion of sary to resolve shared problems throughout community participation aimed at improv- the world. ing accuracy in identifying priority health PAHO/WHO subsequently published a problems and vulnerable groups. series of documents outlining mechanisms PAHO/WHO appointed an interpro- for instituting social participation. A study grammatic group to draft a strategy for social protocol was designed to assist national gov- participation in establishing local health sys- ernments in determining the feasibility of tems. Based on the guidelines that ensued, introducing new approaches and methodo- 17 countries began to conduct feasibility logies to include social participation in the studies. delivery of all types of local services that In 1986, the Ottawa Charter for Health affect health conditions. Promotion was developed and endorsed by To introduce these concepts to key deci- 221 representatives of 38 countries from sion-makers and obtain their commitment around the world at a meeting on health to incorporate them into the priorities of the promotion, held in Ottawa, Canada. The formal health system, PAHO/WHO held a charter promoted a "new public health" series of workshops for nationals and whereby the health services would collabo- PAHO/WHO staff throughout the Region. rate with other sectors and consider the As a result, the Organization has already broader context of social, political, eco- received many requests for technical and Health Systems Infrastructure 29 financial assistance in developing efforts to Health, and the Association for the strengthen social participation in health Advancement of Health Education. The promotion. Program collaborated with governmental PAHO/WHO also promoted opera- and nongovernmental organizations such as tional research in the Bahamas, Colombia, the Canadian Public Health Association, Costa Rica, and Jamaica. Participatory IDRC, and Canadian International Devel- research was chosen as the method because, opment Agency in Canada and the Ameri- by its very nature, it promotes the organized, can Public Health Association, CDC, active participation of the community and Health Resources and Services Administra- facilitates the advocacy of the community in tion, and Office of Disease Prevention and exercising its rights and in expressing its Health Promotion in the United States, as needs in a clear and direct way to the appro- well as with international groups such as priate institutions. Although intersectoral UNICEF, UNESCO, UNDP, UNFPA, and collaboration was emphasized in these the OAS. The Organization and UNICEF projects, it was difficult to achieve and sus- are producing materials for their child sur- tain because of the long-standing tradition of vival programs, and health is being included sectoral independence. in regional and global "Education for All" PAHO/WHO prepared and dissemi- efforts of UNICEF, UNESCO, UNDP, and nated basic conceptual documents and oper- the World Bank. ational instruments to orient similar The Program encouraged the develop- activities in other countries. The essence of ment of training capabilities in health pro- these documents and the results of studies motion, education, information, and related conducted in many of the countries were fields for a wide range of health personnel. published in a book. A framework for con- Training programs for instructors, communi- ducting research about social participation cations experts, and health service officials in local health systems was developed as a focused on priority health problems such as standard addendum to PAHO's guidelines diarrheal diseases, malaria, sanitation, and for research grant applications. maternal and child health care. PAHO/WHO provided technical coop- Original publications, reference docu- eration to include community participation ments, guides, manuals, and audiovisual in the following program areas: appropriate materials were developed, tested, and dis- use of essential drugs, maternal and child seminated to all Member Countries. health, environmental health, veterinary PAHO/WHO facilitated the interchange of public health, adult health, health education health education specialists among countries for school-aged children, and training of in the Region. It also promoted the devel- health personnel in educational methodolo- opment of health training programs for gies. Examples of these efforts include the teachers, communicators, and other key per- development of pilot projects for community sonnel involved in efforts to inform and edu- education in essential drugs in El Salvador, cate the general public and specific Guatemala, and Honduras and the estab- population groups such as children and ado- lishment of guidelines for promoting com- lescents. To accomplish this, the Organiza- munity participation in malaria programs in tion worked with the Carnegie Corporation Guatemala, Honduras, and Panama. of New York to formulate, program, and PAHO/WHO also offered its technical implement a project to strengthen the role of expertise in health education to nongovern- schools in promoting health. The project mental organizations such as the Interna- focused on Eastern Caribbean countries, tional Union for Health Education, the where it brought health workers into the Society for Professional Health Educators, schools to explain the importance of self- the National Council for International care, healthy lifestyles, and participation in 30 Report of the Director 30 Report of rhe Director

community development efforts. Training on Women, Health, and Development was programs were set up through teacher train- created in 1987. Each of the PAHO/WHO ing colleges. Country Representations designated a focal point to coordinate the Program's activities, and a subregional Coordinator for the Pro- WOMEN, HEALTH, AND gram in Central America was posted in San DEVELOPMENT José, Costa Rica. PAHO/WHO supported the organiza- The Women, Health, and Development tion of multisectoral National Commissions Program seeks to promote improvement of on Women, Health, and Development, the social and health status of women; facili- which were established in all the countries. tate analysis and evaluation of policies, pro- The PAHO/WHO project "Women in grams, and laws that affect them; sponsor Health and Development of Central Amer- research and publish and disseminate rele- ica" was funded by Norway, Spain, and Swe- vant findings; foster the design and imple- den, and received the collaboration of mentation of alternative models of health UNFPA, UNIFEM, UNICEF, UNDP, and services for women; and encourage the par- ECLAC. In addition, in mid-1989 the Pro- ticipation of women's groups in the reform of gram entered into cooperation agreements health policies. with Spain's Institute of Women, the Uni- During the 1986-1989 period, the Pro- versity of Iowa (United States), and IICA, gram's focus was largely aimed at establish- among other institutions, to carry out its ing its presence within the structure of activities in Central America. PAHO/WHO and among other interna- In 1989, the PAHO/WHO Technical tional organizations, bilateral agencies, and Discussions on Women, Health, and Devel- women's groups. In addition, it promoted opment took place at Headquarters and at the need for national-level women's pro- the Country Representations. Delegates grams to be established in the Member from the National Commissions, nongov- Countries. Having achieved a fair degree of ernmental institutions, and women's organi- success in these initial undertakings, includ- zations participated. ing the mobilization of significant extra- The Program made a number of contri- budgetary funds for women's projects in butions in the areas of research and informa- Central America, the Program shifted its tion dissemination. It completed an focus in the last quarter of 1989 toward epidemiologic profile of women's health in developing a four-year plan-the "Criteria to the Region of the Americas, which will be Orient Technical Cooperation on Women, published as a PAHO/WHO Scientific Pub- Health, and Development"-that calls for lication, and in condensed form as a chapter the initiation of concrete projects within the in Scientific Publication No. 524, Health countries of the Region. Conditions in the Americas (1990 edition). It The Pan American Sanitary Conference represents the most up-to-date systematic and the Directing Council of PAHO/WHO analysis of the health status of women in the discussed the importance of advancing the Region. Program and passed resolutions to that effect Most of the countries, meanwhile, pro- at all of their meetings during the quadren- moted diagnostic studies on the status of nium. The Advisory Committee of the women's health, the results of which will be Director on Women, Health, and Develop- used to develop more effective policies in ment, established in 1985, became fully that area. In some Central American coun- operational in 1986. Following the recom- tries, studies were completed on existing leg- mendations of the Governing Bodies, the islation in order to identify discriminatory position of Regional Adviser of the Program legal criteria that constitute obstacles to the Health Systems Infrastructure 31 Health Systems Infrastructure 31 full economic and social participation of which was produced in coordination with women. The Program promoted discussion the Health of Adults Program and the of the impact of legislation on women's American Association of Retired Persons. health by sponsoring a series of meetings and The Program collaborated with the disseminating their contents. countries in the preparation of manuals on The topic of women, health, and devel- the health problems and risk behaviors of opment was considered a priority area for adolescent women, and supported the prepa- funding by the PAHO/WHO Research ration of materials on the participation of Grants Program. Twelve research proposals women in primary health care, a topic on were presented from 1987 to 1989, but many which little research had been done. of them had inadequate protocols. It was To facilitate the mobilization of women's decided that greater effort was required to groups to participate in health projects, a promote adequate research proposals, and directory on women in Central America, the Research Grants staff collaborated with which lists women's organizations and their the Program in developing a multicenter pro- projects, was published with the support of posal to study the relationship between the the Institute of Women of Spain. Compila- economic crisis, work, and women's health. tion of a similar directory was begun in The Health Policies Development Program, Mexico. meanwhile, collaborated in the design of a protocol for research on the use and abuse of therapeutic and clinical-surgical technology EMERGENCY PREPAREDNESS AND for women. In coordination with the Health DISASTER RELIEF COORDINATION of Adults Program, a preliminary survey of the mental health status of women in the During the 1986-1989 quadrennium, Andean countries was carried out in Bolivia, natural disasters dealt hard blows to Latin Colombia, Ecuador, Peru, and Venezuela. America and the Caribbean. Hurricanes Support also was given to the develop- Gilbert, Joan, and Hugo swept across the ment of specialized information systems and Caribbean, Mexico, and Central America, networks on women in each of the geo- and the recurrent floods in South America graphic subregions that are the foci of had serious health consequences. PAHO/WHO-sponsored health initiatives Despite the achievements of the national (Andean area, Caribbean, Central America, health sector emergency preparedness pro- and Southern Cone). A feasibility study for grams, the Region's vulnerability to natural the Central American Information System disasters did not diminish. In fact, the mas- on Women, Health, and Development sive population shift from rural to urban (SIMUS) delineated methodological and areas, coupled with the growing threat of technical guidelines for similar studies in technological disasters-factors that are other subregions and countries. Based on beyond the scope of the health sector to rem- the results of the study, a cooperation project edy-heightened the existing vulnerability. to foster the growth of SIMUS was drafted Yet, although disasters continue to threaten and was submitted to UNFPA for development by destroying infrastructure, consideration. burdening health services, and diverting The Institute of Women of Spain scarce resources to emergency or rehabilita- entered an agreement with the Program to tion measures, they sometimes provide an support a series of publications on women, occasion for reform and long-term improve- health, and development. Two annotated ments in the health system. bibliographies on the subject were pub- During the last quadrennium, support- lished, as was the book Midlife and Older ing and strengthening the technical pro- Women in Latin America and the Caribbean, grams in the health ministries continued to REGIONAL PROGRAM ON WOMEN, HEALTH, AND DEVELOPMENT

Women make up half of the population of the Americas. They bear and raise the Region's new generations and are the adults with main responsibility for feeding, clothing, and ensuring the health of its children. Those children under 15 years of age represent from one-third to two-fifths of the total population of Latin America and the Caribbean, depending on the subregion, and are the future work force of the countries. Even if one omits the fact that women also care for men and the elderly within their family circles, the responsibility of women is enormous, as is society's implicit reliance on them. To the extent that key health indicators such as infant mortality rates and nutritional status are used as indicators of a nation's social and economic development, they also reflect the work and role of its women. Yet governments have been slow at best in adopting policies that enhance the well- being of what in fact represents the majority of their populations. Even in the United States, where the economic crisis of the 1980s was felt less severely than in other countries of the Region, fully one-fourth of children live in poverty. Most of them live in households headed by women, whose economic opportunities are notably fewer, demand less skill, and are not as well remunerated than those of men. In Latin America and the Caribbean, the economic picture is far worse. Yet precise information on the relative health risks of female persons is sorely lacking. The paucity of thorough studies on women is in itself a tell-tale sign of the neglect that they face in the formulation of national development policies. The statistics that do exist tend to concentrate on the biological role of the woman as mother. Those figures alone are an indication that, despite the number of maternal and child health programs that exist, much remains to be done. Preventable maternal mortality, to cite one critical indicator of social progress, is still very high in many countries of the Region. Pregnancy, birth, and the perinatal period still figure among the five primary causes of mortality among women between the ages of 15 and 44 in Latin America and the Caribbean. If the maternal mortality rates prevalent in 1980 were used to calculate the number of deaths that would occur between 1980 and 2000, the deaths of roughly a million women would result. If the rates prevalent in more developed countries were applied to the same population, 60,000 deaths would be expected. PAHO/WHO's Governing Bodies have noted repeatedly that women in the Region are subjected to injustices and denied equal rights and partnership in the development process. At every meeting it held during the quadrennium, the Directing Council adopted resolutions in which it noted its concern about the status of women and their health and urged that measures be taken to correct the situation. The PAHO/WHO Women, Health, and Development Program got off the ground during the 1986-1989 quadrennium, being set up as a Regional Program that reports to the Assistant Director of the Organization. In late 1989 the Regional Program developed a plan of work for the next quadrennium, "Criteria to Orient Technical Coopera- tion for Women, Health, and Development," that sets out to close the gap in information on women by carrying out research and making its results available to all national health programs. Well-researched data will not only help dispel the deeply

32 ingrained resistance to improving the status of women that still exists in many countries, but will provide concrete intervention points for health programs. The work plan stresses the need to consider the effects of both the biological function of women and their social roles on their health, on that of their children, and on the larger economic development potential of the Region. While promoting such studies and information dissemination, the main orientation of the Regional Program will be to strengthen advocacy for women among health, university, and other social institutions. Simultaneously, it will sponsor workshops and other activities aimed at enhancing ways of empowering women at the community level.

33 34 Report of the Director 34 Report of the Director be one of the principal objectives of the political leaders. The Program targeted that Emergency Preparedness and Disaster Relief message toward these groups through the Coordination Program. With the Program's wide distribution of print and audiovisual support, every country in the Region desig- material. nated a health sector disaster coordinator or Another principal objective of the Pro- focal point responsible for predisaster plan- gram was to train health personnel in emer- ning and coordination of health sector relief gency response procedures. The effectiveness activities. In some cases, as in the smaller of a nation's response to disasters depends Caribbean islands, coordinators assumed largely on the readiness and qualifications of these duties in addition to other responsibili- survivors who first respond, local leaders, ties. Many ministries of health established and the health services in the affected com- adequately staffed and funded preparedness munity. The more prepared local health ser- offices or units at an appropriate level within vices and communities are, the better the their organizational structures. However, in overall national response will be. The qual- a number of countries, neither a specific ity and timeliness of the national response budget nor posts were established, and too also depend on the capacity of the central few countries placed their units at levels suf- level to support and coordinate the local ficiently high to be compatible with the response. cross-departmental activities and executive Only 10 years ago, the concept of disas- decision making they require. Such measures ter preparedness was still new, and training are essential in a serious commitment to had to begin with the top-level managers. carry out preparedness activities. During the quadrennium, however, the Pro- Because health disaster preparedness gram was able to take advantage of the mul- overlaps with and depends on the activities tiplier effect by training trainers and local of other sectors, the participation of key first responders and health services staff. For sectors was sought. Among these were example, in 1988 (an average year), 147 civil defense; the ministries of planning, inte- meetings/courses/workshops were held, in rior, defense, and foreign affairs; and non- which 7,507 people participated, at a cost of governmental organizations. Representatives $US400,000. from these sectors were invited to participate In 1989 the promotion of intersectoral in PAHO/WHO-sponsored intercountry participation was exemplified by the first workshops and seminars. While the overall Japanese International Cooperation leadership of the health ministries in health Agency-Japan/Peru Center for Earthquake disaster preparedness was stressed, PAHO/ Engineering Research and Disaster Investiga- WHO's technical cooperation and material tion-PAHO/WHO course on the design, support were made available to all national repair, and management of hospitals in seis- institutions working in this area. mic areas. Thirty engineers, architects, and The Organization held a series of work- hospital administrators from 11 countries in shops for ministries of foreign affairs and the Region were chosen to attend. Their promoted the development of guidelines to selection was based partially on their hold- define the role of diplomats at home and ing positions that would allow them to repli- abroad during emergencies. When disasters cate the course nationally. occur, decisions concerning health matters The development of training material is are often made at the highest political levels, indispensable if newly trained "multipliers" instead of at the technical level. Repeated are to reproduce the courses and workshops observation of this tendency underscored in their own environment. During the qua- the need for the Program to increase aware- drennium, the Program's training material ness and understanding of health priorities was expanded to include video programs, and solutions among both the public and new slide presentations, and several techni- Health Systems Infrastructure 35 Health Systems Infrastructure 35 cal publications. In addition, in collabora- that arrives in many cases. To address the tion with the Office of Information and problems of international health relief assis- Public Affairs, the Program built an exten- tance, in 1987 the Member Countries sive library of video footage and slides of endorsed a series of recommendations that disasters that was not only used to prepare now constitute the Organization's regional training materials but also served as an insti- policy. To the same end, PAHO/WHO tutional data bank. undertook the design of a computerized sys- The Emergency Preparedness and Disas- tem to inventory and track the distribution ter Relief Coordination Program assumed a of essential medical supplies. Governments major coordinating role in the aftermath of that provide significant relief assistance in most of the recent disasters in the Region. the Region (Italy, Japan, and the United To streamline emergency response activities, States, for example) participated in the sys- an emergency center was established at tem's design. Headquarters. The low-cost center has the It is difficult to determine at a glance the capability to rapidly add lines for telephones, level of development of a national health sec- facsimiles, electronic mail, and computers. tor disaster preparedness program, or how The Organization also adopted the policy of one country's program compares to that of rapidly mobilizing PAHO/WHO staff from another. The operational criteria for measur- outside an affected country when communi- ing progress must be improved and basic cations are interrupted and preliminary indicators established to evaluate a pro- information suggests major damage has gram's development. An evaluation matrix, occurred. In the Caribbean, an inter-island developed with the assistance of experts from PAHO/WHO Disaster Response Team was CIDA, was employed in an attempt to evalu- formed and is on stand-by during the hurri- ate program progress in some countries. cane season. This team approach in the However, it did not elicit an effective smaller islands of the Caribbean, established response. It is believed that a team of inde- through the efforts of the Caribbean Pro- pendent evaluators, assisted by national gram Coordinator, received full support resource persons, would develop a more from the countries involved. accurate picture of each country's progress, To handle emergency communications including specific strengths and weaknesses. in a sudden-impact disaster, the Organiza- Plans for future activities within each coun- tion purchased portable satellite earth sta- try could then be tailored to existing needs. tions (INMARSAT), which help the affected The United Nations designated the countries communicate with international 1990s as the International Decade for Natu- organizations and the international donor ral Disaster Reduction. However, the pro- community. PAHO/WHO trained a team of posed plan of work included no significant operators who were then able to travel with health component or activity. PAHO, in this emergency communications equipment support of WHO, has actively promoted the to Jamaica in 1988 and Montserrat in 1989 health sector's priorities and interests before in the aftermaths of hurricanes Gilbert and the United Nations, through the Permanent Hugo. Representatives' Group for Latin America The Organization also focused its disas- and the Caribbean, to ensure that the ter response capabilities on assisting in the Decade's Expert Committee balances its pri- rapid assessment of health needs, providing marily basic-research approach with a technical advice to interested donors, and social/health orientation. PAHO/WHO cooperating with the affected government in played the key role in encouraging the managing relief donations of health supplies, health sector to actively participate in the which can be a monumental task, given the establishment of National Committees for large volume of unsolicited medical supplies the Decade and to ensure that its concerns, 36 Report of the Director 36 Report ofthe Directo needs, and priorities are considered by the previous decades, stagnated or declined in national programs for the Decade. 1986-1989. In some countries, recent grad- Adequate preparedness for disasters can uates in medicine faced underemployment or be the portal through which public and com- unemployment, a trend that may worsen. munity activities and services that are At the same time, the supply of dentists, required in normal times are improved or graduate nurses, and other nonmedical developed. A country's level of health pre- health professionals was insufficient to meet paredness for disasters is a reflection of the the needs of the team approach required for overall quality and effectiveness of its health comprehensive primary care. Medical train- services and coverage in normal times. The ees, meanwhile, were being produced in preparedness status can hence only be as greater numbers than ever before, but their good as the organization and resources of training was often inadequate. This training the health sector allow. An encouraging was geared toward specialized, hospital- level of preparedness has been achieved to based care, despite the fact that most coun- date. However, the progress is fragile and tries have a surplus in that area and a may still be affected by changes in the leader- shortage of family practitioners and doctors ship of national health ministries. Contin- trained in infectious disease epidemiology. ued, significant support is required from The difficult task of trying to match PAHO/WHO and other agencies until training with needs has required the adop- national disaster programs have consoli- tion of explicit policies that address the issue. dated their staffing and funding presence At the outset of the quadrennium (1986), within health institutions. the Organization began to restructure its own technical cooperation program as a way to assist Member Governments to take cor- HUMAN RESOURCES rective action. The Human Resources Devel- DEVELOPMENT opment Program grouped its component activities under three broad headings-pol- The adequate supply and effective distri- icy and coordination, health personnel bution of well-trained manpower is one of administration, and training-that reflected the most important determinants of the suc- the importance of tailoring professional edu- cess of public health programs. As part of its cation and training programs to the require- overall assessment of needs for the quadren- ments of reforming the public health service nium, the Organization reviewed the status delivery system. As a corollary, the Program, of health manpower in the Region and whose educational orientation had been pre- found that the distribution of health profes- dominantly technical, began to consider the sionals was skewed in several ways. social and economic determinants that influ- Highly trained professionals continued ence the health care work force. to concentrate in urban areas, to the detri- The document "Orientation and Pro- ment of services in rural zones. Within gram Priorities for PAHO during the Qua- urban areas, they clustered in private-sector drennium 1987-1990," approved at the XXII jobs and in hospitals, instead of clinics and Pan American Sanitary Conference in 1986 other peripheral health units. Liberal univer- (Resolution XXI), stressed the importance of sity admissions policies, meanwhile, meant "the search for a better definition of the roles that more professionals were graduating just of health workers, for better means of man- when the economic crisis was lowering the power education and training, and for public sector's ability to employ staff compet- greater efficiency in their recruitment, con- itively. The rate of employment growth in tinuing education, and use, particularly for the health services, which had increased managing services at the intermediate and more rapidly than that of other sectors in higher levels." Health Systems Infrastructure 37 Health Systems Infrastructure 37

These concerns were addressed in the and the Caribbean for the Twenty-first Cen- Program's medium-term plan, which focused tury" was established with the Union of on promoting personnel administration with Latin American Universities in 1987. Meet- emphasis on the formulation and analysis of ings were held with sectors that do not tradi- policies, improvements in information, rein- tionally deal with health, such as economics, forcement of research in this field, and political science, environmental sciences, advanced training of specialists; developing and engineering, to discuss subjects that are continuing education for health workers critical to solving health problems. that provides training or reorientation The difficulties encountered in adopting responsive to reforms in the health services; policies that coincide with the goals estab- developing a training system based on prior- lished in the health sector were due in part ity needs; reorganizing training in public to the lack of coordination between the edu- health to meet the leadership needs in epide- cation and the health sectors. This gap was miology and administration; and collabo- bridged by establishing mechanisms such as rating with Member Countries in adminis- the Interinstitutional Commission on tering, monitoring, and strengthening the Human Resources Training in Mexico, the use of the Organization's scholarships aimed teaching-care integration councils in Bolivia at promoting the goal of universal and equi- and Chile, and the Interministerial Commis- table health services. sion on Health Planning and Coordination in Brazil. A project in Argentina, which is being carried out with World Bank financing, Policy and Coordination includes a component of policy coordination and analysis in human resources. In Brazil, The Program strengthened its working PAHO/WHO supported the National Con- links with nongovernmental agencies such as ference on Human Resources in Health, the Union of Latin American Universities which was later reflected in the country's (UDUAL), the Pan American Federation of new Constitution. Associations of Faculties and Schools of The Program produces two major Medicine (FEPAFEM), the Latin American sources of scientific and technical informa- Association of Faculties and Schools of Med- tion. The quarterly, Educación Médica y icine (ALAFEM), the Latin American and Salud, completed its twenty-third year of Caribbean Association for Education in uninterrupted publication in 1989, and the Public Health, the American Public Health Human Resources Development Series pub- Association and its branch dealing with lished documents, reports, fascicles, man- schools of public health, the Latin American uals, and handbooks. Association of Faculties and Schools of At the subregional level, the Health Nursing (ALADEFE), the Pan American Training Program for Central America and Federation of Nursing Professionals (FEP- Panama (PASCAP), which is the Program's PEN), the Organization of Faculties, operating arm for the Central American Schools, and Departments of Dentistry of subregion and is based in Costa Rica, com- the Union of Latin American Universities pleted its tenth year of vigorous support for (OFEDO/UDUAL), the Latin American the Plan for Priority Health Needs in Cen- Association of Social Medicine (ALAMES), tral America. PASCAP designed the person- and most national associations throughout nel training component in priority areas Latin America that deal with the develop- such as maternal and child health, essential ment of human resources in health. drugs, food and nutrition, and malaria con- To include universities, a program called trol, and also was responsible for carrying "University and Health in Latin America out specific activities in human resources 38 Report of the Director

that are described in the section on the Cen- Human Resources Training tral American countries in Chapter VI of this report. A new methodology-prospective analy- Finally, as a mandate of the Governing sis-was introduced in training health pro- Bodies, the Program conducted an evalua- fessionals. The method is based on creating tion of the Organization's fellowships pro- standard-setting scenarios for the future gram to determine how fellows put their within the framework of the goal of univer- training to use in their countries of origin. sal access to primary health care. Each institution's position and the factors critical for progress are then established by consensus. Human Resources Administration The context in which the educational process is conducted, the socioeconomic and PAHO/WHO continued to promote the health situation, the structure of the services development of a human resources informa- of which it is a part, and the prevailing edu- tion system for training and deployment cational practices are considered in this anal- strategies. The system was based on collect- ysis, and these elements are recognized as ing primary data and explored the possibility determinants in the resulting professional of using general population censuses. The orientation. findings varied substantially from country to By the end of the quadrennium this country, and there were situations in which methodology had been applied in more than it still was impossible to update available 100 medical schools, a similar number of information. Still, the quality of the data nursing schools, and about 50 dental analyses was significantly improved regard- schools, and in many cases the results served ing the ways in which workers join the labor as points of departure for academic and force, conditions of employment or autono- administrative adjustments in the respective mous practice, and the quantitative and training institutions. qualitative aspects of training. Research pri- The Expanded Textbook and Instruc- orities on the structure and composition of tional Materials Program continued to col- the work force were defined, and a study was laborate in personnel training. It doubled initiated on family medicine as a practice the number of book titles offered and alternative. increased the number of continuing educa- The Program promoted interest among tion manuals for in-service personnel. Origi- national groups to find ways to make health nal materials prepared by national Latin education a continuing process linked to American authors tripled, and distribution routine in-service responsibilities. The Pro- of these books rose by more than 40%. The gram provided technical and financial sup- most important reorientations of the Pro- port to eight national working groups that gram were the inclusion of material on pri- were responsible for designing methodolo- mary care among its subjects and the gies. Their results were published as fascicles expansion of the textbook distribution sys- and work guides and were disseminated tem to the health service system. throughout the hemisphere. Meetings were held to discuss coopera- One of the Program's goals is to form a tion with other sectors, in which health and Latin American Collaborative Network that development, health situations and trends, will research and propose alternative meth- sector financing, the health work force, tech- ods for training health workers on the job. nological development in health, and health The Program also designed training for a services organization were reviewed. core of specialists on how to analyze health The Program continued to support manpower problems specific to Latin Amer- training in the critical areas of administra- ica and how to prepare institutions responsi- tion and epidemiology. The training require- ble for deploying such specialists. ments and uses of the latter were the subject Health Systems Infrastructure 39 Health Systems Infrastructure 39 of a broad review. The Program also contin- sored national meetings of editors and mem- ued to sponsor the participation of young bers of the editorial boards of biomedical professionals in apprenticeship projects and health journals and workshop-seminars through technical cooperation activities car- on editing scientific articles in Chile, Costa ried out by PAHO/WHO's regional pro- Rica, Cuba, Nicaragua, Peru, and Venezuela grams. Thirty-five residents took part in this and in the Mexico-United States border program during the quadrennium; on states. returning to their own countries they Editorial boards were established for the rejoined their institutions, several of them in Scientific Publications Series and the period- positions related to international health. ical publications Boletín de la OSP, Bulletin of Three of the former residents were later con- PAHO, and Educación médica y salud. Begin- tracted by UNICEF and PAHO/WHO. ning in 1986, one issue each year of the Boletín was dedicated to a single theme: mental health in 1986, health economics in 1987, HEALTH INFORMATION SUPPORT AIDS in 1988, and drug abuse in 1989. The Bulletin followed suit starting with the special Official and Technical Publications issue on AIDS. During the quadrennium the publica- The publications of PAHO reflected the tions program issued 32 titles in its Scientific Organization's technical priorities and work, Publications Series and 26 titles under the and reached an audience of 100,000 institu- Technical Papers Series. The latter series was tions and individuals. begun in 1986 to disseminate information The Editorial Service of the Scientific for which timeliness was essential. In the and Technical Health Information Program Official Documents Series the program pro- was entrusted with commissioning, choos- duced 8 titles: the annual reports of the ing, producing, and disseminating publica- Director, final reports of the meetings of the tions on subjects deemed pertinent, timely, Governing Bodies, and the Handbook of valid, and practical to health workers and Resolutions (Table 1). administrators. It sought to fill gaps by In the area of publication distribution bringing to light information that would not and sales, there were three salient develop- be available unless PAHO published it and ments. Sales were decentralized in Argen- that reflected the Organization's work and tina, Brazil, Canada, Mexico, Peru, Spain, supported its technical programs. and the United States. Promotion and mar- The publications produced during 1986- keting activities were expanded, which led to 1989 comprised official documents, periodi- an increase in sales. Finally, a new computer- cals, scientific books, and technical papers. ized distribution list, billing, and inventory These products included original works gen- system was designed that markedly increased erated by technical officers and distinguished efficiency. professionals from the countries, translations into Spanish of original materials from WHO/Geneva and other sources, and joint Scientific and Technical Information publications with organizations such as the American Public Health Association, U.S. The Scientific and Technical Health National Institutes of Health, American Information Program is also responsible for Medical Association, World Bank, and organizing and operating the Latin Ameri- American Association of Retired Persons. can and Caribbean Health Sciences Infor- Special emphasis was placed on direct mation Network. BIREME is the specialized technical cooperation with those countries PAHO/WHO Center in charge of the that expressed interest in improving their regional system that links national systems national publications. The Program spon- with PAHO's, thus enabling information 40 Report of the Director 40 Report of the Director

Table 1. Publications Issued by the PAHO Editorial Service in 1986-1989.

Serial No. Title

Scientific Publications 479 VI International Conference on the Mycoses 480 Enfermedades ocupacionales. Guía para su diagnóstico 494 Manual para el análisis de la fecundidad 495 Criterios de planificación y diseño de instalaciones de atención de la salud en los paises en desarrollo, vol. 4 496 Estudios médicos independientes: Su efecto potencial en el sistema de atención de la salud 497 Recomendaciones de la Comisión Internacional de Protección Radiológica 498 Tuberculosis Control: A Manual on Methods and Procedures for Integrated Programs 498 Control de la tuberculosis: Manual sobre métodos y procedimientos para los programas integrados 499 Control de calidad en radioterapia. Aspectos clínicos y fisicos 500 Health Conditions in the Americas, 1981-1984 (two volumes) 500 Las condiciones de salud en las Américas, 1981-1984 (dos volúmenes) 501 Salt Fluoridation 502 Towards the Eradication of Endemic Goiter, Cretinism, and lodine Deficiency 503 Zoonoses and Communicable Diseases Common to Man and Animals. Second Edition 503 Zoonosis y enfermedades transmisibles comunes al hombre y a los animales. Segunda edición 504 Patterns of Birthweights 504 Caracteristicas del peso al nacer 505 The Challenge of Epidemiology. Issues and Selected Readings 505 El desafio de la epidemiología. Problemas y lecturas seleccionadas 506 Guias para la calidad del agua potable, volumen 2 507 El control de las enfermedades transmisibles en el hombre, 14a. edición 508 Guías para la calidad del agua potable, volumen 3 509 The Right to Health in the Americas. A Comparative Constitutional Study 509 El derecho a la salud en las Américas. Estudio constitucional comparado 510 Crecimiento y desarrollo. Hechos y tendencias 511 IV Seminario Regional de Tuberculosis 512 Diagnóstico de malaria 513 Compendio de enfermedades alérgicas e inmunológicas 514 AIDS: Profile of an Epidemic 514 SIDA: Perfil de una epidemia 515 Guía para evaluar el estado de nutrición 516 Vigilancia alimentaria y nutricional en las Américas 517 Health Economics. Latin American Perspectives 517 Economia de la salud. Perspectivas para América Latina 518 Anestesia en el hospital de distrito 519 Los sistemas locales de salud: conceptos, métodos y experiencias 520 Insuficiencia renal crónica, diálisis y trasplante. Primera Conferencia de Consenso 521 Cirugía general en el hospital de distrito 522 Abuso de drogas

Official Documents 211 Informes finales. 96a y 97a Reuniones del Comité Ejecutivo de la OPS. XXII Conferencia Sanitaria Panamericana. XXXVIII Reunión, Comité Regional de la OMS para las Américas/Final Reports. 96th and 97th Meetings of the PAHO Executive Committee. XXII Pan American Sanitary Con- ference. XXXVIII Meeting, WHO Regional Committee for the Americas 212 Handbook of Resolutions of the Governing Bodies of the Pan American Health Organization, vol. 3 212 Manual de Resoluciones de los Cuerpos Directivos de la Organización Panamericana de la Salud, vol. 3 215 Annual Report of the Director, 1986 215 Informe Anual del Director, 1986 219 Informes finales. 98a y 99a Reuniones del Comité Ejecutivo de la OPS y de la XXXII Reunión del Consejo Directivo de la OPS. XXXIX Reunión, Comité Regional de la OMS para las Américas/ Final Reports. 98th and 99th Meetings of the PAHO Executive Committee and of the XXXII Meeting of the Directing Council of PAHO. XXXIX Meeting, WHO Regional Committee for the Americas 221 Annual Report of the Director, 1987 221 Informe Anual del Director, 1987 Health Systems Infrastructure 41 Health Systems Infrastructure 41

Table 1. Publications Issued by the PAHO Editorial Service in 1986-1989 (cont.).

Serial No. Title

225 Informes finales. 100a y 101a Reuniones del Comité Ejecutivo de la OPS y de la XXXIII Reunión del Consejo Directivo de la OPS. XL Reunión, Comité Regional de la OMS para las Américas/Final Reports. 100th and 101st Meetings of the PAHO Executive Committee, XXXIII Meeting of the Directing Council of PAHO. XL Meeting, WHO Regional Committee for the Americas 228 Annual Report of the Director, 1988 228 Informe Anual del Director, 1988 232 Informes finales. 102a y 103a Reuniones del Comité Ejecutivo de la OPS y de la XXXIV Reunión del Consejo Directivo de la OPS. XLI Reunión, Comité Regional de la OMS para las Américas/Final Reports. 102nd and 103rd Meetings of the PAHO Executive Committee, XXXIV Meeting of the Directing Council of PAHO. XLI Meeting, WHO Regional Committee for the Americas

Technical Papers 1 Malaria en las Américas. Análisis crítico 2 Control del hábito de fumar. Taller subregional para el Cono Sur y Brasil 3 Protección del paciente en radiodiagnóstico 4 Investigaciones sobre servicios de salud. Indice de trabajos 5 Malaria en las Américas. Informe de la IV Reunión de Directores de los Servicios Nacionales de Erradicación de la Malaria en las Américas 6 Polio Eradication Field Guide 6 Guia práctica para la erradicación de la poliomielitis 7 Pautas simplificadas. Control de las enfermedades de transmisión sexual 8 Atención médica de casos graves y complicados de malaria. Reunión técnica informal de un grupo internacional de especialistas patrocinada por la OMS 9 Control del hábito de fumar. Segundo taller subregional. Area Andina 10 Problemas nutricionales en pa;ses en desarrollo en las décadas de 1980 y 1990 11 Assessing Needs in the Health Sector after Floods and Hurricanes 11 Evaluación de necesidades en el sector salud con posterioridad a inundaciones y huracanes 12 Fecundidad en la adolescencia. Causas, riesgos y opciones 13 National Health and Social Development in Costa Rica: A Case Study of Intersectoral Action 14 Los servicios de salud en las Américas. Análisis de indicadores básicos 15 Protección contra la radiación ionizante de fuentes externas utilizadas en medicina 16 Education and Training Needs for Medical Entomology in the Americas 16 Necesidades para la educación y el adiestramiento de entomólogos médicos en las Américas 17 Administración de emergencias en salud ambiental y provisión de agua 18 Vigilancia del crecimiento y desarrollo del niño. Curso integrado de salud maternoinfantil 19 Malaria en las Américas. Informe de la V Reunión de Directores de los Servicios Nacionales de Erra- dicación de la Malaria y Directores Generales de Salud en las Américas 20 Smoking Control. Third Subregional Workshop, Caribbean Area 22 A Profile of the Elderly in Trinidad and Tobago 23 Strengthening Health Research in the Americas through International Collaboration 24 A Profile of the Elderly in Guyana 25 Por una mejor alimentación. Evaluación de programas destinados a mejorar el consumo alimentario y el estado nutricional de familias pobres en Brasil 26 A Profile of the Elderly in Argentina

Periodicals

Boletín de la Oficina Sanitaria Panamericana (monthly) Bulletin of the Pan American Health Organization (quarterly) Educación médica y salud (quarterly)

and documentation resources to be shared at reinforce existing national networks, include a reduced cost. the national systems as part of projects to During the quadrennium the Program's develop health services, and obtain financial goals were to establish national systems in support from foundations and other agencies those countries where they did not exist, to further develop information networks. 42 Report of the Director 42 Report of the Director

The regional system's main services make their regular publication possible; were the Latin American Health Sciences inadequate content validation because of the Literature (LILACS) data base, the Biblio- lack of editorial boards or a system of peer graphic Exchange Service, and provision of review; and a shortage of funds to finance access to other national and international their publication. The Program sought to data bases. LILACS contains publications support national scientific publications by generated by health professionals in the holding meetings with groups of editors and Region and by PAHO/WHO. The docu- members of editorial boards of biomedical ments are processed according to a method- journals in Chile, Costa Rica, Cuba, Peru, ology that BIREME developed and and Venezuela. At these meetings, problem transferred to the countries through courses areas and international cooperation were and periods of in-service training. The examined. It also sponsored courses and National Information Centers gather and workshops on research communication process the literature generated in their methods, with special emphasis on editing countries and send BIREME the processed scientific articles, in Costa Rica, Cuba, Mex- product. BIREME then generates the data ico, Peru, Venezuela, and the states along base in compact disk form (CD-ROM) and the Mexico-United States border. distributes copies of LILACS/CD-ROM free In 1986, PAHO/WHO signed a new of cost to all cooperating institutions, to agreement with the U.S. National Library of which it earlier provided CD-ROM reading Medicine to become an International equipment. CD-ROM readers were given to MEDLARS Center, enabling it to provide 160 institutions in 19 countries, and the the additional service to the countries of on- LILACS/CD-ROM data base was delivered line access to data bases. Simultaneous to all of them. LILACS/CD-ROM is also efforts were made to increase the basic jour- distributed to institutions outside the nal collections in each country, with the goal Region. As of the end of 1989, 12 countries of establishing a reference base that satisfies regularly contributed to LILACS, and plans 80% of the most frequent demands for bio- existed to extend participation to all the medical information. On-line access to countries, continue negotiations to incorpo- MEDLARS outside the United States rate literature generated in Spain and Portu- requires services that the biomedical institu- gal, and start a promotional campaign to sell tions in most of the countries find expensive. LILACS/CD-ROM as a way of generating The Program hence focused on developing income. BITNET (Because It's Time NETwork) in an The institutions forming part of the effort to provide an affordable alternative. In National Information Centers shared biblio- 1988, PAHO/WHO and the National graphic resources through the Bibliographic Library of Medicine sponsored a telecommu- Exchange Service, which provides photo- nications research protocol called BITNIS copies on request of documents that an insti- (BITNET NLM Intercommunication Sys- tution lacks. During the period 1986-1989, tem). Designed by the University of Chile's BIREME delivered 300,000 photocopies of Schools of Medicine and Engineering, the journal articles to libraries in the Regional project sought to use BITNET as a carrier for System. The telefax network of 17 machines accessing MEDLARS to reduce telecommu- in 11 countries facilitated document ex- nications costs. Two versions of BITNIS change between the System's units and will have proved to be efficient, to have few be expanded over the next quadrennium. restrictions, and to be affordable. Biomedical journals produced in Latin During the 1986-1989 quadrennium the America and the Caribbean faced difficulties PAHO Headquarters library experienced stemming from three major shortfalls: an major changes. Among them were the insufficient number of original articles to library's incorporation into the Scientific Health Systems Infrastructure 43 Health Systems Infrastructure 43 and Technical Health Information Program ference provided general information on the in 1986 and its internal restructuring under AIDS pandemic for health workers, decision new leadership in 1987. makers, members of the media, and the gen- The Library provides information ser- eral public. The II Pan American Telecon- vices, bibliographic searches, periodicals ference on AIDS was broadcast from Rio de control, photocopying, selective distribution Janeiro, Brazil, in December 1988 to audi- of documents, and technical cooperation ences throughout the Americas as well as in with Headquarters programs, PAHO/WHO Europe, the Middle East, and Africa. It cov- Representations, and the Pan American ered the key issues in AIDS prevention and Centers. control for an audience of medical and Regarding information processing, docu- health care personnel, social scientists, and ments of the Headquarters' technical pro- others who design, carry out, and monitor grams and the documentation centers in the AIDS control and treatment projects. The PAHO/WHO Country Offices began to be contents of both the conferences were edited included in the MicroISIS computerized pro- and distributed in English, French, Portu- gram. This software made it possible for the guese, and Spanish to Member Countries. first time to share resources and actively On 1 July 1989, the Office sponsored the exchange biomedical information in the Americas-wide television special on health Region by cooperative indexing and dissemi- "Salud para todos." The first event of its nation on compact disk. kind, "Salud para todos" was an entertain- ment television program that was broadcast live from Miami, Florida, to over 30 coun- Information and Public Affairs tries in the Americas and Europe, reaching an audience of more than 100 million view- The Office of Information and Public ers. It featured popular entertainers from Affairs changed dramatically over the 1986- Latin America and Spain who interspersed 1989 quadrennium. By the end of the health messages on such topics as infant period, an in-house video production unit mortality, environmental contamination, had been created, and this new video capa- the role of women in health services, drug bility, together with the related strategy of abuse and tobacco use, and childhood employing satellite technology for telecon- immunization programs with musical and ferencing, significantly augmented the Orga- dance performances. A series of documenta- nization's capacity to reach large audiences ries on health conditions in the Americas, with health information. The success of this produced by the Office, was shown during approach and its support by Member Coun- the program. tries led to the decision in late 1989 to The Office produced some 60 short, develop a project-Communicating for' timely documentaries and educational video- Health-that will build comprehensive mul- tapes on key health issues during the qua- timedia communications campaigns for the drennial period. The Office's video crew public in the countries of the Americas. traveled extensively in the Americas to doc- The Office organized two telecon- ument health conditions, risk factors, tech- ferences on AIDS in collaboration with the nical projects, and special events. These PAHO/WHO Program for the Prevention visual records were then edited by the Office and Control of AIDS. The I Pan American into video productions for general distribu- Teleconference on AIDS, held in Quito, tion. Several of the productions with a less Ecuador, in 1987, was transmitted by satel- technical content were broadcast as public lite to an audience of 45,000 in 30 countries information programs by television stations in the Americas. Broadcast in English, Span- in the Region. ish, French, and Portuguese, the telecon- The Office's core functions of media HEALTH AND COMMUNICATIONS TECHNOLOGY

