Pan American Health Organization

Public Health in the Americas. Conceptual Renewal, Performance Assessment, and Bases for Action. Washington, D.C.: OPS.

Scientific and Technical Publication No. 589

ISBN: 92 75 11589 3

I. Title II. Author

1. Public Health 2. Steering Role of the Health Sector 3. Essential Public Health Functions (EPHF) 4. Public Health Workforce 5. Performance evaluation of health services 6. Techniques for evaluation

Book cover illustration: Gustav Klimt, Hygieia. Work/Art “Medicine”. Ceiling panel for the Magnum Hall of the University of Vienna, 1900–1907. Oil on canvass 430 X 300 cm., destroyed in 1945 in the Immen- dorf Castle. Reproduced from the photographic archives by permission of ARTOTHEK. Hermfeldstrasse 8 D-82362 Weilheim, Germany.

Pan American Health Organization, 2002

Publications of the Pan American Health Organization enjoy copyright protection in accordance with the provisions of Protocol 2 of the Universal Copyright Convention. All rights reserved.

The designations employed and the presentation of the material in this publication do not imply the ex- pression of any opinion whatsoever on the part of the Secretariat of the Pan American Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the de- limitation of its frontiers or boundaries.

The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by the Pan American Health Organization in preference to others of a similar na- ture that are not mentioned. Errors and omissions excepted, the names of proprietary products are distin- guished by initial capital letters. The authors alone are responsible for the views expressed in this Publications. Preface

This book represents the realization sure that people enjoy that “posses- sitions that have altered their epi- of a dream of a work on public health sion” that is universally valued above demiological profiles. The nature of in the Americas that was worthy of all others. the burden of public ill health has being a Centennial publication of the changed. The data show clearly that Pan American Health Organization It is proper and natural in considering it has been the discovery and use of (PAHO). I did not wish this to be a this as a Centennial publication to re- technology that has played a major document that analyzed the data on vert at least briefly to our origins and role in the improvement of the health the characteristics of the health of the the public health of that day. The na- indicators of populations. We have people of Latin America and the Ca- ture of scientific knowledge of 100 experienced the power of technology ribbean. There are other publications years ago made it inevitable that the to add years to life, and in the enthu- that will show in great detail the major concern would be for infec- siasm for the magic of the technolog- health situation and the trends that tious diseases, and the appreciation ical imperative for individual benefit are occurring. Therefore, I am pleased that it was possible to control these we have tended to lose sight of the that we have in this book, a work that through social and sanitary engineer- difference between sick individuals reflects on the context in which pub- ing in the widest sense, was a major and sick populations. The concern for lic health is perceived and practiced development. There was no doubt the health of the public had been con- and sets out the extent to which those about the role of the government in sumed by the fervor for individual functions that are essential to pro- so modifying the environment that care as the miracles of scientific re- moting and preserving the public’s the health of the public would be im- search promised ever greater good for health are being discharged. No text proved. The data PAHO collected individual life and health. on the people’s health is definitive, it were related to infectious diseases and can at best be one of the rivulets that the possibility of informing decisions We were witnesses to the growing join but enrich the stream of think- about quarantine measures. concern in developed countries about ing about one of the most important the state of their public health enter- problems of our time-how to improve But we live in different times. All our prise even in the midst of a veritable the health of our people, how to en- countries have undergone health tran- cornucopia of scientific advances

iii that augured so well for individual and prevent illness, the focus was pre- ing a measure that is useful for our health. The enquiry in the United dominantly on the individual and countries in improving health. States showed a public health system there tended to be neglect of the in disarray and the situation was little health of the public. The organized It is especially gratifying to note the better in the United Kingdom. At- efforts of society were not being fo- emphasis placed here on the acqui- tracted as I was to the working defini- cused on the public’s health. sition of information, the role of tion of public health used in the latter epidemiology in establishing whether study—“the science and art of pre- But in order to determine how these the functions are being discharged, venting disease, prolonging life and efforts should be directed, it is intu- and the definition of systems neces- promoting health through organized itively obvious that there must be sary to measure any change that efforts of society,” I expressed my dis- some measure of the functions that might occur. It is epidemiology that quiet as to whether in our Region we the state must discharge if the public’s forms the bridge between the concern could indeed discern what were these health is to be promoted and avoid- for the individual and the wider pub- organized efforts of society and how able illness prevented. We have lic. PAHO was born out of a necessity they were made operational. Rudolf posited repeatedly that the responsi- for the collection and dissemination Virchow is one of my heroes and bility of the state and that of the gov- of information, and throughout its many of my concerns of today can be ernment are not coterminous, and history there has been steady growth found in his writings. In 1848, as he this book makes it clear that it is not and maturation of the methods and too agonized over the state of public only the government that has the sole systems for carrying out that pristine health, he wrote: and unique responsibility for dis- mandate. Now in PAHO’s 100th year, charging all these functions. But let us this Centennial publication shown “It is not enough for the gov- be clear that there are some that are that provision of information about ernment to safeguard the mere indeed within the nondelegable re- what is upon the people is the first of means of existence of its cit- sponsibility of the government as the the essential public health functions. izens, i.e. to assist everyone principal actor within the state. This certainly speaks to a continuity whose working capacity is not of focus and purpose. sufficient to make a living. The The exercise of measuring the extent state must do more. It must help to which there are essential public This work by PAHO is intended everyone to live a healthy life. health functions and they are being mainly for the Americas, but we This simply follows from the discharged, has been an open and know that it has informed practice in conception of the state as the participatory process as indeed any other agencies and in other parts of moral unity of all individuals exercise of this nature must be. The the world. The spread of any ap- composing it, and from the ob- selection of the functions is a result of proach opens one to wider critique, ligation of universal solidarity.” repeated iterations and consultations but that is healthy. Perhaps we should as a basic premise that in this field say as John Graunt did when he pre- We saw the call for solidarity take there is no absolute truth. It is highly sented the famous Bills of Mortality: shape more recently in the call for eq- likely that there will be others in dif- uity, and this has been a value that has ferent places who will establish differ- “How far I have succeeded in underpinned much of the reform of ent functions as being essential to be the Premisses, I now offer to the health sector that is occupying the discharged in the quest for improved the world’s censure. For herein attention of almost all our govern- public health. But what will stand is I have like a silly Scholeboy, ments. But in the reform movements the concept behind the exercise, the coming to say my Lesson to that sought equity in the delivery of methodology that sustains it and the the World (that Peevish, and services needed to promote health basic and prosaic purpose of provid- Techie Master) brought a bun-

iv dle of Rods wherewith to be of the functions that must be carried I hope you enjoy this Centennial whipt, for every mistake I have out by organized society to ensure the publication of the Pan American committed.” health of the public, nor the meth- Health Organization. ods in applying the tools that have Any mistakes that there may be are been developed in great part by the George A.O. Alleyne certainly not in the conceptualization public. Director

v Contents

Preface iii

Table of Contents vii

Acknowledgment ix

Navigational Chart xv

Part I. The Initiative “Public Health in the Americas” and its Rationale 1 1. The Initiative Public Health in the Americas and the need to improve Public Health Practice in the Region 3 2. The Steering Role in Health and Institutional Strengthening of the National and Subnational Health Authorities 7

Part II. Public Health’s Conceptual Renewal 15 3. Origins and Current Scenarios 17 4. Foundations of the Conceptual Renewal 35 5. Social Practices and Public Health 49 6. Essential Public Health Functions 59 7. Framework for Action to Improve Public Health Practice 71

vii Part III. Performance Measurement of Essential Public Health Functions 89 8. Rationale for the Performance Measurement of EPHF 91 9. Development of the Measurement Instrument 97 10. Measurement Process 109 11. Results of the Measurement of the Essential Public Health Functions in the Americas 123 1. Regional Analysis 123 2. Subregional Analysis 161 3. Major Conclusions From the First Performance Measurement of the EPHF in the Region 225 12. A Case Study in Performance Measurement at the Subnational Level: United States of America 231

Part IV. From Measurement to Action 247 13. Institutional Strengthening for the Performance of the EPHF 249 14. Estimate of Expenditures and Financing for EPHP and Mechanisms for Determining Cost and Budgeting 261 15. Development of the Public Health Workforce 285 16. International Cooperation for Improving Public Health Practice 307

Appendices A. EPHF Performance Measurement Instrument 313 B. Performance Measurement of the Essential Public Health Functions by the National Health Authority in Country X 363

viii Acknowledgments

The Initiative “Public Health in the the Centers for Prevention and Dis- Americas that had some type of direct Americas” has been one of the main ease Control (CDC), of the Depart- involvement in the processes related strategic areas of technical coopera- ment of Health and Human Services to the conceptual and methodological tion sponsored and guided by the Di- of the United States of America, has development, to the application of the rector of the Pan American Health been actively involved. It was offi- instruments to measure the perfor- Organization, Dr. George A.O. Al- cially designated a PAHO/WHO Col- mance of the Essential Public Health leyne, during his second term (Febru- laborating Center during this process. Functions, to evaluate the results of ary 1999–January 2003). The design CDC contributed the time of several the national exercises, and to prepare and general coordination of the Initia- of its staff members, especially that of the different aspects of this book. Fol- tive has been responsibility of the Di- Paul Halverson and “Wade” Joseph lowing are the names of those individ- vision of Health Systems and Services Hanna, and made available their meth- uals who contributed the most to this Development of PAHO, under the odological instruments to measure task. We hope that in our will to ex- direction of Dr. Daniel López-Acuña. the performance of Essential Public press such recognition we have not Dr. Carlyle Guerra de Macedo, Emer- Health Functions, at the state and unintentionally overlooked some im- itus Director of the Organization, has county level. portant contributions. counseled and inspired the develop- The Latin American Center for Re- ment of the initiative throughout its This book, which is the result of col- different stages. The Coordinators of search in Health Services (CLAISS), lective work, describes the Initiative the Program of Organization and based in Chile, also participated ac- developments to date. The prepara- Management of Health Systems and tively in the implementation of the tion of its different sections and chap- Services, and of Human Resources Initiative, particularly involved were ters have been the result of numerous Development, José María Marín, José Fernando Muñoz and Soledad Ubilla. contributions, multiple work ses- Luis Zeballos, and Pedro Brito respec- tively, have managed at different times They are many people who in one sions, and frequent consultations. the multiple tasks related to imple- manner or another contributed to the The authors shared interest is for the menting the Initiative. evaluation of the Initiative tasks sum- book to reflect, to the highest degree marized in this book. It would be possible, a product resulting from The Division of Development and quite a long list to name the over two interdisciplinary and participatory Research of Public Health Systems at thousand public health workers in the consensus.

ix General Coordination Daniel López-Acuña

Editorial Committee Carlyle Guerra de Macedo Paul K. Halverson “Wade” Joseph Hanna Daniel López Acuña José María Marín Fernando Muñoz Soledad Ubilla

Authors The following persons contributed to the discussion and formulation of the chapters in its different stages:

Gisele Almeida Pan American Health Atlanta, Georgia, United States Specialist in Health Information Organization/World Health of America Systems Organization Division of Health Systems and Washington, DC, United States “Wade” Joseph Hanna Services Development of America Deputy Director WHO Pan American Health Collaborating Center for Public Susana De Lena Organization/World Health Health Practice Researcher Organization Division of Health Systems Universidad Nacional de La Plata Washington, DC, United States Buenos Aires, Argentina Development and Research of America Centers for Disease Control Angel Ginestar and Prevention Felix Alvarado Professor Atlanta, Georgia, United States Manager Instituto Universitario Fundación of America Consultores Asociados ISALUD Guatemala City, Guatemala Buenos Aires, Argentina Monica Isabel Larrieu Consultant Natalie Brevard Perry Carlyle Guerra de Macedo Division of Health Systems and Health Scientist Emeritus Director Services Development Division of Public Health Systems Pan American Health Pan American Health Development and Research Organization/World Health Organization/World Health Centers for Disease Control and Organization Organization Prevention Brasilia, Brasil Atlanta, Georgia, United States Washington, D.C., United States of America Paul K. Halverson of America Director Pedro Brito Division of Public Health Systems Daniel López Acuña Coordinator Development and Research Director Human Resources Development Centers of Disease Control and Division of Health Systems and Program Prevention Services Development