When PAHO/WHO launched its campaign to build a modern communications capability in 1986, many asked what advanced communications technology had to do with primary health care. Since then, the Office of Information and Public Affairs has shown that a lot can be accomplished in that area. For instance, many parents learned for the first time of the vital importance of immunizing their children during a two-hour television special: "Salud para todos," organized by PAHO and carried by television networks in 30 countries. Many children watched the famous mouse character Topo Gigio overcome his fear of needles in a skit on the same show. Well-known Latin American entertainers performed and gave health messages related to such topics as infant mortality, environmental pollution, diarrheal diseases, women's role in health services, drug abuse, and smoking. These performers attracted a large viewing audience that would not normally tune in to a health documentary and probably had a greater impact on health behaviors than would have been the case if the same messages had been issued by health authorities. During the show, Mexican television actor Humberto Zurita announced PAHO's plan to eradicate wild poliovirus transmission from the Americas by 1990 and offered a $US100 reward for any person reporting a confirmed case of the disease. In another example, health workers in remote areas, who would never have had the financial means to attend international scientific meetings, were able to see, hear, and query the world's leading authorities on AIDS during the I and II Pan American Teleconferences on AIDS. These two groundbreaking events used modern technology-television networks, international satellites, local reception sites in countries all over the Americas and Europe, and direct telephone links-to allow direct questions of the presenters, who thus reached much larger audiences than they could ever find at scientific meetings. Thirty countries and over 45,000 participants at more than 300 sites throughout the Americas were linked by satellite on 14-15 September 1987 by the I Pan American Teleconference on AIDS, which was transmitted in four languages.

relations, preparation and dissemination of Director and PAHO/WHO technical staff. nontechnical publications, response to pub- In support of the technical programs of lic inquiries, and the production of photo- the Organization, the Office produced a graphic exhibits and slide shows were all number of multimedia instructional pack- upgraded. ages consisting of videotapes, publications, The demand for information from and slide shows. It also mounted 50 large PAHO/WHO grew significantly during the photographic exhibits that documented quadrennium. In 1989, 8,000 information health projects sponsored by PAHO/WHO. requests were received from television net- The Office collaborated with national orga- works, newspapers, radio stations, maga- nizations and with UNICEF in producing zines, researchers, students, and the general visual and print materials. The extensive public. In responding to the media requests, photographic documentation center that the the Office often arranged interviews with the Office built up over the period served as a

44 The II Pan American Teleconference, which aired live on 12-14 December 1988, brought together more than 40 of the world's leading experts on AIDS at a site in Rio de Janeiro, Brazil, for three days of scientific presentations, panel discussions, debates, and daily press conferences. These were transmitted to health workers via satellite and televised in more than 26 countries of the Americas, as well as many countries in Europe, Africa, and the Middle East. In addition, the entire teleconference was transmitted live over educational television in Bolivia, Brazil, and the Dominican Republic.

resource for technical programs and country publishing equipment and slide presentation offices, which used photos for technical, sci- workstations were acquired or upgraded to entific, and nontechnical publications, as enhance the quality of the Office's publica- well as posters and other visual displays. tions and slide shows. Magazines, newspapers, and other publications in the Region and in Europe also made use of photographs from the Office's library RESEARCH PROMOTION AND to illustrate the health situation in the DEVELOPMENT Americas. The long-needed purchase of modern During the quadrennium, methods for equipment allowed the Visual Aids Unit of the promotion and development of science the Office to significantly expand its com- and technology for health received concen- puter-generated graphics capability. Desktop trated attention. Pivotal to this end were the

45 46 Report of the Director contributions of the PAHO/WHO Advisory Committee was led to recommend that Committee on Health Research (ACHR) closer ties be established with national and its subcommittees on Biotechnology and research councils and that specialists be on Health Systems and Services Research. enlisted to develop protocols for multicoun- The Program reoriented its support away try projects in priority research areas. By the from isolated or fragmented initiatives, end of 1989, working agreements had been instead investing its limited resources in established with six national research coun- process-oriented approaches that favor tech- cils, and multicountry protocols were initi- nical cooperation among countries. ated in four of the Research Grants In spite of the noted progress, the need Program's priority areas. still exists to develop a comprehensive tech- In 1988 a study involving five countries nical cooperation program with the partici- in Latin America was launched to identify pation-from design to execution-of all the trends in research and scientific production technical programs. Given the difficulties from 1978 to 1988 and their relationship to inherent to interprogrammatic work, this is the socioeconomic characteristics of the a complex task, but one that will be under- respective countries. Once completed, the taken in 1990 with the support of in-house study will have identified existing data banks committees and subcommittees instituted by that can then be linked. Since the five coun- the Director, PASB, in support of research tries involved produce 90% of the scientific coordination activities. research in Latin America, the data bank One of these committees, the Internal linkage should permit major research trends Advisory Committee on Health Research in the Region to be followed and analyzed. (IACHR) oversees the PAHO/WHO The Program sponsored a number of Research Grants Program, which approved seminars aimed at improving the manage- 94 of the 364 grant applications it received ment of research and development. The sem- during the 1986-1989 period (Table 2). inars were attended by participants from 30 Given the number of rejected proposals, countries and territories in the Region. They especially during the last two years, the covered such topics as health research infor-

Table 2. PAHO research grants for projects approved during 1986-1989, by priority area.a 1986-1987 1988-1989 Number of Amount Number of Amount projects ($US) projects ($US) Aging and health 3 20,000 Biotechnology 9 176,021 2 40,000 Economy and financing 3 87,545 1 20,000 Growth, development, reproduction 2 22,450 6 100,377 Health systems and services 3 59,964 Health and illness in adults 8 121,527 4 68,705 Health and work 6 43,748 3 60,100 Health profiles 5 58,340 1 10,000 Labor force in health 3 57,814 4 84,691 Political process and health 2 35,000 4 75,800 Process of technological development 7 90,189 5 87,760 Health sanitation systems/services 6 79,150 2 41,500 Scientific activity in health 5 100,000 Total 54 791,784 40 748,897 a As of 31 December 1989. Health Systems Infrastructure 47 mation systems, research evaluation, meth- The Program has produced a variety ods for setting research priorities, and of documents and reports in the area of technical cooperation in health science and health systems and services research, and the technology. Governing Bodies have repeatedly recog- The ACHR recommended the design of nized the need to base the transformation of a Regional Program in Biotechnology health systems on a solid scientific founda- Applied to Health and a Regional Program tion. However, it was not until 1985 that for Health Systems and Services Research, PAHO/WHO made a concerted effort to selecting these areas because of their poten- stimulate research in this area, and, despite tial value to health development and the this promotional activity, the response of the promotion of science and technology in the scientific community has been minimal. A Region. In both cases, scientific infrastruc- Subcommittee of the Advisory Committee ture development is the long-term objective, on Health Research was therefore appointed and it is pursued by means of research to further this purpose. The Subcommittee projects addressing priority health needs. first met in May 1989 and recommended a In the area of biotechnology, 11 projects series of guidelines that was approved by to develop procedures for diagnosing blood- the Advisory Committee, which also urged transmitted diseases were funded, and most of the Director of PASB to put them into effect them were completed by 1989. One of the promptly. projects led to the development of a diagnos- The Research Coordination Unit and tic kit for AIDS that is now being validated in the Health Services Development Program two reference serum panels. In 1989 research- submitted a proposal to the Director in ers from three Latin American countries November 1989 to carry out a multicentric, designed a project to develop strategic tech- 18-country evaluation of the implementa- nology for the production of immunodiagnos- tion of local health systems. The design tic reagents. The project, financed by the of country-specific protocols for the Organization and staffed by the participating $US1,000,000 project is in progress and is institutions, will last two years. scheduled for completion in 1990. CHAPTER IV

HEALTH PROGRAMS DEVELOPMENT

INTRODUCTION other national institutions in health projects promoted by the programs. During the quadrennium, work in the The evaluation of technical cooperation Health Programs Development Area was activities also improved. Emphasis contin- channeled along two main approaches. First, ued to be given to evaluating the pro- attention concentrated on structuring the grammed activities' accomplishments; the Organization's technical cooperation so that evaluation of the impact of those activities resources were applied effectively, had the on the national health services and on maximum possible impact, and were pro- health conditions, especially among vulnera- grammed and implemented to allow impact ble groups at greatest risk, showed gains as evaluations. Second, the subregional ap- well. proach was consolidated in order to best Support of the subregional initiatives address geographical and public health con- continued, especially for those projects that cerns through the coordinated efforts of sev- targeted vulnerable groups such as mothers, eral countries. children, and workers and priority health The systematization of technical cooper- programs such as communicable diseases, ation emphasized setting target deadlines, food and nutritional deficiencies, environ- ensuring adequate programming, and fol- mental health, and the chronic diseases of lowing six basic strategies for the technical adulthood. cooperation with Member Countries. These The programs made considerable pro- six strategies were the mobilization of gress in certain specific areas: the eradi- resources; dissemination of information; cation of indigenous transmission of the wild manpower training; development of norms, poliovirus is in sight, the urban rabies con- plans, and policies; research promotion; and trol program has entered its final attack the provision of technical consultancy. Some phase, and there is significant national sup- of the principal activities in these six areas port for the campaign to eradicate foot-and- are described in detail under the various pro- mouth disease. gram headings. Regional concern about environmental All the Health Programs Development contamination, environmental health, and projects focused on mobilizing financial drug abuse led PAHO/WHO to devote resources. Significant increases in extra- more attention to these areas. There was budgetary funding were obtained and concomitant effort placed on health promo- applied to programs in the countries, and a tion and the use and application of health concerted effort was made to mobilize services research. Finally, the increased cohe- national institutional and political resources. sion and unity of vision in this area during Results from these efforts include the the quadrennium have led to more interpro- increased involvement of universities and grammatic collaboration and better support

48 Health Programs Development 49 Health Programs Development 49 to the program activities at the country tion in Central America, Mexico, and level. Paraguay. The Interagency (PAHO/WHO-FAO- UNICEF) Food and Nutrition Surveillance FOOD AND NUTRITION Program was launched in 1987 to provide information on health and nutrition for The work of the PAHO/WHO Food advocacy purposes at the national and inter- and Nutrition Program is carried out by Pro- national levels. Its aim was to promote the gram staff and two specialized centers-the nutritional protection of vulnerable groups Caribbean Food and Nutrition Institute and the development of national food and (CFNI), based in Jamaica, and the Institute nutrition surveillance systems. Subse- of Nutrition of Central America and Pan- quently, the International Conference on ama (INCAP) in Guatemala. Food and Nutrition Surveillance in the The Program addresses nutrition defi- Americas, held in Mexico City in 1988, rec- ciency problems (protein-energy malnutri- ommended a set of measures in this regard tion and iron, iodine, and vitamin A (see PAHO Scientific Publication No. 516), deficiencies), as well as health problems aris- including a regional training program on ing from poor dietary habits. In light of the food and nutrition surveillance. The continuing economic crisis, PAHO's Direct- PAHO/WHO Food and Nutrition Program ing Council, at its XXXIII meeting in 1988, presented such training at a meeting in Cali, mandated the Program to promote ways of Colombia, in 1989. ensuring the availability of food for low- The Program and the centers acted in income and other vulnerable groups (Resolu- concert with other international nongovern- tion XVI). The resolution also called for mental agencies and donor governments in technical cooperation in the areas of food carrying out their activities. PAHO/WHO and nutrition surveillance systems, educa- and IDB agreed to accord food and nutrition tion and public information, research into priority status and prepared joint strategies balanced diets that incorporate locally pro- for Latin America and the Caribbean. The duced foods, and preventive nutrition in the Program also collaborated in the design and management of chronic diseases associated evaluation of World Food Program projects with diet. directed primarily toward poor and vulnera- The Joint (PAHO/WHO-UNICEF) ble groups. INCAP received funds from Nutrition Support Program UNSP) was a USAID, France, Switzerland, and Sweden major vehicle through which food and nutri- to support technical cooperation in maternal tion activities were accomplished. In and child health, nutrition education, and Dominica, Haiti, Nicaragua, Peru, and St. development of human resources in health Vincent and the Grenadines, the JNSP sup- and nutrition in Central America. CFNI ported national projects to improve the received support from the International nutrition and health of women and children Center for Research on Women for projects as part of primary care services. The JNSP to control iron deficiency anemia in the projects in Dominica, Nicaragua, and St. Caribbean, and from IDRC for an educa- Vincent and the Grenadines concluded in tional project to improve the nutritional sta- 1989, at which time similar ones were begun tus of children in the weaning age group. in St. Kitts and Nevis and Saint Lucia. The CFNI focused much of its effort on mak- JNSP also successfully carried out projects to ing information on food and nutrition control iodine deficiency disorders (IDD) in widely available to health workers and com- Bolivia, Ecuador, and Peru. In 1989 it per- munities. It continued to publish the journal formed a rapid assessment of the IDD situa- Cajanus, the newsletter Nyam News, and 50 Report of the Director 50 Report of the Director manuals on the control of obesity and a course in 1988 on the application of the related chronic diseases, oral health, nutri- case study method to improve the manage- tion education, and community nutrition. It ment of food and nutrition programs and regularly issued "Nutrient-Cost Tables" to other health projects. CFNI's support for inform the public of the most economical training activities included its collaboration food purchases for building balanced diets. with the first Dietetic Internship in the Its book Children of the Caribbean included a Caribbean; the Faculty of Agriculture of the summary of the nutrition situation in the University of the West Indies; the College of Caribbean and its impact on child survival. Arts, Science, and Technology in Jamaica; CFNI vigorously pursued cooperation with and the Barbados Community College. the mass media to promote nutrition educa- CFNI also used the satellite distance teach- tion. The radio series "With Healthy Liv- ing facility at the University of the West ing," partially supported by the Jamaican Indies, Mona Campus, to offer in-service private sector, was one of its most successful training throughout the Caribbean. The undertakings and one of the most popular PAHO Regional Training Program in Food radio programs in Jamaica. and Nutrition Surveillance aided the Insti- INCAP also gave attention to dissemi- tute of Nutrition and Food Technology of nating information. Its library served over Chile, the Costa Rican Institute for 5,000 users in Central America and 1,500 in Research and Training in Nutrition and other countries. Its bibliography was Health (INCIENSA), and the University of included in the LILACS system, and it Valle, Colombia, in the design of subre- gained access to such international data gional training projects. bases as MEDLARS, MEDLINE, and INCAP's School of Nutrition and Di- DIALOG. The Center produced and dis- etetics was transferred to the University of tributed bulletins dealing with supplemen- San Carlos of Guatemala in 1987, but it con- tary feeding ("Bulletin PROPAG"), child tinued to offer postgraduate courses in nutri- survival ("IRA News," "Mothers and Chil- tion and food science and technology. dren," "Diarrhea Dialog"), and food tech- INCAP conducted a survey of manpower nology ("Amaranto"). needs in the Central American subregion The Food and Nutrition Program collab- and collaborated in formulating and imple- orated with the Maternal and Child Health menting national plans based on the survey's Program in producing a training module for results. the promotion of breast feeding and shared The Program supported a study by the data with the United Nations Subcommittee Colombian Association of Dietitians and on Nutrition for inclusion in the publica- Nutritionists on the academic profile and tions First World Nutrition Situation Report competence of professionals in those fields. and Update of the World Nutrition Situation. It A handbook to be used in conducting simi- also produced scientific publications on lar studies in other countries was also endemic goiter, cretinism, and iodine defi- issued. ciency disorders, and food and nutrition The Regional Program and both INCAP surveillance. and CFNI lent support to Member Govern- The Program and its two centers carried ments throughout the Region in developing out a number of activities aimed at training food and nutrition policies and strategies health workers in food and nutrition. As and monitoring their execution. INCAP also part of the Regional Operative Network of evaluated food aid programs, including the Food and Nutrition Institutions (RORIAN), management and storage of food supplies, the Program, along with the United Nations dietary habits to increase the production of University and the Central American Insti- breast milk, oral rehydration therapy using tute for Business Administration, organized home-made fluids, and feeding practices dur- Health Programs Development 51 HealthProgramsDevelopment 51~~~~~~~~~~~~~~~~~~~~~~~ ing episodes of infant diarrhea. CFNI Sanitary and Environmental Engineering researched strategies to combat iron defi- (AIDIS), a professional association that ciency anemia, the sociological aspects of brings together engineers from all countries street-food vending, and the impact of in the Americas. The Program commis- migration on food and nutrition status. In sioned a study in 1987 to strengthen AIDIS' Jamaica, the school meal program was evalu- institutional capacity to promote environ- ated, as was educational material used to mental health by setting up a viable financial improve the nutritional status of children of plan, establishing its Executive Secretariat in weaning age. The Center also studied the Sáo Paulo, Brazil, and developing its social and economic implications of Hurri- national chapters. AIDIS also held Regional cane Gilbert in Jamaica. congresses every two years and issued several publications with support from the Program. To assist in providing educational oppor- ENVIRONMENTAL HEALTH tunities, the Program prepared the first Regional Directory of education programs The PAHO/WHO Environmental for sanitary and environmental engineers, Health Program is among the most crucial which it updated in 1989. It also sponsored programs of the Organization, since it meetings of professors in the discipline and encompasses services that have a direct and technical cooperation agreements between lasting impact on public health. The Pro- Latin American universities and several in gram has five components: general environ- North America and Spain. CEPIS and ECO mental health, water supply and wastewater provided nine-month to one-year intern- and excreta disposal, solid waste manage- ships to young environmental health profes- ment and household hygiene, prevention sionals who then returned to work in their and control of environmental pollution, and countries of origin. Both CEPIS and ECO workers' health. Its activities are carried out published and distributed texts, newsletters, by staff at Headquarters who are responsible manuals, and training materials on a wide for overseeing Region-wide activities, sani- range of relevant topics. tary engineers who are posted in several The Program collaborated with the countries, the Pan American Center for San- Organization's Emergency Preparedness and itary Engineering and Environmental Sci- Disaster Relief Coordination Program in ences (CEPIS) in Lima, Peru, and the Pan lending technical cooperation to national American Center for Human Ecology and programs in disaster-prone countries for the Health (ECO) in Metepec, Mexico. purpose of preparing environmental health facilities and personnel for natural and technological emergencies. When emergencies General Environmental Health occurred, Program staff were assigned to the PAHO Emergency Response Team responsi- The General Environmental Health ble for advising the affected country on component of the Program coordinates with emergency measures and rehabilitation pri- other institutions and PAHO/WHO pro- orities, and coordinating international relief grams in carrying out activities such as train- in health. ing sanitary and environmental engineers, mobilizing resources, establishing information systems, and preparing for natural and Water and Sanitation technological disasters. In recognition of its important role in At the beginning of the quadrennium, the Region, the Program supported the PAHO's Governing Bodies (see Chapter 1) efforts of the Inter-American Association of reviewed efforts being made by the countries 52 Report of the Director 52 Report of the Director of the Region to extend the coverage of been met or surpassed by the end of 1990-a water, sewerage, and sanitation services. The significant achievement, especially given the review covered progress during the first half deteriorating economic conditions. Yet, of the 1981-1990 International Drinking meeting the coverage goals set in 1980 will Water Supply and Sanitation Decade and set not suffice. Water quality is still far from sat- strategies for the final five-year period. isfactory: 75% of the water supplies were not Decade progress and its development were disinfected adequately to ensure that the also discussed at a consultative meeting of water was safe to drink, and quality control donor and funding agencies sponsored by programs are understaffed and lack sufficient PAHO/WHO and IDB in 1986, in which 22 laboratory support. Furthermore, the con- international and bilateral agencies tinued growth of settlements on the periph- participated. ery of urban areas means that the water Data available in 1985 showed that 86% supply and sanitation sector will require of the urban population of Latin America funds, manpower, and supplies to offset and the Caribbean had water supply ser- potential future deficits in coverage and to vices, and 60% of the same had access to maintain the systems that are in place. sewerage services and sanitary installations. PAHO/WHO hence concentrated a In rural areas, coverage of water supply was large part of its technical cooperation on 45%, and access to sanitation services was helping to develop low-cost technologies to 15%. Studies conducted in Peru of deficien- extend coverage, training personnel in the cies in operation and maintenance of water proper maintenance of facilities to reduce supply and sanitation services showed that leakage and loss in capacity, promoting effi- about 30% of rural water supply systems cient community water use, and instituting were partly or totally inoperative five years preventive and treatment methods to pro- after their construction. A similar situation tect water from biological and chemical may exist in other countries with similar contaminants. characteristics. In urban areas, water losses PAHO/WHO, the World Bank, and the due to poor maintenance and managerial UNDP collaborated on a set of instructional practices were over 40% of capacity (20-25% modules demonstrating low-cost technolo- is considered normal in large distribution gies for water supply and sanitation. CEPIS systems). and the University of Surrey (England) By 1988, preliminary data from 25 coun- developed and tested low-cost technology tries that included over 90% of the popula- kits for water quality improvement (includ- tion of Latin America and the Caribbean ing the DELAGUA field test kit, mixed oxi- showed that urban water supply coverage dant disinfection, and slow sand filters with (including direct connections and easy prefilters). Both the modules and the kits access) had reached 88%, rural coverage was were in use throughout the Region by the 55%, urban sewerage and excreta disposal end of 1989. The Caribbean Development coverage was 80%, and rural sewerage and Bank, meanwhile, collaborated with excreta disposal services covered 32% of the PAHO/WHO in setting up drinking water population. quality control and improvement projects in At the beginning of the International that subregion. Drinking Water Supply and Sanitation CEPIS received backing from IDRC, Decade, Regional targets were set at 91%, GTZ, and the World Bank for its research 56%, 69%, and 31% coverage for urban project with the National Drinking Water water supply, rural water supply, urban sew- Supply and Sewerage Services of Peru on erage and excreta disposal, and rural excreta methods to treat and reuse wastewater. disposal, respectively. The 1988 data indicate PAHO/WHO and CARICOM initiated a that, by and large, these targets will have Regional Sewerage Studies project in the Health Programs Development 53 Healrh Programs Development 53 Caribbean to determine appropriate stan- which municipalities, ministries, financial dards for wastewater discharge and technol- agencies and other institutions, and commu- ogies to prevent contamination of coastal nity groups participated to provide an inte- zones. grated approach to improve the services To support institutional development within a national program. This approach for water supply and sanitation services, 24 was designed by a group of specialists con- extrabudgetary projects designed and imple- vened by the Program, and the results were mented by PAHO/WHO and national made available to the countries. CEPIS, agencies were funded in the amount of meanwhile, carried out experimental $US21 million by IDB, the World Bank, projects to enable slum dwellers to dispose of GTZ, CIDA, the Caribbean Development solid waste themselves with minimal techno- Bank, UNDP, and the countries themselves. logical assistance. The Program sponsored The projects focused on institutional devel- courses throughout the Region, through opment of national and state water agencies, which 1,523 professionals were trained in provision of decentralized water and sanita- solid waste management. tion services to rural communities, develop- Due to the limited resources available, ment of plans to supply water and sanitation most of the Program's activities in the area of in peripheral urban areas, and detection and bettering household hygiene practices con- reduction of water losses. centrated on disseminating information and More than 1,000 technicians and engi- training nationals. neers were trained by PAHO/WHO in leak detection and water loss control in a project financed by IDB and GTZ. CEPIS established groups known as "Technical Nuclei," Prevention and Control of made up of specialists from Brazil, Colom- Environmental Pollution bia, Costa Rica, and Mexico, to prepare guidelines, manuals, and educational materi- The Program's main objective was to als on water conservation and the optimiza- assist national authorities in carrying out tion of existing facilities. health risk assessments regarding chemical hazards and in developing programs to prevent and control the contamination of the Solid Waste Management and environment. The Program also aimed to Household Hygiene increase awareness of chemical pollution hazards in the Region by carrying out stud- Solid waste management required ies, making information available, training increased attention due to expanding rates professionals, and fostering the establish- of urbanization, including crowded settle- ment of interinstitutional networks such as ments established on the periphery of large the PROECOS (see below). Evaluations car- urban areas. The Program concentrated on ried out during the quadrennium revealed extending the coverage of urban sanitation extensive, serious contamination that has services and improving managerial practices been exacerbated by rapid urban growth, in the final disposal of municipal refuse. It is industrial expansion, and agricultural devel- estimated that the proportion of solid waste opment. deposited in sanitary landfills increased to ECO organized three networks of insti- 35% in the major cities of the Region by tutions to improve national capabilities to 1989. The Program lent technical assistance evaluate and remedy problems. By the end to drafting sanitation plans for a number of of 1989, the toxicology network was operat- countries and promoted the formation of ing in seven countries, the environmental "National Urban Sanitation Systems," in epidemiology network in fourteen countries, 54 Report of the Director 54 Reporr of rhe Director and the environmental health impact assess- Agency, participated in Program activities in ment network in nine countries. this area. ECO prepared modular training materi- At the close of the quadrennium, the als in fields such as toxicology, environ- Program prepared a position paper on the mental epidemiology, rapid assessment of relationship between health and the envi- environmental contamination, health effects ronment that delineated a plan of action for of exposure to various chemical agents, and the 1990s and will be used by the XXIII Pan pesticides and health. These materials were American Sanitary Conference (1990) to used extensively in the Region. In the past establish Region-wide policies and program quadrennium, 152 workshops were orga- orientations. nized, which hosted 4,732 participants. ECO supported the creation of national projects in ecology and health (PROECOS) Occupational Health whose functions are to make information available on the extent of environmental More than 80% of the working popula- degradation and its health ramifications and tion of Latin America and the Caribbean to propose viable interagency projects to lacks access to occupational health services. arrest its progression. Among the issues the The Program's 1986-1989 goals in this area PROECOS addressed were air pollution, use consisted of reviewing national occupational of pesticides, the environmental impact of health policies and legislation; promoting large dam projects, and pollution by hydro- occupational health services and expansion carbons, heavy metals, and hazardous chem- of coverage as part of primary health care; ical residues. extending preventive occupational health CEPIS established Technical Nuclei care among the most vulnerable segments of made up of specialists to examine the status the economically active population; and pro- of and the control procedures for toxic sub- viding technical cooperation to countries in stances in surface waters and eutrophication training personnel in occupational health of tropical lakes and reservoirs. The groups measures. The Program collaborates with issued case studies, manuals, guidelines, and several institutes specializing in occupational policy papers, and also conducted work- health research and policies in Bolivia, Bra- shops on the subject. CEPIS itself lent tech- zil, Chile, Colombia, Cuba, Peru, and the nical assistance to several countries in the United States. application of computer modeling programs In Colombia, the Program participated for the evaluation and control of hazardous in drawing up a National Occupational contaminants. It also coordinated a regional Health Plan aimed at the expansion of cover- program to prevent and control ground- age of occupational health services within water contamination, and provided support the health ministry's health services system. to Latin American laboratories that partici- Legislation reviews were supported in several pate in the United Nations' Global Environ- countries, and the Program collaborated mental Monitoring System for Water. with counterparts in Cuba to improve the Both CEPIS and ECO carried out on- quality of and access to occupational health site training for professionals in the Region. services. The centers' visiting professionals programs The groups of workers that the Program drew participants from Europe and Japan as and national health services deemed most well as the Americas. vulnerable included agricultural workers in Other organizations and agencies, such Central America, miners in the Andean sub- as IDB, the World Bank, the Environmental region, and women. A review of the status of Protection Agency and CDC of the United workers' health and its relationship to devel- States, IDRC and CIDA of Canada, GTZ, opment in Central America and the Domin- and the Japanese International Cooperation ican Republic was presented to the V Special Health Programs Development 55 Health Programs Development 55

Meeting of the Health Sector of Central ment, and reproductive health of the America. population of the Region by reducing the The Program also drafted and dissemi- chief causes of morbidity and mortality nated manuals and guidelines on methods of among mothers and children. These are peri- extending occupational health services as natal illnesses, diarrheal diseases, acute respi- part of the Regional primary health care ratory infections, childhood diseases strategy, and sponsored a number of semi- preventable by vaccination, and problems nars and workshops to train national staff in associated with pregnancy and childbirth. the subject. Survey forms were designed and The Program established a series of used in several countries to gather the spe- objectives to address these areas. The first cific work-related demographic, morbidity, was to assist the Member Countries in and mortality data required for planning of increasing the coverage and quality of ser- services. Better baseline information was also vices-especially among underserved, high- obtained by the end of the quadrennium on risk groups-to regulate fertility; monitor unemployment, underemployment, work- pregnancy, deliveries, and the postpartum related accidents, pesticide poisoning, occu- period; provide perinatal care; follow child pational diseases, and the type of services growth and development; and provide care available to social security participants and for adolescents. The second was to support those who lack such coverage. national vaccination programs toward the The Program concentrated as well on goal of immunizing all infants under one galvanizing cooperation between the minis- year of age by 1990. Third, the Program tries of health, social security institutes, sought to strengthen epidemiologic surveil- labor ministries and inspection services, lance systems to ensure that reported cases of large companies, and other groups and agen- poliomyelitis were investigated immediately cies whose actions have a bearing on occupa- and that appropriate measures were taken to tional health. interrupt transmission of wild poliovirus. Training in occupational health took the Fourth, it reinforced diarrheal disease con- form of postgraduate courses that were trol programs and promoted the use of oral offered by several countries, the inclusion of rehydration therapy in homes and at all lev- occupational health in standard public els of care. Finally, the Program aimed to health curricula, and intensive specialized reduce childhood mortality from acute respi- course work for intermediate-level techni- ratory infections through prompt diagnosis cians, trainers, labor leaders, and others and appropriate treatment, encouraging involved in extending coverage. Seminars on standard therapies and the referral of serious epidemiologic research in occupational cases in lieu of the indiscriminate use of health were conducted with a view toward antibiotics. improving the quality of research proposals The PAHO Governing Bodies set sev- designed in Latin America. The Program eral deadlines for the Program: to eradicate focused on building expertise in determining the transmission of the wild poliovirus in the the causal relationship between work and Region by 1990, to eliminate the indigenous pathology and the points at which preven- transmission of measles in the Caribbean by tive interventions are most effective. 1995, and to reduce maternal mortality to 50% of present rates by the year 2000. Fur- ther policy directives include the goal of eliminating neonatal tetanus and develop- MATERNAL AND CHILD HEALTH, ment of a program of integrated adolescent INCLUDING FAMILY PLANNING care. The Program delivered cooperation to The Maternal and Child Health Pro- the countries of the Region in six main areas: gram aims to safeguard the growth, develop- dissemination of scientific and technical THE ERADICATION OF POLIOMYELITIS

In May 1985, the Director of the Pan American Sanitary Bureau, Regional Director for the Americas of the World Health Organization, proposed that the Western Hemisphere launch a campaign to eradicate the indigenous transmission of wild poliovirus by 1990. The XXXI Meeting of the PAHO Directing Council endorsed the proposal in September 1985. Given that an effective vaccine is available, it was considered unacceptable that any child should suffer from the consequences of such a devastating disease. The goal of eradicating poliomyelitis was seen as a springboard for strengthening the entire Expanded Program on Immunization. Its attainment would be used as well to reinforce the Region's health infrastructure, especially since the decentralization of resources for the eradication campaign also strengthened local health systems. The major impediments to polio eradication in the past had been the lack of sustained political and social will, managerial constraints, vaccine efficacy and stability problems, and the inadequacy of epidemiologic surveillance. These impediments had to be addressed jointly by the governments and agencies that supported the initiative. The agencies that immediately rallied behind the PAHO/WHO campaign were the United States Agency for International Development (USAID), the Inter-American Devel- opment Bank (IDB), UNICEF, Rotary International, and the Canadian Public Health Association. Together, they contributed nearly $US100 million toward the five-year effort. To ensure proper coordination of these agencies and institutions with the governments, an Inter-agency Coordinating Committee (ICC) was created at the regional level and replicated with their representatives in the countries. With the external resources made available by the ICC member agencies, managers and supervisors were trained at the various levels of the health system and were provided with transportation to carry out their duties. PAHO/WHO also prepared and distributed the Polio Eradication Field Guide for use by national health personnel. Vaccine cold chain was improved and vaccine efficacy constantly monitored to detect any problems. The monitoring system suggested that low vaccine efficacy might have been responsible for a major polio-3 outbreak in the northeast of Brazil in 1986. As a result, the vaccine was reformulated almost immediately. More recently, a similar problem was detected in Mexico as a result of the investigation of the last outbreak in which wild poliovirus was isolated in 1989. Surveillance was defined as the key for disease eradication and received priority in the overall strategy. Standard case definitions were adopted by all countries, and indicators were developed to monitor the occurrence of the disease and allow for prompt control measures. A network of reporting units was organized that incorporates those health facilities most likely to see cases of acute flaccid paralysis that could be due to poliomyelitis. A weekly reporting system was established for these units that includes negative reporting-that is, they were to report to the central level every week, regardless of whether cases were detected. By the end of 1989, nearly 4,500 such units were reporting regularly on the presence or absence of cases. In 1989, a reward of $US100 was announced for any person who reports and/or investigates a probable case of poliomyelitis that is confirmed as due to wild poliovirus.

56 A poliovirus surveillance system was set up that relies on the examination of stool samples from all probable cases of the disease. In the near future, environmental sampling will be used. For this purpose, a network of eight laboratories was established, reinforced by existing laboratories in the Region. Over the last three years more than 10,000 stool specimens were examined for the possible recovery of wild poliovirus, and the network was in full operation in 1989. The number of positive specimens has declined steadily, and during 1989 only 14 specimens yielded wild poliovirus-a decline from the already small number of 38 during 1988. This information suggests that the circulation of wild poliovirus is limited to very few geographic areas and that it will indeed be possible to interrupt transmission by the end of 1990, as initially proposed. As a matter of fact, it is believed that only about 0.5% of the nearly 14,000 counties in the whole of Latin America were affected with polio cases at any time during 1989. The gains in the Western Hemisphere toward eradicating a disease that not long ago was the scourge of thousands of children paved the way for the goal established by the World Health Assembly, in May 1988, of global eradication of poliomyelitis by the year 2000. The polio vaccination strategy relied heavily on organizing national vaccination days to rapidly increase the immunity level of the population at risk. These national vaccination days-two were usually held within a one-month period-serve as a complement to the routine immunization programs. They also serve to improve overall coverage of childhood vaccinations, since they are all delivered simultaneously with the polio vaccine. The strategy proved effective not only in curtailing polio transmission but in raising the overall level of coverage for all the EPI vaccines. Average regional EPI coverage achieved a historical high in 1990: more than 60% with any of the EPI antigens.

57 58 Report of the Director 58 Report of the Director information; development of policies, plans, than 100 maternity clinics in the Region that and standards; training of human resources; participate in collaborative studies. direct technical cooperation; research; and mobilization of national and international human and financial resources. Policies, Standards, and Programs

One of the strategies that has facilitated the adoption of policies, plans, and stan- Information dards in the technical program areas has been the formation of interagency commit- The weakness of data bases in the tees. These committees allow technical and Region hampered surveillance and evalua- financial cooperation agencies to unite on tion of operations and follow-up of projects. objectives and strategies, avoiding duplica- Therefore, between 1986 and 1989, the tions, confusion, and competition among Program promoted the design and use of national groups and facilitating the coun- data bases that would facilitate analysis and tries' programming, negotiation, and infor- decision-making by those responsible for mation use. operation and management of activities The composition of the interagency at all levels. The most important advances committees depends on the interests of the were made by the Expanded Program on various agencies in different technical areas Immunization, the Program for Control of and in different countries. The Expanded Diarrheal Diseases, and the Program for Program on Immunization has the most Control of Acute Respiratory Infections. The developed committee, which includes repre- development of data bases was slower in sentatives from IDB, USAID, UNICEF, the area of human growth, development, Rotary International, and the Canadian and reproduction because of the subject's Public Health Association (CPHA). It has complexity. been used as a model in efforts to create simi- The Program continued to publish lar interagency committees in other techni- newsletters on perinatal health, polio, vacci- cal areas. Those of the diarrheal diseases and nation programs, respiratory diseases pre- acute respiratory infections programs are vention, and diarrheal diseases, with average basically composed of USAID, UNICEF, pressruns of 15,000 copies per issue. Manuals and PAHO/WHO. and basic technical guidelines were printed Maternal and child health programs through the Expanded Textbook and have been assigned priority status as a mat- Instructional Materials Program (PALTEX). ter of policy by all countries of the Region. Each of the technical units produced and All units of the Program promoted the orga- disseminated training materials, including nization of national groups representing a manuals, sets of slides, videos, and case stud- variety of institutions, including social secu- ies. Some of these materials were prepared in rity institutes, universities, and scientific collaboration with the Schools of Public societies. These groups collaborated in and Health in Rio de Janeiro, Sao Paulo, Buenos supported development and testing of tech- Aires, Cali, Medellín, Mexico City, and nical criteria for the design, administration, Lima. and proper operation of projects. The Latin American Center for Perina- As a result of ongoing discussions and tology and Human Development (CLAP) health status evaluations during the qua- continued publishing articles in some 42 drennium, PAHO/WHO will create a pro- areas of research being conducted at the gram and allocate a budget for adolescent Center itself and in the network of more health starting in 1990. Health Programs Development 59 Health Prograrns Development 59 Research concentrated on child development, adolescent health, and causes of maternal and Research in maternal and child health is infant mortality. critical for improving primary health care services, including devising reforms in the types of technology used and the way ser- Direct Technical Cooperation vices are delivered. Around $US8 million were spent on human reproduction research The Maternal and Child Health Pro- during the quadrennium. gram expanded its ability to provide direct Research projects were carried out using technical cooperation by increasing the hir- resources of the Organization itself-avail- ing of consultants. In 1989, the number of able through the PAHO Research Grants consultants reached the highest level in the Program-and funds the Program received Program's history, with 47 professionals from WHO's global programs, as well as lim- working at the regional, intercountry, and ited extrabudgetary monies. Areas of country levels. In the same year, 10,004 con- research included the development of vac- sultant-days were provided (up from 6,000 in cines against rotaviruses, the use of house- 1986): 70% to Latin America, 12% to the hold oral rehydration solutions and foods Caribbean, and 18% to North America. given during and after diarrheic episodes, Thirty countries from the Region, as well as the operation of treatment units, and study Australia, Belgium, Egypt, India, Italy, of lost vaccination opportunities. Findings of Japan, the Kingdom of the Netherlands, and this last project enabled corrective measures the United Kingdom, have furnished consul- to be taken so that coverage could be tants. The technical cooperation provided increased in several countries. by consultants covered a wide range of activ- Research on high-risk areas for neonatal ities, including the definition of national pol- tetanus made it possible to focus selectively icies and plans; the design, operation, on increasing vaccination coverage in areas monitoring, and evaluation of programs and with the greatest numbers of cases. As a projects; human resources training and result, it is hoped that the incidence of neo- development activities; improvement of natal tetanus will decrease significantly dur- information and logistic systems; and devel- ing the next four years. opment of projects to seek extrabudgetary CLAP continued to promote and con- funding. duct epidemiologic and operational research in fields such as prematurity, frequency of cesarean sections, and low birth weight. Human Resources Training and CLAP also conducted eight workshops on Development research methodology that hosted about 200 participants from different disciplines, and The training of human resources is one collaborated with the Population Council to of the Program's priority cooperation strate- improve the development of protocols and gies, since health personnel are the most with the CDC and the Resources Develop- valuable resource available for reforming ment Institute to conduct demographic and health systems. An estimated 40% of the health surveys, including adolescent health, Program's money and effort is invested in and disseminate their findings in most of the training at all levels. Training material pre- countries in the Region. pared by the Program for Control of Diar- The Human Growth, Development, and rheal Diseases was accepted in 107 nursing Reproduction Unit supported 60 studies in schools and 43 medical schools. Neverthe- 21 countries in the Region. These studies less, it was difficult to change the basic train- 60 Report of the Director ing offered by health sciences schools, $US29 million, of which about 10% came faculties, and similar institutions to make it from regular funds and 90% from extra- more consonant with the day-to-day reality budgetary funds. More than 85% of the Pro- of the graduates' work environment. Out- gram's resources went directly to the moded curricula, constant changes in the Member Countries. technologies used in primary care, and the The scarcity of resources in the countries absence in many countries of an official became acute during the quadrennium. The career pathway for public health profession- effects of this crisis were seen in the stagna- als create the continual need for remedial tion or decline of national expenditures for courses for graduates just starting work in maternal and child health programs. The health units and the retraining of those who Program therefore dedicated a significant have worked in them for some time. amount of its efforts to obtaining interna- The training opportunities offered by tional extrabudgetary funds. It succeeded in the Program included postgraduate scholar- mobilizing $US100 million in commitments ships for study outside the countries, courses from a number of agencies (UNICEF, for senior and intermediate-level supervisors, USAID, IDB, CPHA, and Rotary Interna- administrative and technical training for tional) for the 1987-1991 wild poliovirus health workers, and courses for health pro- eradication campaign, of which $US27 mil- moters and traditional midwives. Course lion was assigned directly to programs exe- content ranged from technical and adminis- cuted by PAHO/WHO. These funds were in trative aspects of service delivery and super- addition to approximately $US450 million visory and management skills to issues of that the countries allocated for their univer- clinical care in areas of Program coverage. sal childhood immunization and polio eradi- Available data show that during the qua- cation efforts. drennium between 12,000 and 14,000 people The diarrheal and acute respiratory dis- were trained using materials prepared by the eases control programs gained substantial Program. increases in their extrabudgetary funds. The CLAP offered postgraduate courses in human growth, development, and reproduc- perinatology, perinatal public health, tion program also succeeded in obtaining research design and execution, and other additional funding thanks to private organi- subjects. Together with courses in maternal zations in the United States, such as the W. and child health conducted by the public K. Kellogg Foundation, Pew Charitable health schools in Chile, Colombia, and Trust, and Carnegie Corporation, and Cuba, this instruction enabled more than donors such as the European Economic 1,000 professionals to be trained as program Community, the governments of Italy and supervisors. The expertise in management of Sweden, UNICEF, and especially the United maternal and child health and population Nations Population Fund. programs and in supervisory skills exists in The Program also optimized its use of the Region to provide the training necessary resources by coordinating activities with for program direction. Paradoxically, how- other PAHO/WHO programs such as ever, the financial resources to make use of Health of Adults; Human Resources Devel- that expertise are lacking. opment; Health Situation and Trend Assess- ment; Women, Health, and Development; and Food and Nutrition. In addition, joint Resource Mobilization activities were conducted with the Organiza- tion's specialized centers, namely, CLAP, Up to 1989, the Maternal and Child INCAP, CEPANZO, and BIREME, and Health Program had a total annual budget of with PASCAP. Health Programs Development 61 Health Programs Development 61 Results incidence of diseases preventable by vaccination continued to fall; poliomyelitis dropped Some goals were fully achieved during to its lowest level ever, with fewer than 130 the quadrennium and others only partially. cases confirmed in the Region by the end of Of the 36 countries and territories in the 1989. Eradication of polio in 1990 seems Region about which information is included more realistic than ever. in the publication Health Conditions in the Efforts made during the last four years Americas, 1990 edition (Scientific Publication have succeeded in putting diarrheal disease No. 524), 19 had infant mortality rates of less control activities into operation in all the than 30 per 1,000 live births, 8 had rates countries of the Region. In addition, 20 between 30 and 49, 7 had rates between 50 countries have prepared a profile which will and 99, and 2 still have infant mortality rates enable them to evaluate their programs. On higher than 100 per 1,000 live births. Of the average, access to oral rehydration salts was 25 countries that reported on maternal mor- 62% at the end of 1989, whereas use stood at tality, 6 (containing 35 million inhabitants) 39%. Fifteen of 18 countries producing oral have rates lower than 50 per 100,000 live rehydration salts surpassed their production births; 11 (in which most of the Region's goals, and most of the countries can now population lives) have rates between 50 and satisfy their needs for the salts locally. 100; and in the remaining 8 countries, with All the countries consider acute respira- around 50 million total population, the tory infections a priority problem, and 20 maternal mortality rate was higher than 100 have developed and implemented national per 100,000 live births. respiratory infection control programs with Coverage rates in the Region as a whole operational plans, national standards, and for prenatal care, institutional deliveries, training modules. and contraception are on the order of 70%, 75%, and 54%, respectively, while coverages of attended deliveries and growth monitor- COMMUNICABLE DISEASES ing of children (under one year old and under five years old) are 60% and 40%, The Communicable Diseases Program respectively. The quality of care being pro- provides assistance to Member Countries in vided to mothers, children, and adolescents establishing and maintaining integrated con- will continue to be a source of concern. trol programs to combat vector-borne, para- In fulfillment of the Program's goal, the sitic, and other endemic infectious diseases. standards for care during pregnancy and The main diseases the Program addresses are delivery, newborn care, and family planning malaria, leishmaniasis, schistosomiasis, were reviewed in 50% of the countries. Nev- American trypanosomiasis (Chagas' disease), ertheless, it is unknown to what extent these filariases (including onchocerciasis), dengue, standards were incorporated in prenatal and yellow fever, tuberculosis, leprosy, viral perinatal care. More than 2,000 gynecology, hepatitis, Argentine hemorrhagic fever, obstetric, and pediatric services in 18 coun- leptospirosis, plague, rickettsioses, taeniasis/ tries were evaluated with support from the cysticercosis, and helminthiases. The Pro- Program. Seven countries conducted a sec- gram's activities were carried out by ond study to analyze proposed changes. furthering epidemiologic knowledge of these Vaccination coverage continued to diseases, which includes analyzing and classi- increase and in 1989 reached the highest fying the risk factors involved in their trans- level yet recorded in the Region: at least 60% mission; supporting the services responsible for all vaccines. Very few countries had cov- for controlling their spread; and mobilizing erages of less than 50% for any vaccine. The national, bilateral, and multilateral 62 Report of the Director 62 Report of the Director resources to support prevention and control More than $US1.5 million were assigned efforts. annually to support national applied The Program cooperated with the research in tropical diseases. An attenuated UNDP/World Bank/WHO Special Program vaccine against Argentine hemorrhagic fever for Research and Training in Tropical Dis- was developed, and the results of a con- eases, USAID, IDB, Swedish International trolled field trial in nearly 6,000 volunteers Development Authority, U.S. Army demonstrated its safety and immunogenicity. Research and Development Command, and Information on its efficacy is pending. other national and international institutions Progress was also made in developing tests to develop and review research proposals, for the diagnosis of infection by T. cruzi and train personnel, provide direct technical Cryptosporidia. In Colombia, a hepatitis B cooperation to control efforts, and monitor (HB) vaccination was introduced in the and evaluate progress. hyperendemic area of Santa Marta as part of The intractable spread of malaria con- a five-year program to immunize all infants tinued to cause great concern. According to and susceptible children and adults. Proto- the 36th report on the status of malaria pro- cols were developed to study the epidemiol- grams in the Americas, presented in 1988 to ogy of hepatitis B and assess its prevalence in the XXXIII Meeting of the PAHO Directing the countries of the Region. Other principal Council, more than one million new cases of research topics included the biology and malaria occurred in the Americas in 1987, a ecology of malaria vectors, malaria diagnosis 6.2% increase over 1986. Despite control methods, the effect of malaria on pregnancy, efforts, reinfestations of the vector were the importance of Anopheles rangeli and A. detected in some coastal areas where it had nuneztovari in malaria transmission, and earlier been eliminated. methods for controlling A. albimanus. The Program redoubled its efforts to In collaboration with research institu- promote active case detection and to tions from eight countries, the Program set improve the epidemiologic mapping of rela- up a network to train personnel in epidemi- tive incidence and risk factors on which ology, medical entomology, parasitology, malaria control activities were based. It also immunology, environmental management, supported research at a number of Latin program management and administration, American institutions, including the Center and social sciences. The University of Pan- for Malaria Research in Tapachula, Mexico, ama, Autonomous University of Nuevo and the School of Malariology and Environ- León (Mexico), Oswaldo Cruz Foundation mental Sanitation in Maracay, Venezuela. (Brazil), and University of South Carolina National efforts to integrate mosquito con- (U.S.A.) cosponsored related postgraduate trol programs in routine primary health care courses. services-an appropriate strategy against In addition to direct training, the Pro- other vector-borne diseases as well-also gram expanded the base of scientific and received Program support. technical information available to health In addition to malaria, the Program sup- professionals by issuing monographs, man- ported research into leishmaniasis, Bancrof- uals, and other publications. Their wide dis- tian filariasis, and onchocerciasis. National tribution also served to promote research laboratories responsible for diagnosing infec- and the exchange of information on opera- tious and parasitic diseases were another tional aspects of infectious disease control. focus of attention, as the Program worked to National programs to control dengue, upgrade their capabilities through staff train- malaria, and leprosy benefited greatly from ing, the establishment of reference centers, this interchange of knowledge. the provision of equipment and reagents, At the end of 1989, several problems and assessment of their performance in diag- were still limiting the countries' ability to nosing viral diseases. successfully carry out disease control projects Health Programs Development 63 Health Programs Development 63 for which the technical and scientific exper- and monitoring and improving national and tise exists. Chief among them was that policy regional case surveillance. makers were not using the available epidemi- To facilitate regional surveillance, a ologic and technical information when PAHO/WHO AIDS case definition was deciding how to assign resources. A related finalized and a regional surveillance work- problem is that epidemiologists, although shop was held in Washington, D.C., in July employed in the public sector, were generally 1989. Furthermore, PAHO/WHO staff not consulted in determining what disease assisted in a recent subregional meeting in control projects should have priority and the Caribbean that focused on strengthen- how they should be organized (see the sec- ing surveillance efforts in Caribbean coun- tion on the Health Situation and Trend tries through case reporting and sentinel Assessment Program for additional observa- studies. tions on this issue). National public health To provide guidance to Member Coun- workers were also found to lack adequate tries, technical guidelines for AIDS preven- training in medical entomology. Several pro- tion were developed by a group of experts grams were developed to strengthen capabili- from throughout the Region and were dis- ties in this regard-including postgraduate tributed widely. Due to the rapid scientific courses on epidemiology at the Oswaldo and technological advances with regard to Cruz Foundation in Brazil and the Univer- AIDS prevention, these guidelines were sity of Valle in Colombia, and master's revised in December 1986 and again in April degree programs in entomology in Mexico 1987. PAHO/WHO staff carried out on-site and Panama-but further manpower train- appraisals of national sexually transmitted ing will be needed if efforts to control tropi- disease (STD) prevention programs and eval- cal diseases in the Region are to succeed. uated AIDS committees set up in Brazil, Chile, Colombia, Ecuador, Guatemala, Jamaica, Mexico, Paraguay, and Trinidad and Tobago. PAHO/WHO staff and consul- ACQUIRED IMMUNODEFICIENCY tants also provided technical assistance to SYNDROME (AIDS) emerging national AIDS prevention and control programs in each of the subregions The Program for the Prevention and of the Americas. Control of Acquired Immunodeficiency Three subregional meetings for national Syndrome (AIDS) followed the guidelines AIDS program directors in Latin America established by the WHO Global Program on were held to standardize criteria for program AIDS for developing national prevention design and implementation. A workshop for and control plans. To that end, it contracted Caribbean national program managers, held experts in epidemiology, program manage- at CAREC, provided collaboration in the ment, health education, laboratory support, systematic review of national program and financing and administration to provide achievements and the design of appropriate technical assistance to Member Countries. medium-term plans. At the end of 1986, PAHO/WHO estab- Given the importance of health educa- lished a post of Regional Adviser for the Pro- tion in AIDS prevention, a special AIDS gram, which launched its formal operations Information, Education, and Communica- in January 1987. The Program has main- tion (IEC) Unit was organized to support the tained surveillance of AIDS cases to monitor countries in developing and strengthening the spread of the epidemic in the Region. this component of their national AIDS Special strategies have included establishing plans. The Unit distributed compact discs laboratory networks; improving laboratory containing MEDLINE-AIDS bibliographies equipment and purchasing supplies and and scientific articles from seven major jour- materials; providing consultancy services; nals. The Program also held health promo- AIDS

The Problem

The graph that represents the spread Number of AIDS cases reported, by major of AIDS in the Americas has the unmis- subregion of the Americas. 1980-1989 takable shape of an epidemic. The curves 100,000 for each of the subregions start in different years because the human immunodeficiency virus type 1 (HIV-1) was 10Nohooo000ca introduced at different times, but the subsequent pattern of increase is almost iden- tical throughout the Americas. Disturbing as they are, the reported 1.000 numbers of AIDS cases, which are used to chart the path of HIV-1 through the Carbbean population, measure only part of the 10o problem. WHO estimates that actual cases exceed by two or three times the number of reported cases. In the Ameri- cas, rates of reporting range from 25% to 100% of cases, and since the incubation period from infection with HIV to symp- Cumulasevercen Subre ion cases Percent i tomatic illness may last 10 years, even 1 Caribbean 1,941 1.3 100% reporting of today's fully developed LatinAmerica 207,89 85.21300 AIDS cases tells us only what happened 1980 1982 1984 1986 1988 in the past. It is estimated that as many as 2.5 million people in the Americas are currently infected with HIV. Most, if not all, of these people will go on to develop the disease and will need medical care. Thus, even if transmission stopped today, the impact of the disease on the Region's health services would be enormous. The immune deficiency caused by HIV brings with it an increase in latent and opportunistic infections. This means that the public health sector may see gains reversed in areas such as tuberculosis control. And infant mortality, which has been declining steadily, also may increase as more infants are born to infected mothers.

AIDS Prevention

The AIDS program in the Americas, which is part of the WHO Global Program on AIDS, has focused its energies and resources on the improvement of regional surveillance and the development of national AIDS prevention programs.

64 :

Effective control measures require accurate information. Not long ago AIDS was dismissed as a blight affecting homosexual men in cn narrowly circumnscribed areas, a belief that is still hlde by some ill-informed persons. Knowledge about the disease, its incubation perio, and its mode of transmission has increased a great deal over the last several years. But surveillance systers are still :to often backed up by inadequate laboratory facilities. Inaccurate case reporting is a function of otherfactors as well. Since AIDS patients die of opportunistic infections, such as pneumonias or other complications, t is these diseases that are often reported as the cause of mortality, due to the relative newness of AIDS and to its social stigma. One reason for inaccurate data concerning HIV nfec- tion rates is JIDS' longincubation period: people may unknowingly be infected with the virus-and spreading it-for many years, Better knowledge of the prevalence or incidence of HIV infection would require studies of seropositivity among various groups of people at risk. But the definition of the population at risk has undergone changes along with our understanding of the disease. Cases resultingi from sexual transmission: of OV arnong homosexual and bisexual men and to their sexual partners stiUl account for the largest group, but heterosexual transmission of AIDS in the Americas is growing. In some countries equal numbers of men and women are being infected. As more women become infected, an increase in mother-to-child (perínatal) transmission will occur. Recipients of blood transfusions and drug addicts who share needles make up another high-risk group. A final group includes people exposed to contaminated redi- cal equipment and health care personnel exposed as a result of accidents during medical, surgical, atnd laboratory procedures. Surveillance activities and case reporting are being focused on the groups at highest risk. National governments have come a long way in a short time;, yet the bulk of AIDS cases reported are still those recognized among patients seen in hospital settings. The problem facing heakh workers in controlling the disease is to gain access to and promote behavior change among those groups who are by their very nature the hardest to reach and the most unlikely to change. I is the marginal populations of male and female prostitutes and drug users that may pose the greatest risk to themselves and to others. Another risk area-that of contaminated blood supplies-is one in which dear, targeted action can be and has been taken. Already, the number of countries reporting that none of their cases were transmitted by blood increased from 17 in 1987 to 24 in 1988, and the number of countries with over 10% of the cases reported as being transmitted by blood ased from two to zero between 1987 and 1988. But widespread screening of blood donots is a relatively recent phenomenon, and screening effciency varies from 100% in some countries to 30% in others where transfusion services do not have the necessary infrastructure. At the end of 1988, some of the blood and blood products utilized in the public sector in some countries still were not screened for the presence of V

65 66 Report of the Director 66 Report of the Director tion workshops, developed and field-tested gress and participated in numerous scientific monitoring and evaluation guidelines, and meetings, congresses, symposia, and work- conducted pilot studies for introducing shops on AIDS. AIDS education into schools. To secure funding for AIDS prevention Together with the Office of Information and control programs, a donors meeting was and Public Affairs and other units, the Pro- held in December 1988 in Barbados, spon- gram organized the I Pan American Telecon- sored by the WHO Global Program on ference on AIDS, which was broadcast from AIDS, the Caribbean ministers of health, Quito, Ecuador, in September 1987 to 650 and other organizations. The meeting sites in nearly all countries of the Americas, resulted in $US15 million being pledged for reaching an audience of 45,000 health care support of the programs of 13 countries in workers. The II Pan American Telecon- the Caribbean area. Since this first meeting, ference on AIDS, in December 1988, was similar resource mobilization meetings have transmitted via satellite from Rio de Janeiro been held for the Central American subre- to audiences from Canada to Chile. The gion, the Dominican Republic, Haiti, and conference was also broadcast outside the Mexico, and have produced an additional Region to Portugal, Kuwait, and five African $US16 million in pledges. The funds will be countries. used for such activities as public education, The Program gathered and disseminated care for HIV-infected persons, assurance of relevant health information materials to safety of donated blood and blood products, Member Countries and played a key role in and surveillance and prevention of perinatal the development of the first AIDS Informa- transmission of HIV. Collaboration with tion Exchange Center for the English-speak- nongovernmental organizations such as the ing Caribbean countries, located at Lions Club International and the Interna- CAREC. Two other centers were established tional Red Cross was undertaken through- in Mexico City and Brasilia under the aegis out the period. of those countries' National AIDS The Program entered into a $US5 mil- Commissions. lion, five-year AIDS research contract with In 1989 several workshops for trainers the National Institute of Allergy and Infec- were conducted, covering subjects such as tious Diseases (NIAID) of the U.S. National counseling, health promotion, condom mar- Institutes of Health. Proposals for future keting, the role of nurses in HIV prevention research in the countries on risk behaviors and control, and ways to ensure balanced and sexual conduct were prepared at a meet- media coverage and to mobilize youth in the ing in Guatemala at which the WHO Global fight against AIDS. Program on AIDS research instruments were Program staff participated in the World reviewed. These instruments were later Summit of Ministers of Health on Programs adapted for use in Latin America and by the for AIDS Prevention in London in January end of 1989 were being employed in research 1988, and they played a major role in plan- projects in Chile and Costa Rica. Other ning, implementing, and evaluating the First activities undertaken as part of the NIAID International Symposium on Communica- contract include an HIV seroprevalence tions and Information on AIDS, held in study in STD clinics completed in the October 1988 in Ixtapa, Mexico. In collabo- Dominican Republic, a project to study het- ration with the Organization's Communica- erosexual transmission of HIV initiated in ble Diseases Program, several international Brazil, and the development of research pro- workshops on AIDS laboratory technology tocols in Jamaica and Mexico. were conducted. The Program also repre- More than $US13 million in funds from sented WHO before the United States Con- the WHO Global Program on AIDS were Health Programs Development 67 Health Programs Development 67 applied in direct support of national pro- the Organization's resources are themselves grams, and over $US4 million were dis- limited in this area. bursed for regional activities. Efforts to rationalize the production and use of complex, high-cost technology are critical to achieving more efficient and equi- HEALTH OF ADULTS table services for the elderly and the chroni- cally ill. The First Consensus Conference on The Health of Adults Program sup- Chronic Renal Insufficiency, Dialysis, and ported actions to prevent and control Transplant, held in Venezuela in 1988 (see chronic noncommunicable diseases and PAHO Scientific Publication No. 520), was a their main risk factors; promote mental landmark meeting that addressed this new health and prevent violent behaviors; pre- aspect of technical cooperation. vent and control alcohol and drug abuse; The Program gave priority to antismok- integrate community rehabilitation activities ing activities, as smoking is considered the into primary health care; prevent blindness most important risk factor for many chronic and provide eye care; prevent accidents and illnesses, such as cancer and cardiovascular injuries; and promote comprehensive ser- and respiratory ailments. Major progress was vices for the elderly. To address these con- made in this area. To promote national cerns, the Program used the strategies of action plans against smoking, subregional promoting healthy lifestyles, primarily workshops were held in the Southern Cone, through individual and population-wide Andean area, English-speaking Caribbean, health promotion; strengthening and adapt- and Central America. The Organization's ing health services to care for adults and the Governing Bodies approved resolutions sup- elderly; and rationalizing production and porting antismoking activities at the regional use of high-cost, complex technology. and national levels. PAHO/WHO and the During the 1986-1989 quadrennium the Office of the Surgeon General of the United chronic noncommunicable disease subpro- States undertook a joint project to prepare a gram focused on an integrated approach to document on the problem of smoking in the preventing and treating cancer, cardiovascu- Region. lar diseases, diabetes, and other noncommu- Other Program efforts against cancer nicable diseases, with special emphasis on involved upgrading and expanding programs their common risk factors. Surveys to deter- for early detection of uterine cancer, which is mine risk factors were carried out in urban a serious problem in the Region. The epide- communities in a number of countries as an miologic profile of the disease and the orga- initial step in identifying the most effective nization of the health services for its effective interventions. Although progress was made control were analyzed in each country in in creating greater awareness of chronic non- order to improve detection and thus lower communicable disease problems, extensive mortality rates from this cancer. By the end integrated preventive programs have been of the quadrennium, Barbados and the East- difficult to develop. Generally speaking, the ern Caribbean islands, Brazil, Chile, Colom- countries invest their limited resources in bia, Costa Rica, Cuba, Nicaragua, and medical care rather than preventive services Venezuela had reoriented their programs. for adults. Changes in individual and collec- The PAHO/WHO Latin American tive behaviors associated with noncommuni- Cancer Research Information Project cable disease incidence in Latin America and (LACRIP) continued to serve as the special- the Caribbean have been difficult to bring ized information network on cancer for the about, since they require nontraditional Region. The Program supported the organi- actions within the health sector. In addition, zation of hospital cancer registries in all the 68 Report of the Director 68 Report of rhe Director countries and, together with WHO's Inter- increase awareness of the problem. The goal national Agency for Research on Cancer, is to enable the health sector to jointly promoted new incidence registries to make develop policies with other sectors responsi- possible more accurate epidemiologic ble for addressing this area. research. The Program also supported the The prevention of blindness subprogram participation of health workers in interna- defined its priorities in the Region according tional training courses in the use of epidemi- to the most frequent causes of this disability, ologic tools for studying chronic non- such as cataracts, glaucoma, refraction disor- communicable diseases. ders, and trauma. In countries where para- The rehabilitation subprogram stressed sitic, infectious, and nutritional deficiency the importance of community-based rehabil- problems persist, priority was given to con- itation services and of integrating the dis- trolling these conditions. The inclusion of abled into society. Community-based eye care in basic health services was empha- rehabilitation, as a component of primary sized, and the Arab Gulf Program for United health care, is under way in 15 countries. Nations Development Organizations Modular training material was prepared (AGFUND) supported the creation of pri- and distributed by PAHO/WHO to the mary eye care programs in several countries countries. of Latin America and the Caribbean. The The mental health subprogram focused establishment of these programs was often on formulating national mental health difficult due to the scarcity of service person- plans. In the 1986-1989 period, commit- nel trained in public health ophthalmology. ments were secured from the countries to The support of several nongovernmental orient their mental health plans toward agencies was critical: the Royal Common- alternative approaches to traditional psychi- wealth Society for the Blind and Spain's atric care, including health promotion and national organization of the blind (ONCE) community preventive efforts. enabled PAHO/WHO to provide continu- The subprogram on the health of the ous technical advice throughout the Region, elderly stressed among its priorities the and support received from Chibret Interna- development of a reliable information base tional was also noteworthy. on the elderly in the Region, the promotion The alcohol and drug abuse prevention of policies and programs that address this and control subprogram supported epidemi- age group, and the training of health work- ologic research to evaluate the status of sub- ers in gerontology and geriatrics. Notable stance abuse in Member Countries and the among the subprogram's achievements was establishment of continuous surveillance sys- the completion of a survey of the needs of tems. Its activities also emphasized creating the elderly in 13 countries. The findings in awareness of the severity of the drug depen- five of the countries have been published. dency and alcoholism problem and promot- The high quality of the data and the rigor- ing national prevention and control efforts. ous standardization process employed will Financial support was received from the make the information invaluable in plan- United States for epidemiologic studies that ning services for the elderly. In addition, the provided a profile of drug addiction in the countries of the Region have begun exchang- Region. ing experiences related to models of elderly care, a first step toward the systematization of policies that will be sought in the future. VETERINARY PUBLIC HEALTH The work of the accident prevention and control subprogram focused on epidemi- The Veterinary Public Health Program ologic research and dissemination of infor- addresses several areas in which animal mation within the scientific community to health affects human health and welfare: Health Programs Development 69 Health Programs Development 69 food protection, zoonoses, foot-and-mouth acceptable Region-wide was the focus of sev- disease, and laboratory animal science. eral other Program activities. The Program works through two centers- A project to make regional standards the Pan American Zoonoses Center uniform, begun by the State Standards Set- (CEPANZO) in Argentina and the Pan ting Committee of Cuba, the Pan Ameri- American Foot-and-Mouth Disease Center can Technical Standards Commission (PANAFTOSA) in Brazil-that offer special- (COPANT), the Central American Indus- ized technical advice, research, and training trial Technology Research Institute to Member Governments. (ICAITI), and FAO, was supported by the The Latin American Ministers of Agri- Program. FAO and PAHO/WHO held their culture identified priority areas in veterinary first joint international workshop on control public health at the V (1987) and VI (1989) and protection programs for imported food Inter-American Meetings, at the Ministerial and foods intended for export in Costa Rica Level, on Animal Health. The eradication of in 1989. The Government of Spain, mean- foot-and-mouth disease by the year 2000, the while, supported development of legislation elimination of urban rabies in the principal and food safety training activities in the cities of Latin America, and the develop- Dominican Republic and Guatemala. ment of integrated national food protection The Program cooperated in developing programs were the chief goals. food protection information systems with a number of countries, and sponsored the first Food Protection meeting of the Working Group on Food Pro- tection Information Systems in 1988. Food-borne diseases are frequent causes Food analysis services were another area of morbidity in the Region and are responsi- of cooperation that the Program offered, ble for the largest portion of illness and mainly through CEPANZO, and, to a lesser death among Latin American children. extent, through the Unified Food and Drug Nonetheless, most countries lack a central- Control Laboratory (LUCAM) of Guatema- ized inspection and control system for food la's Ministry of Public Health and Social supplies. Food safety was hence reaffirmed as Welfare. In addition to offering its tradi- a priority by the Ministers of Health of the tional services in food microbiology and par- Region in 1986 at the XXII Pan American asitology, CEPANZO set up a chemical Sanitary Conference (Resolution XVII). The residue analysis laboratory and began lend- Conference approved the Plan of Action ing technical assistance in that area during (1986-1990) of the Regional Program of the quadrennium. It was also the regional Technical Cooperation in Food Protection, focal point for the Program's technical sup- which seeks to ensure that by the end of port in hazard analysis and critical control 1990 more than half of the Region's coun- points for food protection. The Caribbean tries will have adopted policies, strategies, Food Quality Laboratories Network, with a and technologies to ensure food safety. similar function, was established in 1989. The Program held subregional work- Official food inspection services shops on planning and executing food pro- throughout the Region received support tection programs. An FAO-PAHO/WHO from the Program through training courses, Workshop on Food Legislation and Stan- transmittal of specialized documentation, dards Setting in Latin America, held in and direct technical cooperation. Mexico in 1988, drafted a model Basic Food- In 1989, the Program convened the first stuffs Law that some countries, such as Gua- meeting on epidemiologic surveillance of temala, Honduras, and Mexico, have food-borne diseases, which led to creation of already used to update their national legisla- the Latin American Network for Epidemio- tion. Setting food safety standards that are logic Surveillance of Food-borne Diseases. A 70 Report of the Director

similar voluntary network was created in tral America have undertaken joint rabies Argentina. A guide to epidemiologic surveil- control projects along their borders, as have lance of food-borne diseases and six modules Brazil and Paraguay, Colombia and Vene- for use in intensive training courses have zuela, and Haiti and the Dominican been prepared. Republic. The Program lent timely technical assis- Wild rabies represents a continuing chal- tance to investigations of food poisoning lenge for the rabies control programs. Cattle outbreaks in several countries, such as Gua- most often contract rabies from the bites of temala in 1987 (paralytic shellfish poisoning) vampire bats, which are becoming a signifi- and Peru in 1988 (the first outbreak in that cant animal reservoir in urban as well as rural country of botulism in humans). and forested areas. Twenty-four persons died Technical and financial assistance to of rabies after being bitten by vampire bats in national food protection efforts in the October 1989 in a forested locality in Madre Region was provided by the governments of de Dios Department, Peru. Canada, the Federal Republic of Germany, CEPANZO produced a reference stan- Japan, Spain, and the United States; inter- dard antirabies vaccine that laboratories in national credit and technical cooperation Argentina, Brazil, Chile, Colombia, and agencies such as the World Bank, IDB, and Mexico evaluated. It was then approved at UNDP; and the industrial sector of the an inter-American technical meeting held in countries. December 1988 for use as the regional standard for the quality control of suckling Zoonoses and Foot-and-Mouth mouse brain vaccines. Disease The Arab Gulf Program for United Nations Development Organizations Urban rabies continued to be a problem (AGFUND), EEC, Mérieux Foundation of in Latin America, although there was a sig- France, the French agency BIOFORCE, nificant reduction in case numbers over the Sovereign Order of Malta, Rockefeller Foun- last four years. Generally speaking, control dation, University of Wisconsin, USAID, measures succeeded in large cities, while in and CDC all provided funding support for medium-sized ones urban rabies remains a the campaign against rabies. matter of greater concern. Brucellosis, most commonly seen in Three to four million people in the dairy cattle, is a zoonosis that continued to Region were bitten annually by dogs; of this be a significant occupational disease among number only 10% received complete post- livestock workers. In the Southern Cone exposure preventive treatment. From 1986 countries, the prevalence in cattle was to 1989, the average number of human between 0.5% and 10%; in the Andean Sub- rabies cases in the Region was 200 per year. region, between 2% and 4%; in Central This represents a 27% drop compared to the America, between 0.1% and 9%; and in previous quadrennium, a considerable Cuba, the Dominican Republic, Haiti, and achievement given the estimated 20% Mexico, between 0.3% and 4.7%. The preva- increase in the dog population during the lence in the United States was 0.25%. Most same period. Specific mortality rates indi- of the Caribbean countries are free of the cated that the most affected countries were disease, and in those affected the prevalence Bolivia, El Salvador, Guatemala, and Mex- is 0.1% or less. Canada has been free of the ico. During the reporting period no cases of disease since 1985. rabies in humans were recorded in Argen- Bovine tuberculosis is also present in tina, Canada, Chile, Costa Rica, Cuba, Pan- most of the countries in the Region, ama, Uruguay, or the Caribbean countries although its prevalence has decreased to with the exception of the Dominican Repub- between 0.01% and 12%. The low preva- lic and Haiti. A number of countries in Cen- lence rates of less than 2.0% in Canada, Health Programs Development 71

Chile, Colombia, Costa Rica, Cuba, the Acting through the South American Dominican Republic, Honduras, Jamaica, Foot-and-Mouth Disease Control Commis- Panama, Peru, the United States, Uruguay, sion (COSALFA), the countries in the and Venezuela warrant policy decisions to endemic area adopted common policies and eradicate the disease. CEPANZO provided strategies for their national programs. Signif- technical cooperation to improve the pro- icant morbidity reductions were achieved in duction of diagnostic biologicals for bovine affected herds (the rate in 1989 was 5 per tuberculosis and ensure quality control. It 10,000, compared to 280 per 10,000 in the also acts as an international BCG vaccine 1970s), and vaccination coverage reached a reference center. level of 81% of the bovine population. Leptospirosis has become more common The Hemispheric Foot-and-Mouth Dis- in suburban areas, particularly following ease Eradication Committee (COHEFA) was heavy and frequent rains. The Program formed in July 1988 and met for the first time cooperated with Brazil in controlling out- in April 1989. Composed of representatives breaks that occurred during the rainy season of governments and the livestock industry, in 1986 and 1988 (in which the fatality rates the committee has strengthened the disease were 9.4% and 6.7%, respectively) and with control program by joining public and pri- Costa Rica when 264 human cases occurred vate sector efforts. This committee prepared in the wake of Hurricane Joan in 1989. and approved a plan of action that estab- The Program placed special emphasis on lished strategies for each country, according hydatidosis and taeniasis/cysticercosis, para- to existing foot-and-mouth disease ecosys- sitic zoonoses that affect many Member tems. Three subregions were identified: the Countries. The hydatidosis control pro- basin of the Rio de la Plata/Southern Cone, grams in Argentina and Chile succeeded in the Andean Subregion, and Amazonia. The reducing the prevalence of hydatid disease economic situation of participating countries among humans and lowered its frequency in hampered the execution of the plan, how- canines. Priority was given to establishing ever. The Program therefore concentrated PAHO/WHO technical cooperation related on assisting governments in obtaining finan- to taeniasis/cysticercosis in 1988, the year cial support from such sources as the EEC that immunodiagnostic methods required and IDB. for its surveillance and control were devel- CEPANZO and PANAFTOSA trained oped. In 1989, a PAHO/WHO interprogram 1,425 professionals intramurally and extra- group was formed to draw up guidelines for murally in skills related to vaccine produc- conducting taeniasis/cysticercosis control tion and quality control, diagnosis, and surveillance programs. A number of epidemiology, administration of control pro- countries had adopted the guidelines by the grams, and planning and evaluation. The end of the year. training service is valued by the countries, The Program's efforts toward the eradi- since it lends continuity to disease control cation of foot-and-mouth disease, conducted activities and enables eradication program largely through PANAFTOSA, were suc- technologies and methodologies to be cessful. Areas already free of the disease were shared. maintained free, except for a 1987 outbreak in Chile that was brought under control by Laboratory Animal Science that country's veterinary services and PANAFTOSA. Colombia extended its dis- Nonhuman primates are used to develop ease-free area to include part of its north- and test vaccines against human diseases and western region in 1987. PANAFTOSA, to improve knowledge of disease pathogene- meanwhile, developed an oil-adjuvant vac- sis. In recent years, natural populations of cine and transferred this new technology to nonhuman primates have declined dramati- participating countries. cally, due chiefly to the destruction of their ELIMINATION OF URBAN RABIES IN LATIN AMERICA

Although a deadly disease, rabies can be prevented. Since most cases of human rabies traditionally have been caused by bites from rabid dogs in large urban areas and since vaccines exist to immunize dogs, public health programs have succeeded in reducing the incidence of human rabies significantly. The governments of Latin Amer- ica now consider it feasible to eliminate rabies altogether in their large cities and have entered the last phase of a concerted, intersectoral campaign that sets 1992 as the deadline to reach that goal. The decision to eliminate rabies in large urban areas of Latin America called for reorienting many of the control programs that were in effect by broadening their scope and pooling resources with other sectors. The technical and administrative structures of vertical programs were decentralized to increase the coverage achieved by the resources available to rabies control programs. Simultaneously, agreements were made with local governments to strengthen preventive and control activities. As examples, in Brazil, the Centers for the Control of Urban Zoonoses, run by the county governments, were given greater responsibility for control measures; and in El Salvador, the health and agriculture ministries joined efforts and succeeded in lowering the number of cases of human rabies in the capital from 33 in 1984 to 1 in 1989. Elimination of human rabies will depend directly on community participation, since to reduce the risk of bites by rabid canines, dog owners will have to comply with rabies vaccination programs. This has happened in the Dominican Republic, where 5,000 volunteers were mobilized to assist the health sector in carrying out the rabies vaccination campaign. The consolidation of animal health service and university laboratories with those of the health ministries, another effective campaign strategy, has significantly extended surveillance and diagnostic coverage. In Colombia, for example, the Ministry of Health and the Colombian Agriculture Institute coordinated their laboratory services to provide nationwide diagnostic coverage. One of the problems encountered in attaining total elimination of urban rabies is the supply of biologicals, which is complicated by the fact that the Americas are divided into areas that are free of foot-and-mouth disease and those that are not. National laws in countries that have eliminated foot-and-mouth disease prohibit the importation of any vaccine from countries that produce it if they have not also eliminated the disease. This has often made it necessary to import vaccine-at a far greater cost-from European producers instead of neighbors in the Americas. PAHO/WHO provided guidance and served as an intermediary in obtaining financial support for national rabies control programs. Funds were obtained from such sources as AGFUND, the Sovereign Order of Malta, the European Economic Com- munity, and the Mérieux Foundation. In the United States, the Rockefeller Founda- tion, the University of Wisconsin, the Centers for Disease Control, and the Agency for International Development have provided financial backing to Latin American rabies elimination programs. The PAHO/WHO Veterinary Public Health Program geared its technical cooperation to areas in which the countries were not self-sufficient, such as laboratory services.

72 _ __ _:::___ __

It stationed labratory experts in several countries from which it could simultaneously meet subregional needs, and increased its cooperation in areas such as epidemiologic survelllance, planning, and program management. During the 1982-1985 quadrenrium, the average annual number of cases of hurman rabies was 250. During the 1986-1989 quadrennium, a 20% reduction was achieved, with an average of 20 cases of human rabies being reported annually. Rabies in dogsJ, eanwhile, rose from an average of 13,530 cases annually during the first quadrennium to an averageof 15,651 cases yearly during the following quadrennium. This apparently contradictory increase of 15% is largely due to greater surveillance and reporting from rural and marginal urban areas. To meet the 1992 deeadline for the elimination of rabies in large urban areas of Latin Amerca, PAHO/WHOs three main strategies will consist of increasing the scope of dog vaccination campaigns, strengthening epidemiologic surveillance by use of a weekly reporting system for human and dog rabies, and increasing medical services for persons at risk of ontratiing rabies. Peripheral and rural areas will then be targeted for future rabies elimination programs.

73 74 Report of the Director 74 Report of the Director natural habitat as farming and cattle ranch- serve Saguinus labiatus populations in Peru ing have expanded. was approved in 1988. In 1989 USAID The Program collaborated with Member signed an agreement to finance a regional Governments of countries that have natural project to conserve and breed Aotus and populations of monkeys to achieve their con- other primate species important in research servation and rational use. Ways to increase to develop a vaccine against human their reproduction in captivity and in their malaria. natural habitat and to conserve virgin habi- A meeting of the directors of primate tats were objects of Program study. The gov- centers in the United States was held in 1986 ernments of Bolivia, Brazil, Colombia, and at the Primate Center of Peru. Following this Peru established and/or reinforced nonhu- meeting, distinguished primatologists and man primate conservation and management conservationists attended a workshop and units, as well as captive breeding centers. approved the "Declaration on Technical A new agreement was signed in 1986 Cooperation between the Countries of the with the U.S. National Institutes of Health Americas for the Conservation and Use of to support the Peruvian Primatology Project Nonhuman Primates." and expand its population and breeding In addition to its work with nonhuman study of Aotus sp. The Letter of Agreement primates, the Peruvian Primatology Project's between the Government of Peru and work included participation in the PAHO/WHO to conduct this project was Expanded Program on Immunization, train- extended. An agreement between PAHO/ ing of health promoters, construction of pri- WHO and Merck, Sharp & Dohme mary schools, and mobilization of teachers Research Laboratories to rescue and con- for health education. CHAPTER V

ADMINISTRATION

The Office of Administration's objective $US211,312,430 during 1986-1989, of which has been to improve administrative support $US7,882,041 was transferred to the Tax to Headquarters and field offices, emphasiz- Equalization Fund, leaving $US203,430,389 ing greater administrative flexibility and available for program execution. Quota reductions in operating costs. As a result of assessments totaled $US232,799,000 during this effort, administrative processes were this four-year period. decentralized, more authority was delegated Miscellaneous income derived from to the PAHO/WHO Country Rep- the Organization's investments and resentations, and a new field financial man- other sources of revenue increased agement system was installed at ten field from $US10,945,775 in 1982-1985 to offices; this system provides more accurate, $US14,852,823 in 1986-1989. This increase up-to-date information and better financial can be attributed to the continuation of and program control over funds. In addi- sound cash management practices and tion, the use of machine translations, better improved control and short-term investment communication services, and more word- of nonconvertible currency receipts. processing equipment helped cut costs at Expenditures from trust funds totaled Headquarters. $US91,592,716 in 1986-1989 as compared to $US45,969,360 in the previous quadrennium. The Organization was implementing BUDGET AND FINANCE over 400 extrabudgetary projects at the close of 1989. During the 1986-1989 quadrennium, The Revolving Fund for the Expanded the PAHO Regular Budget totaled Program on Immunization (EPI) has assisted $US233,656,000 as compared to in the financing of vaccine procurements $US194,279,000 for the period 1982-1985, for Member Governments since 1977. Dur- an increase of 20.3% in budget availability. ing the 1986-1989 quadrennium, expendi- The WHO Regular Budget allocations for tures from this special fund totaled the Americas totaled $US112,146,837 as $US26,442,436, reflecting a continuing compared to $US96,057,177 for the previous increase in vaccine procurement activities. quadrennium, an increase of 16.7%. The Organization also continued to assist Total income available for all PAHO/ Member Governments in the procurement WHO programs, excluding transfers to of supplies and equipment for health-related the Tax Equalization Fund, amounted activities during 1986-1989, with purchases to $US612,949,365 as compared to under this special program amounting to $US449,963,260 available during the 1982- over $US19,000,000. 1985 quadrennium, an increase of The Caribbean Epidemiology Center $US162,986,105. Collections of Member (CAREC) is financed jointly by PAHO/ Governments' assessed quota contributions WHO and Participating Countries in the toward PAHO's Regular Budget totaled Caribbean subregion. Program expenditures

75 76 Report of the Director 76 Report of the Director by CAREC totaled $US7,686,000 during languages were provided for a total of 1,419 1986-1989, and the Center's financial condi- interpreter-days. Among these were the live tion at the close of the quadrennium was broadcast, with simultaneous interpretation very sound. The Caribbean Food and Nutri- into English, French, Portuguese, and Span- tion Institute (CFNI) also is financed jointly ish, of the two Pan American Telecon- by PAHO/WHO and Participating Coun- ferences on AIDS. tries of the subregion. CFNI's total program The Department emphasized the full expenditures were $US4,822,000 during implementation of the machine translation 1986-1989, and the Institute's financial con- project, which uses the Organization's sys- dition was satisfactory. The Institute of tems for translating Spanish into English Nutrition of Central America and Panama and English into Spanish. An l1-month (INCAP) had total program expenditures of experiment conducted in 1988 showed high $US21,342,000 during the years 1986 rates of productivity and consistently quick through 1989, with expenditures from trust turnaround. fund activities amounting to $US14,774,000. The experiment's results led to a new policy, adopted in February 1989, whereby machine translation became the primary GENERAL SERVICES AND mode of translation at PAHO/WHO. HEADQUARTERS OPERATING Throughout 1989, machine translation EXPENSES accounted for the major share of the Spanish to English and English to Spanish transla- The Department of Conference and tion production. Translations into French General Services provides conference, trans- and Portuguese have not yet been incorpo- lation, interpretation, and building services rated into the machine translation system. at Headquarters. The Department is also the During 1989, 54.5% of translations were into focal point for general operations at Head- English, 40.1% into Spanish, 2.9% into quarters, the PAHO Building Fund, and French, and 2.5% into Portuguese. other special projects. PAHO/WHO has become a world During the quadrennium, the Organiza- leader in the machine translation field. It tion provided services to, or cooperated in was the first public international organiza- the organization of, 1,445 meetings held at tion to use it, and it remains the only UN Headquarters and throughout the Region, agency that uses machine translation in its which required contracting with editors, daily operations. translators, and précis writers for a total of During the quadrennium, major efforts 971 man-days. Special efforts were devoted were made to improve communication ser- to the organization and preparation of docu- vices, including telex, facsimile, telephone, mentation for the meetings of the Pan Amer- and mail services between Headquarters and ican Sanitary Conference, the Directing the field offices. Facsimile technology intro- Council, and the Executive Committee and duced in 1986 was used increasingly through its subcommittees on Planning and Program- the quadrennium. The corresponding ming and on Women, Health, and Devel- decrease in the use of telex reduced transmis- opment. Organization, staffing, and docu- sion costs by 23.5%, even though the num- mentation services were also provided for ber of messages doubled. Despite a 142% the two Inter-American Meetings, at the increase in long-distance telephone calls Ministerial Level, on Animal Health. since 1986, the introduction of a call- To support technical and administrative accounting computer program and a new meetings held at Headquarters and in the policy of accountability in the use of this field during the quadrennium, simultaneous service resulted in lower long-distance interpretation services in the four official expenditures in 1989 than in 1988. These Administration 77 Administration 77 measures also allowed authorized staff to tise and an intimate knowledge of local con- place long-distance calls without operator ditions, including the social and economic assistance. situation, who could complement the inter- PAHO/WHO has taken advantage of national experience of non-national profes- competitive courier services, including those sionals. By the end of 1989, 140 national offered by the U.S. Postal Service, bulk mail- professionals were on duty at four Centers ing of regular correspondence (at up to 44% and sixteen field offices. lower costs), and concentration of its busi- In 1989, as in previous years, short-term ness with one courier company selected consultants and temporary advisers formed through competitive bidding. part of the Organization's core work force. The formal capitalization of the PAHO An analysis indicated that the 2,056 consul- Building Fund made it possible to plan the tants and temporary advisers recruited in long-term maintenance and repair of PAHO- 1989 contributed an equivalent of 60,874 owned buildings. A study of the Headquar- days of work and worked mainly in project ters building, commissioned in 1988, and program planning and, to a much lesser evaluated the present condition and the extent, in data processing, management remaining useful life expectancy of the information systems, and general adminis- mechanical equipment and recommended tration. This pattern generally holds for the criteria for a comprehensive equipment period under review. repair and replacement strategy. In order to comply with the Governing Bodies' directives concerning women, health, and development, efforts were pur- PERSONNEL sued to increase the proportion of and to promote opportunities for women in the At the end of 1989, PAHO/WHO had a Organization, particularly in decision-mak- staff strength of 1,055 (plus 71 temporary ing positions. As part of its monitoring role, employees), which represents a 7% reduction the Department collaborated with the from the end of 1985 when it was 1,134 (plus Women, Health, and Development Program 34 temporary employees). Of the total, more to identify successes and shortcomings in than half were assigned to the field. attaining the goals set forth by the Govern- One of the most significant accomplishing Bodies and, where appropriate, to ments of the personnel management pro- develop specific measures for making gram during the quadrennium was the improvements. Moreover, the Department implementation of Resolution XIX, adopted cooperated with the Office of Information at the XXII Pan American Sanitary Confer- Coordination to gather extensive statistical ence, which addresses the mobilization of data to monitor the status of women in the national resources. Accordingly, the Depart- Secretariat. Female staff members occupied ment of Personnel diversified its functions, 26% of the posts in the professional catego- emphasizing the design of new methods for ries as of December 1989, compared to 23% classifying posts, administering salaries, in 1985. The number of women assigned to recruiting staff, and monitoring and evaluat- grade P.4 and above increased from 38% of ing staff performance. the female professional work force four years The effort to build a national profes- earlier to 45%. sional system also constituted a significant As in previous quadrennia, high priority change in the orientation and priorities of was given to staff development and training. the Organization's human resources man- The PAHO Human Resources System was agement. This effort was undertaken to strengthened in collaboration with the address the need in some duty stations for Office of Information Coordination. By the national professionals with a specific exper- end of the quadrennium, the system, which 78 Report of the Director

is linked to the financial management sys- PAHO/WHO Headquarters, field offices, tem, had been expanded to include data on and projects, as well as to Member Govern- short-term consultants, temporary advisors, ments under the Reimbursable Procurement national professionals, and those hired Program, the Expanded Program on Immu- under local conditions of employment. Fur- nization, and the Essential Drugs Revolving ther development and refinement of the sys- Fund for Central America. Total procure- tem will continue in 1990. ment during the quadrennium amounted to $US121,451,938. Acquisitions for Member Governments included $US27,886,663 for PROCUREMENT EPI and $US19,204,278 for other reimbursable procurements. Purchases for goods and The Procurement Department is respon- services for PAHO/WHO-funded projects sible for the cost-effective purchase and and administrative and logistic support timely delivery of goods and services to totaled $US74,360,997. I

CHAPTER VI

PAHO/WHO TECHNICAL COOPERATION AT SUBREGIONAL AND COUNTRY LEVELS

INTRODUCTION

The PAHO/WHO technical coopera- ing to an analysis carried out by national tion programs at the national level make up authorities of the possible implications for the core of the Organization's proposed pro- the health sector of the collective commit- gram and budget. The fundamental aim of ment to transform health systems by devel- all the other PAHO/WHO technical cooper- oping their infrastructure; the need to ation activities is to support the country pro- respond to priority health needs of the most grams through regional programs, sub- vulnerable population groups; and the man- regional initiatives, and the mobilization of agement of knowledge required to make other resources that advance achievement of headway in these two major areas, in accor- the goals sought. dance with the "Managerial Strategy for the The programming for each country is Optimal Use of PAHO/WHO Resources in based on the identification of national prior- Direct Support of Member Countries." ities for technical cooperation through an The subregional initiatives, meanwhile, ongoing dialogue between the Organization are a key strategy of cooperation among and national authorities. Priorities for the groups of countries toward meeting the quadrennium covered by this report were set jointly identified priority health needs in within the framework of the "Orientation each subregion. and Program Priorities for PAHO during the This chapter provides a brief overview of Quadrennium 1987-1990," a collective man- the main developments in the health sector date adopted by the XXII Pan American of each country between 1986 and 1989, as Sanitary Conference in September 1986. well as activities carried out within the Country programs are designed accord- framework of the subregional initiatives.