x Pan American Health Monica Padilla Instituto Universitario Fundación Organization/World Health Regional Advisor in Management ISALUD Organization of Human Resources Buenos Aires, Argentina Washington, D.C., United States Division of Health Systems and of America Services Development Soledad Ubilla Pan American Health Advisor Sandra Madrid Organization/World Health Interministerial Coordination Physician Epidemiologist Organization Division Primary Health Care Department Washington, D.C., United States Ministry of Health of America Office of the Presidency Santiago, Chile Santiago, Chile Ana Cristina Pereiro José María Marín Chief of Cabinet Advisors Manuel Enrique Vázquez Valdés Ministry of Health Coordinator (since January 2002) Consultant Buenos Aires, Argentina Organization and Management Division of Health Systems and of Health Systems Matilde Pinto Services Development and Services Program Regional Advisor in Health Pan American Health Division of Health Systems and Economics Organization/World Health Services Development Division of Health Systems and Organization Pan American Health Services Development Washington, D.C., United States Organization/World Health Pan American Health of America Organization Organization/World Health Washington, D.C., United States Organization Guillermo Williams of America Washington, D.C., United States Director, Health Services Quality of America Graciela Muñiz Saavedra Ministry of Health Consultant Magdalena Rathe Buenos Aires, Argentina Division of Health Systems and Executive Director Services Development Fundación Plenitud José Luis Zeballos Pan American Health Santo Domingo, República Coordinator (1999–2001) Organization/World Health Dominicana Organization and Management Organization of Health Systems Washington, D.C., United States Horacio Rodríguez and Services Program of America Professor Division of Health Systems and Instituto Universitario Fundación Fernando Muñoz ISALUD Services Development Chief Buenos Aires, Argentina Pan American Health Steering and Sanitary Regulation Organization/World Health Division Arturo L.F. Schweiger Organization Ministry of Health Director Washington, D.C., United States Santiago, Chile Economics and Health Management of America

xi Curator of the English and Technical Revision of the Desktop Publishing Spanish Editions Translations Barton Matheson Willse & María Teresa Gago Manuel Enrique Vázquez Valdés Worthington – BMWW Carrie Farmer Consultant Leroy Stirewalt and James Taylor Paola Morello Division of Health Systems and Baltimore, Maryland, United States Priscilla Rivas-Loria Services of America Patricia Schroeder Pan American Health Christiane West Organization/World Health Edwina Yen Organization Washington, D.C., United States of America

Technical Editor for the Spanish Cover Design English and Spanish Translation Edition Chemi Montes Armenteros Translation Services Roger Biosca Graphic Designer Pan American Health United Nations Editor and Falls Church, Virginia Organization/World Health Translator United States of America Organization Barcelona, Spain

Text Formatting Esther Alva Matilde Cresswell Carol Lynn Fretwell Tomás Gómez Ana Gooch Maritza Moreno

Division of Health Systems and Services Development Pan American Health Organization/World Health Organization Washington, D.C., United States of America

xii Navigational Chart

The following section is designed to In any case, the leitmotif of this work ing of the public health infrastructure give the reader some hints on how to is the construction of an approach in- (Part IV). “navigate” through this book. This is volving: first, an overview that en- because its modular structure allows ables us to view with fresh eyes and Part I presents two gateways or points for different points of entry. The mod- sufficient conceptual and analytical of entry that are particularly relevant ules, while complementary, need not problem-solving capacity the respon- to the understanding of this work. be approached in a linear fashion. In sibilities of state and non-state pub- These are discussed in two chapters, fact, each chapter affords an opportu- lic entities in contemporary work in one in the Public Health in the Amer- nity to begin reading a clearly differ- public health in the Region of the icas Initiative, and the other on entiated unit that can be analyzed Americas (Parts I and II); second, strengthening the steering role of the separately. These individual analyses the possibility of translating this con- health authority. Both offer comple- combine and connect to form a com- ceptual framework into highly prac- mentary dimensions that intersect. plete picture of the topic at hand. tical working definitions, which have That point of intersection is the exer- made it possible to measure the per- cise of the Essential Public Health Readers from the field of public formance of the essential public health Functions by the health authority. Ei- health, from both academia and the functions appropriate to the health ther of the two chapters could have sphere of practice—that is, policy- authority in all the Latin American been used to open Part I of this book, making, management, and health and Caribbean countries (Part III); since they have areas of convergence care—will surely recognize many and third, the formulation and dis- and offer common inferences, and be- signposts that will enable them to cussion of different processes and cause there were positions that sup- enter certain sections directly. Readers instruments that permit a shift from ported both options. After much dis- from different spheres of activity or measurement to action, from the di- cussion, the authors have opted to other disciplines whose link with the agnosis of strengths and weaknesses begin with the arguments that iden- work in public health is less direct, on to improvements in public health tify the raison d’être that they consider the other hand, will require a more practice, focusing efforts on institu- fundamental: the need to strengthen detailed perusal of the chapters. tional development and strengthen- public health practice in the Region

xv and, subsequently, to address the con- mined its evolution. The basic chal- results of its application in 41 coun- comitant challenge of strengthening lenges are identified as well as the tries and territories of Latin America the steering role of the different levels need to ponder on the conceptual and the Caribbean are presented. of the health authority (national, sub- basis in an effort to reorient its prac- Thus, a valuable self-evaluation tool is national, and local), whose basic re- tice. It concludes with a summary of presented that allows the National sponsibilities include the exercise of the most important initiatives that Health Authority to identify the exis- the essential public health functions have preceded the existent one. tent strengths and weaknesses to exer- (EPHF). cise the EPHF as part of its steering In Chapter four the central areas of role. This tool, moreover, facilitates Part II deals with the conceptual revi- public health are revised, as well as its the use of objective criteria in deci- talization of public health. Through- objectives, actors and the distinctive sion-making, which should lead to an out its chapters, it explores the com- elements for its promotion and prac- improvement in public health prac- plex, diverse web in which the tice in the health systems. Public tice. Furthermore, it places the exer- concept was born, nourished, and in health is conceived as health of the cise in the broader context of health which this sphere of action devel- population which is comprised mainly system performance evaluation, at- oped. This is key to promoting an un- of public goods and is a responsibility tempting to bring measurement closer derstanding of the historical path of of society and the State that is to serve to the elements of structure, process, public health, not only among people them. Chapter five provides an in- and results, so that it can impact man- from other fields and disciplines, but depth look at the concept of social agerial decision-making and the allo- among public health specialists and practices and its relationship with cation of resources. other health professionals as well. It public health emphasizing the great will enable them to more fully grasp potential that exists to utilize it for a Finally, Part IV describes some paths the importance of conceptual revital- comprehensive, inclusive and sustain- that must be followed, based on the ization in this field, the relationship able public health practice. knowledge that this tool provides. It between social practices and public leaves the door open to the possibility health, and the origins and relevance Chapter six underscores the impor- of developing new processes and in- of the concept and categories of the tance of its theoretical revision link- struments to meet the challenges that EPHF. ing it to a practical exercise through emerge from this performance mea- the introduction of the operational surement exercise: the need to pay For this reason, in each chapter in- concept known as the 11 Essential greater attention to the institutional cluded in Part II, the concept of pub- Public Health Functions. This is an development of the health authority lic health acquires increasing impor- explicit and precise formula of the and to upgrading the public health tance in an effort to move from fundamental attributes that should be services infrastructure; the impor- theory to practice looking relentlessly the responsibility of the State, par- tance of improving knowledge about for the connection among the two. As ticularly of the sanitary authorities. financing, expenditure, cost analysis, a result, the essential conceptual is- Finally, Chapter seven presents the and budgeting for the EPHF; the im- sues are presented to increase their framework for action. The purpose is perative of resolutely promoting the understanding within the current to identify the necessary elements re- development of the public health global state of affairs, and for their ef- quired to implement the concepts workforce and the possibilities offered ficient implementation at the same and complete the connection between by international cooperation in all these time that reflection and debate on the theory and practice. Thus, in parts III areas. subject is stimulated opening the area and IV, a link between proposals and under discussion for future proposals. actions is sought. The character of this collective work Thus, in chapter three a selective has been inclusive and pluralistic from summary is included on the history of In Part III the basis for the measure- the outset. The authors have at- health and public health which iden- ment of the performance of the Essen- tempted to harmonize the history, in- tifies the basic factors that have deter- tial Public Health Functions, and the stitutional direction, experience, and

xvi different visions of public health They have sought not only to conduct The basic corollary that emerges from found throughout our Hemisphere. a systematic performance evaluation this effort is that we must continue They have engaged in a broad dia- of the EPHF and thereby conclude navigating the new and the old waters logue with experts from the Region the task entrusted to them by the in this exciting and critical area in throughout the preparation of the Governing Bodies of PAHO, but have order to lay a broader, better founda- work and have made the necessary ad- also left room for us to continue ex- tion for the development of health in justments to respond to the individual ploring all that remains to research, to our societies and consolidation of situations of the member countries. learn, to measure, and to transform. human security in our countries.

xvii PART I The Initiative “Public Health in the Americas” and its Rationale The Initiative Public Health in the Americas and the Need to 1 Improve Public Health Practice in the Region

1. Introduction tutional development efforts to improve Reintroducing public health into the public health practice. program for transforming the sector de- The proposed reforms in the public mands that its scope and function be health sector address the need to Health sector reform processes have fo- clearly defined and its basic concepts strengthen the steering role of the cused mainly on structural, financial, applied. For this reason, the concepts health authority. An important part of and organizational changes in the health and methodologies linked with the this role is the exercise of the essential systems, as well as modifications in the EPHF must be developed, for they are public health functions (EPHF) for delivery of health care to the public. Up the wellspring of this instrument’s great which the State is responsible at the na- to now, improvements in health system potential for mustering the will and the tional, intermediate, and local levels.1 performance have targeted the following resources to strengthen the public For the State to fulfill its responsibilities areas: reducing inequalities in health sta- health services infrastructure and the in this area, it is imperative to create in- tus and access to services; health care fi- steering role of the health authorities. struments that will facilitate a situation nancing; reducing gaps in social protec- analysis of the health authority’s exer- tion in health; boosting the effectiveness of health interventions; and promoting 2. The Concept of EPHF cise of these functions. Such an analysis and their Link to Public will identify the strengths and weak- quality in care. However, changes de- nesses of the health authority and thus signed to strengthen the steering role Health Practice and the lay the foundations for concerted insti- of the health authorities and improve Strengthening of the public health practice have received far Health Authorities’ less attention. Aspects related to public Steering Role 1 PAHO/WHO, Essential public health health have largely been neglected, as if functions. Document CD 42/15. The XLII they were not a social and institutional The concept of public health that sup- Directing Council, Meeting of the Pan responsibility—precisely when state sup- ports the definition of the EPHF is that American Health Organization. The LII Re- port is most needed to modernize the in- of collective intervention by the State gional Committee, Meeting of the World Health Organization. Washington D.C., frastructure required for the exercise of and civil society to protect and improve September 2000. the essential public health functions. the health of the people. It is a defini-

3 tion that goes beyond non-personal that represent a contribution to culture action, defined by the object of inter- health services or community/popula- and health practice as both an individ- vention of the action taken. The con- tion-based interventions to include the ual and a social value and the result of cepts are actually linked in practice, responsibility for ensuring access to collective intervention that combines forming a matrix that yields a set of in- services and quality health care. It also with state action in this area. stitutional capacities used in a variety of involves activities to promote health and key interventions. The basic premise is development of the public health work- Likewise, it is important to mention the that if the functions are well-defined force. Thus, public health is not referred difficulty of drawing a clear distinction and encompass all the institutional ca- to as an academic discipline, but rather, between the scope of public health in pacities required for good public health as an interdisciplinary social practice. It the delivery of disease prevention and practice, the necessary infrastructure is a concept that goes beyond the notion health promotion services for specific will be created for the good operation of of public goods with positive externali- population groups—that is, in collective each sphere of activity or key area of the ties for health, since it encompasses interventions—and in the delivery of work in public health. semiprivate or private goods whose di- personal health care. The traditional mensions make their impact on public concept of public health is identified ba- Defining and measuring the EPHF are health an important factor. sically with the first of these dimensions. thus conceived as a contribution to the However, in the second dimension, institutional development of public The concept of public health is fre- there is no doubt that public health has health practice. They are a first step in quently confused with that of the State’s some important responsibilities related developing capacities and competen- responsibility in health, when actually to the guarantee of equitable access to cies. Furthermore, better defining which the two are not synonymous. Public services, quality in care, and use of the functions are essential helps to improve health goes beyond the responsibilities public health perspective in the reorien- the quality of the services and develop a that are the purview of the State, yet at tation of health services delivery. more precise definition of the institu- the same time does not cover all that tional responsibilities necessary for their the State can do in the field of health. In order to restore the concept of pub- exercise. Although the State has a series of re- lic health and place it at the heart of the sponsibilities it cannot delegate in exe- processes aimed at transforming the sys- Moreover, the accountability of public cuting or guaranteeing fulfillment of tem, it is important to typify and mea- entities to the people for the results of the EPHF, they represent but a fraction sure operational categories such as the their work begins with the part that of its responsibilities in health. It is cer- EPHF to determine the degree to which is most inherent to them, the part that tainly a very important fraction whose they are fulfilled by the State at the na- is exclusively their own—not with re- proper exercise is not only fundamental tional and subnational level. sponsibilities that they share with other for improving health and the quality administrative areas involved in general of life of the population, but is part of Thus, the EPHF have been defined as decisions on health policy. The legiti- the State’s steering role in health—a the structural conditions and aspects of macy and power of the health author- role characterized by responsibilities in institutional development that permit ities to bring other actors together to strategic management, regulation, fi- better performance in terms of public devise intersectoral interventions to pro- nance modulation, incurance monitor- health practice. However, as explained mote health therefore increase with the ing, and delivery harmonization. in Part I of the book, in order to reach definition of the essence of their opera- this conclusion, it has been necessary to tions and the capacity for more accurate In addition, many non-state public di- develop indicators and standards for the performance measurement. mensions form part of the universe of EPHF to help characterize the critical action of public health. Thus, there are elements that will make it possible to Performance measurement with respect areas in which civil society promotes identify which aspects of public health to the EPHF should ultimately permit changes in the population that result practice need to be strengthened. This better identification of the resources in an improvement in people’s health. approach complements the definition needed to guarantee an adequate public There are also aspects of social capital of the thematic areas of public health health infrastructure and better analysis