79 80 Report of the Director 80 Report of the Director

CARIBBEAN AREA

CARIBBEAN COOPERATION IN HEALTH

In 1986, the Tenth Conference of Minis- projects were designed. The Government of ters Responsible for Health in the Caribbean Trinidad and Tobago, for example, prepared launched the Caribbean Cooperation in a portfolio of national projects addressing Health initiative, a subregional approach for the priority areas designated in the Carib- conducting joint health projects in the bean Cooperation in Health initiative and Caribbean. That same year, the XXII Pan arranged a donor conference in November American Sanitary Conference adopted a 1989 which received substantial support. resolution endorsing the initiative. The ini- To support the initiative, PAHO/WHO tiative rests on the premise that the health and CARICOM developed a range of docu- services can function better and more effi- ments and presentations: printed and audio- ciently when national and subregional inter- visual promotional materials have been ventions target priority areas. prepared and distributed, and a regular The governments initially selected six newsletter reporting on the initiative's priorities-environmental protection includ- progress has been circulated. An evaluation ing vector control, human resource develop- of the Caribbean Cooperation in Health ini- ment, chronic disease control and accident tiative was carried out in 1988 and presented prevention, strengthening health systems, to the Ministers of Health that same year. food and nutrition, and maternal and child The results demonstrated satisfactory health-and subsequently added AIDS as a progress in accomplishing the general objec- seventh priority. tives and showed the funding status for the PAHO/WHO and the CARICOM Sec- various project areas. retariat function as the joint secretariat for As the CARICOM Ministers of Health the initiative, supporting the governments in have indicated repeatedly, securing external the twin strategies of promotion and project financing is only one measure of the initia- preparation. Countries such as Canada, the tive's success, since several of the projects Federal Republic of Germany, France, and originally developed at the national level Italy; agencies including those of the United were supported entirely with national Nations System; and government bilateral resources. However, external support for the aid agencies backed the Caribbean Coopera- initiative has been gratifying. Three years tion in Health initiative. Projects were pre- after its inception, approximately $US32 pared at three levels-the Caribbean million had been committed and several of subregion, the Eastern Caribbean states, and the projects were being executed. The bulk individual national governments. of the funding was for AIDS control, envi- Initially, attention and funding focused ronmental protection, and maternal and on subregional projects, partly because child health. Food and nutrition and donor agencies considered the subregional chronic diseases attracted the least support. approach to be a useful means of supporting Not all of the resources that were mobi- the countries and partly because the Carib- lized were financial. The Caribbean public bean Ministers of Health themselves wished health workers, for example, formed the to promote the initiative as a way to foster Caribbean Public Health Association, and intra-Caribbean collaboration. Toward the there was greater information and staff inter- end of the quadrennium, more national change between the French- and English- PAHO/WHO Technical Cooperation at Subregional and Country Levels 81 speaking Caribbean nations. The latter tate the flow of additional resources to the development led the Government of France Caribbean health sector. to lend considerable technical support, pre- PAHO/WHO, CARICOM, and the dominantly to the Eastern Caribbean coun- Caribbean health sector consider that the tries. A Canadian-Caribbean partnership initiative has succeeded in becoming the also developed, as a collaboration between guiding framework for most of the PAHO/ the University of Toronto and the Univer- WHO technical cooperation projects, and sity of the West Indies and between the has provided a viable mechanism to facilitate Caribbean and Canadian public health asso- interagency and intergovernmental collabo- ciations. PAHO/WHO developed formal ration in health. These gains prove that the cooperation agreements with the Caribbean strategies adopted for carrying forward the Development Bank and the University of initiative can be good vehicles to attract sup- the West Indies. PAHO/WHO and CARI- port for health projects at the national and COM collaborated with the Caribbean subregional levels. Development Bank in assisting the countries The ongoing progress of the initiative to strengthen their capability to develop and will depend on the efficiency with which par- manage projects and in mobilizing Carib- ticipating countries, assisted by PAHO/ bean nongovernmental organizations WHO, CARICOM, and Caribbean insti- involved in health, especially those whose tutions, execute the projects that have been interests are related to the seven priority designed and supported. The ultimate mea- areas. These agreements are designed to sure of its success in the future will be a mobilize internal national support and to quantifiable improvement in the Caribbean promote links with non-Caribbean nongov- health systems and the consequent improve- ernmental organizations, in order to facili- ment of health indicators in priority areas.

ANTIGUA AND BARBUDA

During the 1986-1989 quadrennium, planning, monitoring, and evaluation, and the government's national priorities for tech- mobilizing an intersectoral approach to the nical cooperation in health focused on the delivery of health services. development of the health infrastructure. A large intersectoral workshop on the Emphasis was placed on the development of primary health care approach was held in a national health information system, insti- 1986, and Antigua and Barbuda participated tutionalization of the family services, the in related workshops in other countries of development of a national health plan, the the Caribbean subregion. The Ministry of introduction of a drug supply system, and Health emphasized strengthening the health the identification of health care financing information system at the community level alternatives. The technical cooperation lent to improve the primary care approach. A by PAHO/WHO reflected these national grant from WHO's Essential Drugs Action priorities. It concentrated upon establishing Program was used to upgrade the drug sup- the information base needed for effective ply systems and establish the basis for the 82 Report of the Director country's eventual participation in the East- from CAREC. The plan was fully funded at ern Caribbean network. the donors' meetings organized by PAHO/ In the area of environmental health, the WHO and the Global Program on AIDS. ministry drew up projects for funding under The Pan Caribbean Disaster Prepared- the Caribbean Cooperation in Health initia- ness and Prevention Project that is based in tive, and the Solid Waste Management Antigua served as a primary focal point for Company Limited of Trinidad and Tobago the coordination of relief efforts following assisted the Government of Antigua and Hurricane Hugo, which severely affected the Barbuda in improving the collection and dis- northern Leeward Islands in 1989. posal of solid waste. Basic sanitation in Bar- Antigua and Barbuda participated fully buda was improved with PAHO/WHO and in the formulation and promotion of the UNICEF collaboration. Caribbean Cooperation in Health initiative. The government continued its campaign The country's Minister of Health was a to reduce mortality and morbidity in chil- member of the PAHO/CARICOM team dren, focusing on vaccination and control of that promoted the initiative in Europe. diarrheal diseases. Considerable success was Although not many of the projects funded achieved, particularly through the Ex- are specific to Antigua and Barbuda, the panded Program on Immunization, for country will benefit from the subregional which coverage at the end of the period projects that are now being initiated in such exceeded 90%. areas as maternal and child health and envi- Given the changing age profile of the ronmental health. country, the government formulated pro- A highly successful country-PAHO/ grams to control chronic diseases, in particu- WHO joint evaluation of the Organization's lar diabetes and hypertension. It also revised technical cooperation was conducted in its mental health laws with PAHO/WHO's 1989. This evaluation not only reviewed pre- assistance, and developed a medium-term vious efforts but provided guidelines for plan for the control of AIDS with support future cooperation.

BAHAMAS

The Commonwealth of the Bahamas is In 1986, the Ministry of Health reviewed an archipelago of some 700 islands spread its existing Policy Document and prepared a over 100,000 square miles. Its 248,000 inhab- revised document that specified 16 priority itants reside on 24 of these islands; about areas to guide its program in the short and 75% of the people live in urban settings on medium terms. The revised Policy Docu- two islands and the remainder in scattered ment, which received Cabinet approval in rural communities. In addition to apprecia- 1987, incorporated all areas covered in the ble logistical problems in the delivery of "Orientation and Program Priorities for health care and the provision of physical PAHO during the Quadrennium 1987- facilities, supplies, and manpower, this geo- 1990." In November 1989, the Prime Minis- graphic configuration has also given rise to ter committed the government to "the economic and social pluralism. Thus, aggre- further democratization of the political man- gate data must be interpreted with caution agement of the country" in the 1990s in the determination of indicators. through the establishment of local govern- PAHO/WHO Technical Cooperation at Subregional and Country Levels 83 ment in the Family Islands. This policy 80% by the end of 1989. PAHO/WHO has should imply significant strengthening of actively promoted activities related to local health systems. women in health and development. A concerted effort was made to Environmental health became a high strengthen the organization and systems of national priority. Environmental monitoring the ministry headquarters, to complement and risk assessment were improved through the decentralization of services in hospitals the training of local staff and the use of sig- and health centers and the strengthening of nificant funding obtained from the local pri- local health systems. External consultants vate sector. The problem of solid waste were funded by the IDB to assist in health disposal remained intractable, although systems development-a national priority. international assistance contributed to its With considerable government funding, a mitigation. Vector control-particularly the number of new health centers were built in control of Aedes aegypti-was stepped up in New Providence and the Family Islands and 1988 and 1989. the substantial upgrading of others was In response to a cocaine use epidemic, a started. A new nursing school was commis- large number of educational activities tar- sioned in 1987. geted at vulnerable groups and "gate keeper" The Health Information and Coordinat- organizations were initiated. Prevalence ing Services Unit (HICS), essential for plan- studies were conducted in schools, prisons, ning and decision making, received special and colleges to provide sound information emphasis in the areas of improving data col- for use in formulating national prevention, lection and analysis, computerizing hospital treatment, and rehabilitation policies. Up to information, and updating the cancer regis- 1989, these activities were principally funded try. The quality of primary health care data by UNFDAC. for the Family Islands was improved. The The Bahamas has one of the highest HICS also successfully completed a national incidence rates of AIDS in the Region, about nutrition survey, the preliminary results of 54 per 100,000 population. To study the which are now being analyzed to determine problem and coordinate the health sector's their national food and nutrition policy response, the government set up a multidis- implications. ciplinary National Standing Committee. An The government recognized the need to AIDS Secretariat was established as its oper- examine alternative means of financing ating arm. The AIDS program addressed health services because of the escalating three main areas-public education, surveil- cost of health care, which stands at ap- lance, and laboratory support-and carried proximately 13% to 14% of the annual recur- out a knowledge, attitude, and practice rent national budget. A Working Party study that was nearing completion at the appointed to study this matter submitted a end of 1989. report in late 1987. At the Cabinet's request, The government expanded efforts to its principal recommendations were then train health personnel, assigning a signifi- presented in a form suitable for extensive cant part of the health ministry's budget for public dialogue, which took place in 1989. staff development in a variety of disciplines. In the area of maternal and child health, PAHO/WHO provided assistance mainly by the government maintained its campaign to awarding fellowships and funding nationals' vaccinate children under one year of age and attendance at courses and seminars. formed national Coordinating Committees During the quadrennium the share of for the control of two chief causes of infant the national budget allocated directly to mortality, diarrheal diseases and acute respi- health remained consistently high at about ratory infections. Vaccination coverage for 13.5%. In addition, the government mobi- DPT, polio, and measles vaccines surpassed lized funding from external sources, includ- 84 Report of the Director 84 Report of the Director ing its own private sector. Other sources of fited from a multidisciplinary and intersec- funds included service organizations, for toral approach. The Working Group on mental health facilities; IDB, for infrastruc- National Health Insurance, the Committee ture; UNFDAC, for drug abuse prevention on Trauma Research, the AIDS National and control; and PAHO/WHO, for AIDS Standing Committee, the National Drug prevention and control, health manpower Council, and the coordinating committees planning, solid waste management, and for the National Nutrition Survey and the health information. National Drug Use Survey were all intersec- Many of the activities undertaken bene- toral in composition.

iica A Comparati ve Cnsttutal Scdy (Scientific Pubiication No.: 50,

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Twa tte inngo boo rvid a theoretical franework for it na btioc u iosnternainl -uranRih Las and lnstiutions" discusses contemporary international efforts to promoteth0Xeight to health, while "The Ríght to et a ti th easoaeo scareas a legal right.

tohel bu tlo aie s pr:ovoaie si o h theoretical veru the 0a a i to tor protection really mean in a given societ it applto eryone oron to certain gu? Lsit rely an abstract( prinipI odoaseittoivitsbtneAdif are such ws, d

{iJen the great variety of political, economc, social, and calt differences aoeAicsitsno t ng that hese issues are addressed

:i::i:::i:_i·ii; ·:::i :::·:i::_:i:i:.ii::· :i : :: : ::,: ::,_ ::: :: : : :: :-:: : : PAHO/WHO Technical Cooperation at Subregional and Country Levels 85

BARBADOS

The new administration elected in May health system. Hospital services also were 1986 established the national priorities for extended through the acquisition of the St. the quadrennium. Health was affirmed as a Joseph's Hospital, which was formerly basic human right, the establishment of a administered by the Roman Catholic health planning committee to plan improve- Church. The project, funded by the IDB and ments in the health care delivery system was executed by PAHO/WHO, reviewed all proposed, and all Ministry of Health policies aspects of the hospital's management, and activities were reviewed. The govern- designed systems for bringing about ment decided to postpone the development improvements, and provided training in the of a comprehensive National Health Service utilization of these systems. similar to the United Kingdom's model, opt- In response to the increasing incidence ing instead for an expansion of the polyclin- of AIDS, the government added a vigorous ics system, including plans for the campaign to control the disease to its prior- construction of three additional polyclinics. ity programs. To that end, a detailed strategy The government focused on developing pro- and plan of action were designed, and the grams and services in polyclinics and hospi- public education program served as a model tals to reduce morbidity and mortality from for several Eastern Caribbean countries. chronic noncommunicable diseases. To sup- New initiatives were undertaken in envi- plement this effort, research to study risk ronmental health, including the conduct of behaviors that influence diabetes and hyper- feasibility studies on environmental protec- tension was designed and will be carried out tion measures. New, comprehensive in the early 1990s. environmental legislation was under consid- Polyclinics were reviewed and restruc- eration toward the close of the quadren- tured as necessary; they were provided with nium. The government evaluated its Envi- the adequate quality and number of staff to ronmental Health Services, and, with the deliver preventive and curative health ser- assistance of the U.S. National Institute for vices in a community setting. In line with the Occupational Safety and Health, reviewed national commitment to universal access to the potential hazards from the use of asbes- health services, the Barbados Drug Service tos in certain public buildings. The recom- was reviewed to ensure that high-quality mendations of the review are currently being essential drugs were available either free or at studied. At the end of 1989, the government moderate cost. The Service, which contin- was preparing a project to alleviate the asbes- ued to function as a WHO Collaborating tos problem. Center, set up a Drug Information Center CEPIS assisted the British Geological and automated its information system. Survey and the Government of Barbados in A Health Education Unit was estab- establishing a system for monitoring the lished to promote healthy lifestyles. Some quality of the country's groundwater, which health services for elderly, indigent, handi- is its main water supply source. CEPIS also capped, or mentally ill patients were pro- provided technical advice on submarine out- vided at home rather than in institutions. falls so that the new sewerage systems would A government priority was a project to not contaminate the marine environment increase the efficiency of the Queen Eliza- on which Barbados so heavily depends. beth Hospital by integrating it within the A feasibility study on psychiatric and 86 Report of the Director 86 Report of the Director

geriatric care conducted during 1986 and of health manpower needs was undertaken 1987 pointed to the need for closer links in conjunction with the Queen Elizabeth between these services and the general Hospital Extension Project, and local train- health services. The services of the main geri- ing took place in association with the Barba- atric hospital were modified accordingly, and dos Community College. community mental health services were PAHO/WHO technical cooperation developed. was extended to facilitate technical coopera- In the last two years of the quadren- tion between Barbados and the rest of the nium, the Ministry of Health increasingly Caribbean. Barbados increasingly became focused on human resource development, the main reference center for the Eastern which was regarded as a critical factor in Caribbean, and Barbadian expertise has improving the quality of care and in permit- been made available to the other Caribbean ting an expansion of the services. A review countries.

BERMUDA

During the period 1986-1989, the fellowship was provided to the health pro- national health priorities of Bermuda were motion coordinator to participate in a in the areas of human resource development, "Health City" seminar in Liverpool (United primary health care, surveillance and evalua- Kingdom), and the PAHO/WHO Nursing tion for disease control, environmental qual- Adviser participated in a visit to a Canadian ity, dental health, and vector control. Nursing School and advised on the curricu- Bermuda, along with two other north- lum that would best enhance the training of ern Caribbean British territories (the Turks Bermudan nurses. The limited availability of and Caicos and Cayman Islands), receives human resources in the territory restricted technical cooperation from PAHO/WHO the implementation of other proposed train- through its Jamaica Country Office. PAHO/ ing activities. WHO supported the development of health PAHO/WHO also provided assistance plans and health services delivery by offering in the evaluation of the preventive dental training in workshops and through fellow- health program. ships, by providing short-term consultants External resources were mobilized and staff visits, and by strengthening the through the Caribbean Cooperation in health information systems. CAREC lent Health initiative to support the vector con- technical assistance to improve epidemio- trol program and the maternal and child logic surveillance and analysis. health services. The mobilization of internal Human resource development contin- resources was limited, as it was in the other ued to receive priority, but changes were Northern Caribbean territories, by the small made in specific activities. For example, a number of trained professionals. PAHO/WHO Technical Cooperation at Subregional and Country Levels 87

BRITISH WEST INDIES

Three British Dependent Territories in cation project was successfully concluded, the Eastern Caribbean-Anguilla, the Brit- and in Anguilla, local health programs were ish Virgin Islands, and Montserrat-are con- developed with PAHO/WHO assistance. sidered in this section under the rubric Situational analyses were conducted in British West Indies. The problems character- all the territories and a draft of a National istically encountered in small island States Health Plan was completed for Montserrat. are emphasized by the small size of the popu- However, the gains made in Montserrat were lations in these territories, ranging from jeopardized by the devastation caused by 7,000 to 14,000. Hurricane Hugo. PAHO/WHO technical PAHO/WHO technical cooperation cooperation was instrumental in establishing during the quadrennium focused on helping communications immediately after the hur- the territories to implement the primary ricane and in coordinating international health care approach to delivering services. relief efforts. The ongoing planning for the In recognition of difficulties experienced by reconstruction and rehabilitation of the all the territories in obtaining trained per- health services is being supported by sonnel and the lack of well-developed train- PAHO/WHO. ing institutions, the fellowships program was The environmental health services of all strengthened through the provision of ongo- territories were evaluated by PAHO/WHO, ing technical support to the fellows upon and a Solid Waste Master Plan was devel- their return to duty. Assistance was also pro- oped for Anguilla. Assistance was provided vided in improving information systems. to Montserrat in the management of sani- The maternal and child health services tary landfills. received continued support. The success of Medium-term AIDS prevention plans efforts in this area was shown by decreases in were prepared with CAREC's assistance. infant mortality and the expansion of immu- They were fully funded at a donors' meeting nization coverage to 100%. In the British organized by PAHO, CAREC, and the Virgin Islands, a health and family life edu- WHO Global Program on AIDS.

CAYMAN ISLANDS

The Cayman Islands is one of three Development Plan was a high priority during northern Caribbean British territories (the the quadrennium. The health plan empha- others being Turks and Caicos Islands and sized improving mental health and drug Bermuda) that receive technical cooperation abuse prevention services, and reaffirmed from PAHO/WHO through its Jamaica the policy of developing human resources to Country Office. support the country's well-developed health Development of the National Health infrastructure. Plan as an integral part of the National Within the area of health services deliv- 88 Report of the Director

ery, priorities included child health, with The school dental health education pro- specific concern for the prevention and con- gram was upgraded significantly. A nutrition trol of genetic diseases; oral health, with workshop was implemented with assistance emphasis on prevention; the control of sexu- from PAHO/WHO, including a visit from a ally transmitted diseases; family life educa- CFNI staff member. A workshop was also tion; and hospital maintenance. Increasing held on the management of drug-addicted concern about environmental health condi- patients. tions led to planning and support for more PAHO/WHO acted as- an executing activities in that area, which will become a agency for international projects in the chief focus of technical cooperation in the Northern Caribbean territories. These future. AIDS prevention and control was included the UNDP-funded "Development another program that received special of Health Services" projects in both the Cay- attention. man Islands and the Turks and Caicos PAHO/WHO cooperated in the devel- Islands. External resources were also mobi- opment of the health services infrastructure lized through the Caribbean Cooperation in through providing training, improving the Health initiative in support of vector control health planning capacity, and developing a and maternal and child health services. health information system. Training took The mobilization of internal resources the form of fellowships and the participation was limited in the Northern Caribbean terri- of nationals in local and overseas work- tories, due to a lack of a sufficient number of shops/conferences. PAHO/WHO supported trained professionals. However, Cayman the development of the health plan and the Islands nationals did collaborate in the strengthening of health services delivery implementation of AIDS control program mainly through provision of shart-term con- activities. sultants and PAHO/WHO staff visits. The As in Bermuda, some programmed acquisition of a computer improved the col- training activities were not implemented. lection and consolidation of data for the Registered nurse training was supported by health information system. both the UNDP and government funds.

CUBA

Cuba continued to make marked diseases accounted for 13% of deaths; by improvements in the health status of its 1988 and 1989, they caused 1.5% and 1.3% population. Life expectancy reached 74.2 of deaths, respectively. Poliomyelitis, indig- years in 1988, and infa'nt mortality was enous malaria, diphtheria, and neonatal reduced from 16.5 per 1,000 live births in tetanus have been eradicated. Other com- 1985 to 11.5 per 1,000 in 1988 -and 11.1 in municable diseases have been brought 1989. Simultaneously, the birth rate contin- under control. ued to decline, due to the combined effects While it made significant progress in of improved economic and educational lev- these traditional areas, Cuba witnessed an els, the ready availability of contraceptives, increase in noninfectious diseases. As the and couples' counseling. population lived longer, the morbidity and The trend continued toward the sig- mortality profiles changed. The government nificant reduction in morbidity and mortal- hence gradually shifted its emphasis toward ity due to infectious diseases. In 1962 these developing facilities and retraining man- PAHO/WHO Technical Cooperation at Subregional and Country Levels 89 power to care for chronic illnesses and to with the Council of State, Ministry of Plan- promote their prevention, and toward insti- ning, State Council for External Coopera- tuting rehabilitation programs that facilitate tion, Ministry of Agriculture, Ministry of the full integration of elderly patients into Industry, Academy of Sciences, Ministry of the community. Labor, and Ministry of Education. The Fed- Teams consisting of a family doctor and eration of Cuban Women, the National family nurse have been the main providers of Association of Small Farmers, and the Com- medical care in Cuba. This was especially mittees for the Defense of the Revolution true in rural areas, where most of the public participated in carrying out community- health programs revolved around commu- based health programs. nity interaction with doctor/nurse teams. The public health and epidemiology sub- During the quadrennium, Cuba began to system, which employs the family doctor/ add a public health worker to each of these family nurse/public health worker team, core teams, with the aim that in 10 years the extended the scope of its work to include entire country will have a ratio of one doc- prevention of chronic noncommunicable tor/nurse/public health worker team for diseases. Preventive programs included spe- every 600 inhabitants. cial projects for pre- and postnatal care and One of Cuba's top national health prior- for the well-being of the elderly. Lifestyle ities during the quadrennium was to campaigns were also important, especially improve the quality of its medical care those geared toward preventing smoking, through, among other activities, assessing alcoholism, obesity, and stress. Physical exer- and acquiring new health technologies, cise and team sports were the primary pre- training its manpower, and constructing or ventive behaviors promoted among families, refurbishing facilities. During the 1980s, the workers, and students. number of hospital beds in the city of The epidemiologic surveillance system Havana increased from 17,605 to 23,730, and sanitary inspection services increased with 3,990 of these beds being added during their manpower and budgets to combat the the 1986-1989 period. Pediatric hospital chief communicable diseases and to improve facilities were also extended and modernized sanitary conditions in neighborhoods and at throughout the country by constructing work sites. Local public health and epidemi- and inaugurating 31 pediatric intensive care ology centers and units worked more closely wards, upgrading existing wards and poly- with polyclinics and the family doctor/fam- clinics, and modernizing equipment avail- ily nurse/public health worker team. This able for pediatric care. collaboration allowed the team's work vol- Ultrasound equipment was installed in ume to be reduced, thereby improving the the country's entire hospital network, and quality of its services while reducing their specialized facilities received magnetic reso- costs. nance imaging and hyperbaric oxygen cham- As a complement to the Public Health bers. Cuba also invested in computerized Plan, the ministry drafted a program to axial tomography and extracorporeal litho- develop the pharmaceutical industry. The tripsy equipment as part of its national pro- goal is to raise the industry's technological gram to modernize diagnostic and treatment level and to speed up construction of new techniques. plants to produce antibiotics, blood deriva- Meanwhile, the Ministry of Public tives, vaccines, reagents, and other biologi- Health continued to carry out preventive cals. The country also made advances in health programs that centered on interven- the realm of genetic engineering and ing in risk factors determined by epidemio- biotechnology. logic studies. To carry out its five-year health The medical education subsystem had to plan, the health ministry worked closely be adjusted to the changes noted above in 90 Report of the Director 90 Report of the Director

the health services system. Existing person- factors were used as the primary means of nel took courses to upgrade their expertise, gauging the population's changing needs and and new health workers were trained to staff the resulting adjustments required in the the system. During the first phase of this health services. The curiculum for training human resources development, nurses were medical doctors-with the exception of sur- trained in preventive work at the commu- geons and those involved in basis research- nity level. The primary health care educa- underwent similar changes. tional curriculum focused especially on The ability of the science and technol- deepening nurses' understanding of a com- ogy subsystem to conduct research activities prehensive epidemiologic approach-includ- increased substantially. Ways will be sought ing hygiene and ethical and psychosocial in the future to create a scientific and techni- factors in health care-in addition to giving cal publication and information dissemina- them specific technical training. Epidemio- tion system that will be accessible to health logic surveillance and determination of risk workers through the polyclinics.

DOMINICA

The priority of the Ministry of Health of tal, and the integration of primary and Dominica during the first half of the qua- secondary care. The capital costs entailed drennium was to continue efforts to extend were financed by the Government of France. access to primary health care services to the In the area of environmental health, entire population. The measures started PAHO/WHO executed a UNDP-funded under the 1982-1987 five-year health plan project that studied the feasibility of install- were completed and a new plan was drawn ing sewerage systems in the city of Roseau. up. The focus of the government shifted Technical cooperation was also extended toward an emphasis on improving the qual- toward improving the quality of the water ity of care and, in particular, toward increas- supply and upgrading basic sanitation in ing the operating capacity of the main rural areas. The participation of communi- hospital, the Princess Margaret Hospital, ties in vector control projects was examined and integrating its services more closely with in a project funded by WHO and UNICEF. the primary level of care. Technical cooperation in maternal and PAHO/WHO technical cooperation child health services promoted the achieve- reflected the national priorities. The Organi- ment of the subregional Plan of Action tar- zation conducted a complete situational gets set out within the Caribbean analysis of the health sector and sponsored a Cooperation in Health initiative. Consider- series of retreats at which performance under able progress was made in reducing infant the previous health plan was evaluated. The mortality due to diarrheal diseases through retreats produced guidelines for the prepara- the use of oral rehydration therapy and in tion of the new health plan and for the cor- increasing coverage of the Expanded Pro- responding evaluation of PAHO/WHO gram on Immunization, which reached a technical cooperation in 1988. rate of over 90% by the end of 1989. Technical cooperation was extended in The first case of AIDS was reported in the administrative reform of the Ministry of Dominica in 1986. CAREC assisted in the Health, the installation of automated finan- preparation of a medium-term AIDS plan cial systems in the Princess Margaret Hospi- which was fully funded at a donors' meeting PAHO/WHO Technical Cooperation at Subregional and Country Levels 91 conducted by PAHO and the WHO Global tion services provided by the government Program on AIDS. and to develop nutrition education pro- Among chronic diseases prevalent in the grams for mothers and children, as well as country, diabetes received special attention. the general adult population. The health ministry designed control pro- Technical cooperation between countries grams with PAHO/WHO assistance, and was featured strongly in PAHO/WHO pro- collaborated in their execution with a num- grams in Dominica. The government hosted ber of nongovernmental organizations, most visits from the French Departments, Haiti, notably the Diabetes Association of and neighboring islands for the purpose of Dominica. observing the experiences of Dominica. PAHO/WHO, CFNI, and UNICEF col- A case study on Dominica, being pre- laborated in the implementation of the Joint pared at the close of 1989, will enable infor- Nutrition Support Program in Dominica. mation on its successes to be widely This program aimed to augment the nutri- disseminated.

DOMINICAN REPUBLIC

The sharp decline in gross domestic the periurban area by overcrowding, envi- product (GDP), total public expenditures, ronmental deterioration, and malnutrition. and social expenditures in the Dominican Accelerated urbanization and the introduc- Republic from 1984 to 1985 leveled off at the tion of foreign behavioral mores contributed beginning of the 1986-1989 quadrennium. to problems such as drug addiction, vio- There was a boom in the construction indus- lence, alcoholism, the abuse and mistreat- try in mid-1986 and a real increase in GDP ment of women and children, and traffic for the next two years. In 1988, however, accidents. The progressive aging of the popu- GDP figures were again negative, and despite lation was reflected in an increase in chronic an increase in social expenditures and per diseases. capita outlays for health, many health indi- After the hospital crisis of 1985, the cators did not return to 1984 levels. The cri- medical union, through strikes and long sis in basic services (water, electricity, waste walkouts, succeeded in obtaining sustained management, fuels, and transportation) dra- increases in posts and salaries. Attention to matically affected the quality of life, while other demands-for more complex diagnos- the health sector itself felt the impact of tic and treatment facilities, new equipment, strikes and a shortage of materials. and remodeling of hospitals-caused the The epidemiologic profile reflected the budget to be concentrated on capital goods situation. Maternal and infant mortality and personnel costs. Toward the end of the rates remained high, with perinatal and neo- quadrennium the hospital crisis reintensified natal causes strongly predominant, as well as as poor maintenance, scarcity of essential water-borne communicable diseases (diar- drugs, and increasing indebtedness to pri- rheas, typhoid fever, hepatitis), respiratory vate providers caused a regression in the conditions (acute respiratory infections, quantity and the quality of public sector tuberculosis), vector-borne diseases (dengue, care. malaria), and sexually transmitted diseases At the start of the new governmental (AIDS, syphilis, gonorrhea), aggravated in period in 1986, the Secretariat of State for 92 Report of the Director 92 Report of the Director

Public Health and Social Welfare and graduate curricula of health professionals PAHO/WHO carried out a joint review of and in public health and occupational the Organization's technical cooperation. health master's degree programs. The secre- The secretariat identified the following tariat, IDSS, and ISSFAPOL signed several health sector priorities: administrative reor- agreements among themselves and with the ganization, child survival, rehabilitation of country's universities regarding the develop- the hospital infrastructure, supply of phar- ment of their health personnel. maceuticals, and eradication of poliomyeli- Local-level health activities were sup- tis. The main avenues it requested for ported by means of direct consultation, PAHO/WHO cooperation were the mobili- training, and information through joint zation of external financial resources, human working agreements among the secretariat, resources training, access to scientific and IDSS, grassroots organizations (neighbor- technical information, and direct technical hood, labor, youth, religious, and women's cooperation. groups), nongovernmental organizations One of the ways in which PAHO/WHO concerned with regional development, scien- addressed the Dominican Republic's priori- tific societies, health workers' unions, and ties was to include the country in the Plan the numerous local arms of foreign public for Priority Health Needs in Central Amer- welfare institutions. ica. Admitted as a permanent observer at Noteworthy accomplishments were the the IV Meeting of the Health Sector of Cen- eradication of polio, the elimination of tral America (RESSCA), the Dominican human rabies and reduction in animal Republic reached several cooperation agree- rabies, the introduction of the AIDS Con- ments with the seven Central American trol Program, the successful National Scien- countries and, as a result, was included in tific Meeting on Epidemiology, and progress certain projects undertaken as part of the in the Integrated Epidemiology Develop- Central American initiative. ment Plan. At the sectoral level, the health secretar- Significant advances have been made in iat tried to coordinate activities with the the field of information management, as Dominican Social Security Institute (IDSS), reflected in the Program Budget for the first the Social Security Institute of the Armed time with funding for two projects: one on Forces and National Police (ISSFAPOL), dissemination of scientific and technical and semiprivate public welfare institutes, so information and another on information for as to preclude duplication of efforts. To this the general public. As part of the first end, the secretariat, IDSS, and PAHO/ project, the National Biomedical Informa- WHO signed a cooperation agreement and tion Network was organized. It consists of IDSS took part in RESSCA. Relations were the PAHO/WHO and health secretariat also strengthened between the secretariat documentation centers, university and and water, sewerage, and sanitation agen- teaching hospital libraries, the Dominican cies, especially in the areas of institutional Medical Association, and the Network development, water quality and loss control, Coordinating Center at the Autonomous reduction of vulnerability to natural disas- University of Santo Domingo. Support was ters, solid waste management, and rodent given to the training of specialized personnel control. and to direct access to the MEDLINE and Efforts to better utilize and retain LILACS data bases. national human resources were supported by With PAHO/WHO collaboration, the promoting continuing education and in-ser- secretariat completed an infrastructure vice training, as well as teaching-service inte- extension project with IDB and carried out gration. Priority health problems were activities in the Plan of Action for the Eradi- emphasized in the undergraduate and post- cation of Polio by the end of 1990, supported PAHO/WHO Technical Cooperation at Subregional and Country Levels 93 by IDB, PAHO/WHO, USAID, Rotary medium-term AIDS control program culmi- International, and UNICEF. The secretariat nated with a donors' meeting, and funds also developed a joint program with the were obtained through WHO's Global Pro- Regional Potable Water Committee, IDB, gram on AIDS and the European Economic PAHO/WHO, and GTZ, and began several Community. Family planning activities were projects in the Plan for Priority Health continued with UNFPA funds, and a new Needs in Central America with funds from five-year project was drafted. Spanish Cooperation and UNDP. Its

FRENCH ANTILLES AND FRENCH GUIANA

The Office of the PAHO/WHO Carib- nology, with the exception of the training of bean Program Coordination, based in Bar- nurses, is largely dependent on institutions bados, assumed responsibility for in France. coordinating technical cooperation activities The PAHO/WHO Office identified a with the French Caribbean territories half- number of opportunities for technical coop- way through the quadrennium. The PAHO/ eration. Exchanges were promoted to enable WHO Representative Office in Suriname the French Departments to study the eco- had ably executed this task in previous years. nomic advantages of health services organi- The health care system of the French zation and management in the English- Departments in the Americas is similar to speaking Caribbean countries, which, in that of France. Hospitals and tertiary care turn, reviewed and learned from the state of facilities and health technology and research technology-intensive medicine in the standards are hence comparable to those in French-speaking Caribbean. metropolitan areas of France. It was there- PAHO/WHO also identified other areas fore unclear whether the Departments were in which the French Departments could to be thought of as "donors" or "recipients" benefit and provided access to fellowships, of assistance within the Caribbean. How- research exchanges, seminars, and work- ever, closer examination and the exchange of shops in Canada, Latin America, and the visits with other parts of the Caribbean United States to various health personnel made it clear that they could both provide from Martinique, Guadeloupe, and French and benefit from technical cooperation Guiana. arrangements in the subregion. Guadeloupe collaborated in a CFNI Tertiary care is highly developed and research project, and Martinique and Gua- tends to be very expensive, based as it is on deloupe were designated to be "first medical the model of care in a metropolis. The responders" in the event of disaster in accompanying support systems, such as labo- Dominica and Saint Lucia, respectively. ratory and research facilities, are equally With the inception of the subregional expensive and not necessarily correlated initiative, Caribbean Cooperation in with local needs. The secondary care facili- Health, endeavors to link the English- and ties are less developed, since most care is pro- French-speaking Caribbean were intensified, vided at the primary level in the offices of culminating in the Agreement of Coopera- private physicians or through the public tion that emerged from the meeting held in health promotion and preventive services. Saint Lucia in April 1989. The Agreement Development of health manpower and tech- provides access to tertiary care facilities in 94 Report of the Director 94 Report of the Director the French Antilles to patients in the ipation of the French Departments in subre- English-speaking Caribbean and neighbor- gional institutions, and technical assistance ing countries and makes available technical by English-speaking Caribbean countries assistance for development of secondary care through the sharing of their experience in in neighboring countries. It also established the development of primary health care/ the joint execution of certain projects, such local health systems with the French-speak- as one on cancer of the cervix, greater partic- ing Caribbean.