4 of financing, expenditures, costs, and tion and implementation of some na- • Development of a framework for the necessary budgets. This informa- tional, subregional, and regional lines measuring the performance of the es- tion, moreover, is essential for the na- of action that will help to strengthen sential public health functions, appli- tional and subnational governments, as the public health infrastructure and cable to all the countries of the Region. well as the international organizations thereby enhance the leadership of the that provide technical and financial health authority at all levels of the • Support for self-evaluation of public cooperation. State. health practice in each country, based on EPHF performance measurement, Finally, the characterization and mea- The Initiative, promoted by the Direc- within the conceptual and instru- surement of EPHF performance are key tor of PAHO, Dr. George Alleyne, on mental framework developed by the to improving the training of the person- assuming his second mandate in Febru- Initiative. nel that carry out the work in public ary 1999, has been coordinated by the health. This process provides a better Division of Health Systems and Ser- • Support to the countries in identifying foundation for specifying the competen- vices Development and has enlisted the the activities necessary for strengthen- cies required for the exercise of the efforts of all technical units in the Or- ing the public health services infra- EPHF and for identifying the pertinent ganization, as well as the PAHO delega- structure and formulating institu- professional and other staff profiles. This tions in each country. It has also bene- tional development programs that goes hand in hand with improvements fited from the participation of PAHO’s will lead to an improvement in public in training and continuing education in Director Emeritus, Dr. Carlyle Guerra health practice—programs whose public health and will help inspire train- de Macedo, who served as an advisor progress can be evaluated periodically ing institutions to reorient their efforts and collaborator on the project. The through EPHF performance measure- in public health toward greater relevance Initiative has developed the perfor- ment. and quality in their work. mance measurement instruments for the EPHF in collaboration with the • Laying the foundations for a regional 3. Nature and Scope of U.S. Centers for Disease Control and program to strengthen the infrastruc- the “Public Health in the Prevention (CDC) and the Latin Amer- ture and improve public health prac- Americas” Initiative ican Center for Health Systems Re- tice, based on the conclusions derived search (CLAISS). from EPHF performance measure- As mentioned in the two previous sec- ment in the Region. tions of this chapter, in 1999 PAHO The project has also involved many ex- • Publication in September 2002 of the decided to implement the “Public amples of interaction with experts from present book, Public Health in the Health in the Americas Initiative”, with the academic world, scientific associa- Americas, which brings together the the following main objectives: tions, health services, and international different elements and results of the organizations, forming a network that project and provides an overview of • Development of a regional definition has been consulted on many occasions, the degree to which EPHF are being of the EPHF, obtained by consensus thus enriching the conceptual, method- exercised in the Americas. after an extensive debate among ex- ological, and instrumental development perts from academe, the government, of the Initiative. and professionals working in public After the initial call issued by the Direc- health. tor of PAHO, the member countries The scope of the Public Health in the enthusiastically welcomed the Initiative • Development of instruments to meas- Americas Initiative can therefore be and closely collaborated in its different ure their performance as the basis for summarized as follows: stages. This led to a debate on the improving public health practice. EPHF in the 42nd Directing Council • Promotion of a common concept of of September 2000 and the adoption of • Development of the methodology and public health and of its essential Resolution CD 42/18 (see box), which instruments to support the formula- functions in the Americas. urged the Member States to participate

5 THE 42nd DIRECTING COUNCIL, RESOLVES: (b) Carry out, in close coordination with the national authorities of each country, an 1. To urge the Member States to: Having considered document CD42/15 exercise in performance measurement with on essential public health functions; (a) Participate in a regional exercise to mea- respect to the essential public health func- sure performance with regard to the es- tions, using the methodology referred to Taking into account that the Pan Ameri- sential public health functions to permit in Document CD42/15; can Health Organization has implemented an analysis of the state of public health in the Public Health in the Americas initiative, (c) Conduct a regional analysis of the state of the Americas, sponsored by PAHO; aimed at the definition and measurement of public health in the Americas, based on a the essential public health functions as the (b) Use performance measurement with re- performance measurement exercise target- basis for improving public health practice and gard to the essential public health func- ing the essential public health functions strengthening the steering role of the health tions to improve public health practice, in each country; authority at all levels of the State; develop the necessary infrastructure for (d) Promote the reorientation of public this purpose, and strengthen the steering Considering the need for health sector re- health education in the Region in line role of the health authority at all levels of forms to pay greater attention to public with the development of the essential the State. health and to increase the social and institu- public health functions; tional responsibility of the State in this re- (e) Incorporate the line of work on the essen- 2. To request the Director to: gard; and tial public health functions into coopera- Taking note of the recommendation of (a) Disseminate widely in the countries of the tion activities linked with sectoral reform the 126th Session of the Executive Com- Region the conceptual and methodologi- and the strengthening of the steering role mittee, cal documentation on the definition and of the health authority. measurement of the essential public health functions;

in the regional exercise to measure per- country level, articulating it with efforts EPHF in 41 countries and territories of formance with respect to the EPHF and to strengthen the steering role of the the Region of the Americas, based on to use the results obtained to carry out health authority within the framework the performance measurement exercises interventions develop their infrastruc- of the new generation of health sector conducted jointly by the participating ture and improve public health practice. reforms. countries and the Secretariat. The book It also requested the Director of PAHO concludes with a discussion on a num- to support these activities in the coun- The present document outlines the ber of strategic issues for strengthening tries, conduct a regional analysis of the principal conceptual, methodological, the public health infrastructure in the state of public health in the Region, and and empirical developments stemming countries of the Region and, with some adopt EPHF performance measure- from the institutional efforts of PAHO, comments aimed at contributing useful ment and institutional development as which have benefited from the broad insights to lay the foundation for a re- a line of work for improving public and committed participation of the gional program to improve public health practice in PAHO’s technical co- member countries. In addition, it pro- health practice in the Americas. operation programs at the regional and vides an overview of the exercise of the