GRENADA

In the first half of the quadrennium, disposal, and extension of the sewerage sys- PAHO/WHO assisted the government in tem of St. George's. Assistance in pollution coordinating technical cooperation and prevention was also provided in the Grand assistance that was received from many Anse area, the site of the main sewerage sources. A joint country-PAHO/WHO development. review of the Organization's technical coop- The focus of technical cooperation in eration, conducted in 1987, pointed to the maternal and child health programs was to need to strengthen the planning process support the continuing efforts of the govern- throughout the entire health system and to ment to meet the subregional Plan of Action proceed with developing the human targets set out within the Caribbean Coop- resources critical to improving the health eration in Health initiative. Some success services infrastructure. PAHO/WHO tech- was achieved, as evidenced by a decrease in nical cooperation therefore focused on these infant mortality. Vaccination coverage was two areas. A National Health Plan was being extended to over 85% of children under one drafted at the end of 1989 with the full year of age, and hospital admission of infants involvement of all portions of the health due to diarrheal diseases decreased with the sector. increasing use of oral rehydration salts at the During 1988 and 1989, increased atten- primary care level. tion was paid to expanding the operating Grenada was affected by the global pan- capacity and improving the efficiency of the demic of AIDS and received advisory ser- main hospital and other hospital services. A vices to develop and carry out a short-term feasibility study on the construction of a new plan to address the disease's spread. CAREC hospital was carried out by PAHO/WHO in assisted national authorities in the develop- conjunction with a team of consultants from ment of a medium-term plan, which was Canada. Recommendations for improving fully funded and was being implemented by the management systems were made and 1989. incorporated into a project funded by PAHO/WHO also provided technical PAHO/WHO under the Caribbean Cooper- cooperation to the government in formulat- ation in Health initiative. ing programs for the control of diabetes and PAHO/WHO assisted the government hypertension, and assisted in creating a dia- in improving aspects of environmental betic association which became active in health such as vector control, solid waste public education activities. PAHO/WHO Technical Cooperation at Subregional and Country Levels 95

GUYANA

Guyana faced severe economic problems ratory services were supported through staff during most of the quadrennium-serious training, and the system for provision of sup- trade deficits, balance of payment problems, plies and aspects of the health information lack of foreign exchange, high inflation, system were updated. In addition, prelimi- inability to meet production levels in major nary studies were done on existing systems of sectors of the economy, devaluation of the health financing (1987) and on the current national currency, and high levels of emigra- health manpower situation (1989). tion of skilled labor. The health sector con- In response to the country's vulnerabil- fronted serious foreign exchange shortages ity to floods, special training in disaster man- that led to difficulties in replenishing sup- agement was provided locally, and Guyanese plies and equipment, including spare parts. health professionals attended related semi- The loss of skilled manpower added to the nars in the Region. health sector's operational difficulties; how- The maternal and child health program ever, a newly created Agency for Health Sci- emphasized monitoring high-risk pregnan- ences Education and the Environment and cies and reducing infant mortality rates and Food Policies gave new impetus to govern- the incidence of low birth weight in new- ment health programs. borns. The system for prenatal and perinatal Another major government initiative care was assessed and the level of care was the establishment of a medical school at upgraded. Family planning and family life the Faculty of Health Sciences of the Univer- education projects were designed and put ' sity of Guyana, which offers innovative and into operation, and the use of Pap smear community-based teaching as a way to offset testing was surveyed. the brain drain of medical doctors. During A four-year plan of action was devel- 1986-1989, the government also decentral- oped for the Expanded Program on Immuni- ized its health services, organizing their man- zation, and funding was obtained for its agement into 10 regional administrative execution. PAHO/WHO provided vaccines units. and trained national staff on technical and The PAHO/WHO technical coopera- administrative aspects of the immunization tion programs that were given priority in program. The country's cold chain system Guyana during the period were human and transport/communication capabilities resources development, development of for managing the vaccination program health services, maternal and child health, received special attention. Maternal and food and nutrition, control of communica- child health personnel were trained in the ble diseases, and environmental health. The management of acute respiratory infections dental health and adult health programs and diarrheal disease control, and the sys- were also active. tem of collection, dissemination, and utiliza- The Ministry of Health's efforts to tion of data on mothers and children was develop the country's health services infra- upgraded. Drug use among schoolchildren structure involved planning, programming, was investigated. and budgeting strategies to institute a net- Regarding food and nutrition, emphasis work of local health systems. To help create was placed on monitoring the growth and viable local health systems, intersectoral improving the nutritional status of children. cooperation was pursued, government labo- The UNESCO School Feeding Program was 96 Report of the Director 96 Report of the Director

evaluated and health workers received train- tal health legislation. PAHO/WHO helped ing in community nutrition and food admin- train environmental health officers and par- istration. A food and nutrition situation ticipated in the Occupational Health and analysis was performed, which served as the Safety Training Program. A Pesticide Unit basis for initiating a national food and nutri- was established, training was provided in the tion policy and plan; a computerized food epidemiologic surveillance of pesticides in and nutrition surveillance system was health and agriculture, and a survey was ini- started. tiated to monitor this potential health In the area of communicable diseases, hazard. the management of malaria and other vec- The Dental Health Program provided tor-borne diseases, leprosy, tuberculosis, and supplies for the national fluoride mouthrinse HIV infection and other sexually transmit- program and procured plastic sealants and ted diseases were the chief targets for control trained personnel in their use. projects. A surveillance plan and a vector In the area of human resources develop- control project for Aedes albopictus were pre- ment, PAHO/WHO assisted in the training pared. The technical and operating skills of of doctors, nurses, and allied health person- health teams working against malaria and nel at the government's training institutions, other vector-borne diseases, leprosy, and and helped to develop and revise curricula tuberculosis were upgraded. Malaria labora- for that purpose. Efforts were made to tory diagnostic services were developed and improve the management and supervisory education materials on malaria prevention skills of health workers and to establish and prepared. Short- and medium-term plans for evaluate a health manpower policy and plan. AIDS control were drawn up, and the first The Faculty of Health Sciences of the Uni- phase of the short-term plan, along with epi- versity of Guyana was strengthened and demiologic surveillance to monitor the links were established with the University of spread of the disease, was put into effect. Galveston (Texas, U.S.A.). PAHO/WHO provided laboratory support Assistance was given for the develop- for the detection of AIDS cases and trained ment of a center to provide health learning relevant personnel. Public education pro- materials and for the development of tech- grams also were conducted. nology to prepare local materials for health The Ministry of Health's main focus in education and community participation. environmental health was to improve the The use of fellowships remains an important water supply system, including the installa- tool for improving the skills and knowledge tion of new wells in some rural communities, of national personnel; during 1986-1989, 30 the upgrading of the skills of relevant per- overseas fellowships were awarded. In addi- sonnel, the conduct of a pilot project in tion, several workshops/seminars were held which women participated in the provision at the national level to upgrade the technical of potable water, and the implementation of and managerial competence of national a program to fluoridate the overall water health personnel. supply. Training and technical advice in An important aspect of PAHO/WHO's solid waste management also were provided work involved the mobilization of resources by PAHO/WHO. During 1989, a proposal from international agencies. UNDP pro- for technical cooperation in solid waste dis- vided funds for malaria control, veterinary posal was developed with the Government public health, and the Regional Program for of Trinidad and Tobago, and PAHO/WHO the Training of Animal Health Assistants. provided collaboration in the area of envi- Funds were obtained from CIDA for the ronmental impact assessment. malaria program and from the Canadian The government set up an Environmen- Public Health Association, Rotary Interna- tal Council and began to draft environmen- tional, and UNICEF for the Expanded Pro- PAHO/WHO Technical Cooperation at Subregional and Country Levels 97 gram on Immunization. UNICEF provided cal cooperation arrangement among Guy- assistance in nutrition and in improvements ana, Cuba, and PAHO/WHO for the of the water supply system. Technical assis- development of the health services, health tance was obtained from UNFPA in the fam- manpower development, and maternal and ily life education and family life planning child health programs. Through the Carib- projects. bean Cooperation in Health initiative, the The Government of Australia assisted in governments of Italy and the Federal Repub- the community water supplies project. Brazil lic of Germany supported subregional and Venezuela collaborated with Guyana in projects in maternal and child health and in the control of malaria along border areas. environmental health that include develop- Cuba provided personnel through a techni- ment of these services in Guyana.

HAITI

The collapse of the government on more than doubling national coverage of 7 February 1986 resulted in high expecta- children one year of age, as well as substan- tions among the public that democratic tially lowering childhood morbidity due to social institutions would be rapidly installed vaccine-preventable diseases. and the standard of living would improve. The program to control diarrheal dis- However, the subsequent years have seen eases and promote breast-feeding continued continuous political instability, marked by its social marketing strategy, thereby increas- changes of governments and successive mili- ing knowledge of oral rehydration tech- tary coups d'etat. niques and making prepackaged oral National health priorities remained rehydration salts available throughout the unchanged from those described in the 1982 country. By the end of 1989 it was felt that document "Nouvelles Orientations," which the strategy, and the general program, outlined the health policy. In 1986 AIDS was needed to be reevaluated, mainly to ensure added to the list of priority health problems, the active involvement of health sector and a national control program had been institutions. developed by mid-1988. By the end of 1989, The program to improve nutrition was AIDS had become a major public health based on nutritional surveillance through issue with implications for all areas of health maternal and child health clinics and food care, services, and programs. In general, the supplementation for malnourished children. priority health programs are to be carried By 1989 this program was still expanding out through the application of a primary and was attempting to establish intersectoral health care strategy, utilizing decentralized coordination and a more global approach to institutions. nutrition in order to move beyond strictly The government's seven priority health clinical surveillance and treatment. programs and their activities during the qua- The tuberculosis control program strug- drennium are outlined below. gled with low case detection coverage and The Expanded Program on Immuniza- high default rates, which exacerbated the tion adopted the goal of eradicating polio increasing problem of drug resistance. A and received ample financial support from a World Bank project was developed to intro- consortium of agencies. It was successful in duce short-term treatment strategies, using a 98 Report of the Director 98 Report of tbe Director

collaborative approach between the public vices provided. Intersectoral linkages and and nongovernmental sectors. Subunits of community participation remained areas the program also addressed leprosy control that needed strengthening in the struggle and acute respiratory infections. against the priority health problems. The maternal health and family plan- At the beginning of the quadrennium, ning program suffered greatly from the cur- PAHO/WHO's cooperation focused on a tailing of external financial support and the large project for the development of health disintegration of its coordinating institution. services, smaller projects to support malaria By the end of 1989, it was again receiving control and maternal and child health/fam- UNFPA financial support and was also ily planning, and support for the water and assuming a coordinative role with nongov- sanitation sector. As national policies ernmental organizations active in this area. changed, cooperation was restructured along The program to control malaria and three programmatic lines: first, to develop an other vector-borne diseases also had its epidemiologic base for building the national external financial support curtailed, and its capacity to define and analyze priority coordinating institution, which had existed health problems and programs; second, to as a vertical program since the early 1960s, assist national authorities in coordinating was disbanded. The government was with external agencies and the nongovern- attempting to integrate these activities into mental sector toward decentralized adminis- existing health institutions and programs at tration and management of services; and the close of 1989. third, to ensure continuity in the water and AIDS prevention and the control of sex- sanitation sector, for which PAHO/WHO ually transmitted diseases was a program served as catalyst and coordinator of the area that grew rapidly. With PAHO/WHO multiple national and international agencies support, the Ministry of Public Health and involved. Population developed a medium-term plan Each of these projects required its own that was presented to the international training program, consisting of local semi- donor community in April 1989 and nars and fellowships abroad. A highlight of received over $US10 million in pledges. the training activities was the 10-month Unstable external financial support field epidemiology program, through which affected the priority programs and made pro- four regional epidemiologists were trained. A gramming very difficult. The collapse of ver- second round of training for eight additional tical institutions produced a clear mandate epidemiologists was in progress at the end of for priority programs to carry out their 1989. projects through existing health institutions, In resources mobilization, PAHO/WHO without creating parallel channels. In order was instrumental in facilitating the health to diminish duplication and competition ministry's dialogue with the World Bank, among the different programs, the ministry which committed itself to its first health established a national coordinating unit, project in Haiti, scheduled to commence in which combined the seven priority programs early 1990. PAHO/WHO also provided geographically and programmatically for the technical cooperation and coordination with first time. the IDB in the preparation of follow-up stud- A prominent feature of Haiti's health ies that led to a new loan for health services policy, strengthened since mid-1989, has development in support of local health sys- been to coordinate with nongovernmental tems. PAHO/WHO mobilized adequate organizations and to prornote their actions funds from a variety of sources to support to complement the decentralization thrust. the medium-term plan for AIDS control. To Nongovernmental organizations are already support the maternal health and family plan- responsible for a significant share of the ser- ning program, PAHO/WHO obtained PAHO/WHO Technical Cooperation at Subregional and Country Levels 99 financial support from UNFPA and from received PAHO/WHO and UNDP assis- UNDP, the latter for training midwives. tance for carrying out the training needed to PAHO/WHO mobilized funds to aid Haiti's integrate its services into primary health care polio eradication campaign from USAID, projects. PAHO/WHO regional funds made IDB, Rotary International, and CIDA, possible a small pilot initiative in the preven- among others; USAID earmarked a grant in tion of blindness, and another in disaster support of the Expanded Program on Immu- preparedness. nization. The malaria control program

JAMAICA

The national health priorities of Jamaica meanwhile, provided support in the area of during the 1986-1989 quadrennium, as set improving health care financing. out in its policy document of 1984, were to With technical cooperation from reorganize the health care delivery system PAHO/WHO, the ministry completed a for greater cost effectiveness and to identify map of health district boundaries in the alternative financing mechanisms; to reach country and upgraded its health information the national population policy target; and to system, including the epidemiologic surveil- raise the competence of management and lance system that tracks the spread of AIDS. support staff to the high level prevailing PAHO/WHO also supported the AIDS pre- among the technical personnel responsible vention and control program and collabo- for the direct delivery of health services. The rated in the improvement of epidemiology technical programs within the health service services and the prevention and control of delivery system that were assigned priority drug abuse. were maternal and child health (especially The Organization aided the country's improved immunization coverage, neonatal efforts to develop human resources by pro- care, and adolescent health), family plan- viding training in maternal and perinatal ning, nutrition, communicable disease con- care, as well as supplementary training for trol (emphasizing sexually transmitted dental auxiliaries and hygienists. Preventive diseases), curative services, and environmen- oral health activities were furthered by the tal health. development of the salt fluoridation pro- In early 1986 the Ministry of Health program. In the area of environmental protec- posed restructuring several of its manage- tion, advances were made in improving ment systems, including that of the ministry water quality and strengthening environ- itself and those responsible for the adminis- mental health programs through provision tration of the hospital network and the of staff support to the Environmental Con- maintenance of health facilities. In 1988 the trol Division. government initiated a program to rational- In September 1988, the national health ize hospital services, improve ambulatory sector was called upon to respond to the dev- care, and link primary and secondary levels astation caused by Hurricane Gilbert. Its of health care. Several hospitals were reor- role included providing relief services, estab- ganized and reclassified as primary health lishing emergency epidemiologic reporting care facilities. An IDB-funded hospital resto- systems, and instituting special restoration ration project, for which PAHO/WHO was measures for damaged environmental health an executing agency, upgraded a number of and hospital facilities. key facilities. Project HOPE and USAID, The Organization cooperated in the 100 Report of the Director loo Report of the Director

mobilization of national resources, sup- part of the effort to develop local health sys- ported national training institutions, and tems in the country. Under the Caribbean promoted intersectoral collaboration and Cooperation in Health initiative, PAHO/ community participation. It also mobilized WHO promoted interagency participation external support for the immunization pro- in the development of food protection and gram, leprosy and diarrheal diseases control, safety projects. AIDS prevention and control, improvement With PAHO/WHO collaboration, the of the immunology and family planning ser- government improved distribution of techni- vices, and disaster preparedness. The King- cal information and introduced computer dom of the Netherlands funded a project to facilities able to utilize CD-ROM technology train district health management teams as at the University of the West Indies.

NETHERLANDS ANTILLES AND ARUBA

The Netherlands Antilles and Aruba are expanded, and an epidemiologic survey of dependencies of the Kingdom of the Nether- the status of oral health among schoolchil- lands. In 1986, Aruba gained "separate sta- dren was conducted on Aruba. tus" within the Netherlands Antilles and The drug abuse prevention project was appointed its own Minister of Public Health. geared toward providing information at the Starting in 1987, the economy of the King- community level and obtaining community dom of the Netherlands underwent a con- participation. PAHO/WHO collaborated in traction that was reflected in the islands' an epidemiologic study of the use of psycho- policies of cost containment in the health tropic substances on Curaçáo. sector during the 1986-1989 quadrennium. Community participation was also Nonetheless, the delivery of health services mobilized for the maternal and child health, was not adversely affected. PAHO/WHO AIDS prevention, and immunization pro- continued to provide technical cooperation grams. Curaçao became a participant in to the islands in the areas covered below. PAHO/WHO's Revolving Fund for the The health sector placed emphasis on Expanded Program on Immunization, and developing preventive health services; devel- the islands' laboratories received support in oping environmental health programs improving their capability to diagnose sexu- including vector control, the regulation of ally transmitted diseases, including AIDS. pesticide use, and the containment of air, PAHO/WHO technical cooperation soil, and water pollution; and expanding the included promoting collaboration between activities of its veterinary public health pro- the health ministry and the Social Security grams, especially in the areas of controlling Bank and private agencies. The Organiza- the quality of imported food, safeguarding tion also obtained an agreement whereby animal health, and inspecting sanitation in the Government of Venezuela donated labo- slaughterhouses and retail food outlets. ratory reagents and vaccines to the Nether- In the area of reorganizing health ser- lands Antilles. As one of its major functions vices, emphasis was placed on psychiatric in the Netherlands Antilles and Aruba, services and drug abuse prevention, the PAHO/WHO made technical information development of health legislation, expansion available by providing advisory services, dis- of ambulatory and inpatient care, and disas- seminating publications, and sponsoring ter preparedness, with a focus on ambulance workshops, seminars, and fellowships. services. Oral health programs were PAHO/WHO Technical Cooperation at Subregional and Country Levels 101

SAINT KITTS AND NEVIS

The strategy followed in the delivery of was introduced, and the Expanded Program PAHO/WHO technical cooperation in on Immunization supplied vaccines and Saint Kitts and Nevis during the quadren- advisory services on program development. nium was to mobilize resources from all Infant mortality fell, and immunization cov- PAHO/WHO programs that addressed the erage of children under one year of age rose country's needs. to over 90%. CAREC assisted in upgrading the AIDS A joint country-PAHO/WHO evalua- surveillance system and in preparing a tion of the Organization's technical coopera- medium-term AIDS plan, which was fully tion was conducted in 1988, and one of the funded at a donors' conference sponsored by recommendations it produced was to the WHO Global Program on AIDS and strengthen the national health sector plan- PAHO. CFNI, UNICEF, and PAHO/WHO ning process. As a result, a Draft National developed a program aimed at combating Plan was prepared, with PAHO/WHO assis- the persistence of protein-energy malnutri- tance; it will undergo review in a series of tion among some pockets of the population. seminars before being submitted to the Cabi- This project was executed by CFNI. To net for final approval. address problems associated with solid waste Human resources development was disposal, a special grant provided by PAHO/ another focus of PAHO/WHO technical WHO and technical advice obtained from cooperation. Support was given for the the Office of the Caribbean Program Coor- training of family nurse practitioners, and dination were used to improve sanitary land- fellowships were provided that the govern- fills in Basseterre. ment used to upgrade the qualifications of its Assistance was also mobilized in support health personnel, including those working in of ongoing government programs to reduce the area of nursing education. infant mortality. Oral rehydration therapy

SAINT LUCIA

The focus of the Ministry of Health, services with the primary level of care. Saint Housing, Labor, Information, and Broad- Lucia participated fully in Caribbean subre- casting shifted from extending coverage of gional workshops held to promote local primary health care to improving the quality health systems and was a signatory to the of the services provided. This new focus Declaration of Tobago, which reaffirmed stressed the importance of the hospital sys- commitment to the primary health care tem in improving care. The government approach and local health systems undertook the gradual refurbishment of the development. Victoria Hospital, as well as a project An effort to improve the health minis- (funded by PAHO/WHO) to improve man- try's information systems was begun. It agement systems and coordinate hospital included the installation of automated data 102 Report of the Director 102 Report of the Director

processing facilities with collaboration from in eradicating measles. Immunization cover- a French Technical Mission and PAHO/ age of polio vaccine exceeded 85% by the WHO. end of the quadrennium. Another area on which the government A medium-term plan to combat the concentrated was increasing the quantity spread of AIDS, formulated with CAREC and quality of the water supply. With assis- assistance, was fully funded at a donors' tance from CIDA and the World Bank, con- meeting organized by PAHO and the WHO struction began on a new dam on the Global Program on AIDS. Resources were Roseau River. PAHO/WHO technical coop- also provided by CFNI, UNICEF, and eration was extended to prevent the recru- PAHO/WHO for development of a Joint descence of schistosomiasis. PAHO/WHO Nutrition Support Program in Saint Lucia also assisted the government in projects that addresses childhood malnutrition, adult aimed at preventing water-borne typhoid nutritional problems, and diabetes and fever and improving the disposal of solid hypertension. waste. Technical cooperation with the govern- The government obtained PAHO/ ment emphasized human resource develop- WHO cooperation in formulating a popula- ment, including the establishment of a tion policy and establishing a population Health Science Division in the Sir Arthur unit. Through a UNFPA-funded project, Lewis Community College. Support was family life education was vigorously pro- provided to the government in conducting a moted. Technical cooperation in the other course for community nutrition officers, areas related to maternal and child health improving the standards of nursing educa- provided assistance to the government in tion, and providing training opportunities meeting the subregional Plan of Action tar- through the Fellowships Program to those gets set out in the Caribbean Cooperation in nationals who could not obtain training in Health initiative, in eliminating polio, and the country.

SAINT VINCENT AND THE GRENADINES

An evaluation of PAHO/WHO techni- both at the headquarters and in the districts, cal cooperation over the quadrennium was were prepared by the end of 1989. Man- conducted jointly with the Government of power policy will be addressed in the techni- Saint Vincent and the Grenadines in 1989. cal cooperation program of the next This evaluation pointed to the need to more biennium. clearly focus technical cooperation upon the PAHO/WHO's technical cooperation following priority areas: the development of during the quadrennium placed considerable infrastructure, including improvements in emphasis on human resources development, management and information systems; the and a large portion of its funding was used in formulation of realistic and appropriate offering opportunities through the Fellow- health manpower policies; and the strength- ships Program. The highly successful family ening of public education programs to pro- nurse practitioner program that had been mote healthier lifestyles with a view toward based in Saint Vincent was terminated, preventing chronic disease. since it was felt that it had satisfied the need Projects designed to improve the man- for this category of health worker in the par- agement systems of the Ministry of Health, ticipating territories. PAHO/WHO Technical Cooperation at Subregional and Country Levels 103

In maternal and child health, coopera- laborated in the implementation of the Joint tion was extended to the government in Nutrition Support Program, which strength- meeting the Caribbean targets and, in par- ened the government's nutrition services ticular, in expanding immunization coverage and was effective in reducing the prevalence and reducing infant mortality from diarrheal of protein-energy malnutrition. disease. Infant mortality has fallen, and Saint Vincent and the Grenadines was immunization coverage is now in excess of represented at the subregional workshops on 90%. local health systems development and social A medium-term AIDS prevention plan, participation. A project under the Carib- prepared with the assistance of CAREC, was bean Cooperation in Health initiative to funded and is now under way. PAHO/WHO strengthen the District Health Services was also provided assistance toward improving developed and funded. Saint Vincent and the blood transfusion services. In the area of the Grenadines participated fully in the environmental health, technical cooperation development of the initiative and is expected aimed to improve the operation of sanitary to benefit from the subregional projects that landfills and other services related to the dis- are now being initiated in the fields of mater- posal of solid waste. nal and child health and environmental CFNI, UNICEF, and PAHO/WHO col- health.

SURINAME

Suriname's health priorities over the last diseases for control; and mobilizing four years were dictated largely by an econ- resources through project development. omy that was in serious and continuing cri- Despite Suriname's immense difficulties sis. Health service delivery was profoundly during this period, major accomplishments affected by shortages of even the most basic were achieved in the health sector. Perhaps supplies and equipment. most important, the entire health care deliv- Substantial emigration among their col- ery system was maintained. In addition, the leagues forced many health professionals regional health service, which is responsible who remained to fulfill multiple roles and for primary health care in the coastal area of functions, and compelled many others to Suriname, completed its decentralization prematurely enter levels of management for process. A national health plan was devel- which they were not adequately prepared. oped as part of the five-year national devel- Health priorities therefore centered on the opment plan. Major effort went into following activities: preventing further dete- establishing a primary health care informa- rioration of health services caused by the tion system, and an environmental health economic crisis; using existing resources division was also established. Other achieve- more effectively and efficiently by strength- ments included provision of management ening essential infrastructure and by pursu- training at all levels of the health ministry, ing more vigorous intersectoral cooperation; drafting of a national drug formulary, and decentralizing the regional health services; creation of a national AIDS program. The completing and/or strengthening programs government also pursued a vigorous polio that were already under way; improving the eradication campaign as part of the overall skills of existing manpower; establishing a Expanded Program on Immunization. national AIDS program; targeting specific Suriname's political and administrative 104 Report of the Director system strongly promotes intersectoral link- groups, the major challenge of PAHO/ ages at all levels of activity. Therefore, inter- WHO's program of technical cooperation sectoral cooperation was a daily reality in was to prevent the deterioration of services carrying out health programs. For example, and coverage. Other focuses were the mater- the environmental health division of the nal and child health program and its six Ministry of Health maintained daily contact components (Expanded Program on Immu- with the rural Water Supply Service of the nization, control of diarrheal diseases and Ministry of Natural Resources and Energy, acute respiratory infections, nutrition, with the Department of Environment of the school health, perinatology, and day care), Ministry of Education, Culture, and Envi- the establishment of a national AIDS pro- ronment, and with the Ministry of Public gram and reference laboratory, and leprosy Works. control. Because of the economic conditions, The major focus of PAHO/WHO's pro- the country was not able to expand or gram of technical cooperation over the qua- develop special programs for many vulnera- drennium was to strengthen the health ble groups, such as the mentally ill, diabetics, service infrastructure. Specifically, the gov- hypertensives, the blind, and the elderly. ernment sought PAHO/WHO technical The national situation underlined the cooperation in the following areas: decen- primacy of sharing and spreading health tralization of local health systems, including information as widely as possible. Work- upgrading the various subsystems; compre- shops were held to disseminate information hensive studies and analyses of the health on a regular basis, and the PAHO/WHO system, including management, planning Country Office and the Regional Health and programming, and financial evalua- Service arranged for all visiting consultants tions; bed-needs analysis; studies of utiliza- to address national health personnel. A sig- tion and maintenance of health facilities, nificant proportion of the ministry's budget and drug supply profiles; development of epi- went toward distributing technical informa- demiologic surveillance systems for disease tion for the various program managers. control; establishment of a community- Close ties were maintained with the print based primary care health information sys- media and television, and press releases and tem; manpower development and training, clarifications on health matters were issued including nursing and medical education; frequently. design and execution of environmental During the years 1986-1989, PAHO/ health measures in the areas of water supply, WHO sponsored 70 courses, workshops, and sanitation, vector control, and malaria con- seminars on a wide variety of topics. It also trol; and general maintenance of all ongoing supported 826 consultant days, 586 staff programs. days, and 164 fellowship months to train In addressing the needs of vulnerable national health staff.

TRINIDAD AND TOBAGO

Health priorities for the Government of strengthening management capacity, with Trinidad and Tobago in the 1986-1989 special focus on information systems and period included improving the secondary planning; and training health personnel and care infrastructure; identifying alternative improving their deployment. Priority was means of financing the health sector; also given to health education, the role of PAHO/WHO Technical Cooperation at Subregional and Country Levels 105 women in health and development, mater- funding proposal for a national health insur- nal and child health, chronic disease con- ance scheme. The IDB will fund the start-up trol, and environmental health. AIDS phase. emerged as a major priority area. PAHO/WHO awarded 58 fellowships A major policy document issued in that supported 258 person-months of study 1988-the Draft Medium-Term Macro Plan- in health-related fields. Major support was ning Framework, 1989- 1995-designated also given to the development of nursing ser- primary health care as the main strategy to vices, including strengthening senior nursing ensure equity of access to basic services and administration, dental nursing, midwifery provide special attention to vulnerable training, and in-service training for commu- groups. Simultaneously, the government nity nurses. In-country training was found to sought to increase the role of the private sec- be the most cost-effective approach, given tor in health care to reduce its cost to the the high level of expertise available and the State. presence of a campus of the University of the The program of the Ministry of Health West Indies as well as a national institution consisted of three major initiatives: strength- of higher learning (NIHERST). ening the ministry's infrastructure while As an ancillary to training, PAHO/ decentralizing health services; bolstering the WHO collaborated in developing a docu- secondary and tertiary care infrastructure; mentation center and a center newsletter and introducing a national health insurance ("DOCINFO"), which was first issued in scheme that addresses the growing issue of 1989. PAHO/WHO carried out an assess- health care financing. In this last area, a ment of the Health Education Unit of the working group was appointed by the Cabi- Ministry of Health, and also funded a study net and assisted by a task force. on predisposing and lifestyle factors that The Ministry of Health requested influence chronic disease development. PAHO/WHO technical cooperation in the Reflecting the priority given the role development of managerial capacity, second- of women in health and development by ary and tertiary care infrastructure, hospital the national government, PAHO/WHO investment projects, alternative financing increased support in this area, and its efforts methods, training, health education and focused on both the public sector and non- mobilization of resources at the community governmental organizations. A subregional level, the role of women in health and devel- workshop on this subject was held in 1988 in opment, disaster preparedness, essential Port of Spain, and the government carried pharmaceuticals supply management, and out a situation analysis on the health status plant and equipment maintenance. of women in 1989. In the strengthening of secondary and The ministry also undertook national tertiary care infrastructure, PAHO/WHO and local-level disaster preparedness plan- collaboration focused on the commissioning ning with PAHO/WHO cooperation, of the Eric Williams Medical Sciences Com- including mass casualty management in hos- plex, which was to open on a phased basis in pitals. A national disaster plan for health 1990, and support of feasibility studies was developed and included in the overall required for investment programs. IDB plan of the National Emergency Manage- pledged assistance for subsequent phases of ment Agency, but it has yet to be tested and the Complex's development. generalized. To aid in the development of alternative Under the guidance of the PAHO/ methods to finance the health sector, WHO Regional program, support was given PAHO/WHO provided a consultant to to medical technology management. As a work with a Cabinet-appointed working first step, in 1988 a contract was awarded to group to produce policy guidelines and a the national Hospital Management Com- 106 Report of the Director

pany to develop software for medical devices for measles and rubella vaccination were information systems. In 1989, a subregional lower than for the other EPI diseases, but workshop produced guidelines for their use these programs were strengthened to meet in the Caribbean, which led to development the subregional target of measles eradication of a project proposal requesting IDRC fund- by 1995. The program to control diarrheal ing for their application in three countries, diseases received support in program review including Trinidad and Tobago. and supervisory skills training. A research At the 1989 joint country-PAHO/ project on infant mortality and morbidity in WHO review of the Organization's technical Caroni, carried out in 1986-1987, was fol- cooperation, the government identified lowed up by a national infant mortality and property, plant, and equipment management morbidity study funded by PAHO/WHO and maintenance as a priority area, and and UNICEF within the framework of the PAHO/WHO pledged support for an Caribbean Cooperation in Health initiative. exhaustive equipment and medical devices With the assistance of CFNI, support inventory in hospitals and health centers. was offered to the national nutrition services In the area of health programs develop- through community health services, includ- ment for vulnerable groups, PAHO/WHO ing those of nongovernmental organizations; technical cooperation concentrated primar- at institutional dietetic services; through ily on environmental health, maternal and training, both in-service and at training child health, nutrition, AIDS control, institutions; and finally through surveys, chronic diseases control, drug abuse preven- research, and direct provision of expertise tion, and mental health. for policy formulation. The formulation of a In support of the environmental health food and nutrition policy, adopted by the program in Trinidad and Tobago, PAHO/ Cabinet in 1989, received technical input WHO gave assistance for improvement of from CFNI/PAHO. drinking water quality and water supply leak Trinidad and Tobago has one of the detection, eradication of Aedes aegypti, and highest reported numbers of AIDS cases in malaria surveillance. PAHO/WHO also sup- the subregion, with over 500 cases at the end ported the national toxicity testing capabil- of the period, and is experiencing increases ity, the public health engineering training in cases among females and in perinatal program, the development of preliminary transmission. A National AIDS Committee performance indicators for national food administers the program to address the safety programs, chemical safety measures spread of the disease. CAREC supported and the management of toxic and hazardous laboratory services and the screening pro- materials, and the training of health and gram; collaborated in a knowledge, attitude, agriculture personnel in the safe use of and practices study funded by the European pesticides. Economic Community; and assisted in a In the maternal and child health area, public education campaign. assistance to the Expanded Program on Chronic diseases were the most preva- Immunization was the most comprehensive, lent causes of morbidity and mortality comprising program management training, among adults. Prevention of cancer of the planning of targets, supervision, reinforce- cervix, the most frequent cancer in women, ment of cold chain logistics, and assurance of was addressed through preparation of a joint vaccine supply continuity through the project with La Meynard Hospital of Marti- PAHO/WHO-administered revolving fund nique, which will provide training in Pap for vaccine supplies. There was a marked smear reading for cytotechnologists. A decrease in morbidity from vaccine-preven- $US40,000 PAHO/WHO grant was used for table diseases, and poliomyelitis had been a pilot cancer screening project in St. George nearly eradicated by 1989. Coverage levels Central County. PAHO/WHO Technical Cooperation at Subregional and Country Levels 107

TURKS AND CAICOS ISLANDS

The Turks and Caicos Islands are one of the services of a United Nations medical three British territories in the northern volunteer. Caribbean which receive PAHO/WHO Attempts were made to promote inter- technical cooperation through the Organiza- sectoral coordination for pre-health sciences tion's Jamaica Country Office. and nutrition programs. As part of the The government developed and AIDS prevention and control program, approved a National Health Plan. A health national personnel collaborated in monitor- manpower development plan was prepared ing case detection and in carrying out public with the assistance of the Office of PAHO/ education campaigns. WHO Caribbean Program Coordination. PAHO/WHO acted as an executing General and clinical nursing, midwifery, agency for international efforts, including operating room techniques, dental nursing, the UNFPA-funded project, "Strengthening and basic sciences were the greatest training Maternal and Child Health and Family needs; UNDP and PAHO/WHO sponsored Planning," in the Turks and Caicos Islands fellowships in these areas. Training also and the UNDP project, "Development of focused on strengthening management at Health Services." External resources were the local level. mobilized through the Caribbean Coopera- The nutrition program emphasized ane- tion in Health initiative to support vector mia control and received support from the control activities and to further strengthen Caribbean Food and Nutrition Institute maternal and child health services. Mobiliza- (CFNI). PAHO/WHO evaluated programs tion of internal resources has been limited for the control of both sexually transmitted due to the shortage of trained professionals. diseases and leprosy and supported vector Under the Organization's auspices, the control activities and services for the handi- Dental Officer received training in AIDS capped. A UNFPA project contributed to prevention and control, fellowships were strengthen the family planning program, awarded for nursing courses in Barbados and and included a family life workshop con- Jamaica, and considerable technical input ducted by PAHO/WHO. UNDP provided was given to environmental health projects.

CENTRAL AMERICA

PLAN FOR PRIORITY HEALTH NEEDS IN CENTRAL AMERICA

The Pan American Health Organization tries-Belize, Costa Rica, El Salvador, and the Ministers of Health of the Central Guatemala, Honduras, Nicaragua, and Pan- American subregion founded the Plan for ama-to address critical, shared health prob- Priority Health Needs in Central America in lems. In so doing, it was hoped that the 1984. The purpose of the initiative was to consensus concerning health problems and unite the resources of and stimulate coopera- the progress in the health sector would serve tion between the seven neighboring coun- as a catalyst for other cooperative efforts and 108 Report of the Director thereby strengthen attempts to obtain peace Bridge for Peace" conference three years in the war-torn area. later in Madrid. At the 1988 conference, the By 1989 the Central American initia- health ministers of Central America and tive-the first of four such subregional efforts PAHO/WHO technical advisers presented to be launched by PAHO/WHO-had progress reports and proposals for medium- achieved notable progress in marshaling the term health projects to officials from the resources of the participating countries international community. toward addressing a number of common With the collaboration of PAHO/ health problems and, in some cases, had WHO, the Central American countries obtained clear results. The governments of reviewed the status of the priority projects the countries of the Central American Isth- and presented an analysis of progress to the mus-representing widely varied political V Special Meeting of the Health Sector of systems-engaged with resolve in sustained Central America, held in August 1989. cooperation that involved discussing, plan- Coordinating the review of a priority area ning, and executing key preventive health was the responsibility of a given country: projects. Costa Rica, strengthening of health services; Within each country, the health minis- El Salvador, food and nutrition; Guatemala, ters and directors of the social security insti- human resource development; Honduras, tutions pledged greater coordination essential drugs; Nicaragua, tropical disease between sectoral institutions and agreed to control; and Panama, child survival. The increase coverage and provide services for Regional Potable Water Committee high-risk groups. Together, they initiated the (CAPRE) assisted in preparing the water and Special Meeting of the Health Sector of Cen- sanitation report. tral America, held yearly since 1985, which In the area of strengthening health ser- replaces the former meetings held exclusively vices, the review found that important for the Ministers of Health. progress had been made in extending ser- The Central American nations and the vices to groups lacking access, by beginning Pan American Health Organization also to develop local health systems. Although accomplished another chief objective of the services have improved for refugees and dis- health priorities plan: to mobilize financial placed persons, those groups still do not support from outside the Region to make have full coverage. possible critical projects for which national The review found that operational funds were lacking. By the end of the qua- capacity had been improved and resource drennium, more than 25 agencies and orga- use made more efficient by coordination of nizations had lent their technical and projects undertaken by the ministries of financial support to the initiative. Included health and social security systems. Chief among them are the European Economic achievements in this area were joint projects Community (EEC); the governments of Bel- to set up local health systems and to support gium, Denmark, the Federal Republic of epidemiologic, nutritional, child survival, Germany, Finland, France, Italy, Japan, the and essential drugs monitoring networks. Kingdom of the Netherlands, Norway, However, the insufficiency of the infrastruc- Spain, Sweden, Switzerland, and the United ture and the great need to provide coverage States of America; and agencies such as to the population, principally the groups at UNICEF, IDB, the World Bank, OAS, highest risk, were recognized. UNFPA, and UNDP. The national health sectors made head- The Government of Spain, which has way in reforming the procurement and dis- backed the subregional initiative since its tribution of critical supplies in accordance inception and held a conference in 1985 to with the administrative decentralization inaugurate it, sponsored a second "Health, a strategy. The respective ministries prepared PAHO/WHO Technical Cooperation at Subregional and Country Levels 109 lists of long-term critical equipment needs are sponsoring subregional projects that will and drafted procedures for systematic inven- provide Central American governments tory and maintenance of equipment and with technical cooperation toward building spare parts. A special project to support the organizational and human resources to these activities was initiated with funds from respond to needs singled out by the review. the Kingdom of the Netherlands. The projects will aim at establishing national Progress was made in establishing subre- intersectoral committees on drug policies gional norms for delivering primary care ser- and pharmaceutical production; developing vices to women, children, and the elderly. modern pharmaceutical services in hospitals The countries also worked on devising stan- and health centers; improving the physical dard procedures for AIDS surveillance, case infrastructure of pharmacies and storage detection, blood screening, and treatment. facilities in selected sites; strengthening drug Costa Rica and Honduras established bilat- regulation and quality control; producing eral agreements with Nicaragua to control essential drugs in the subregion when possi- the spread of malaria in those countries' bor- ble; ensuring WHO drug manufacturing der areas. standards; and providing up-to-date infor- In order to train the personnel required mation on drugs. for their execution, projects such as tropical In the area of food and nutrition, the disease control, child survival, equipment health sector progress review noted that the maintenance, and essential drugs included a governments must be urged to step up manpower development component. How- actions aimed at increasing the availability ever, the review found gaps and the need for of food for low-income groups, such as allo- further work to achieve the subregional cating greater agricultural production for plan's main objective in that field, namely, to domestic use. Simultaneously, the health sec- train health professionals in all the disci- tors resolved to expand their own programs plines needed to ensure the delivery of com- to monitor nutritional deficiencies due to prehensive primary care services to priority insufficient intake of vitamin A, iodine, population groups. At the end of the qua- iron, and fluoride. The Institute of Nutrition drennium, resources were obtained from the of Central America and Panama (INCAP) Government of Denmark in support of continued to lend its collaboration in these human resources development and activities in the subregion. PASCAP. Malaria is the tropical disease of greatest National essential drugs programs have concern to the Central American countries. constituted an area of continuing concern in Although malaria transmission declined in Central America, one which has repeatedly the first part of the quadrennium, in 1988 it been assigned priority, since large numbers was on the rise again. The disease was diffi- of people continue to lack access to basic cult to control for a number of reasons. drugs. In a meeting in Panama in 1989, rep- Chief among them were the danger to vector resentatives of the health sectors passed a control personnel in some border areas occu- resolution calling for the rapid development pied by contending forces in the period of policies and legislation to remedy the situ- under review, the cross-border displacement ation. They also recognized that the limited of people infected by the disease and of coverage of health services, their deficient healthy people who entered malaria-infested organization, and the lack of trained staff regions, the development of insecticide resis- were underlying conditions that would tance among the anopheline mosquitoes, restrict drug availability even if national pro- and faulty epidemiologic surveillance capa- duction capacity were increased. The gov- bilities. At the end the quadrennium, feasi- ernments of Denmark, Finland, Norway, bility studies were under way for specific Sweden, and the United States of America projects for which the countries had 110 Report of the Director

requested support from the Inter-American in Honduras reported that coverage of pota- Development Bank. ble water and sanitation services increased The governments of Central America between 1984 and 1988, although popula- continued to place special emphasis on tion growth offset some of the gains. The improving the protection of mothers and review of water quality pointed out that children and reducing infant mortality. Key water tends to be treated in urban areas of interventions included expanding immuniza- 100,000 inhabitants or more, and is gener- tion coverage against vaccine-preventable ally not treated in rural areas. An additional diseases and ensuring the practice of oral concern is the unchecked contamination of rehydration therapy for children suffering water by fertilizers, pesticides, and industrial from diarrheal diseases. waste, as well as the unsanitary disposal of During the quadrennium, PAHO/ sewage and solid waste. WHO and UNICEF, with financial support Overall, the Plan for Priority Health from the EEC and the governments of Italy Needs in Central America was considered a and the United States, succeeded in estab- success in demonstrating the vast potential lishing all of the educational centers origi- for subregional cooperation on areas of com- nally planned in this area and in developing mon concern. The concerted work of the the proposed program. In addition, the health authorities of these seven countries Treatment Modules and Pediatric Care demonstrated that health can indeed serve Norms produced during the quadrennium as a "bridge" for peace and subregional were being used in all of the countries development. The health sector's efforts involved. have contributed to advances in other In the area of water and sanitation, the spheres, particularly at the political level, Regional Potable Water Committee leading to greater understanding and soli- (CAPRE) and the PAHO/WHO office staff darity in the area.

BELIZE

During the 1986-1989 period, the Gov- nurses-emigrated to work elsewhere once ernment of Belize, which became indepen- they received their training. dent in 1981, was consolidating the transition Personnel shortages notwithstanding, to public administration by nationals. In the Belize's health indicators remained good. At health sector, this process involved studying the end of the quadrennium, infant mortal- the status of the country's health services' sys- ity was around 20 per 1,000 live births, tem and taking charge of the planning immunization coverage against vaccine-pre- process. The five-year health plan covering ventable childhood diseases reached 80%, 1989-1994 was developed as part of the over- and malnutrition was rare. In large part, the all national development plan. favorable health profile can be attributed to The major problem that concerned the small size of the population (under health authorities and limited the sector's 200,000) and the fact that rapid urbaniza- effectiveness was the continued scarcity of tion, with its attendant burden on services, trained public health professionals and clini- has not taken place. Most of Belize's inhabit- cians to staff projects and treatment units. ants live in rural farming communities. Many of these professionals-especially Malaria, tuberculosis, and sexually transmit- PAHO/WHO Technical Cooperation at Subregional and Country Levels 111

ted diseases were the key health problems The Ministry of Health made headway targeted by treatment and preventive ser- in its efforts to monitor and prevent the vices among low-income groups. Due to a transmission of AIDS; there is no evidence lack of qualified staff at the local level, the so far of indigenous spread. It also planned malaria control program was less successful and obtained funding for the construction of than anticipated. a new hospital in the capital city. Training health manpower was the Min- The government transferred responsibil- istry of Health's priority, and PAHO/WHO ity in the area of environmental health to lent its support by providing the opportunity the Ministry of Natural Resources at the for fellowships abroad and developing and beginning of the quadrennium. As a result, implementing intensive, short-term training projects in that area were coordinated programs in the country. A number of pub- jointly with the health ministry. lic health inspectors received training Belize is the only English-speaking coun- through the fellowships program. try that is a member of the Plan for Priority Epidemiologic research on the most Health Needs in Central America. The urgent health problems and the interven- European Economic Community, CAREC, tions they require was given special attention CFNI, INCAP, PASCAP, UNICEF, by the government. Such research will be a USAID, and other agencies lent technical major focus of activity during the next qua- and financial support to health projects that drennium, once a sufficient cadre of investi- Belize carried out with its neighbors in Cen- gators has been trained. tral America.

COSTA RICA

Costa Rica's stable economic and politi- 3.8 per 1,000 population. Life expectancy at cal climate has permitted the steady evolu- birth in that same year was 74.7 years. tion and institutionalization of health policy Coverage against diseases preventable over the last 40 years. That policy-focused by vaccination reached high levels. Provi- on achieving universal access to health ser- sional data from 1988 indicated that it was vices-has been consistent with the orienta- 86% for oral polio vaccine, 87% for DPT, tion of the country toward social develop- 97% for measles vaccine, and 87% for BCG. ment and economic growth. The incidences of undernutrition, dis- Costa Rica was able to implement eases preventable by vaccination, dehydra- important new strategies effectively during tion from acute diarrheal disease, acute the last quadrennium by building strong ser- respiratory infections, and serious parasi- vices systems for communities and families. toses decreased notably. Its efforts to deploy resources toward priority The low general mortality and the groups and problems produced marked increase in life expectancy resulted in a grad- improvements in key health indicators, a ual aging of the population, with an atten- trend that accelerated in the 1970s and that dant increase in chronic and degenerative continues to the present time. From 1986 to diseases as well as other disorders of old age. 1988, infant mortality declined from 17.76 to The almost complete disappearance of seri- 14.67 per 1,000 live births. In 1988, the ous undernutrition has been accompanied death rate for children aged 1 to 4 years was by problems caused by bad eating habits, 8.48 per 10,000, and general mortality was leading the health authorities now to con- 112 Report of the Director sider preventive nutrition programs a country and to decentralize resources, grant- national priority. ing greater administrative autonomy to the Environmental sanitation is also a topic local services. of concern and it has been given special As a result, consolidation of the SNS attention. Coverage of the population has was set as a medium-term objective, and for reached 93% for potable water and 94.8% that purpose joint programming was pro- for the sanitary disposal of excreta. However, moted at the local and regional levels among problems caused by pollution, solid wastes, the Ministry of Health, the Costa Rican and the assault on the natural environment Social Security Fund (CCSS), and commu- are becoming increasingly frequent, and nities. This process has already been hence environmental health will be afforded extended to the entire country and is accom- very high priority. panied by measures aimed at the technical- Costa Rica established the framework administrative decentralization of both for its health policy during the quadrennium those institutions. in the National Economic and Social Devel- The development of new models of opment Plan for 1986-1990, which treats the health care, such as medical cooperatives improvement of health conditions as an and family medicine, was encouraged in a integral part of overall development. During search for greater efficiency, effectiveness, the Meeting for Analysis of PAHO/WHO and social participation in outpatient care. Cooperation to Costa Rica, the validity of Through joint local programming among this policy, the adherence of the national sector institutions and the community, such programs to it, and the relevance of the models are being articulated and improved Organization's support of those programs over the entire country and, when fully were analyzed. This exercise and the First established, will comprise 56 local health sys- Forum on Health and Development consti- tems. Development of institutions, human tuted important milestones in the consider- resources, social participation, and physical ation and analysis of the evolution of health infrastructure will require external funds for in the country. which negotiations with IDB are under way, The health policy for the 1986-1990 with the support of PAHO/WHO. period was oriented toward guaranteeing Substantial effort has been devoted to access to health services for all individuals, reviewing the information system for deci- without restrictions and with equity. It seeks sion-making in the local health systems, to narrow the social gap and achieve the developing human resources, and using and maximum possible physical and mental well- evaluating technology aimed at resolving pri- being for all inhabitants through reduction ority problems. of infant mortality, eradication of predispos- The Ministry of Health and the CCSS ing risk factors, reduction of avoidable pre- have united their resources to give special mature deaths, and recovery and rehabilita- attention to the least protected cantons, by tion of the ill and disabled. means of programs oriented toward revers- The National Health System (SNS) and ing their current marginalized status. the functions of each of its agencies were In an attempt to identify the risk factors defined with the aim of fulfilling the goals that predispose to priority health problems, noted above. The SNS includes all the with a view toward adopting preventive health programs in the country within a sin- measures, the health ministry collaborated gle political orientation and emphasizes with other sectors whose services have an projects selected in accordance with develop- impact on health. Thus, it joined with other ment goals. Specifically, it strives to increase ministries, universities, specialized agencies, access to services and preventive health pro- and private groups in conducting a compre- grams in the less-developed regions of the hensive review of the potable water supply, PAHO/WHO Technical Cooperation at Subregional and Country Levels 113 sanitary services, pollution control, food diseases has adopted the multisectoral risk protection, occupational health, zoonoses approach as its principal strategy. control, and environmental impact assess- The nutrition of specific population ments of major development projects. groups continues to be a major focus of the The consolidation of local health sys- ministry's activity. With support of INCAP, tems calls for massive and intensive training work related to preventing poor nutrition programs. For that purpose, the University was intensified. of Costa Rica, together with the health sec- In 1989, the disaster preparedness pro- tor and with the collaboration of PASCAP, gram developed significantly. It trained pub- has established a continuing education pro- lic health personnel throughout the country gram that makes use of self-instruction mod- and developed emergency plans for desig- ules. A first step centered on the training of nated hospitals that were evaluated and administrators for local health systems and deemed essential for responding to major training of the Technical Councils, in order disasters. Collaboration with the CCSS, the to guarantee community participation in the National Emergency Commission, the min- preparation and evaluation of local istries of education, government, and foreign programming. affairs, the Red Cross, the School of Journal- The Costa Rican training program in ism, the University of Costa Rica, and the equipment maintenance and energy conser- National University for Distance Education vation attracted students from other coun- was fundamental for the institutionalization tries in the Central American subregion. of that type of national planning. The program for maternal and child Costa Rica participated actively in the health has had high priority. Its activities subregional initiative, the Plan for Priority have centered on normative updating and Health Needs in Central America, the politi- the development of perinatology. The pro- cal and technical objectives of which are gram dealing with adult health and chronic consistent with those of the country.

EL SALVADOR

Because of persistent violence, which participation-were revised. The ministry became acute during the last quarter of 1989, also replaced division and department chiefs El Salvador experienced economic and social at the central level, regional directors, and deterioration that hampered public sector heads of health facilities. programs. Cooperation activities in the Because of the instability, progress in the health sector also were hindered by the designated priority areas of work was only uncertainty preceding and surrounding the partial. Health indicators did not evolve as presidential election of March 1989. The favorably as had been hoped, despite the change in national authorities that occurred health ministry's efforts and substantial for- on 1 June 1989 entailed a fundamental eign support. Nonetheless, malaria morbid- change in health policies and priorities. ity continued to decline, as it has since 1983, The areas on which the Ministry of Pub- as a result of the combined intervention lic Health and Social Welfare had concen- strategy of vector control and chemopro- trated earlier-including local health systems phylaxis. The increase in vaccination cover- development, integrated health programs, age, despite the risks to health personnel intersectoral coordination, and community working in war zones, was also a significant 114 Report of the Director 114 Report of the Director

achievement. Poliomyelitis decreased in inci- dated in 1989, and PAHO/WHO supported dence, and by the end of 1989 no cases their joint programs in such areas as drug caused by the wild poliovirus were detected. purchasing, human resources training, and During the second half of 1989, PAHO/ facilities' maintenance. WHO supported health ministry authorities The project to restructure the delivery of by helping to define the national priorities primary care services, financed by a grant that were issued as "Health Policies, 1990- from the Kingdom of the Netherlands, was 1994." These priorities were based on the implemented and continues to be carried guidelines set out in the National Economic out. The Government of Italy, the Kingdom and Social Development Plan. of the Netherlands, UNDP, ILO, UNHCR, An 18-month senior health administra- UNFPA, USAID, INCAP, and PASCAP all tion course, offered as part of the manage- lent cooperation to social development ment capacity development project, was projects in El Salvador. The Ministry of Pub- concluded in May 1989. Meanwhile, the lic Health and Social Welfare continued its strategy to integrate health sciences educa- efforts to integrate external cooperation in tion with service in related fields was carried the health sector and determined that out through agreements between the health PAHO/WHO should be the coordinating ministry and the University of El Salvador, agency. which collaborated in modifying the stan- Because of the state of emergency in the dard curriculum. country in late 1989, all officials of United Relations between the Ministry of Public Nations system agencies, including those of Health and Social Welfare and the Salva- PAHO/WHO, were evacuated by order of doran Social Security Institute were consoli- the Secretary-General.

GUATEMALA

Guatemala's economy remained rela- changes in national policies, including the tively stable over the quadrennium, but approval of a new constitution in 1985 and growth was slow. A large portion of the peo- the change in government in 1986. ple-including over half of the rural resi- The new government's political plan dents, who constitute the majority of the focused on consolidating democracy in Gua- population-did not earn enough to cover temala by establishing a pluralist system basic food costs. Undernutrition and diar- based on the decentralization of government, rheal, infectious, and parasitic diseases as called for in the new constitution. Attend- ranked among the main causes of morbidity ant legislation created a region-based eco- and mortality. nomic development plan that would The 1987-1988 National Reorganization strengthen local health systems and foster Program provided the framework for Guate- social participation. Health directors were mala's health policy during the quadren- designated for each region and were nium. Based on the goal of equity in access appointed to the regional development coun- to health services, the program expressed the cils. These measures bolstered the health sec- government's commitment to pay its accu- tor's attempt to transform the national health mulated "social debt" by investing in educa- system into a community-based, primary tion, health, and housing. The government's health care service that reaches even the most health program was shaped by a series of underserved rural areas. PAHO/WHO Technical Cooperation at Subregional and Country Levels 115

In shifting from a curative to a preven- grams, including preventive activities, to tive model, the primary goals established by larger groups of the population. The Minis- the Ministry of Public Health and Social try of Education collaborated with the Assistance were to reduce childhood and health ministry in designing and carrying maternal mortality, eradicate the transmis- out community education projects in pre- sion of wild poliovirus, reduce the incidence ventive health. A number of nongovern- of vaccine-preventable diseases, and increase mental organizations active in health care rural access to potable water and essential also carried out joint training activities with pharmaceuticals. the ministry at the local level. Coverage of the Expanded Program on The Ministry of Agriculture signed an Immunization increased notably by 1989, agreement with the Ministry of Health in not long after national vaccination days 1986 establishing collaboration in the area of were introduced as a strategy. Currently, veterinary health. Urban rabies control and coverage has reached 60%. However, as a improvement of meat inspection practices consequence of the low measles vaccination were among their main joint projects. The coverage throughout the decade, an out- rabies control project was supported by a break of measles peaked toward the end of public information campaign spearheaded 1989. PAHO/WHO's cooperation was cru- by the Ministry of Education and the cial in the epidemiologic analysis that led to National University of San Carlos, both of strategies to control the outbreak, and in the which were members of a commission delivery of vaccine within two days of the formed by the agriculture and health minis- government's request. tries. The incidence of rabies started to In general, the period was characterized decline as a result of the joint effort and the by slow and gradual progress as primary care increased availability of vaccines that criteria were applied in formulating, carrying resulted from improved national production out, and evaluating the priority health pro- capacity. The Ministries of Health and Agri- grams. Emphasis was placed on training culture also collaborated on reducing health personnel in primary care methods in another important health hazard in the lieu of the traditional hospital-based country: the improper use and disposal of approach. pesticides. The development of the health infra- All national agencies involved in health structure was based on the constitutional activities were participants in the National mandate to decentralize government admin- AIDS Commission. Although relatively few istrative procedures. The corresponding plan cases have been confirmed in Guatemala to for institutional development reorganized date, the commission's purpose is to address the health ministry and emphasized areas of common interest to all health care strengthening local services. agencies. Chief among these are guarantee- In order to create strong local services, ing the safety of blood bank supplies through the ministry brought community workers provision of adequate laboratory services, and volunteers into health projects, pro- and establishing protocols for the treatment moted preventive health campaigns, and of AIDS patients. forged links with "informal" health workers In the area of public health research and such as midwives, whom it trained in mod- documentation, the government took steps ern, safer birthing practices. to establish a national Institute of Health. Its The ministry signed an agreement with purpose will be to promote and facilitate the Guatemalan Social Security Institute to national capability for health problem analy- cooperate in the primary care strategy. The sis, research, and the formation of high-level institute extended coverage of its health pro- technical resources. 116 Report of the Director 116 Report of the Director

HONDURAS

Honduras' political and economic cli- results, especially in increased efficiency and mate during the quadrennium was marked equity of services. In Villanueva, for exam- by uncertainty stemming in large part from ple, the health ministry, Honduran Social the conflicts in its neighboring countries, Security Institute (IHSS), and local govern- Nicaragua and El Salvador. National ment attained the full functional integration resources in the corresponding border areas of their respective health services for the first were taxed by the influx of displaced persons time in the country's history. The success of and refugees. their efforts led other regions to adopt simi- In 1987, the Ministry of Public Health lar models. and Social Welfare called on all internal and While these reforms were being tested external agencies and organizations support- and instituted, routine preventive health ing the health projects of Honduras to join programs continued. The campaign to forces in helping to define a basic policy and strengthen the Expanded Program on Immu- designing a comprehensive health plan. In a nization and to eradicate wild poliovirus consultation meeting, the agencies-includ- transmission succeeded in obtaining the ing PAHO/WHO, UNICEF, USAID, highest vaccination coverage in the coun- UNDP, the Government of Spain, and try's history. In addition to PAHO/WHO Project HOPE-cooperated with the country support, the ministry's campaign was backed in identifying its main health problems and by USAID, UNICEF, Rotary International, ranking them according to their frequency and the IDB. of occurrence in each of the eight health Record vaccination coverage rates were regions. The government then outlined also achieved in the campaign against urban strategies for tackling the priority problems rabies, a project that was directed by PAHO (maternal and child health risks, inadequate and received funding and material support immunization coverage, diarrheal diseases, from the European Economic Community acute respiratory infections, tuberculosis, and the French agencies BIOFORCE and vector-borne diseases, malnutrition, sexually the Mérieux Foundation. transmitted diseases, rabies, epilepsy, alco- Excellent results were also obtained in holism, and drug addiction) at the national, the effort to create a core of health profes- regional, and local levels. sionals trained in management who in turn The government decided that the trained local health workers in the methods National Health Plan should be revised to and technical requirements for reforming gear services toward the groups at highest the delivery of services. With strong backing health risk: the rural and urban poor who from PAHO/WHO, many of the staff of the have limited access to health care. To that health ministry and the IHSS were trained end, the Ministry of Public Health and in this fashion. Social Welfare focused on upgrading its oper- The AIDS control project focused on ations and management systems and rehabil- training medical and health personnel in itating critical facilities in the national case recognition and management, and in network according to the priority needs setting up laboratory facilities and training detected in each catchment area. their staff in diagnostic techniques and In four of the eight regions, the new blood screening processes. The ministry also comprehensive approach produced marked designed a medium-term AIDS prevention PAHO/WHO Technical Cooperation at Subregional and Country Levels 117 plan that has been submitted for consider- tem to ensure a regular supply of key drugs ation to and has gained support from fund- in underserved areas. In support of the ing agencies. health ministry's efforts to boost national The Institute of Nutrition of Central pharmaceutical production capacity, the America and Panama (INCAP) lent its tech- Central American Economic Integration nical assistance to a national survey to deter- Bank (BCIE) engaged in formulating mecha- mine the incidence of malnutrition and to nisms for the joint purchase of necessary raw evaluate the effectiveness of the food assis- materials. tance program. The ministry then took mea- During 1988 a joint PAHO/WHO- sures to improve the program's impact on country evaluation of the Organization's the nutritional status of mothers and chil- technical cooperation was conducted with dren. The drive to improve the overall the extensive participation of experts from health conditions of women received sup- all health sector agencies (Ministry of Public port from the National Planning Secretariat Health and Social Welfare, IHSS, National and the Economic and Social Office, which Autonomous Water and Sewerage Service, approved a National Policy for Women Faculty of Medical Sciences, and profes- intended to increase their well-being and sional associations). The pertinence, effi- participation in the economy. ciency, and impact of PAHO/WHO Honduras continued to experience cooperation to the country were analyzed. chronic shortages of essential pharmaceuti- The review served to adjust programming for cals due to their high import costs. The gov- the 1990-1991 biennium, chiefly along the ernment took steps to revive the idle lines of increasing cooperation activities capacity of its national production facilities, aimed at managerial reform throughout the and reorganized its existing distribution sys- national health network.

NICARAGUA

Nicaragua's economy deteriorated mark- cities, creating a need to reallocate State edly between 1986 and 1989. Its productive resources. Scarce funds were also depleted by capacity was diminished by the decade-long natural disasters, as the country tried to state of war, and goods and services-both recover from droughts, floods, and Hurri- those produced domestically and those cane Joan, which struck Nicaragua in 1988 obtained from abroad-were curtailed. and affected 2.8 million people. At the end of the quadrennium, real The Government of Nicaragua made per-capita consumption was 21% lower than major efforts to improve the well-being of its in 1980. In 1988, the gross domestic product people despite these conditions. Social assis- fell by 8.0% and the balance of payments tance programs increased their coverage dur- showed a $US353.9 million deficit. Reper- ing the last four years, and morbidity and cussions of the war economy were felt in the mortality indicators stabilized even though social sector, as budgets had to be cut despite economic indicators deteriorated. worsening living conditions. National health priorities were estab- Migration related to the armed conflict lished by analyzing the general structure of was extensive; rural migrants fleeing war morbidity and mortality and the national zones settled in new slums around the main health system's capacity to deal efficiently 118 Report of the Director with the main problems that were identified. programming method for local health sys- These are as follows: childhood morbidity tems and political and administrative decen- and mortality; injuries caused by firearms, tralization. It is hoped that this technique and deaths from other violent causes and will enable the political, social, and military accidents; morbidity and mortality affecting situation of each municipal catchment area combatants and workers; communicable dis- to be taken into account in health planning. eases, including potentially epidemic ones In addition, since hospitals have a piv- such as malaria; and noncommunicable dis- otal role in local health systems in Nicara- eases. The chief specific causes of childhood gua, the improvement of facilities and morbidity and mortality were diarrheal dis- supplies was given special attention. eases, neonatal complications, acute respira- One of the country's principal initiatives tory illnesses, septicemia and meningitis, during the quadrennium was the National malnutrition, and vaccine-preventable Campaign to Protect Children's Lives, diseases. which focused on reducing mortality and the Injuries from war and other violent main causes of illness in children one to five causes resulted in a substantial increase in years old. The campaign was headed by the the number of handicapped persons. The Ministry of Health and pooled resources National Health System did not have the from all sectors in the country. means to reduce the number of deaths and PAHO/WHO focused its technical incapacities caused by war injuries, but it cooperation on several key areas, including placed emphasis on rehabilitation and the the development of health infrastructure to production of prosthetics for handicapped improve institutional response capacity and survivors. the design of a legal framework for the new The communicable diseases of greatest system's implementation. Within that basic concern are malaria, parasitoses, and tuber- framework, special attention was given to culosis. Their increase was favored by the improving financial analysis capabilities and progressive deterioration in sanitation and to reforming health financing methods. in the overall standard of living; rapid migra- In addition, PAHO/WHO cooperated tion and unsanitary, overcrowded new set- in improving engineering and maintenance, tlements were intractable risk factors for training personnel, and developing adminis- their transmission. Furthermore, the hazards trative methodologies and instruments. As encountered by workers in war-torn areas part of the Regional Emergency Prepared- meant that some critical vector control pro- ness and Disaster Relief Coordination Pro- grams were interrupted. gram, PAHO/WHO supported national All of these factors created precarious projects that organized emergency services conditions that could also promote increases and personnel training and that promoted in dengue and sexually transmitted diseases. intersectoral coordination for emergencies. The Ministry of Health issued a warning In the area of pharmaceuticals, PAHO/ that these diseases may reach epidemic WHO cooperated toward improving the proportions. supply system, training distribution person- One of the principal initiatives under- nel (especially at the local level), and increas- taken by the Ministry of Health was the ing quality control. Progress was made in design and implementation of a new model instituting a standardized national drug pol- of health services organization. The model is icy, which included efforts to revitalize the based on the development and strengthen- pharmaceutical industry. To this end, meth- ing of local health systems, as part of the ods were sought to coordinate State and pri- Master Plan for Developing the Unified vate production capabilities. National Health System. In this endeavor, In the area of priority health needs, "Situational Planning" is being tested as a projects were carried out regarding food and PAHO/WHO Technical Cooperation at Subregional and Country Levels 119 nutrition; water supply and environmental (SIDA) collaborated with PAHO/WHO on sanitation services; human growth, develop- many of these projects. ment, and reproduction; prevention and The health ministry and PAHO/WHO control of communicable diseases; tropical cooperated in developing a model for a disease research; malaria; rehabilitation of nationwide scientific and technical informa- the handicapped; ophthalmology; and tion system. Special support was given to zoonoses. UNICEF, UNFPA, UNDP, the health research and to a five-year human World Food Program (WFP), the Norwegian resources plan. The latter seeks to redefine Agency for International Development key health personnel functions, improve (NORAD), the Finnish International Devel- training programs, and reshape continuing opment Agency (FINNIDA), and the Swed- education projects to lend support to the ish International Development Authority local health systems.

PANAMA

Panama, which had a population of at about 20 per 1,000 live births, and life 1,831,400 and an annual growth rate of expectancy at birth was between 70 and 72 1.9% in 1980, was estimated to have years. The chief causes of death in children 2,300,000 people in 1989. The population is under 15 years of age continued to be acute young-45% of the people are under 20 years respiratory infections and causes associated old-and is approximately 48% rural and with malnutrition, especially in deprived 52% urban. Population density is variable, areas. The main causes of general mortality with people highly concentrated in metro- were those related to old age and urban liv- politan areas and dispersed in rural areas. It ing conditions. Drinking water services is estimated that around 20% of the popula- improved, reaching 95% urban and tion is critically poor; most of the poor live 80% rural coverage by the end of the in isolated rural communities and on the quadrennium. periphery of large cities. In 1986 health authorities placed prior- After a brief economic recovery, the ity on the development of service infrastruc- gross domestic product declined by 15% in ture and management capacity and on mid-1987 compared to 1986, and in 1988 interventions to control the diseases affect- and 1989 it decreased an estimated 17% each ing vulnerable, socioeconomically deprived year. Overt unemployment remained at groups. To these ends, a Strategic Develop- between 17% and 21% during the entire ment Plan for health services was conceived, quadrennium, and consumption of goods to commence in 1986 and end in 1990. Its and services declined, as did public and pri- concrete goals were to extend health ser- vate capital investment. The worsening eco- vices, drinking water, and basic sanitation nomic situation was felt by health sector coverage to 90% of the population. It also institutions as shortages occurred in phar- aimed to improve efficiency, reduce costs, maceuticals, supplies, and equipment. and achieve a balanced distribution of During the 1986-1989 period, the popu- resources. lation's health conditions were good, The strategic plan comprised seven pro- although no major improvements were grams: (1) the strengthening of health ser- observed. Infant mortality remained stable vices, with projects to mobilize external 120 Report of the Director

resources for the development of manage- Despite the above-mentioned con- ment capacity in the sector, to involve other straints, PAHO/WHO provided technical sectors of the economy in health activities, cooperation in the strategic plan to develop and to extend and modernize infrastructure; services, including the selection of program (2) the pharmaceuticals program, aimed at priorities. The Ministry of Health especially modernizing existing quality assurance, asked for PAHO/WHO cooperation in the inventory and control, supply, and logistics area of pharmaceuticals, human resources, systems; (3) the human resources program, and equipment maintenance. The Organiza- which included designing new care models, tion helped analyze and reestablish the modernizing the work force, and redefining national pharmaceuticals system and lent manpower requirements; (4) the nutrition assistance in improving its administrative program, aimed at improving general nutri- and technical management. Through the tional status, but emphasizing those at high Essential Drugs Revolving Fund for Central risk; (5) the epidemiology program, focusing America and Panama, $US500,000 was on the control of vaccine-preventable dis- spent to acquire pharmaceuticals for eases, malaria, dengue, yellow fever, sexually national institutions. transmitted diseases (including AIDS), and With IDB support, PAHO/WHO other health problems; (6) the childhood assisted in developing the National Mainte- survival program, with components that nance System. Starting in September 1988, included improved access to services in the the system received backing from the Subre- most deprived districts, prevention and gional Maintenance Project financed by the treatment of acute respiratory infections, Kingdom of the Netherlands. The project oral rehydration, perinatal care, promotion supported manpower training programs, the of breast-feeding, and pre- and postnatal acquisition of tools, and the purchase of crit- care; and (7) the potable water program, ical spare parts. which emphasized a project to build 400 PAHO/WHO also cooperated in the aqueducts and improve 300 existing development of special programs for vulnera- systems. ble groups living in rural and peripheral A study of the services' network was urban areas. These groups lack access to san- completed in 1986 and the strategic plan to itary services and have high morbidity and mobilize external resources was begun the mortality rates from poverty-related causes. following year. It sought to obtain funds to Major protein-energy malnutrition, anemia, extend, rehabilitate, and modernize the and infectious diseases are endemic among entire network, and included projects to them. As a result, maternal and child health construct water mains and latrines in rural and immunization projects, the promotion areas and to build and remodel a number of of better nutrition, and studies to determine hospitals and health centers. social factors influencing health were pri- The strategy of emphasizing prevention mary interventions. Health workers and activities, particularly with respect to high- community groups in these areas were tar- risk groups, was maintained throughout the geted for health education projects. quadrennium, as was the policy of promot- In addition to its routine projects, the ing community participation in health infectious disease control program launched projects. However, the extent to which pro- an intensive drive to reduce the population grams were carried out was affected by of Aedes aegypti, the dengue-carrying mos- repeated changes in leadership and staffing quito that reinfested Panama City. of the Ministry of Health. A number of The University of Panama revised the projects, including the Expanded Program nutrition curriculum for student physicians, on Immunization, could not be evaluated as nurses, and teachers, and the Technologic a result. University of Panama introduced training in PAHO/WHO Technical Cooperation at Subregional and Country Levels 121 disaster response administration in the engi- nel administration, and management of the neering curriculum. In-service health minis- critical inputs supply system, including phar- try personnel were trained to manage the maceuticals, biologicals, and spare parts. All Expenses, Production, and Costs System, of these manpower training activities were which was created as a management infor- carried out with PAHO/WHO technical mation tool to assess cost components, cooperation. The UNDP was a primary fun- trends, and determinants. In support of the der of the pilot programs to train health per- development of local health systems, sonnel in management and local program- national technicians took courses in infor- ming techniques. mation systems, local programming, person-

SOUTH AMERICA

ANDEAN COOPERATION IN HEALTH

The beginning of the Andean Coopera- Health of the subregion stipulated that tion in Health initiative coincides with the PAHO/WHO and the Secretariat of the start of the 1986-1989 quadrennium. Hipólito Unanue Agreement (their Secretar- Encouraged by the experiences of the Cen- iat) should work closely together to promote tral American and Caribbean initiatives, and implement the initiative. As a result, the which demonstrated the merits of a subre- actions of both entities were closely coordi- gional approach in dealing with selected nated and joint programs of work were common problems, the Ministers of Health developed in the last two years. of Bolivia, Colombia, Ecuador, Peru, and Groups of national experts, with Venezuela embarked on the Andean Coop- PAHO/WHO and Hipólito Unanue Agree- eration in Health effort in 1986. ment support, met on several occasions to The five areas originally selected for con- detail areas of cooperation. Focal points for certed action were the development of each priority area were established in each health services systems, maternal and child country to promote and coordinate the health, malaria and other vector-borne dis- efforts in their respective areas of expertise, eases, drug dependency, and essential drugs and the Director General of Health of each and biologicals. In 1987, the Ministers added country was designated as the coordinator of disaster preparedness as the sixth priority the initiative. area for joint action. Within the subregion, the Director of The basic approach has been to identify PASB assigned specialized staff to work key activities for each of the six priority areas almost exclusively on malaria and vector- that are of interest to two or more countries borne diseases, essential drugs, maternal and and that would have a significant impact, be child health, and disaster preparedness. As a within the capabilities of the governments to result, several subregional and national carry out, lead to short- and medium-term project proposals were drafted and submit- positive results, and strengthen national ted to potential donors. A number of them capacity in the chosen field of action. have already been approved and others are In their approval of the Andean Cooper- being reviewed. ation in Health initiative, the Ministers of At the international level, the existence 122 Report of the Director 122 Report of the Director of the Andean Cooperation in Health the Amazon Cooperation Treaty, which has initiative was made known through the established its own Health Secretariat and publication of a basic document that was dis- addresses the same countries and priority tributed to more than 60 governments, areas, but does so through thee Ministries of international organizations, and institutions Foreign Affairs rather than the Ministries of that might support its efforts. In several cases Health. this initial step was followed by visits and While the Andean Cooperation in discussions with representatives of these Health initiative is not yet in full operation, entities. The document was also presented to positive results are already being noted. This WHO in Geneva, to the Andean Parlia- is most evident in the area of maternal and ment, and to the Cartagena Accord for their child health, in which each government has formal endorsement. A video on the initia- prepared a national plan of action along sim- tive also was prepared and distributed. In ilar lines. The same approach has been used some of the priority areas, PAHO/WHO is to define the problems involved in mainte- working closely with other institutions, such nance of infrastructure and equipment, and as UNICEF and UNDP. In addition, there is a detailed analysis of needs, by country and now a need for very close coordination with by institution, has resulted.

BOLIVIA

Health conditions in Bolivia are among people in their jurisdiction receive compre- the most precarious in the hemisphere. Pub- hensive services rather than isolated, vertical lic health problems are caused predomi- programs. nantly by poverty, inadequate housing, and This community-based, comprehensive lack of basic services in a geographic area approach is in full consonance with PAHO/ with many serious endemic diseases. WHO's own principle of building a network Although inflation was brought down of local health systems that serve as the basic from almost 300% in 1986 to around 16% at functional units of the national health struc- the end of the quadrennium, unemployment ture. PAHO/WHO's technical cooperation was still over 20% and resources for the pub- was hence delivered with an emphasis on lic sector were sorely lacking. Economic supporting and strengthening the local hardship notwithstanding, the stable politi- units. cal climate made it possible to carry out The Ministry of Social Welfare and Pub- health programs without interruption and to lic Health set out its priorities for the qua- obtain external financing for several priority drennium in the 1985-1989 Global Health projects. Plan. The plan was established to address One of the key reasons that health pro- the needs of particularly vulnerable groups grams were carried out successfully was col- and to tackle tropical diseases, which are still laboration between the national Ministry of a major cause of morbidity and mortality. Social Welfare and Public Health and the The most important groups targeted for People's Health Committees. Organized at special projects are women of childbearing the local level throughout the country and age, children, and periurban and rural popu- made up of community leaders, the commit- lations that traditionally have lacked access tees determine needs, implement programs, to the health care delivery system. negotiate resource requirements with the Malnutrition, endemic goiter, vaccine- central government, and ensure that the preventable childhood diseases, gastrointes- PAHO/WHO Technical Cooperation at Subregional and Country Levels 123 tinal illnesses, yellow fever, malaria, dengue, which were reported in 1987. Studies also and Chagas' disease are the most stubborn showed a troublesome rise in drug-resistant health problems that affect large numbers of strains of Plasmodium falciparum. Simultane- the population, whose 51-year life expect- ously, Chagas' disease is widespread through- ancy is the lowest in the Americas. Environ- out the country, and yellow fever and mental health-especially the extension of dengue outbreaks occurred over the last two access to potable water supplies and sewerage years. The dengue epidemic-affecting over and sanitation services-was a priority in 200,000 people-was quickly arrested with rural areas, in which 52% of the country's an intensive mosquito control campaign population lives. that lowered the household index to 6.5%. PAHO/WHO collaborated with the However, given the constant surveillance Bolivian health ministry in designing the and difficult control measures required to national health policy and in carrying out prevent a new outbreak, authorities are con- the specific projects called for in the 1987- cerned about not being able to guarantee the 1989 three-year plan. The plan was based on availability of material and personnel for the twofold strategy of training physicians such an undertaking. and other health workers to join local Peo- Access to potable water increased mark- ple's Health Committees and obtaining the edly in cities over the last decade, and also educational materials and primary health was extended in the countryside. Extension equipment necessary for them to deliver pri- of coverage of sewerage and sanitation ser- mary health care services. vices was less dramatic, but also showed The recently elected President of the improvement. Given the critical nature of Republic launched a plan for childhood sur- these services, a number of agencies, includ- vival and growth and maternal health. ing IDB, World Bank, CARE and other PAHO/WHO is the Secretariat for the nongovernmental organizations, USAID, plan's executing committee. Given that the the International Bank for Reconstruction main illnesses involved in infant mortality- and Development, the German Develop- which is over 169 per 1,000 live births by ment Bank (KfW), and the Agency for Tech- conservative estimates-are respiratory and nical Cooperation of the Federal Republic of diarrheal diseases, the plan stressed their Germany (GTZ), collaborated on projects to emergency treatment. To this end, antibiot- extend their coverage. These services, whose ics and oral rehydration salts were distrib- lack is at the root of many health problems, uted widely, at no cost to the recipients, and will receive the ministry's priority attention nutritional monitoring systems and supple- and PAHO/WHO's intensive technical mentary feeding programs were strength- cooperation in the future. ened throughout the country. With limited capital and manpower The national health strategy also singled available, the health ministry focused on car- out a nutrition-related disease-endemic goi- rying out its projects by eliciting the support ter-which affects up to 65% of the popula- and collaboration of other national sectors tion. The ministry's control measures and updating the training of its own person- included facilitating the marketing and dis- nel. It sought to involve the social security tribution of iodized salt, educating the public system in preventive health projects, for to use it, and providing oral supplements of example, and worked closely with the Minis- iodized oil to pregnant women and rural try of Agriculture in a campaign to eradicate population groups at high risk of developing foot-and-mouth disease. goiter. Meanwhile, PAHO/WHO participated In the area of infectious disease control, regularly in meetings of international donors surveillance and reporting systems detected and, together with USAID, UNICEF, an increase in malaria, over 24,000 cases of UNFPA, WFP, UNDP, and nongovernmen- 124 Report of the Director 124 Report of the Director tal organizations, carried out a systematic to design and promote the generalized use of review of external cooperation in order to a standardized list of essential pharmaceuti- ensure that supplementary funds were cals, train health professionals in modern obtained. management methods, review curriculum The health sector obtained funding from requirements and future deployment pros- international agencies for several projects pects of RN and MPH graduates, support developed with PAHO/WHO's technical health services research, publish and widely cooperation. The nutrition and supplemen- disseminate technical information needed tary feeding program, for example, was a for priority projects, and coordinate zoono- joint UNICEF-PAHO/WHO-government sis control and other border projects with project. UNICEF, PAHO/WHO, Rotary neighboring members of the Andean Coop- International, and USAID joined forces eration in Health and Southern Cone health toward increased coverage of the Expanded initiatives. Program on Immunization, while the IDB One of the most significant accomplish- financed several rural water and sanitation ments of the quadrennium in the area of projects. UNFPA funded a reproductive information management was the comple- health project administered by PAHO/ tion of a national health profile and trends WHO, the Government of Italy underwrote assessment. Developed by the health minis- the endemic goiter control project, and the try and PAHO/WHO, the profile has been World Bank developed and funded a project used as the basis for several of the projects to strengthen the health infrastructure. for which outside funding was obtained. A PAHO/WHO also lent its technical concomitant effort to train health personnel cooperation to the government for activities in research methods is progressing with in several key areas that were intended to PAHO/WHO's support and will be reduce unnecessary expenses and improve strengthened in coming years. project management. These endeavors were

COLOMBIA

Colombia's economy was more stable Having to accommodate to more meager than those of most of its South American funds than needed, the health sector none- neighbors, with a manageable inflation rate theless vigorously pursued its campaign to and slow but steady economic growth. Its reach the goal of universal access to primary good prospects for development were ham- health care services. This longstanding pered, however, by the powerful drug trade. objective of the health sector was bolstered The country's crackdown on drug traffick- by the national executive and legislative ers, and their violent attacks on government commitment to spreading economic and officials and institutions, called for the social development beyond major metropoli- expensive mobilization of special resources. tan areas by decentralizing social services This necessary expenditure diverted part and democratizing their planning and execu- of the national budget from development tion. Toward the end of the quadrennium, projects that might have otherwise counted the National Congress passed a reform of the on greater funding. There is concern that National Health System proposed by the the national war on drugs may further sap Ministry of Health. The reform transfers a resources for social programs in the coming large measure of control of the country's years. health policy to the municipalities. The aim PAHO/WHO Technical Cooperation at Subregional and Country Levels 125 of this political, administrative, and fiscal with different social, economic, political, decentralization is to strengthen the munici- and technical sectors of the country in devel- pal level and to decentralize services, thereby oping norms to regulate the organization ensuring primary care services for the entire and financing of the health institutions at population. the municipal, departmental, and national Further certifying the government's gen- levels. However, the reorganization has still eral commitment to decentralizing and not been carried out at some of these levels. democratizing all development projects, the The national health sector and PAHO/ creation of 3,500 Community Participation WHO collaborated on designing an innova- Committees nationwide was mandated by tive methodology for organizing the delivery decree. Meanwhile, Bill 120-expected to of services, based on epidemiologic surveil- pass in early 1990-spells out the relation- lance to detect priority problems and their ship between these committees and national risk factors. The approach seeks to deliver health, family welfare, and social security services that not only treat but prevent the systems. causes of morbidity in given geographic The community-based social action pro- areas, in keeping with the decentralization grams, such as the National Plan for Sur- process. By defining geographically distinct vival and Development, the National health "ecosystems," it enables local authori- Rehabilitation Program, and the Plan of ties to design projects in which government Attack against Absolute Poverty, as well as and other agencies can coordinate their programs to generate employment, require efforts toward the precise needs of a specific both educated civic involvement and link- population group. ages between different government sectors The technical cooperation provided by responsible for rural development projects, PAHO/WHO during 1986-1989 thus water and sanitation coverage, nutrition and stressed supporting national and departmen- health, infrastructure, and education. In sev- tal decentralization of health services, train- eral municipalities covered by the national ing personnel to run them, developing reform plan, for example, the Ministry of infrastructure, reforming hospital care, Health has awarded management responsi- encouraging community participation, pro- bilities to community organizations for con- moting intersectoral coordination, and tracting the construction and expansion of designing projects to address the most press- health facilities. Already, municipalities have ing communicable diseases and other health built or remodeled 422 facilities, constructed concerns of vulnerable groups. These prob- or improved 313 water supply systems, built lems include malaria and dengue, vaccine- 1,346 school health units, trained 132 new preventable childhood illnesses, zoonoses staff members, provided refresher courses for such as urban rabies as well as foot-and- 18,382 other staff and 5,500 community mouth disease, AIDS, cancer and other leaders, financed 173 community pharma- chronic diseases, and maternal health, fam- cies, and supplied 2,162 health and sanita- ily planning, and occupational health. tion promoters and nursing auxiliaries with In its effort to limit the spread of AIDS, vehicles for transportation. Community the ministry reorganized the responsible action was evidenced in projects such as the committee. PAHO/WHO assisted in devel- Community Rehydration Units (URDC), oping legal/ethical guidelines for the control which combated infant mortality due to program, set up a network of eight blood diarrhea by teaching mothers how to pre- screening laboratories, and prepared instruc- pare and use oral rehydration solutions. tions and facilities for the treatment of AIDS To make decentralized management and patients. operations of the sector more dynamic and The maternal and child health project efficient, the Ministry of Health coordinated was backed by UNICEF, which, together 126 Report of the Director 126 Report of the Director with the Ministry of Health and PAHO/ some of which are of dubious quality. WHO, formed a tripartite Child Health Colombia has also determined that it could Committee. National vaccination days, save in import expenses by promoting the started in 1984 to improve coverage, were national production of essential vaccines successful. By 1989, provisional data showed and laboratory reagents. vaccination coverage of children under one The Pan American Health and Educa- year of age as follows: trivalent oral polio tion Foundation collaborated on projects to vaccine, 89%; DPT, 78%; measles, 74%; and train medical and nursing professionals in BCG, 94%. In addition, the government has areas that are suited to the decentralized pledged its commitment to the eradication of approach. wild poliovirus transmission by 1990, elimi- The PAHO/WHO Emergency Prepared- nation of neonatal tetanus, and 90% reduc- ness and Disaster Relief Program actively tion of measles by 1995. Epidemiologic assisted the government in imparting emer- surveillance of vaccine-preventable diseases gency management skills to health profes- was strengthened, especially with respect to sionals through courses offered in the suspected cases of poliomyelitis. faculties of medicine, schools of public PAHO/WHO technical cooperation health, and the Ministry of Health. also included advice in the production, con- The World Bank, Rotary International, trol, and purchase of vaccines, and the USAID, UNICEF, UNFPA, UNFDAC, and design of a national pharmaceutical policy. the governments of the Federal Republic of The purpose of the policy is to correct the Germany, Italy, Japan, the Kingdom of the existing situation in which the country Netherlands, and Spain were major partners imports a wide range of pharmaceuticals, in funding support for national priority many of which are redundant and costly and programs.