6 The Steering Function in Health and the Institutional 2 Strengthening of the National and Subnational Health Authorities

1. Regional Scenario in the trend toward the separation of tor, are shifting responsibility for service functions in the system: steering role, fi- delivery, especially personal health care, The reform of the State and the decen- nancing, insurance, purchasing and de- away from the national ministries of tralization of the political, economic, livery of services, as well as the descrip- health. The delivery of public health and social life of the countries have made tion of activities, in some countries, to services and the execution of regulatory the redefinition of institutional roles in one or more public and/or private ac- activities in health are undergoing sim- the health sector a priority in the Region tors or agencies. Consequently, these ilar changes; here, intermediate and of the Americas to guarantee the full circumstances demand greater institu- sometimes local agencies have assumed exercise of the health authority and tional capacity on the part of the health responsibility for these functions to one strengthen the steering role of the State authority to manage, regulate, and carry degree or another, consistent with the in health system performance and the out the EPHF. redistribution of competencies and geo- sectoral reform1 processes. graphic divisions established by the The national ministries of health in the country. The essential health responsibilities of countries of the Region are faced today the State are undergoing significant with new realities in sectoral organiza- Many sectoral reform processes in the changes as a result of a general shift in tion, which have been exacerbated by countries of the Region have been mov- the balance between the State, the mar- the health sector reform processes cur- ing in the direction of the separation of ket, and civil society. This is expressed rently under way. This has led to the sectoral functions, leading to the insti- need for a swift and flexible definition tutional disaggregation of activities con- 1 PAHO/WHO. The Steering Role of the of better ways to improve their capacity nected with the steering role, financing, Ministries of Health in the Processes of to exercise their new steering role in the insurance, purchasing and provision of Health Sector Reform. Document CD 40/13. sector. services. However, most commonly, all XL Meeting of the Directing Council of the five functions are concentrated in a sin- Pan American Health Organization, XLIX Progress in State and sectoral decentral- gle institution, or a small group of insti- Meeting of the Regional Comittee of the World Health Organization, Washington, ization, together with the emergence of tutions, a problematic arrangement that D.C., September, 1997. new actors in the public and private sec- segments the population according to

7 whether or not it belongs to the formal rise in chronic pathologies and the izens and not to greater exclusion, mar- economy and contributes to some form growth of the elderly population has ginalization, and lack of social protec- of health insurance, and its ability to heightened the demand and the need for tion, including protection in health. pay. As a consequence, striking differ- more frequent and complex care, which ences in insurance coverage and service consumes a considerable volume of re- At the dawn of the new millennium, delivery arise. sources. Populations are beginning to the countries of the Region find them- have greater expectations of the health selves faced with an enormous challenge This is compounded by other important, services, demanding higher quality care of growing proportions: to guarantee all longstanding factors. Health services and the use of costly innovative tech- citizens basic social protection in health have not attained a level of development nologies. This has given the State regula- that will help to eliminate the inequali- that can be described as efficient, equi- tion, control, and surveillance functions ties in access to basic quality services table, harmonious, and of good quality. in these areas. However, it does not al- for all people and give excluded social Lack of coordination is a problem, com- ways have the institutional organization, groups the opportunity to receive com- bined with the simultaneous duplication the critical mass of human resources, prehensive care to meet their needs and of efforts and gaps, mainly in personal and the necessary financial resources to demands in health, regardless of their and non-personal service coverage in exercise them. ability to pay. rural areas and among the disadvantaged populations of major cities. The Region today is witnessing an in- In light of these challenges, it is of the crease in its population, combined with utmost importance to strengthen the Exclusion in health and the other side economic stagnation, rising unemploy- steering role of the national ministries of the coin, the lack of social protection ment, growth of the informal economy, of health in the sector, as well as the in health, are characteristic of vast pro- a deepening of absolute and relative leadership of the sector as a whole in portions of the Hemisphere’s inhabi- poverty, and a widening of the dispari- health advocacy and its negotiations tants. The health sector in many coun- ties in income distribution. All of this with other sectors. Leadership is needed tries of the Region has been unable to is causing the economic, social, ethnic, that will enable governments to stay provide full and comprehensive cover- and cultural exclusion in the countries firmly on track to promote the health of their peoples in the midst of the sectoral age to all citizens. Marginal groups with to assume increasingly serious propor- reform processes. no access to basic health services can be tions. At the same time, the current found in virtually every country. At the mechanisms for social protection in In the final analysis, this strengthening same time, urban centers have ex- health that should guarantee the popu- of the steering capacity in the health tremely costly, high-quality services to lation a series of benefits through pub- sector should be guided by the goal of which the majority of the population lic health measures—either through the reducing inequities in health condi- has only limited access. ministries of health or the social secu- tions, within the framework of inte- rity systems—are incapable of address- grated and sustainable human develop- Other significant factors compound the ing the new problems in this area. ment and the elimination of unjust situation: the inefficiency of sector insti- inequalities in access to personal and tutions; structural weaknesses in mana- The current situation in many coun- non-personal health services and in the gerial capacity, which make institutional tries of the Region, especially in Latin financial burden linked to it. development in health management im- America and the Caribbean, is charac- perative; the high cost of care, often as- terized by high economic and social sociated with growing numbers of inter- volatility, a breakdown in governance, 2. Tasks Comprising the ventions with little or no effectiveness; and the alarming growth of poverty and Exercise of the Sectoral and poor quality services with low levels inequity. Now more than ever, this Steering Role by the of user satisfaction. Emerging problems, makes it imperative to ensure that the Health Authorities such as AIDS, are accompanied by other changes introduced in the social sectors, reemerging problems, such as tuberculo- health among them, contribute to the The phenomena outlined in the preced- sis, cholera, malaria, and dengue. The creation of inclusive societies for all cit- ing section clearly point to the need to