ECUADOR

The regional economic crisis was felt ture, and health facilities, setting back many sharply in Ecuador, where it was aggravated costly development projects. by the drop in international oil prices. The As a result of the crisis, the rapid, petroleum-rich country had an economic import-dependent development to which the boom during the 1970s, and public develop- country had been geared underwent a sud- ment policies during those years were den contraction. Increased unemployment designed around plentiful resources. The and underemployment (affecting 63% of the government undertook costly development population in 1988), a drop in real wages, a projects with long-term completion sched- lowered standard of living, and the weaken- ules, including construction of modern, ing of social development programs ensued. high-technology hospitals. In the public sector the impact was felt in the When petroleum prices plummeted in extension of project completion dates, the the 1980s, Ecuador lost its main source of increase in their cost, legal problems with foreign earnings. The 1987 earthquake com- contractors, and delays in supplying and fur- pounded difficulties when it ruptured pipe- nishing installations. lines, delaying explorations and exports for Programs already in operation also felt six months, during which time the country cutbacks in real budgets. Buildings, equip- had to import oil. The earthquake also dam- ment, and installations deteriorated because aged roads, bridges, other basic infrastruc- of delayed maintenance. There were short- PAHO/WHO Technical Cooperation at Subregional and Country Levels 127 ages of pharmaceuticals, medical and public In addition to promoting the delivery of health supplies, and critical raw materials integrated health services, the local systems whose rising costs became prohibitive. The actively seek out underserved population quality of the delivery of services to the groups in a campaign to ensure universal population further declined when health access. During a childhood vaccination workers-demoralized by low pay and poor drive, for example, mothers, fathers, and sib- working conditions-often went on strike or lings are also provided with primary care. worked inefficiently. PAHO/WHO has responded to the The 1988 elections brought in a govern- change in the national government by reor- ment with a social democratic philosophy to ganizing its technical cooperation accord- replace its neoliberal predecessor. The new ingly. Program support is provided through government set aside 7% of the national interproject coordination that is based on budget as a Social Fund and formed the risk assessments developed through epidemi- Social Front, made up of the Ministries of ologic surveillance. The Director, PASB, has Health, Education and Culture, Labor and pledged special attention to the Ecuadorian Human Resources, and Social Welfare. The reform experiment, the results of which may Front is responsible for coordinating social prove useful for other countries. programs at the executive level and reflects Within the three broad priority areas, the social base and participative organiza- national attention and PAHO/WHO tech- tion of the ruling party. nical cooperation focused on a number of The health program priorities defined by specific projects; The program of free distri- the new government were provision of inte- bution of prescription generic drugs for grated family health care, the fight against minors was expanded to cover children up to malnutrition, and expansion of coverage of the age of 14, and the Center for Pharmaceu- potable water supply and sanitary services. ticals and Medical Inputs was formed. The The creation of the Social Front was National Committee on AIDS was also cre- part of a dramatic shift in the concept of ated to determine the incidence of the dis- delivering public health services. The Minis- ease and devise measures to halt its spread. try of Health focused on projects aimed pri- PAHO/WHO technical cooperation in marily at strengthening the operational the development of health services infra- capacity of services, especially those located structure was aimed primarily at the follow- in rural and marginal urban areas. This was ing: general planning to enlarge the areas done by constructing, equipping, and sup- receiving services; development of and plying smaller, less technologically complex experimentation with plans for the regional- health care units in underserved areas. ization and decentralization of services; These local health units are part of the design and testing of new models of inte- local health systems on which the new grated family health care; development of national health policy is based. The main local services networks; projects for increas- strategy consists of building a stepwise net- ing the efficiency with which essential phar- work of preventive and curative services maceuticals and vaccines are procured, organized according to level of complexity. stored, and distributed; institutional devel- Simultaneously, other development efforts opment; social participation, including that that have a bearing on health are included in of women; promotion of the subregional ini- program planning to maximize the joint use tiative and border health projects; and mobi- of resources. Because of the restricted lization, coordination, and evaluation of national budget, provincial and municipal external aid. governments must assume greater respon- The priority health problems of vulnera- sibility in financing and staffing the ble groups received special attention. These programs. included growth, development, and repro- 128 Report of the Director 128 Report of rhe Director

duction; diarrheal and respiratory diseases; was critical in the determination of specific tuberculosis; food and nutrition; oral health; needs. The importance of this information water quality, domestic hygiene, and waste was brought to light particularly during the disposal; environmental risks to health; economic crisis, when it became clear that malaria and leprosy; endemic sexually trans- many large development projects had been mitted diseases and AIDS; foot-and-mouth based on only a generic notion of what was disease and urban rabies; cervical and uter- required. PAHO/WHO built an analytic ine cancer; and smoking, alcoholism, and data bank to serve as the basis for drafting drug abuse. projects that address specific national prob- The search for and compilation and dis- lems, and its documentation center is linked semination of technical and scientific docu- to a network of national information mentation analyzing national health trends centers.

PERU

During the quadrennium, Peru under- achieving the goals set out in the strategy of went the most serious and prolonged eco- health for all by the year 2000. nomic crisis in its history. Unemployment Rural workers and periurban dwellers, and the cost of living rose, and at the same other economically and socially deprived time food production dropped, partly as a groups, pregnant and lactating women, and result of arrested agricultural production in children under one year of age received pri- war-torn rural areas. These conditions ority attention as high-risk groups. Because increased the serious nutritional problems of financial and staffing limitations, the min- faced by low-income rural and periurban istry tackled these front-line areas by chan- families, who are the groups already at great- neling its resources into a few critical est health risk. preventive projects: the Expanded Program The National Health Policy, developed on Immunization, control of acute respira- during the second half of 1985, has been the tory and diarrheal diseases, food and nutri- framework guiding the conduct of health tion, family planning, child growth and activities. It delineates the following broad development, tuberculosis prevention, envi- categories for program emphasis: strengthen- ronmental health, and malaria control. ing local health systems through decentral- Meanwhile, it gave attention to refurbishing ization; improving collaborative efforts with health centers, installing and supplying pri- other development sectors; developing new mary health services in outlying areas, approaches to carrying out programs in remodeling and stocking key hospitals, and maternal and child health, communicable completing major infrastructure works that disease prevention, food and nutrition, envi- had been started earlier. ronmental health, emergency preparedness, As noted above, efforts were made to mental health, and control of some chronic improve the efficiency of the care delivery diseases; reorganizing the health services system by functionally integrating the ser- delivery structure by the functional integra- vices provided by the health ministry and tion of the Peruvian Social Security Institute those of the IPSS, decentralizing them along (IPSS) and the Ministry of Health; reestab- regional lines. Coordination of resources lishing the leadership role of the health min- with other social services and ministries istry; mobilizing community participation; involved in development projects was also and reaffirming the national commitment to strengthened. The strategy to reform the PAHO/WHO Technical Cooperation at Subregional and Country Levels 129 organization of services was coupled with tion succeeded in beginning the decentraliza- attempts to mobilize community participation of services and health programs and in tion at the local level. obtaining the functional integration of the The National Health Policy drafted Ministry of Health and the IPSS in some of early in the quadrennium aims to treat the most vulnerable regions of the country. health problems in an integral fashion with PAHO/WHO also collaborated with the the participation of other sectors, and the ministry in developing a four-year, $US70 ministry achieved positive results in this million project to rehabilitate, expand, and endeavor. In a joint project with the housing equip hospitals (including laboratories, sector, it obtained substantive increases in blood banks, and radiology units); the pro- investments for potable water supply and posal will be presented to the IDB for sanitation works. In collaboration with the financing. education sector, the ministry designed new In conjunction with projects to reduce university-level curricula and graduate pro- morbidity and mortality among infants and grams, such as one in occupational health young children, the government initiated a and toxicology. By 1989 five dissertations family planning program with $US4.2 mil- had already been completed in this new lion in funds from the UNFPA to be spent area. Improving food safety was the object of over four years. Likewise, with financing a major campaign undertaken together with from the Government of Italy, the five-year the Ministries of Education, Agriculture, program PROCAN was established, with a and Municipalities. view toward improving nutrition in eight The national attempt to improve inter- severely deprived microregions of Puno, sectoral coordination was spelled out in the Tacna, and Moquegua, areas in which the Triennial Plan-a multisectoral project for food and nutrition surveillance system was child survival-that was designed with first established. PAHO/WHO formed an PAHO/WHO cooperation. The plan coor- Executive Secretariat with UNICEF and dinates actions in the areas of the Expanded USAID to coordinate this and other nutri- Program on Immunization, diarrheal disease, tion programs under the Joint Nutrition acute respiratory infections, nutrition, peri- Support Program, including one aimed at natal care, child growth and development, eliminating endemic goiter. Moreover, nutri- and environmental health during the period tion surveillance was introduced as a stan- 1988-1991. Together with the National Vac- dard planning and evaluation criterion for cination Plan for 1987-1991, this joint effort community health programs. of several agencies and national sectors Progress also continued on projects achieved higher immunization coverage motivated by the International Drinking than in the past few years. By 1988, provi- Water Supply and Sanitation Decade, and sional evaluation results showed vaccination Canada provided financial support for the coverages as follows: OPV3, 68%; DPT3, development of a national information net- 51%; measles, 49%; and BCG, 78%. work on the subject. PAHO/WHO supported national efforts PAHO/WHO gave strong support to through cooperation in all of the priority the development and strengthening of local program areas, providing technical expertise health systems through research, meetings, and funding, assisting in the purchase of sup- and collaboration in the drafting of legal plies and equipment, offering courses and instruments and regulations for the estab- seminars, and acting as an adviser and third lishment of local health systems in Lima, party in negotiations with other sectors and Trujillo, Iquitos, Arequipa, and Piura- agencies. Tumbes. The ministry is now considering Despite the state of insolvency and expanding the use of local health systems as shortages in the sector, technical coopera- the basic organizational units of the health 130 Report of the Director 130 Reporr of the Director

care system throughout the country, as mental Health Unit now has a focal point part of the process of strengthening for emergencies and disasters. regionalization. At the end of the period, cooperation PAHO/WHO was also instrumental in a was being directed toward the process of study of the Lima-Callao area and proposal political-administrative regionalization, of an improved emergency response system, begun by the government in November 1989 which was adopted by a permanent commis- when representatives were elected and the sion made up of the IPSS, Armed Forces, first 5 of 12 regions into which the country Police, and Ministry of Health. Each Depart- was divided began to operate.

VENEZUELA

The beginning of the quadrennium was health under the management and adminis- relatively auspicious for Venezuela, but by tration of the health ministry. These services 1989 the drop in revenues from oil exports include all medical care and related activities and the increase in the cost of imports provided by various state agencies and caused concern. Inflation more than dou- autonomous institutions, with the exception bled between 1988 (35.5%) and 1989 of those of the National Armed Forces. (77.9%), reaching an alarming rate when The law also nationalizes services pro- compared to the 1986 level (11.5%). In 1989, vided by federal institutions and agencies, purchasing power fell 60%. The economic municipalities, and civil and commercial contraction and inflation sparked labor companies in which the national govern- unrest and concern about the future of ment holds a controlling share, capital investment and development projects. investment, or interest. This reform process Hence, the next quadrennium may be char- reorganized the health system so that its acterized by austerity measures in the public basic administrative units are now centered sector, including health programs. in "health subregions" based in each state. During the last four years, the VII In addition to medical care services, the National Plan for Social and Economic new National Health System is made up of Development for 1985-1989 set the context other subsystems, including environmental for the major developments in the Venezue- protection and environmental health hazard lan health sector. The Ministry of Health control and social welfare programs. and Social Welfare was charged with design- The government also created the Stand- ing and putting into effect a national health ing Commission on Primary Health Care to system that would bring the 72 separate enti- oversee the delivery of preventive services ties that provided health care services in the throughout the country. Based on a recently country under unitary and cohesive strengthened epidemiologic surveillance sys- leadership. tem, the preventive services are aimed at In 1985 and 1986 the ministry drafted addressing the most pressing problems in a the foundations of an historic new health community-such as maternal and child system and introduced the bill to the health, nutrition, and environmental sanita- National Congress. The Congress passed tion-through controlling key risk factors. this bill, the Organic Law for the National In adopting this approach to the deliv- Health System, in 1987. It places all public- ery of primary care services, the ministry also sector services devoted to the protection of placed emphasis on training personnel in PAHO/WHO Technical Cooperation at Subregional and Country Levels 131 epidemiology and its main analytic tools. As ter's degree in preventive medicine in the a result, effort was put into strengthen- Veterinary School. Venezuela has already ing the National Commission for Develop- donated yellow fever vaccine to the Carib- ment of the Teaching and Practice of bean Epidemiology Center (CAREC) and, Epidemiology. through PAHO/WHO, to several Carib- In regard to priority health projects, the bean countries. ministry executed a medium-term program In the area of physical infrastructure, the to arrest the spread of AIDS, developed pro- health sector completed a three-year plan to tocols and carried out in-service research on reconstruct and remodel existing hospitals occupational health, continued its campaign and 1,000 ambulatory care facilities, serving to extend the coverage of the Expanded Pro- 20,000 people each. The Infrastructure and gram on Immunization (including the polio Equipment Foundation was established as a eradication campaign), evaluated and stand- means of ensuring the maintenance of the ardized food safety projects, and promoted facilities and their expansion when neces- family involvement in nutrition education. sary. PAHO/WHO carried out a detailed In the area of tropical diseases, special survey of needs in this area and has proposed emphasis was placed on control of malaria, a subregional project for consideration by leprosy, and leishmaniasis. The Pan Ameri- outside funding sources. can Center for Research and Training in In addition to lending technical coopera- Leprosy and Tropical Diseases served as the tion on the above projects, PAHO/WHO epidemiologic intelligence center for these was particularly active in efforts toward the projects. The AMERICARE Foundation training of highly qualified health personnel provided financial support for the national and creation of a first-rate information base. leprosy control program. To that end, special emphasis was placed on The UNDP, meanwhile, financed a redesigning the Central University of Vene- research project on tropical diseases endemic zuela's curriculum for health professionals to the Amazonas Federal Territory. The and establishing a master's program in the project benefited from advice by PAHO/ epidemiology of metoxenous diseases at the WHO technical staff and also received funds School of Malariology, which trains people from the World Bank/UNDP/WHO Special from all over the Americas. Attention was Program for Research and Training in Tropi- also paid to training health promoters and cal Diseases. nurses, working with the National Commis- Urban rabies and foot-and-mouth dis- sion for Development of the Teaching and ease were not completely eradicated, Practice of Epidemiology, and collaborating although progress was made toward that with the National Council on Scientific and goal for both diseases. In a project under- Technological Research and other national written by the IDB, the Agricultural Invest- agencies to set up a documentation base and ment Fund and the Ministry of Agriculture information network. and Livestock collaborated with PANAF- The Sanitary Works Institute made TOSA toward creating a national foot-and- headway in a joint project with the IDB and mouth disease vaccine production capability PAHO/WHO to improve the quality of that will eventually provide enough immu- drinking water in the central region of the nobiologicals for export to the rest of the country. It also assigned priority resources to Andean Subregion. The University of Zulia the environmental sanitation and recovery was selected as the School of Animal Health project in the Tuy River Basin that was for Latin America, and it established a mas- undertaken with UNDP and UNEP support. 132 Report of the Director

SOUTHERN CONE HEALTH INITIATIVE

In August 1986 the Ministers of Health and preparedness; to assign countries as of Argentina, Brazil, Chile, Paraguay, and focal points, on a rotating basis, to monitor Uruguay began the Southern Cone Health the technical and educational activities car- Initiative. Meeting in Montevideo with tech- ried out (Argentina is to be the first site); to nical teams and the PAHO/WHO Represen- request that PAHO/WHO find extrabudge- tatives from those countries, as well as the tary funds to finance a full-time technical Director, PASB, and technical staff, the officer to support the subregional effort; to Ministers examined common problems and modernize direct communications between planned joint actions to address them. the national disaster programs; and to step The Ministers decided to update existing up emergency training programs. agreements on border health problems and Border health. To draw up legal instru- to meet every two years. They also agreed ments to facilitate joint health projects along that annual technical discussions should be borders; to develop an epidemiologic control held to foster the exchange of information project focused on malaria, dengue, yellow and experiences on priority health problems, fever, and American trypanosomiasis (Cha- decide on subregional or bilateral actions gas' disease); to train staff in control methods that promote better use of resources, and for infectious diseases prevalent in border assess the extent to which each country com- zones; and to design and test a common epi- plies with the recommendations of the joint demiologic intelligence system. technical and ministerial meetings. AIDS. To rank risk factors in patients At the Southern Cone Ministers' Meet- presenting with several; to study the possibil- ing held in Buenos Aires in November 1988, ity of adopting subcategories for classifying Bolivia was incorporated as a full member of heterosexual transmission; to adopt the case the initiative. definition used by PAHO; to provide the The October 1989 technical working material, technical, and administrative group meeting that took place in Santiago, requirements to study and manage infected Chile, selected four common priority areas, cases; to ensure 100% screening of blood reviewed work done so far, and programmed supplies; to take into account existing regula- activities in detail. The four priority areas tions related to infectious diseases before cre- are disaster preparedness, border health, ating new legislation regarding AIDS; and to AIDS virus transmission control, and essen- consider the ethical principles established in tial pharmaceuticals and biological products. the UN Declaration of Human Rights, in The following were some of the key recom- order to avoid social segregation and stigma- mendations of the meeting: tization of infected persons and their Disaster preparedness. To make prepared- families. ness a permanent priority for discussion at Pharmaceuticals, vaccines, and blood prod- the Ministers' meetings throughout the ucts. In continuation of the areas of work International Decade for Natural Disaster agreed upon in the technical meeting held in Reduction; to include manmade hazards April 1988, to stimulate bilateral and multi- such as chemical and radiation accidents in lateral activities in production and commer- the definition of "disasters"; to form a subre- cial exchange of essential pharmaceuticals; gional Operational Committee of the South- to study and resolve the classification and ern Cone for Health Emergencies, made up certification of pharmaceuticals and biologi- of the technical officers of the ministries cal products; to exchange information responsible for disaster relief coordination regarding procurement and purchase; to PAHO/WHO Technical Cooperation at Subregional and Country Levels 133 carry out public information programs on ucts; and joint subregional studies on the use the proper use of drugs; and to coordinate and consumption of medicines. information regarding ethical norms for The selection of these concrete areas for drug advertising, quality control to ensure joint subregional action represents signifi- their safety and effectiveness, and storage cant headway in coordinating resources to and distribution. The group furthermore solve critical problems in the area. Since the called for the establishment of a data bank difficult financial situation of the countries on pharmaceuticals, equipment, services, involved may jeopardize the full execution of manpower, and analytic capability; a com- the projects, PAHO/WHO has presented parative analysis of health legislation; a several of them to interested funding study of supply and demand of vaccine prod- sources.

ARGENTINA

Argentina's public health sector has health development, health policy coordina- come under serious scrutiny since civilian tion, program and service development, rule was reinstated in 1983. Two distinct institutional development, financial coordi- phases marked the last quadrennium: 1986 nation, federalization of the health sector, through 1988, and 1989. The first period was and health and welfare intersectoral characterized by relative political stability, coordination. the second by an early change in govern- The analysis phase, which concentrated ment as the long-brewing economic crisis largely on the distribution and coverage of came to a head. The political climate had a curative services based in hospitals and decisive impact on health policies. health centers, showed that funding for the Up to 1989, the Ministry of Health and public health sector had eroded over the Social Action worked steadily to ensure that years as more and more of these services the country's health care delivery system were taken over by the private sector. As of would increase coverage as well as equity in late 1988, for example, 66% of hospital beds the quality of care. "Federalization" with were in the public sector, but they accounted respect to health measures was at the core of for only 40% of total hospital discharges. the new planning approach. The loss of revenues exacerbated the inequi- In undertaking this initiative to revamp ties inherent in a two-tiered health care sys- and modernize the health services delivery tem, in which those who could afford private system, the health ministry made use of care paid for it, while those who could not expertise in the fields of health financing, were treated in increasingly deficient public strategic analysis, and planning, and carried facilities. As a result, the ministry's planning out extensive staff training programs. It also strategy emphasized finding new means of requested that PAHO/WHO provide assis- financing public care. tance by evaluating the status of health care Another problem that emerged from and by organizing its technical cooperation study of the configuration of the national in accordance with the modern management health services was the skewed manpower techniques called for by structural reform. profile. Medical doctors were graduating at a After an extensive evaluation of the sta- rate of 5,000 yearly. This meant that Argen- tus of the national health care delivery sys- tina had a ratio of one doctor for every 355 tem, seven program categories emerged as people, although most of them practiced in priorities: managerial reform for national the Buenos Aires metropolitan area. Mean- 134 Report of the Director 134 Report of the Director while, there was a critical shortage of ade- and child health, environmental health, and quately trained public health personnel, nutrition programs, the new government including nurses. The ministry therefore has singled out AIDS and vector-borne dis- concentrated its efforts-and the technical eases as targets for special control measures cooperation it requested from PAHO/ over the coming period. Likewise, health WHO-on bolstering the federalization pol- information and statistics are being reap- icy through diversified manpower training in praised and given priority at the level of the the provinces. Health Status Secretariat, as these areas were Simultaneously, the newly reinstated substantially affected in recent years by per- Environmental Health Project developed a sonnel and funding reductions. National Environmental Plan to address sev- PAHO/WHO has strong regional pro- eral key areas: expansion of the water and grams in each of the above technical areas sewerage network, occupational health, and and will also assist the ministry in obtaining toxicology and hazardous substances external financing and arranging collabora- control. tive projects with other agencies. In the By 1988, most of these reform initiatives meantime, the Organization has acted as a were in place. The process culminated source of program continuity. While reor- toward the end of the year when new legisla- ganization was taking place at the central tion-the National Health Insurance Law- level of the ministry, PAHO/WHO pro- was enacted to create a single health system ceeded with manpower training in the prov- guaranteeing universal coverage. However, inces and provided extensive technical the new policy impetus was thwarted by the cooperation in water supply and sanitation, explosion of the economic crisis. preparedness for radiological accidents and Spiraling inflation, unemployment, and handling of hazardous substances, environ- the first food riots in the country's history mental pollution control, occupational brought public programs to a standstill. Pres- health, and hospital infection control. At idential elections resulted in a new govern- the ministry's request, PAHO/WHO dedi- ment headed by the main opposition party, cated a large amount of its resources to this which took over earlier than scheduled environmental health component. A project because of the escalating social emergency. and a protocol that are ready for signature Faced with public demands for urgent mea- establish a subcenter of the Pan American sures, the new government's health ministry Center for Human Ecology and Health in allotted its resources to emergency distribu- the province of Misiones. tion of food and medicine, nutritional sur- With PAHO/WHO technical coopera- veillance, supplementary feeding programs tion, the government has obtained support for children, and preventive health care for from two major lending institutions. The pregnant women and infants. IDB is providing $US124 million for devel- The changes taking place in national opment of provincial hospital infrastructure, health policies are reflected in the technical and the IBRD approved US$12 million for cooperation that PAHO/WHO will be offer- manpower training, health information, ing over the next quadrennium. In addition national health insurance, and decentraliza- to placing continued emphasis on maternal tion plans. PAHO/WHO Technical Cooperation at Subregional and Country Levels 135

BRAZIL

In 1986 the VIII National Health Con- ties, as well as activities concerning worker's ference of Brazil launched a reform move- health; directing the training of human ment founded on the principle that health is resources in the health sector; participating a right of all citizens and, as such, its protec- in the drafting and implementation of basic tion should be guaranteed through a sanitation measures; promoting scientific Unified National Health System that is or- and technological development within the ganized democratically. Moreover, according health area; supervising food processing and to the Health Reform Statement, health inspecting foodstuffs (including monitoring status should be considered "the result of their nutritional content) and beverages and nutritional conditions, habitat, education, water for human consumption; helping to adequate income, environment, work, trans- control and supervise the production, transport, freedom, leisure time, access to land, portation, storage, and utilization of psycho- and access to health services." The Unified tropic, toxic, and radioactive substances and National Health System would consequently products; and collaborating in protection of be based on a comprehensive epidemiologic the environment, including the workplace understanding of health interventions that environment. are broader than medical-hospital care. The transition to full reorganization of In October 1988, the national constitu- the health services started prior to its tion incorporated this groundbreaking con- promulgation in the constitution and will cept in its articles, thereby expressly continue until it succeeds in replacing the asserting the State's responsibility to safe- market-based system of the past. National guard the health of all of its citizens and health authorities and PAHO/WHO staff establishing the juridical basis for the Uni- hence spent a major part of the quadren- fied National Health System. Specifically, nium designing the Health Reform proposal, Article 196 states that "Health is the right of models for delivery systems, managerial all [citizens] and the duty of the State to changes, and continuing education pro- guarantee, through social and economic pol- grams for health professionals. icies that aim to lessen the risk of sickness A second major focus of action was the and other ills and to [ensure] universal and production and quality control of essential equal access to actions and services for its pharmaceuticals and vaccines. The aim of promotion, protection, and rehabilitation." the program is for Brazil to supply its own The main directives set out in the 1988 oral polio, measles, yellow fever, rabies, DPT, constitution are to decentralize services to DT, tetanus toxoid, and diphtheria vaccines, the states and municipalities, provide inte- as well as snake antivenin, by 1992. Soon grated services with emphasis on preventive thereafter, Brazil hopes to produce enough of health, and democratize the delivery of ser- these biologicals for export to other coun- vices by promoting community participa- tries in Latin America and Africa. tion. The following priority functions are PAHO/WHO and the Institute of Qual- assigned by law (Article 200) to the health ity Control in Health collaborated on qual- sector: controlling and supervising health ity control and trained technicians in liquid procedures, products, and substances and chromatography, toxicology, and research participating in the production of drugs, methods for the medicinal use of native flora equipment, immunologic antibodies, blood (a joint project with Cuba and China). In products, and other inputs; carrying out support of the research and production health and epidemiologic surveillance activi- aspects of vaccine and pharmaceutical self- 136 Report of the Director sufficiency, work toward supplying the nec- The food control program also focused essary infrastructure continued throughout on training and on coordinating the export the quadrennium. and import of food with other countries and Maternal and child health was a priority international agencies. The Monitoring among national preventive health programs, Commission maintained surveillance of and PAHO/WHO and UNICEF were active meat commerce with the countries in the in this area. Brazil sponsored two interna- Rio de la Plata Basin. tional WHO meetings on the subject and set Regarding zoonoses, urban rabies is up its own national, state, and municipal responding to control measures and is committees to monitor and analyze data on declining steadily, especially in the south of maternal and infant morbidity and mortality the country. The control program empha- patterns. Childhood survival measures that sized training personnel in the use of rabies were undertaken included controlling diar- vaccine and diagnostic supplies. The Secre- rheal and respiratory diseases, developing tary of Health of Paraná State drew up a community health education projects, and project to control taeniasis and cysticercosis, planning a data reporting system on mater- which includes environmental engineering nal and child health. As a complementary and sanitation as well as nutrition and vac- activity, the National Food and Nutrition cine components. Institute carried out research projects and Technical cooperation between Brazil manpower training in coordination with and other countries took the form of infor- other agencies. mation sharing and collaboration with its 10 In environmental health, the State Basic bordering neighbors, especially in the con- Sanitation Technology Company played a trol of infectious diseases, the exchange of leading role in training engineers through consultants, and the training of personnel. various courses, including one on water Joint projects were discussed with Argen- treatment plant design and water quality tina, Bolivia, Chile, Paraguay, and Uruguay monitoring. regarding infectious diseases, AIDS, pharma- In December 1988 Brazil was the site of ceuticals and vaccines, disaster preparedness, the II Pan American Teleconference on and women in health and development. AIDS. The national program to control and Brazil signed pacts with Paraguay to con- prevent AIDS invests a large part of its trol rabies; with Mexico to cooperate in resources in measures to prevent human environmental health; with Colombia to immunodeficiency virus contamination of collaborate in health education; with the blood bank supplies, as well as in health edu- Amazonian countries to control malaria, cation and promotion of behavior change. leprosy, and dengue; with Bolivia to supply In addition to the AIDS program, con- health inputs and control diseases in the tinued surveillance and control were neces- border zones; and also with Argentina, Guy- sary for yellow fever, schistosomiasis, ana, and Uruguay to control border-area malaria, and other endemic diseases in the diseases. Technical cooperation with the northeast and the Amazon Basin. The Portuguese-speaking African countries has World Bank provided financial support to been increasing in recent years through pro- these efforts and, along with the United vision of equipment, materials, reagents, and Nations Development Program, sponsored drugs and biologicals, and through the train- special training to qualify people to carry out ing of human resources in nursing and medi- operational research in tropical diseases. cal schools in Brazil. PAHO/WHO Technical Cooperation at Subregional and Country Levels 137

CHILE

As was the case with most of its South- PAHO/WHO technical cooperation has ern Cone neighbors, Chile underwent a supported the development of a medical major political change during the quadren- information system for personnel, continu- nium, holding democratic presidential elec- ing education for health professionals in all tions for the first time since 1970. Since the disciplines of the health sector, and elections took place in December 1989 and research. the transition to the new government is Notwithstanding the stable economic scheduled for March 1990, public policy and political environment, an estimated changes will not be felt until the next period. 45% of Chilean families lived in poverty. The Chilean economy showed a modest Therefore, the maternal and child health growth rate throughout the quadrennium, program, including supplementary feeding real wages stayed steady, and the increase in and intensive control of diarrheal and respi- copper prices meant that foreign exchange ratory diseases, continued to be one of the earnings rose. health ministry's priorities. Given the low The nation's health care delivery system rates already achieved, progress in reducing has been administered on a decentralized maternal and infant mortality was less basis for many years. The National Health marked than in the past, but by 1987 infant Services System (SNSS) comprises the Min- mortality reached the lowest rate in the istry of Health, 13 regions and 27 geographi- country's history, at 18.5 per 1,000 live cally decentralized health services, a births, down from 120.3 per 1,000 in 1960. National Health Fund, and the National Simultaneously, life expectancy rose to Institute of Health. There is also a private 71.5 years, and the burden of health prob- prepayment system that covers about 10% of lems typical of older, heavily urban societies the population. A large part of the ministry's (such as cancer and cardiovascular diseases) attention was focused on improving the rose with it. Aware of the changing health management efficiency of the regional ser- profile of its population, the government vices by ensuring that critical supplies and established programs in adult and adolescent equipment were available in the most eco- health. In addition to the problems of aging, nomically deprived zones and by carrying urban concentration has caused serious out training courses for key personnel. A environmental pollution that now reaches number of health care professionals working alarming levels in the Santiago metropolitan at the municipal level received grants for area, especially during summer months. intensive course work in modern manage- Health authorities consider pollution a pri- ment methods. Sponsored by the University mary health hazard, and it is proposed that of Chile, the courses were partially funded substantial funding be obtained to get con- by the W. K. Kellogg Foundation. trol measures under way. Technical cooperation provided by In the area of endemic infectious dis- international organizations and agencies, eases, ongoing surveillance and control pro- including PAHO/WHO, has contributed to grams remained successful, except in regard the development of health services in Chile. to tuberculosis, which has not declined as Of special value has been the training of per- rapidly as expected. Sexually transmitted sonnel in the implementation of the primary diseases have responded well to prevention health care strategy, which is the basis of the and treatment measures, and the ministry National Health Services System. In other has set up a surveillance project and public areas of human resources development, education campaign for AIDS. 138 Report of the Director 138 Report of the Director

Lastly, the newly established National sities. PAHO/WHO has played an instru- Health Sciences Information System (Sis- mental role in the development and tema Nacional de Información en Ciencias implementation of this system, providing de la Salud) linked its bibliographic services technical and administrative support. to key health service institutions and univer-

PARAGUAY

In February 1989 Paraguay underwent former organization provided support for the most significant political change in its the in-service training program. postwar history: the government that had As part of its work to promote the well- ruled for 35 years was transformed into a being of mothers and children, the health min- democratic government through the elec- istry concentrated on reducing perinatal toral process. This change in national gov- mortality and extending coverage of the ernment set into motion a process to reform Expanded Program on Immunization, includ- the policy and management structure of the ing the campaign to eradicate polio. A large public sector. Thus, health activities during number of resources were required to maintain 1989 were characterized by emphasis on the vaccine supplies and cold chain equipment planning of health sector services. and to mobilize the population on special vac- In the three years preceding 1989 the cination days. The vaccination days approach national health strategy focused on several was problematic, and health authorities major fronts: to extend coverage by increas- decided that better coverage would be ing the number of care facilities and their achieved if vaccination is done as a regularly capacity (including the building and equip- scheduled activity throughout the year. ping of the Grand National Hospital), to Although chronic illnesses are gradually train public health professionals, and to pro- becoming the main causes of morbidity and ceed with regular baseline projects such as mortality among adults, infectious diseases maternal and child health, tropical disease still take a significant toll in lives and well- control, and environmental health. being. Surveillance and control of malaria Meanwhile, health authorities contin- and dengue received priority. Both these ued the manpower training program mosquito-borne illnesses are major causes of planned for five years, by the end of which mortality and morbidity and are difficult to time the country would have a sufficient control. Dengue control measures included number of qualified public health profession- attempts at systematically cleaning up mos- als to staff national programs. This approach quito breeding sites in population centers, was taken to correct the lack of physicians, such as those found in refuse areas. Urban dentists, pharmacists, and public health per- rabies, tuberculosis, food contamination, sonnel that existed in the country. The Min- Chagas' disease, and leishmaniasis are still istry of Public Health and Social Welfare and important public health risks in Paraguay, PAHO/WHO designed several new curric- and ongoing programs for their control were ula for advanced training that included, for maintained. It is hoped that foot-and-mouth example, a graduate program in environ- disease will soon be eradicated in the eastern mental health. The W. K. Kellogg Founda- zone of the country. tion and UNFPA also supported the Notwithstanding the fact that few con- maternal and child health program, and the firmed cases of AIDS have been reported so PAHO/WHO Technical Cooperation at Subregional and Country Levels 139 far, the ministry established an AIDS sur- The new government's health priorities veillance system and the beginnings of a lab- were set out in the Plan for Immediate oratory research project in the hope of being Health Actions. This interim plan served to able to detect and stem the spread of this ensure the continuity of projects during deadly disease before it affects large segments 1989, while the medium-term health strate- of the population. gies were written up in a National Health The extension of potable water supplies Plan. Published in early 1990, the National to rural and periurban dwellers progressed Health Plan includes an organic charter and slowly but steadily throughout the quadren- organization manual for the health ministry. nium. While that infrastructure project con- It also outlines steps to make better use of tinued, city-based water treatment facilities the existing infrastructure and idle capacity, were studied to determine the most efficient enhance resource use by collaborating with means of improving their capacity. In related other public sectors, and convert the statis- work, PAHO/WHO and the ministry of tics division into an integrated health infor- health also undertook a study of the contam- mation system. ination of the Paraguay River. PAHO/WHO lent its technical coopera- When the change in government tion to all of the above projects in the form occurred in 1989, a National Health Council of personnel, supplies and equipment, spe- was created with advice from PAHO/WHO. cial training programs and grants, and epide- Made up of all the institutions that are miologic surveillance and information active in health care delivery, the council dissemination, as well as in an advisory now serves a national advisory function. capacity during the planning phases.

URUGUAY

By virtue of its demographic and epide- insurance featuring monthly prepayments miologic situation, Uruguay presented few and equal quotas for all affiliates indepen- changes in mortality indicators during the dent of their income, had perpetuated social quadrennium, with the exception of a signifi- inequities. Finally, the health system model cant decline in infant mortality (from 29.4 operating in the country did not satisfy the per 1,000 live births in 1985 to 20.9 in 1988, needs of the population. a 28.9% reduction). The government that was installed A proposed law sent by the executive shortly after the beginning of the quadren- branch to the Parliament summarized the nium carried out a democratic transition health services situation in the country as and developed its management policies in follows: The National Health Organization the middle of an economic crisis similar to was described as a complex and poorly orga- the one faced by the majority of the Region's nized mosaic made up of a variety of hetero- countries. In spite of the government's geneous and uncoordinated institutions. In efforts to increase the proportion of public recent years, both public and private institu- spending allocated for health, the resources tions were unable to spend the funds neces- available did not allow reversal of the deteri- sary to ensure their proper functioning, oration of many public establishments nor owing to the socioeconomic crisis in the restoration of acceptable levels of country. Mutualism, a voluntary form of investment. 140 Report of the Director 140 Report of the Director A funding proposal was submitted to Master Plan, a major part of which is exten- IDB for the replacement of a large hospital in sion of water supply coverage in rural areas. Montevideo, as well as the strengthening of Regional concern about the spread of programs aimed at improving adult health. AIDS, and the fact that 29 deaths had The Ministry of Public Health fostered and occurred out of 50 diagnosed cases and 309 obtained the institutional decentralization of known HIV-positives as of early 1989, led the State Health Services Administration, the National AIDS Program to strengthen an action that reinforced the ministry's its public education campaign and to import responsibility. reagents and testing equipment needed to A family physician program was insti- guarantee the safety of the national blood tuted and now includes a corps of more than supply. 100 professionals, remunerated by means of In the rural interior of the country, a head tax, that provide coverage for more health personnel worked with the Ministry than 150,000 persons. Vaccination coverage of Stockraising, Agriculture, and Fisheries to is close to 100%, and both cold chain opera- eradicate foot-and-mouth disease, which still tion and vaccine availability are adequate. takes a toll on the economy. Funds for the Thorough surveillance has not detected any project were provided by the IDB. cases of wild virus poliomyelitis. Another subregional program that Health authorities emphasized environ- gained momentum was the disaster pre- mental sanitation, especially urban waste paredness project. Special attention will be disposal (at sanitary landfills and the Monte- given to the threat of technological disasters video biogas production plant, for example) in countries of the Southern Cone. Several and treatment of wastewater discharged in workshops on norms and procedures are coastal areas. A project is under study at the scheduled to take place in Montevideo in IBRD to develop an Environmental Health 1990.

NORTH AMERICA

CANADA

Throughout the 1986-1989 period, Can- both males and females, reaching 72.9 years ada experienced a deepening social aware- for males and 79.8 years for females. More- ness of the importance of responsible health over, the primary change since 1931 was not behavior, of a safer environment, and of the so much the lengthening of old age as an involvement of patients in health matters in increase in the proportion of the population order to maintain and increase its present reaching an advanced age. In 1931, 66% of good levels of health care. the male population could expect to reach Canada's high life expectancy attests, at the age of 60; by 1981 the proportion had a minimum, to the successes achieved in its increased to 83%. The corresponding figures battle against infectious diseases, which were for females were 68% and 90%. primarily a threat during infancy. According The present Canadian policies and to preliminary life tables prepared for the approaches toward health issues began to 1983-1985 period, average life expectancy emerge in the late 1950s. In 1957, federal increased by approximately one year for legislation provided the basis for universal PAHO/WHO Technical Cooperation at Subregional and Country Levels 141

prepaid hospital insurance. A decade later, service); secondary care is available in area comprehensive complementary medical hospitals; tertiary care is available in insurance legislation provided a broad range regional hospitals. of medical and hospital benefits to the peo- Provincial, regional, and municipal ple of Canada. Services were provided by the health authorities manage primary health provinces in accordance with national stan- care services, such as the provision of safe dards. Provincial governments added a wide water and sewage treatment; operate public array of other benefits beyond those covered health programs, such as communicable dis- by the national insurance program, ranging ease surveillance and control and health from dental services for children and free education; provide inspection of food ser- prescription drugs for senior citizens to vices; offer home and hospital care to moth- orthodontic and prosthetic aids. ers and newborns; and provide health Five basic principles guide the current services in schools, such as immunization Canadian approach to health care: univer- clinics and preventive care dental clinics. In sality (all Canadians have access to the sys- the province of Québec, for example, local tem regardless of income); portability community health centers are involved in (moving from one province to another does such activities as providing referrals to hospi- not change a person's type of coverage); tals and social service agencies and assisting comprehensiveness (all services provided by in the development of support groups. Reha- hospitals-drugs, dressings, rooms, surgery- bilitation and home care services often are are covered, and all physician visits are paid supplied by the health authorities and vol- for by the government); accessibility (health untary agencies. facilities are reasonably accessible to every- Awareness of the importance of health one); and public administration (the system promotion and disease prevention through is directed by the government, not the pri- healthful behavior, a safer environment, and vate health sector, although the provision of patient involvement paved the way for a services rests with the private sector). The reorientation of health initiatives and the federal government refunds the provinces development of new promotion and preven- about 50% of the cost of care. The provincial tion programs. National health concerns governments pay the remainder through also included health care cost increases, an various methods, including taxation, indi- issue common to North America and other vidual premiums, or premiums shared by developed countries; provincial differences employer and employee. in financing long-term and home care; excess The present federal-provincial health hospital capacity; and oversupply of physi- insurance program covers about 97% of the cians. The number of active civilian physi- Canadian population. National health poli- cians, including interns and residents, cies are in accord with provincial and territo- increased almost 33% from 1975 to 1985, rial policies, since they are developed with while the population grew only 11.4%. federal, provincial, and territorial represen- Nonetheless, the geographic and functional tation. Professional medical and voluntary distribution of physicians remains uneven. health agencies contribute substantially to To stimulate interest in practicing in nonur- the formulation and design of health policy. ban areas, many of the provinces have estab- Attention is targeted to groups with special lished incentive programs in collaboration needs, such as the elderly and handicapped. with the federal government and profes- Heart diseases, cancer, accidents, mental ill- sional associations to support undergraduate ness, and chronic diseases are priority issues. and postgraduate medical students in terms There are three levels of service: primary of guaranteed incomes, location grants, and care is available and accessible to all through on-the-job training in rural areas. local family practitioners (in sparsely popu- Canada developed a set of health poli- lated areas, public health nurses provide this cies and orientations, which it released in a 142 Report of the Director 142 Report of the Director strategy document, "Achieving Health for provincial governments, and is designed to All: A Framework for Health Promotion," at protect the public and the environment the first International Conference on Health from industrial chemicals; and the healthy Promotion held in Ottawa in 1986. The doc- cities project involved creating a network ument defines the country's three major that includes the Federation of Canadian health challenges: reducing inequities in Municipalities, the Canadian Institute of health, increasing disease prevention, and Planners, and the Canadian Public Health enhancing abilities to cope with chronic Association, as well as founding a national illness and disability. Public participation, coordinating office supported by the Depart- strengthened community health services, ment of National Health and Welfare. and coordinated public health policy were Canada's international health develop- seen as essential elements in achieving the ment and assistance policies are imple- self care, mutual aid, and healthy environ- mented through various governmental ments needed to meet these challenges. agencies and, increasingly, with the collabo- Collaboration among federal, provin- ration of nongovernmental organizations. cial, territorial, regional, and municipal gov- The priorities and resources for Canadian ernments, together with the efforts of development assistance are determined by private, professional, and voluntary agen- the Cabinet, and funds are channeled pri- cies, has also produced several health poli- marily through the Canadian International cies and initiatives. These include the Development Agency (CIDA). Official national program to prevent driving under development assistance is currently 0.5% of the influence of alcohol, the national AIDS the Canadian gross national product (1988 strategy, the senior citizens initiative, the figures). The Department of National Health national program to strengthen community and Welfare provides technical advice and health, and guidelines to develop mental carries out a well-established program of health policies and programs. These and information and personnel exchange with other initiatives are evidence of the strong developed and developing countries. intersectoral collaboration for achieving PAHO/WHO contributed to develop- health goals that occurred in Canada over ing and mobilizing Canadian resources to the period. As further examples, the federal help make Canadian expertise available to departments of health and labor and the PAHO/WHO and the other Member Coun- Treasury Board announced a policy to tries. It also supports training of Canadian strengthen the existing tobacco control pro- professionals by providing short-term fellow- gram and include smoking cessation as a ships. Some competitively selected Canadi- goal; the Action on Drug Abuse Program ans were provided fellowships for studies to was coordinated by 10 federal departments; increase their understanding of state-of-the- the Canadian Environmental Protection art approaches in fields such as multilateral Act resulted from wide consultation with development, public health, and the bio- environmental groups, industry, labor, and medical sciences.

MEXICO

Despite severe resource limitations, ties, and regulated population growth has Mexico made advances in bettering the been achieved. However, coverage by health health of the population. The majority of services of adequate quality is still insuffi- Mexicans have access to health service facili- cient in marginal urban and rural areas, and PAHO/WHO Technical Cooperation at Subregional and Country Levels 143 in general there continue to be shortages of of the health sector. Agreements and proce- medical materials, equipment, instruments, dures were established to overcome prob- and pharmaceuticals, as well as inadequate lems in training personnel, maintaining funds for their maintenance. Notwithstand- supplies of basic inputs, and conserving and ing the country's accelerated urbanization, maintaining logistical support requirements. the population continues to settle in rural The Secretariat of Health began rehabil- areas, making the improvement of services itating 1,550 health centers and 950 other more difficult. In accordance with the broad health service units, representing 70% of its goal of its health, social welfare, and social facilities. It also added 118 new rural health security policy, the government continued to centers to its services, as well as 94 family promote universal access to preventive treatment units that were transferred from health care. the Mexican Social Security Institute. These The specific national health priorities additional facilities extend coverage to 2,385 during the 1986-1989 quadrennium were to localities with a combined population of one increase the quality of health services; million. redress inequalities in access; modernize and Among the most' important achieve- decentralize the management of the health ments of PAHO/WHO technical coopera- system; ensure adequate availability of tion were the improved administrative and drinking water, sewerage, and sanitation ser- technical capacity of health services opera- vices; and undertake measures to control tion in the states that were decentralized, the environmental pollution. Services Reconstruction Project in the met- PAHO/WHO technical cooperation in ropolitan area, the project to extend primary Mexico was oriented toward developing and secondary health care infrastructures, local health systems and was focused on the reorientation of epidemiologic surveil- seven national programs: the development lance and control toward clustering preven- of health services, disease control, health tive health measures designed to reduce promotion, environmental sanitation, fam- risks, coordination with the Mexico-IDB ily planning, social welfare, and support management improvement project, and sup- programs. port for the environmental health program PAHO/WHO cooperated in the imple- in the prevention and control of air, water, mentation of the 1984-1988 National and soil pollution. PAHO/WHO also lent Health Program and the decentralization of technical cooperation for a project to pro- health services in order to improve their mote efficient water use and control water coordination. Other activities involved loss in Cuernavaca and for the institutional updating the juridical framework within development of the State Commission on which the health sector operates and estab- Tijuana-Tecate Public Services. lishing planning and coordination mecha- The new government administration nisms to avoid duplications and waste of that was installed on 1 December 1988 for resources. Support also was provided for the period 1988-1994 ratified the political consolidation of the national information decision to decentralize the health services, system on health services infrastructure, pro- emphasizing the strengthening of their oper- grams, productivity, control, and impact. ative structure, and intensified actions of sol- Emphasis was placed on strengthening idarity as means of extending coverage and local health systems by increasing manage- improving the quality of life of the popula- ment and decision-making skills at key levels tion served. 144 Report of the Director

PAHO/WHO FIELD OFFICE, EL PASO, TEXAS

The 2,000-mile long United States/ extent of that problem along the border and Mexico border is shared by 10 states that- identified opportunities for future epidemio- despite socio-cultural, economic, and logic research and prevention initiatives, as political differences-also share public health well as barriers to those activities. concerns. During the 1986-1989 quadren- The U.S./Mexico Border Health Associ- nium chief concerns included providing con- ation's maternal and infant risk assessment tinuing education for public health and training improvement project (Project professionals, building information systems MIRAR), funded by the United States Gov- in support of technical projects, and stan- ernment, sponsored workshops on high-risk dardizing reporting procedures for epidemio- pregnancy assessment for lay midwives, aux- logic surveillance of diseases in the border iliary health workers, and nurses on both area. sides of the border. The PAHO/WHO Field Office in El The Carnegie Corporation of New York Paso, Texas, acted primarily as an informa- and Pew Charitable Trust awarded the Field tion coordination center to facilitate the Office a two-year grant for a project on pri- identification of border health projects and mary health care and maternal and child assist in their execution. The projects in health technologies for women, adolescents, which it participated increased in number and children. The project is scheduled for during the quadrennium from 26 to 36 and completion in 1990. addressed key areas of binational concern: In July 1988 testing of a counseling out- maternal and child health, AIDS prevention reach program began in Ciudad Juárez, Chi- and control, substance abuse prevention, huahua. The program collects data and tuberculosis control, hospital administra- carries out health education and promotion tion, and rabies control. programs among women who engage in The Field Office carried out its coopera- prostitution, use drugs intravenously, or are tion activities principally by supporting the sexual partners of I.V. drug users. efforts to obtain and transfer information The Field Office issued six bimonthly, through such means as surveys, research quarterly, or annual health publications and projects, workshops, seminars, publications, established a system to routinely forward and coordination with the mass media. It information on its activities to newspapers, also contracted specialists for short-term radio stations, and state and local public assignments in direct technical cooperation. health agencies. By 1989 the Field Office was Information systems were established for offering 80 courses and seminars yearly, and border maternal and child health projects had sponsored or supported another 70 (including the Perinatal Information Sys- binational technical meetings over the qua- tem), AIDS public education materials, a drennium. It also provided support to border border laboratory network, the University health programs by reviewing or developing Network for 'information exchange, and project proposals and submitting them to other binational technical projects. A survey funding sources. on drug abuse reviewed the nature and PAHO/WHO Technical Cooperation at Subregional and Country Levels 145

UNITED STATES OF AMERICA

The approach toward health issues in also indirectly supports most service pro- the United States of America reflects some grams through contracts with states, locali- of the most basic assumptions of the society: ties, and private organizations. individual rights, individual responsibility, Most of the federal resources available to and an emphasis on private, nongovernmen- the states are in the form of block grants that tal production and distribution of goods and the states use to support their own priority services. Thus, about 60% of health care activities. State health agencies, which have costs are paid by private insurers or the major responsibility for administering these patients themselves, while federal, state, or health activities, vary in the breadth of their local governments finance most of the rest. mandate and their placement within the The provision of health services is over- state government. With guidance from the whelmingly in the hands of the private federal government, state legislature, and sector. outside groups, these agencies set health Decision making and resources are not policy. controlled at one single point in the health The nearly 3,000 local health agencies system. Decisions regarding a provider are also vary in size and responsibility, but generally made by the patient, although mainly provide preventive health services some newer organizational approaches, such such as communicable disease control, res- as health maintenance organizations, limit taurant inspections, and food- and water- choices to some degree. borne disease investigation. Their funding Health planning and management are primarily originates from state and federal highly dispersed among federal, state, and program grants. local entities-both governmental and non- Other entities involved in health plan- governmental. The states are the principal ning, research, and policy development governmental units responsible for public include professional organizations, nonprofit health activities and have in turn delegated organizations formed around specific health responsibility for some health-related issues or diseases, organizations that repre- efforts-particularly the direct delivery of sent specific citizen groups, and foundations health services-to local entities. All states that support health research and programs. are involved in planning and policy develop- These groups seek to influence or support ment, and data collection occurs at federal, specific health issues through encouraging state, and local levels. political action, focusing public attention, The federal government directly sup- and financing health projects. ports activities such as assessment, policy A major planning effort that has drawn making, resources development, knowledge these various entities together has been the transfer, financing, and some delivery of per- establishment of Objectives for the Nation- sonal health care. Its role includes establish- 1990 and the current development of the ment of national health goals and objectives; Year 2000 National Health Objectives, which management of surveys regarding the pub- identify achievable goals for the nation in lic's health status and health needs; conduct specific priority areas. In developing and of biomedical, clinical, and health services monitoring these objectives, the federal gov- research; regulation and inspection of foods ernment has worked and continues to work and drugs; and provision of technical assis- with health-field entities at all levels within tance to states and local health systems. It and outside of government. The objectives 146 Report of the Director have provided a planning tool at the network of hospitals and clinics, and other national level and have guided state health population groups. Federal block grants pro- agencies in setting priorities. vide funds to states for maternal and child The 1990 objectives address reductions health and preventive health programs, as in mortality and morbidity among U.S. citi- well as alcohol and drug abuse prevention zens in five major age groups, focusing on and mental health activities. A federal grant special problems in each group. For healthy program furnishes limited support for com- infants (below one year of age) the goal is to munity health centers for the underserved reduce mortality by 35%, with special focus population. on low birth weight and birth defects. For The federal government sponsors pro- healthy children the goal is 20% fewer grams for graduate education of physicians deaths, with special focus on growth and in primary care, concentrating on family development. The goal for healthy adoles- medicine, general internal medicine, and cents and young adults (ages 15-24) is 20% general pediatrics. In implementing health fewer deaths, with emphasis on preventing manpower plans, two particularly trouble- motor vehicle injuries and alcohol and drug some problems are providing sufficient abuse. For healthy adults (ages 25-64), the health personnel in geographic areas that are target is 25% fewer deaths, with a focus on unattractive practice settings due to insuffi- heart attacks, stroke, and cancer. Lastly, the cient or marginal economic support, profes- goal for healthy older adults (age 65 and sional isolation, or other factors, and over) is to achieve 20% fewer sick days, by financing additional training for health pro- focusing on functional independence and fessionals in a time of increasing competition prevention of influenza/pneumonia. These for funds. The current supply of nurses may goals are supported by 226 measurable objec- be insufficient and a shortfall in the supply tives-set in 1980 to be achieved by 1990- of dentists is projected. Rehabilitation spe- that emphasize many aspects of primary cialists and certain types of public health care. workers are in demand. The approach to Federal-level programs exist to help solving the complex problems of the U.S. assure that primary care services are pro- market for health personnel is to achieve a vided to persons living in medically under- higher degree of coordination in efforts of served areas and to persons with special the federal government, the states, and the needs. The Public Health Service, within the private sector to remove manpower con- federal Department of Health and Human straints on the delivery of necessary health Services (HHS), is responsible for providing services. primary health care services in underserved It is expected that by 1990, 35% of the areas and for the redistribution of health national objectives for the year 2000 will care professionals to areas with shortages. have been met. Revision of the national Although only about 0.2% of the population health objectives for the year 2000 started in lacks access to a practicing physician and 1987, and the final document is expected to 98% of the population resides within 25 be published in September 1990. The revi- miles of a general or family practitioner, sions were necessary because of changing some 35 million persons reside in under- health conditions during the recent qua- served areas, evenly divided between urban drennium. AIDS, for example, has become a and rural locations. matter for serious public health and sociopo- In an effort to close this gap, the federal litical concern. government provides health care to specific Projections made in the fall of 1989 sug- populations. HHS is directly responsible for gest that approximately 390,000 to 480,000 the health care of almost one million Ameri- AIDS cases will have been diagnosed in the can Indians and Alaska Natives, through a United States by the end of 1993, causing PAHO/WHO Technical Cooperation at Subregional and Country Levels 147 between 285,000 and 340,000 cumulative devoted close to $US100 million per year to deaths. The number of diagnosed and such projects in recent years. This amount reported cases is expected to increase each includes grants and contracts to foreign sci- year. Current estimates put the average cost entists and institutions to carry out research of care at $US75,000 per AIDS patient as a part of the NIH extramural research throughout the course of the disease, but program, and funding for over 1,500 foreign cost projections are difficult due to the avail- scientists who work in NIH laboratories. ability of drugs such as AZT and better The regulatory role of the Food and patient care. Drug Administration (FDA) also requires it Health care financing emerged as an to interact with a number of foreign govern- important public concern. While the United ments. It provides technical assistance and States spends a larger share of its gross guidance to other governments regarding national product on health than any other U.S. import regulations and restrictions industrial nation, the system still leaves applied to food, drugs, medical deliveries, many gaps in meeting the needs of the poor, and cosmetics. the elderly, the unemployed, and those who The U.S. Agency for International require long-term care. Approximately 52 Development (USAID) functions as the million of the nation's citizens had their country's main channel for international health care needs partially met in 1988 financial contributions in health and health- through Medicare (for the elderly) and Medi- related areas. In fiscal year 1990, funding for caid (for the poor)-an increase of five mil- USAID's programs in health, family plan- lion people, or 11%, above 1980 levels. ning, child survival, and AIDS prevention These programs have been assisting approxi- in the Americas totals $US85.7 million. The mately one in every five U.S. citizens. USAID health policy continues to stress PAHO/WHO provides technical coop- increasing life expectancy in developing eration to the United States in the form of countries through reduction of infant and fellowships for U.S. health professionals, child mortality and morbidity, as well as and arranges for U.S. nationals who are maternal mortality and morbidity, and use experts in specialized fields to serve as con- of child survival interventions, including sultants in other countries, upon request. broadened coverage of new, basic, and effec- Public Health Service bilateral programs his- tive technologies and improved systems for torically have been the main mechanism of delivery of child survival services. Other pri- HHS cooperation with other PAHO/WHO orities include primary health care, water Member Countries. Within the Public and sanitation, vector control, AIDS pre- Health Service, the National Institutes of vention and control, health care financing, Health (NIH) is particularly active in inter- and research. national cooperation activities, having INDEX

Accidents, 11, 67, 68, 80 Bahamas, 29, 82-84 Acquired immunodeficiency syndrome (AIDS), xiv, 3, Barbados, 50, 67, 85-86 7, 39, 43, 44-45, 47, 63-67, 80, 82, 83, 87, 90, 93, Basic Radiology System (WHO), 27 94, 96, 97, 98, 99, 100, 101, 102, 103, 106, 107, 109, Belgium, 59, 108 111, 115, 116, 131, 132, 134, 136, 137, 139, 140, Belize, 11, 20, 27, 110-111 143, 144, 146-147 Bermuda, 24, 86 Acute respiratory infections, 26, 55, 58, 60, 61, 119 Bibliographic Exchange Service, 42 Administration, 38, 75-78 BIOFORCE (France), 70, 116 Adolescents, health of, 31, 55, 58, 59 Biologicals (see Vaccines and biological products) Adults, health of, 16, 29, 48, 67-69 Biosafety, 26-27 Advisory Committee on Health Research (PAHO/ Biotechnology, 47 WHO), 45, 47 BIREME (see Latin American and Caribbean Center Aedes aegypti, 3, 83, 106, 120 on Health Sciences Information) Aedes albopictus, 3, 96 BITNET, 10, 42 Agency for International Development (see United Blindness prevention, 67, 68 States Agency for International Development) Blood and blood products, 22, 65 Agency for Technical Cooperation of the Federal Boletln de la Oficina SanitariaPanamericana, 39 Republic of Germany (GTZ), 52, 53, 54, 93, 123 Bolivia, 22, 27, 31, 37, 45, 49, 54, 70, 74, 122-124, 136 AIDS (see Acquired immunodeficiency syndrome) Brazil, xii, 12, 15, 16, 18, 20, 23, 25, 26, 27, 37, 39, 45, AIDS Information Exchange Centers, 66 54, 56, 63, 66, 67, 70, 71, 72, 74, 97, 135-136 AIDS: Profile of an Epidemic, 10 British Virgin Islands, 87 Alcoholism, 67, 68 British West Indies, 87 Amazon Cooperation Treaty, 122 Brucellosis, 70 American Association of Retired Persons (AARP), 31, Budget and finance, viii, 1, 2, 5, 6, 7-8, 10-11, 75-76 39 Building fund, 4, 76, 77 American Hospital Association, 18 Bulletin of the Pan American Health Organization, 39 American Medical Association (U.S.A.), 18, 39 American Public Health Association (U.S.A.), 29, 37, 39 Cajanus, 49 American Region Planning, Programming, Monitoring, Canada, xiv, 7, 29, 39, 70, 80, 93, 94, 129, 140-142 and Evaluation System (AMPES), 6 Canadian International Development Agency (CIDA), AMERICARE Foundation, 131 29, 35, 53, 54, 96, 99, 102, 142 Andean Cooperation in Health, xiv, 2-3, 7, 11, 121- Canadian Public Health Association (CPHA), 29, 56, 122 58,60,80,96, 142 Andean Parliament, 122 Cancer, 23, 67-68 Andean Subregion, 22, 31, 54, 67, 70, 71, 121-131 Cardiovascular diseases, 67 Anguilla, 87 CARE, 123 Animal health (see Veterinary public health; Zoonoses; Caribbean Area (see also under each country), xiv, 16, individual diseases) 18, 24, 29, 31, 34, 35, 49, 50, 52, 53, 55, 63, 66, 67, Annual Operating Program Budget (APB), 6 70, 80-107 Anopheles, 62 Caribbean Community (CARICOM), 1, 80, 81, 82 Antigua and Barbuda, 81-82 Caribbean Cooperation in Health, xiv, 1, 2, 7, 11, 80- Arab Gulf Program for United Nations Development 81,82, 86, 93, 94, 97, 100, 102, 103, 106,107 Organizations (AGFUND), 68, 70, 72 Caribbean Development Bank, 52, 53, 81 Argentina, xii, 7, 12, 15, 16, 18, 23, 25, 26, 27, 37, 39, Caribbean Epidemiology Center (CAREC), 12, 63, 66, 70, 71, 132, 133-134, 136 75-76, 82, 86, 87, 90, 94, 101, 102, 103, 106, 111, Argentine hemorrhagic fever, 61, 62 131 Aruba, 100 Caribbean Food and Nutrition Institute (CFNI), 49-51, Association of Schools of Public Health (ASPH, 76,88,91, 101,102, 103, 106, 107, 111 U.S.A.), 13 Caribbean Program Coordination, 35, 93, 101, 107 Australia, 59, 97 Caribbean Public Health Association, 80

148 Index 149 índex 149

Caries, dental (see Oral health) Disabled, health of, 67, 68, 118 Carnegie Corporation, 7, 29, 60, 144 Disasters (see Emergency preparedness and disaster Cartagena Accord, 122 relief coordination; Hurricanes) Cayman Islands, 87-88 Diseases (see specific diseases) CD-ROM, 7, 10, 42, 100 Documentation and information centers, 11, 42-43 Center for Biologics Evaluation and Review (U.S.A.), Dominica, 49, 90-91, 93 22 Dominican Republic, 22, 26, 27, 45, 54, 66, 69, 70, 72, Centers for Disease Control (CDC, U.S.A.), 13, 25, 29, 91-93 54, 59, 70, 72 Drug abuse, xiv, 3, 39, 48, 67, 68, 121 Central America, 15, 20, 21-22, 30, 31, 37, 49, 54, 66, Drug policy, 20 67, 70, 107-121 Drugs, essential, and vaccines, 18, 21-23, 29, 37, 109, Plan for Priority Health Needs in, xv, 7, 11, 21, 37, 118, 121, 132-133, 135 (see also Vaccines and bio- 92, 93, 107-110, 111 (see also under each coun- logical products) try) Central American Economic Integration Bank, 22, 117 Central American Industrial Technology Research Institute, 69 ECO (see Pan American Center for Human Ecology Central American Information System on Women, and Health) Health, and Development (SIMUS), 31 Economic Commission for Latin America and the Central American Institute for Business Administra- Caribbean (ECLAC), xii, xiii, 16, 18, 30 tion (INCAE), 18, 50 Economic crisis, effect on health, xi-xvi, 3, 9, 11, 16, 36 CEPANZO (see Pan American Zoonoses Center) Ecuador, 16, 20, 22, 25, 26, 31, 49, 63, 126-128 CEPIS (see Pan American Center for Sanitary Engi- Editorial service, 39 neering and Environmental Sciences) Educación médica y salud, 37, 39 Chagas' disease, 61 Education (see Health education and community par- Challenge of Epidemiology, The; Issues and Selected Read- ticipation; Human resources development; Train- ings, 10, 13 ing of personnel) Chibret International, 68 Egypt, 59 Children, health of (see Maternal and child health, Elderly, health of, 11, 67, 68 including family planning) El Salvador, 25, 26, 27, 29, 70, 72, 108, 113-114 Children of the Caribbean, 50 Emergency preparedness and disaster relief coordina- Chile, 20, 24, 26, 27, 37, 39, 42, 50, 54, 60, 63, 66, 67, tion, 3, 31, 34-36, 51, 118, 121, 126, 132 70, 71, 136, 137-138 Environmental health, xv, 15, 29, 48, 51-55, 80, 85, 96, China, 135 112 (see also Pollution, environmental) Chronic diseases, xiii, 67, 80 Environmental Protection Agency (U.S.A.), 54 CLAP (see Latin American Center for Perinatology and Epidemiological Bulletin (PAHO), 13 Human Development) Epidemiology, 11-14,30, 68 Clinical technology, 26-28 surveillance, 55, 57, 63, 64, 68, 69-70, 71, 73 Colombia, 15, 18, 20, 22, 24, 26, 27, 29, 31, 50, 54, 60, training in, 13, 38, 63, 68 63, 67, 70, 72, 74, 124-126, 136 Essential drugs (see Drugs, essential, and vaccines) Communicable diseases, 48, 61-63, 66, 96, 131, 132 Essential Drugs Action Program (WHO), 22, 81 Community participation, 28-30, 72 Essential Drugs Revolving Fund for Central America Computer systems, 7-8, 10, 35, 42, 43, 75, 100 (FORMED, PAHO), 21-22, 78, 120 Conference and general services, 76 European Economic Community (EEC), 7, 60, 70, 71, Conference of Ministers Responsible for Health in the 72,93, 106, 108, 110, 111,116 Caribbean, 1, 80 Excreta disposal, 51-53 Consultants, technical, 48, 59, 63, 77 Executive Committee, PAHO, viii, 1, 4, 76 Costa Rica, xiv, 18, 21, 23-24, 25, 26, 27, 29, 39, 42, 50, Expanded Program on Immunization (EPI), xiv, 22, 56, 66,67,70,71,108, 109, 111-113 57, 58, 74, 78, 82, 90, 95, 97, 103, 106, 115, 116, Country Representations, PAHO/WHO, 6, 10-11, 30, 126, 128, 129, 131, 138 43, 75 Revolving Fund, 22, 75, 100, 101 Cuba, xiv, 18, 24, 26, 27, 39, 42, 54, 60, 67, 69, 70, 88- Expanded Textbook and Instructional Materials Pro- 90, 97, 135 gram, 38, 58 Cysticercosis, 61, 71

Family planning (see Maternal and child health, Decentralization (see Local health systems) including family planning) Democratization, xi, xiv, 9, 15 Fellowships program, 4, 38, 102 Dengue, 61, 62 Field Office, PAHO/WHO, El Paso (Texas), 144 Denmark, 7, 108, 109 Filariases, 61, 62 Dental health (see Oral health) Finance (see Budget and finance) Diabetes, 67 Financial management, 5, 7-8, 11, 75 Diarrheal diseases, xiii, 29, 51, 55, 58, 59, 60, 61 Finland, 7, 108, 109 Directing Council, PAHO, viii, 1, 2-4, 30, 32, 49, 56, Finnish International Development Agency, 119 62, 76 Fluoridation of water and salt, 23-24 150 Report of the Director 150 Report of the Director

Food and Agriculture Organization of the United Hurricanes Nations (FAO), 69 Gilbert, 5, 31, 35, 51, 99 Food and Drug Administration (FDA, U.S.A.), 23, 147 Hugo, 3, 31, 35, 82, 87 Food and nutrition, xv, 4, 37, 48, 49-51, 60, 80, 96, Joan, 5, 31, 71,117 109, 129 Hydatidosis, 71 Food protection, 69-70 Hygiene, household, 51, 53 Foot-and-mouth disease, 48, 69, 71, 72 France, 7, 49, 80, 81, 90, 93, 102, 108 French Antilles, 91, 93-94 Immunization (see Expanded Program on Immuniza- French Guiana, 91, 93-94 tion) India, 59 Infants, health of (see Maternal and child health, General services, 76-77 including family planning) German Development Bank, 123 Information and public affairs, 35, 43-45, 66 Germany, Federal Republic of, 7, 70, 80, 97, 108, 126 centers (see Documentation and information centers) Global Program on AIDS (WHO), 63, 64, 66, 82, 87, coordination, 7-8, 77 91, 93, 101, 102 management and dissemination, 27, 30, 39-43, 48, Goiter, endemic, xv, 24, 50, 123 53, 58, 62 Governing Bodies, vii-viii, 1-4, 5, 6, 32, 39, 47, 55, 67, systems, 6, 10, 15, 24-25, 31, 39, 41-43, 50 76 Institute of Nutrition of Central America and Panama Grenada, 26, 94 (INCAP), 49-51, 60, 76, 109, 111, 113, 114, 116 Guadeloupe, 93-94 Institute of Women (Spain), 30, 31 Guatemala, 15, 20, 23, 26, 29, 63, 69, 70, 108, 114-115 Instructional materials, 16, 17, 20, 22, 29, 31, 34-35, 38, Guyana, 7, 24, 95-97, 136 44,51,54,58,59,60,68,70 Inter-Agency (PAHO/WHO-FAO-UNICEF) Food and Nutrition Surveillance Program, 49 Haiti, 27, 49, 63, 70, 91, 97-99 Inter-American Association of Sanitary and Environ- Headquarters, 76-77 mental Engineering (AIDIS), 51 Health communications, 43, 44-45, 63 Inter-American Development Bank (IDB), 6, 7, 14, 16, Health Conditions in the Americas, 14, 30, 61 20, 21, 49, 52, 53, 54, 56, 58, 60, 62, 70, 71, 83, 84, Health economics, 39, 141, 147 85, 92,93,98, 99, 105, 108, 110, 112, 116, 120, 123, Health education and community participation, 18, 124, 129, 131,134, 140, 143 28-30 Inter-American Institute for Cooperation on Agricul- Health information, xiv, 12-14, 49-50, 63, 66 ture (IICA), 30 Health legislation, 15, 17, 21, 30-31, 54, 69, 84 Inter-American Meetings, at the Ministerial Level, on Health personnel (see Human resources development) Animal Health, 69, 76 Health planning, 14-17, 48, 58, 68 International Agency for Research on Cancer (IARC), Health policies development, 9, 14-17, 30, 48 67-68 Health programs development, 48-74 International Atomic Energy Agency (IAEA), 27 Health promotion, 18, 28, 48, 63, 67, 68 International Bank for Reconstruction and Develop- Health services ment (IBRD), 123, 134, 140 development, 9, 16, 17-21, 24, 30, 47, 48-74, 121 International Center for Research on Women, 49 organization of, 141, 145 International Classification of Diseases (ICD), 14 research, 21, 47, 48 International Decade for Natural Disaster Reduction, Health Services Research Bulletin, 21 35-36, 132 Health Services Research Foundation (U.S.A.), 21 International Dental Federation, 25 Health situation and trend assessment, 9, 11-14, 60, 63 International Development Research Center (IDRC, Health systems infrastructure, 9-47 Canada), 21, 29, 52, 54, 106 Health Training Program for Central America and Pan- International Drinking Water Supply and Sanitation ama (PASCAP), 37-38, 60, 109, 111, 113, 114 Decade, 52, 129 Helminthiases, 61 International Red Cross, 66 Hemispheric Foot-and-Mouth Disease Eradication International Union for Health Education, 28, 29 Committee, 71 Intersectoral and interinstitutional coordination, 34, Hepatitis, viral, 61, 62 37, 55 (see also Social security institutions, coordi- Hipólito Unanue Agreement, 2, 121 nation with health sector) Honduras, 15, 16, 29, 69, 108, 109, 116-117 Iodine deficiency disorders, 49, 50 (see also Goiter, Hospitals, xv, 18, 20, 22, 34 endemic) Human growth, development, and reproduction, 55, lodization of salt, 24 59, 60 Italy, 7, 35, 59, 60, 80, 97, 108, 110, 114, 124, 126 Human immunodeficiency virus (HIV), 23, 25, 26, 64, 65, 66 Human resources development, 9, 13, 15, 23, 24, 25, 34, Jamaica, 15, 20, 23-24, 29, 35, 50, 51, 63, 99-100 36-39, 59-60, 80, 101, 108, 109 Japan, 7, 34, 35, 59, 70, 108, 126 Human resources system, 8, 77-78 Japanese International Cooperation Agency, 34, 54 Index 151 índex 151

Joint Commission on Health Services Accreditation, 18 WHO Resources in Direct Support of Member Joint (PAHO/WHO-UNICEF) Nutrition Support Pro- Countries," 79 gram, 49, 102, 103, 129 Martinique, 93-94 Maternal and child health, including family planning, xiv, xv, 24, 29, 32, 37, 48, 49, 50, 55-61, 80, 95, 97, Kellogg Foundation, W. K., 7, 20, 24, 60, 137, 138 98, 102, 103, 110, 121, 123, 129, 137, 144 Kingdom of the Netherlands (see Netherlands, King- Measles, xiv, 55 dom of the) Medicine, traditional, 25, 135 MEDLARS, 42 MEDLINE, 50, 63, 92 Laboratory animal science, 69, 71, 74 Mental health, 31, 39, 67, 68 Laboratory services, 22-23, 26-27, 62, 69, 72-73 Mérieux Foundation, 70, 72, 116 Latin American Association of Faculties and Schools of Mexico, 11, 15, 16, 18, 20, 24, 25, 26, 27, 31, 37, 39, 42, Medicine (ALAFEM), 37 49, 56, 63, 66, 69, 70, 136, 142-143, 144 Latin American Association of Faculties and Schools of Midlife and Older Women in Latin America and the Carib- Nursing (ALADEFE), 37 bean, 31 Latin American Association of Social Medicine, 37 Mobilization of external resources, xiv, xv, 6-7, 48, 56, Latin American Cancer Research Information Project 60 (LACRIP), 67 Montserrat, 35, 87 Latin American and Caribbean Association for Educa- Mortality tion in Public Health (ALAESP), 13, 37 infant, xv, 59, 61 Latin American and Caribbean Center on Health Sci- maternal, 3, 32, 55, 59, 61 ences Information (BIREME), 7, 15, 25, 39, 42, 60 Latin American and Caribbean Health Sciences Infor- mation Network, 39 National Institute of Allergy and Infectious Diseases Latin American and Caribbean Institute for Economic (U.S.A.), 66 and Social Planning (ILPES), 18 National Institute of Occupational Safety and Health Latin American Center for Perinatology and Human (U.S.A.), 85 Development (CLAP), 58, 59, 60 National Institute of Virology (Mexico), 22 Latin American Center on Demography (CELADE), National Institutes of Health (U.S.A.), 25, 39, 66, 74, 14 147 Latin American Development Administration Center, National Library of Medicine (U.S.A.), 42 16 National Organization of Blind Spaniards (ONCE), 68 Latin American Economic System (SELA), 11 Netherlands Antilles, 27, 100 Latin American Health Sciences Literature Data Base Netherlands, Kingdom of the, 7, 59, 100, 108, 109, 114, (LILACS), 10, 15, 39, 92 120, 126 Latin American Network for Epidemiologic Surveil- Nicaragua, xii, 20, 39, 49, 67, 108, 109, 117-119 lance of Food-borne Diseases, 69 Noncommunicable diseases, 67-68 Latin American Network of Drug Quality Control North America, 140-147 Laboratories, 22 Norway, 7, 30, 108, 109 Leishmaniasis, 61, 62 Norwegian Agency for International Development, 119 Leprosy, 61, 62 Nursing, 20 Leptospirosis, 61, 71 "Nutrient-cost tables," 50 LEYES data base, 15 Nutrition (see Food and nutrition) Library (PAHO), 42-43 Nyam News, 49 Library of Congress (U.S.A.), 15 LILACS (see Latin American Health Sciences Litera- Occupational health, 15, 48, 51, 54-55 ture Data Base) Onchocerciasis, Lions Club International, 61, 62 66 Oral health, 23-26 Local health systems Oral rehydration therapy, 50, 55, 59, 61 development of, xiv, 2, 9, 10, 17-21, 24, 26, 28, 47, Organization of American States (OAS), 16, 29, 108 56, 108, 127, 129 Organization of Faculties, Schools, and Departments of research on, 20 Dentistry of the Union of Latin American Univer- sities (OFEDO/UDUAL), 25, 37 "Orientation and Program Priorities for PAHO during Madrid Conference, II, 7, 108 the Quadrennium Malaria, 1987-1990," vii, xiv, xv, 1, 6, 36, 3, 29, 37, 61, 62, 109, 121, 123 79, 82 Malnutrition, 49 (see also Food and nutrition) Oswaldo Cruz Foundation (Brazil), 62, 63 Management Ottawa executive, 5 Charter for Health Promotion, 28 Overseas Development Agency general program development and, 5-8 (U.K.), 22 Managerial process for national health development, 10-11 PALTEX (see Expanded Textbook and Instructional "Managerial Strategy for the Optimal Use of PAHO/ Materials Program) 152 Report of the Director 152 Report of the Director

Panama, 29, 63, 70, 108, 119-121 Reagents, laboratory, 26, 47 Pan American Center for Human Ecology and Health Recomendaciones de la Comisión Internacional de Protec- (ECO), 51, 53-54, 134 ción Radiológica, 10, 27 Pan American Center for Research and Training in Regional Director's Development Program, 5 Leprosy and Tropical Diseases, 131 Regional Operative Network of Food and Nutrition Pan American Center for Sanitary Engineering and Institutions (RORIAN), 50 Environmental Sciences (CEPIS), 51-54, 85 Regional Potable Water Committee (CAPRE), 93, 108, Pan American Federation of Associations of Faculties 110 and Schools of Medicine (FEPAFEM), 37 Regional Training Program in Food and Nutrition Sur- Pan American Federation of Nursing Professionals veillance (PAHO), 50 (FEPPEN), 20, 37 Rehabilitation, 67, 68 Pan American Foot-and-Mouth Disease Center Renal insufficiency, chronic, 16, 67 (PANAFTOSA), 69, 71, 131 Research Pan American Health and Education Foundation grants program, 16, 31, 46 (PAHEF), 126 promotion and development, 30, 45-47, 48, 59 Pan American Sanitary Bureau, vii, viii Residents program, 38-39 Pan American Sanitary Conference, vii, 1-2, 30, 36, 54, Resources Development Institute, 59 69, 76, 77, 79, 80 Rickettsioses, 61 Pan American Technical Standards Commission, 69 Right to Health in the Americas, The: A Comparative Con- Pan American Teleconferences on AIDS (I and II), 43, stitutionalStudy, 84 44-45, 64-65, 66, 76, 136 Rockefeller Foundation, 21, 70, 72 Pan American Zoonoses Center (CEPANZO), 22, 60, Rotary International, 7, 56, 58, 60, 96, 99, 116, 124, 126 69,70,71 Royal Commonwealth Society for the Blind, 68 Paraguay, 15, 49, 63, 70, 136, 138-139 Parasitic diseases, 61-63 (see also individual diseases) Participation, social (see Health education and commu- Saint Kitts and Nevis, 4, 49, 101 nity participation) Saint Lucia, 7, 49, 93, 101-102 PASCAP (see Health Training Program for Central Saint Vincent and the Grenadines, 49, 102-103 America and Panama) "Salud para Todos," 43, 44 Perinatal health, 32, 58, 61 (see also Maternal and child Sanitation, xv, 29, 51-53, 110 health, including family planning) Schistosomiasis, 61 Personnel, PAHO/WHO, 77-78 (see also Staff develop- Scientific and technical information, 9, 39-43 ment and training) Sewerage (see Sanitation) Peru, xii, 15, 16, 18, 24, 25, 26, 27, 31, 34, 39, 42, 49, 52, Sexually transmitted diseases, 63 54, 70, 74, 128-130 Smoking (see Tobacco use) Peruvian Primatology Project, 74 Social security institutions, coordination with health Pew Charitable Trust, 60, 144 sector, xv, 10, 15, 17, 55 Pharmaceuticals (see Drugs, essential, and vaccines) Solid waste management, 51, 53, 110 Plague, 61 South America, 121-140 Plan for Priority Health Needs in Central America (see South American Foot-and-Mouth Disease Control Central America, Plan for Priority Health Needs in Commission (COSALFA), 71 Central America) Southern Cone, 31, 67, 70, 71 Poliomyelitis, eradication campaign, xiv, 3, 7, 44, 48, Southern Cone Health Initiative, xiv, 11, 22, 124, 132- 55, 56-57,60,61 133 Pollution, environmental, 11, 48, 51, 53-54, 110 Sovereign Order of Malta, 70, 72 Population Council, 59 Spain, 7, 13, 18, 26, 30, 31, 39, 42, 51, 69, 70, 108, 116, Portugal, 42 126 Primary health care, 17, 18, 24, 28, 31, 55, 62, 67, 68 Spanish Cooperation, 93 Primary Health Care and Local Health Systems in the Special Meeting of the Health Sector of Central Amer- Caribbean, 18 ica (RESSCA), 54-55, 92, 108 Primates, nonhuman, 71, 74 Special Program for Research and Training in Tropical Procurement services, 78 Diseases (UNDP/World Bank/WHO), 62, 131 Program budget, 2, 6 Staff development and training, 6 Program development, general, 5-8 Staff Rules, 4 Project Hope, 99, 116 Standing Subcommittee on Inter-American Nongov- Publications, distribution and sales, 39 ernmental Organizations in Official Relations with Publications, official and technical, 10, 31, 39, 40-41 PAHO, 4 Puerto Rico, 25 Subcommittee on Planning and Programming, viii, 4, 76 Subcommittee on Women, Health, and Development, Quota contributions, 2, 75 4, 76 Subregional initiatives, xiv, xv, 2-3, 79 (see also under each initiative) Rabies, xv, 48, 69, 70, 72-73, 115 Suriname, 24, 103-104 Radiological technology, 27-28 Sweden, 7, 30, 49, 60, 108, 109 Index 153 mdcx 153

Swedish International Development Authority, 62, 119 United States of America, xiv, 7, 11, 18, 27, 29, 30, 32, Switzerland, 49, 108 35, 39, 42, 54, 67, 68, 70, 74, 93, 108, 109, 110, 144, 145-147 United States Army Research and Development Com- Taeniasis, 61, 71 mand, 62 Technical cooperation, PAHO/WHO, at subregional United States Congress, 14, 66 and country levels, 79-141 United States-Mexico Border Health Association, 144 Technical cooperation among countries, 11 University and Health in Latin America and the Carib- Technology bean in the Twenty-first Century (USALC-XXI), 9, development, 16, 17, 25 37 evaluation, 16 University of Valle (Colombia), 50, 63 rationalization, 67 University of the West Indies, 15, 16, 50, 81, 100, 105 research, 45-47 University of Wisconsin (U.S.A.), 70, 72 Telecommunications, 35, 43, 44-45, 64-65, 66 (see also Uruguay, 16, 25, 26, 70, 136, 139-140 Pan American Teleconferences on AIDS) Tetanus neonatal, 55-58 Tobacco use, 3, 67 Vaccination, xv, 55, 57, 59, 61 (see also Expanded Pro- Training of personnel, xv, 13, 16, 20, 23, 25, 26, 29, 34, 36-37, 38-39, 48, 50, 51, 53, 55, 59-60, 62, 63, 66, gram on Immunization) Vaccines and biological products, 21-23, 56, 62, 70, 71, 71 (see also Human resources development) 72 Translation and interpretation, 75, 76 Vector-borne diseases, 61-63 (see also individual dis- Trinidad and Tobago, 7, 24, 25, 27, 63, 80, 82, 96, 104- eases) 106 Venezuela, 12, 15, 18, 23, 24, 25, 26, 27, 31, 39, 42, 67, Tuberculosis, 61 bovine, 70-71 70, 97, 100, 130-131 Veterinary public health, 29, 68-74, 131 Turks and Caicos Islands, 107 Violence, 11, 67

UNICEF (see United Nations Children's Fund) Union of Latin American Universities (UDUAL), 9, Water supply, xv, 51-53, 102, 110 25, 37 "With Healthy Living," 50 United Kingdom, 7, 59, 85 Women, health, and development, 3, 7, 29, 30-31, 32- United Nations, vii, 35, 114 33, 77 Subcommittee on Nutrition, 50 Advisory Committee of the Director on, 30 United Nations Center for Human Settlements, 18 Regional Program on, 30-31, 32-33, 60 United Nations Children's Fund (UNICEF), 6, 7, 29, Subcommittee on, 4, 76 30, 38, 44, 56, 58, 60, 82, 90, 91, 93, 96, 97, 101, Technical discussions on, 30 102, 103, 106, 108, 110, 111, 116, 119, 123, 124, Workers' health (see Occupational health) 125, 126, 129, 136 World Bank, 6, 7, 20, 29, 37, 39, 52, 53, 54, 62, 70, 97, United Nations Development Program (UNDP), 6, 7, 98, 102, 108, 123, 124, 126, 136 18, 20, 26, 29, 30, 52, 53, 62, 70, 88, 90, 93, 96, 99, World Food Program, 49, 119, 123 107, 108, 114, 116, 119, 121,123, 131, 136 World Health Assembly, 57 United Nations Educational, Scientific, and Cultural World Health Organization, vii, viii, 1, 7, 20, 21, 25, 27, Organization (UNESCO), 18, 29, 95 39, 62, 67, 75, 81, 90, 122 United Nations Environmental Program (UNEP), 131 World Summit of Ministers of Health on Programs for United Nations Fund for the Development of Women AIDS Prevention, 66 (UNIFEM), 30 United Nations Fund for Drug Abuse Control (UNFDAC), 83, 84, 126 X rays (see Radiological services) United Nations High Commissioner for Refugees, Office of (UNHCR), 114 United Nations Population Fund (UNFPA), 6, 7, 29, 30, 31, 60, 93, 97, 98, 99, 102, 107, 108, 114, 116, Yellow fever, 61 123, 124, 126, 129, 138 United Nations University, 50 United States Agency for International Development Zoonoses, 69, 70-71, 72-73, 136 (see also Pan American (USAID), 49, 55, 58, 60, 62, 70, 72, 74, 93, 99, 111, Foot-and-Mouth Disease Center; Pan American 114, 116, 123, 124, 126, 129, 147 Zoonoses Center) Acronyms and Corresponding Agencies or Programs

ACHR PAHO/WHO Advisory Committee on Health Research AMPES American Region Planning, Programming, Monitoring, and Evaluation System BIREME Latin American and Caribbean Center on Health Sciences Information CAREC Caribbean Epidemiology Center CARICOM Caribbean Community CDC Centers for Disease Control (U.S.A.) CEPANZO Pan American Zoonoses Center CEPIS Pan American Center for Sanitary Engineering and Environmental Sciences CFNI Caribbean Food and Nutrition Institute CIDA Canadian International Development Agency CLAP Latin American Center for Perinatology and Human Development COSALFA South American Foot-and-Mouth Disease Control Commission ECLAC Economic Commission for Latin America and the Caribbean (UN) ECO Pan American Center for Human Ecology and Health EEC European Economic Community EPI Expanded Program on Immunization FAO Food and Agriculture Organization (UN) GTZ Agency for Technical Cooperation of the Federal Republic of Germany IAEA International Atomic Energy Agency IBRD International Bank for Reconstruction and Development (World Bank) IDB Inter-American Development Bank IDRC International Development Research Center (Canada) IICA Inter-American Institute for Cooperation on Agriculture INCAP Institute of Nutrition of Central America and Panama LACRIP Latin American Cancer Research Information Project NIH National Institutes of Health (U.S.A.) OAS Organization of American States PAHEF Pan American Health and Education Foundation PAHO Pan American Health Organization PANAFTOSA Pan American Foot-and-Mouth Disease Center PASB Pan American Sanitary Bureau PASCAP Health Training Program for Central America and Panama UN United Nations UNDP United Nations Development Program UNEP United Nations Environmental Program UNESCO United Nations Educational, Scientific, and Cultural Organization UNFDAC United Nations Fund for Drug Abuse Control UNFPA United Nations Population Fund UNHCR Office of the United Nations High Commissioner for Refugees UNICEF United Nations Children's Fund UNIFEM United Nations Development Fund for Women USAID United States Agency for International Development WFP World Food Program WHO World Health Organization A I 00444 UD E RM 001 USF 480 ZIVER, MAGDALENA HSM-L WASHINGTON DC USA

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