8 reconfigure and adapt the responsibili- Figure 1. Sanitary Authority Tasks for the Health Sector ties and operations of the health au- Reform thorities—especially the national min- istries of health—to strengthen their Modulating health Conducting steering capacity, defining the substan- care financing tive, nondelegable responsibilities that are proper to them. Regulating Health Authority Ensuring compliance with This implies building institutional ca- insurance pacity in the following areas: in sectoral schemes management, in the regulating and con- trolling of goods and services connected Fulfilling essential Harmonizing health public health services delivery with health, in the exercise of essential functions public health functions, in the modula- tion of financing, in the monitoring of coverage, in overseeing the purchasing of It should be noted that the range of and consensus-building, and the mobi- services and in harmonizing the delivery competencies exercised by the national lization of the necessary resources to of health care to bring about the changes ministry of health will depend on the carry out the proposed actions. necessary to attain universal and equi- degree of public responsibility in table access to quality health services. health, the degree to which sectoral ac- In order to do this, the national min- tion is decentralized, and the structural istries of health need to develop and/or The changes in the organization of separation of functions in the institu- strengthen their institutional capacity health systems and the nature of the tional structure of each country. to carry out the following activities: work of the health sector, coupled with a growing awareness of the importance In some cases, these functions already a) Analysis of the health situation and of other sectors in improving the health exist in practice or are set out in codes, its determinants, with emphasis on status of the population, have gradually laws, or regulations. In others, new identifying inequities in health con- been defining a series of basic, well-dif- competencies are involved that require ditions and access to services, and on ferentiated functions that, taken as a institutions to strengthen and often the impact on the population’s cur- whole, constitute sectoral regulatory ac- modify their operations, their organiza- rent and future demands and needs; tion. There is a growing tendency to tional structure, and the professional avoid concentrating all these functions profile of their managerial, technical, b) Periodic evaluation of sector opera- in a single institution, as in the past, and administrative staff. tions, institutional operations, and creating instead a series of complemen- system performance, especially in tary institutional mechanisms to carry 2.1 Sectoral Management terms of monitoring and evaluating out the differentiated functions in a the impact and dynamics of the separate and specialized manner. Sectoral management is the capacity of sectoral reform processes; the entities that exercise the sectoral These tasks can be divided into various steering role to formulate, organize, and c) Development of methods and pro- categories and will always be subject to direct the execution of the national cedures for prioritizing health different groupings and alternative in- health policy through the definition of problems, vulnerable populations, terpretations. The proposal that follows viable objectives and feasible goals, the programs, and interventions, based is one of the many ways of establishing preparation and implementation of on the criteria of effectiveness, cost, a taxonomy of tasks for exercise of the strategic plans that articulate the efforts and positive externalities; sectoral steering role. Here, the work of public and private institutions in the is divided into in six major categories sector and other social actors, the estab- d) Formulation, analysis, adaptation, (Figure 1). lishment of participatory mechanisms and evaluation of the public poli-

9 cies that impact on health and sec- 2.2 Sectoral Regulation not always have the capacity or re- tor policies; sources to fully execute the types of reg- Some of the sectoral regulation tasks in- ulation and control indicated above. e) Building of national consensus on volved in the exercise of the steering the strategic development of the function are: sector, leading to the development 2.3 Exercise of the Essential of State policy in health; a) Development and refinement of Public Health Functions national health legislation and its pertaining to the Health f) The setting of national and subna- necessary harmonization with the Authority tional health objectives, in terms of health legislation of countries par- health processes and outcomes. ticipating in regional integration If there is one area of action in the sec- These will serve as the basis for co- processes; toral steering role that cannot be ig- ordinating the work of public and nored it is the exercise of the essential private actors in the sector and for b) Analysis, sanitary regulation, and public health functions proper to the developing guidelines for efforts to oversight of basic markets allied health authority, especially those with improve public health practice. with health, such as public and pri- high positive externalities for the health vate health insurance, health service of the population and/or that constitute g) Direction, involvement, and/or mo- inputs (such as drugs, equipment, public goods in the field of health. bilization of sector resources and and medical devices), health tech- actors and those of other sectors nologies, mass communication in- Exercise of the steering role in health that influence the formulation of volving goods and services related to involves substantive, nondelegable tasks national health policy and actions health, and consumer health prod- on the part of the national or subna- to promote health; ucts, as well as sanitary conditions tional health authority. These are funda- in public establishments and the mental to the work of the ministry of h) Health advocacy; environment; health as the agency responsible for safe- guarding public well-being in health. i) Promotion of social participation c) Analysis, technical regulation, and These functions can be delegated to or in health; oversight of health service delivery, shared by several levels and institutions certification, and professional prac- within the state apparatus, but the pri- j) Coordination of the technical, eco- tice in health, as well as training and mary mission of the national ministries nomic, and policy assistance that continuing education programs in of health is to ensure that they are exer- multilateral and bilateral agencies the health sciences; cised as effectively as possible. devoted to technical and/or finan- cial cooperation in health can pro- d) Establishment of basic standards This section delves no further into this vide for the formulation and im- and guidelines for health care; devel- topic, since the subsequent sections that plementation of national health opment of quality assurance pro- constitute the bulk of this book are policies and strategies; grams; formulation and application devoted to the conceptual and method- of frameworks for the accreditation, ological underpinnings that have pro- k) Political and technical participa- certification, and licensing of insti- duced a regional consensus on 11 essen- tion in regional and subregional or- tutional service providers; and tial public health functions considered ganizations and agencies for policy health technology assessment. to be the purview of the national health coordination and economic inte- authority. These sections also measure gration of relevance to the health Many of these tasks are performed in the performance of these functions in sector, to promote greater sensitiv- some extent but must be improved and more than 40 countries and territories ity in these entities to the health in- broadened to fully meet the objective of the Region and discuss the lessons terests of the population and the safeguarding health as a public good. learned from that exercise in order to health sector. Moreover, institutional structures do take action to improve public health

10 practice and reinforce the infrastructure to eliminate the segmentation of insur- An important part of these sectoral that makes it possible. ance coverage and health service deliv- changes in health are the reforms in the ery produced by differentiated financ- scope and modalities of social security 2.4 Sectoral Financing Tasks ing systems (public services not linked health coverage. This dimension of sec- to specific contributions; compulsory toral change has not always reached the The structural separation of sectoral social security-type health insurance most disadvantaged population groups. functions characteristic of the sectoral plans, paid for with subscriber premi- Thus, there will be a real opportunity to reform processes in the Region shows ums; mutual aid societies or obras so- turn this situation around if progress is three major trends in financing. ciales; and private health insurance or made in the design, implementation, prepaid health plans) imply new chal- and evaluation of innovative mecha- The first is the creation of autonomous lenges and responsibilities for the min- nisms to expand the coverage of social national funds independent of the min- istries of health in the organization of security in health, targeting groups that istries of health. These funds pool the fol- sectoral financing. do not participate in the formal sector lowing resources: the public revenues of the economy or have the financial from general taxes; specific taxes for These developments in sectoral financ- wherewithal to subscribe to the custom- health purposes, when they exist; and ing give the ministry of health responsi- ary social security health plans. workers’ and/or employers’ contribu- bility for: a) establishing the policies tions, when steps have been taken to needed to ensure that the different fi- New formulas must be found that rely merge the social security health funds nancing modalities have the necessary more heavily on the social capital of ex- with general State appropriations for this complementarity to ensure equitable cluded groups; that attempt to rational- purpose. This can involve a single public access to quality health services for the ize the regressiveness of out-of-pocket insurance system or several insurance sys- entire population; b) smoothing out expenditures in health, which today tems, public or private, that either com- and correcting any deviations that may impose a greater financial burden on pete with or complement one another. occur in sectoral financing, and c) de- households and the most disadvantaged veloping the capacity to oversee the sec- population; that take advantage of com- The second trend is an increase in the toral financing process. munity mechanisms for cooperative or- share of public sector financing that ganization to find responses to comple- comes from the taxes collected by inter- 2.5 Responsibilities ment the social protection in health mediate-level and local State entities in Insurance currently offered through state inter- and/or from resources of the national ventions and the social security health fiscal authority, transferred from the The countries of the Region are im- systems, which, regrettably, do not central government as block grants ear- mersed in intense processes of change in cover all citizens. marked for activities in health. the institutional organization of their health sectors, in the structure of health The degree to which the social security The third trend is related to the growing care delivery, and in the systems for fi- health system is developed in each share of private health insurance and nancing it, which together have come country (and not just the number or certain prepaid service modalities in the to be known as health sector reform. the coverage of social insurance plans) is composition of global sector financing Implementation of these agendas for what determines the State’s responsibil- in certain countries of the Region— change has opened up an opportunity ity for ensuring a basic package of ser- services that are paid for by the benefici- to move toward equitable access to vices or guaranteed health plan that of- aries themselves and/or their employers, health care. However, to accomplish fers coverage to all inhabitants or special at least with respect to some types of this, it will be necessary to secure effec- population groups (the poor, the el- coverage that supplement the compul- tive coverage for excluded groups, par- derly, etc.). When this responsibility ex- sory plans established by the State. ticularly those working in the informal ists, it generates a role ordinarily re- sector of the economy and those who served for the ministries of health or The combination of these three ele- are marginalized for cultural, ethnic, some of their deconcentrated agencies: ments in countries that have taken steps and/or geographical reasons. that of guarantor of the insurance es-

11 tablished. For this, mechanisms are poorly developed in the ministries of stalled capacity in a rational and com- needed that permit the fulfillment of a health of the countries of the Region plementary way and to define basic social mandate often found in the and their deconcentrated territorial standards for health services to give users countries’ national constitutions. agencies. This implies the particular a reasonable guarantee of quality in the need to intensify actions to foster services they receive. A second element that has a bearing on progress in this area. this dimension of the sectoral steering 3. Institutional role is related to the public, private, or 2.6 Tasks in Health Service mixed nature of the service providers Delivery Development of National that participate in the compulsory cov- and Subnational Health erage plans. Health service delivery is perhaps the Authorities for Exercise sectoral function that has undergone the of the Steering Role Thus, the ministries of health in coun- most pronounced changes in the coun- tries in which this separation of func- tries of the Region over the past two The preceding section’s review of the tions is under way or has been consoli- decades. This is the result of two simul- tasks involved reveals numerous chal- dated must develop the institutional taneous phenomena: first, the decentral- lenges. There is a considerable lack of framework required to perform the ization and/or deconcentration of sector consistency between the new functions task. They must therefore broaden their activities, particularly those related to of the national ministries and their range of capacities to enable them to: the delivery of public health services and structures, competencies, and profes- personal health care; and second, grow- sional profiles. What they do have in a) Define the content of the guaran- ing private sector participation in health this area is more appropriate to the teed basic coverage plans that must care delivery, either to implement the functions currently exercised by the in- be available to all citizens covered guaranteed coverage offered by public termediate, local, or regional entities, by social security health systems or social health insurance, or to operate which are responsible for the delivery of that are public in nature; private insurance or direct, out-of- personal and non-personal services and pocket, fee-for-service plans. for the exercise of certain health author- b) Monitor the administration of these ity functions. plans by public and private health With varying degrees of deconcentra- insurance and/or service delivery in- tion, the ministries of health were long Given the decentralizing, deconcentrat- stitutions (directly or through the accustomed to directly managing the ing, or privatizing trends that currently supervisory authorities or similar delivery of public health services and characterize the organization of the sec- agencies), guaranteeing that no ben- personal health care through the hospi- tor, the ministries of health need to as- eficiary of the compulsory social se- tals and outpatient clinics of their own sume a series of new tasks, which can be curity health plans is denied insur- service networks. They are now delegat- summarized as follows: ance for reasons of age or preexisting ing or have already delegated this re- conditions; sponsibility, having fully or partially a) Define the criteria for allocating transferred these competencies to inter- the resources to be channeled to c) Enhance the purchasing power of mediate levels of government (states, the decentralized or deconcen- public and/or private health ser- departments, or provinces) and/or the trated public agencies and/or facili- vices through group plans, when local level (municipios or cantons), or ties that provide personal and non- public insurance is involved, to to decentralized autonomous regional personal services. In so doing, it ensure delivery of the guaranteed agencies devoted exclusively to health is important to utilize the criteria packages of services or coverage service delivery. of need, performance, and impact. plans offered by the current social Resources can be allocated through security health systems. Exercising the steering role thus poses direct transfers from the ministry the challenge of properly orchestrating of health or from the ministries of These three aspects of the exercise of the the many public and private service economy, finance, or the treasury, steering role in insurance tend to be providers to take advantage of their in- based on well-defined criteria; 12 b) Harmonize the plans of action and It is also necessary to design and execute istries of health, coupled with adequate management models of the decen- a complete and ambitious transforma- financing of the level of effort required tralized or deconcentrated public tion of the structures and functions of to faithfully execute the basic tasks de- agencies responsible for health ser- the ministries of health in order to scribed in the section above. vice delivery in the country; adapt the technical capacity and exper- tise of their staff at all levels to the new It is often assumed that this whole task c) Define the content of the basic demands and realities. An analysis of exists or must exist without realizing public health services that are the outcomes and processes will enable the that behind it must be the capacity for purview of the State, and, based on ministries of health of the countries to organization, a critical mass of human the criteria of complementarity, dis- initiate and move forward with the resources trained for this purpose, and tribute competencies and resources transformation of the steering role in the financial resources and public health among the different levels of public health required by sectoral reform. infrastructure that make it possible. administration (central, intermedi- ate, and local) that must assume However, in order to spearhead the ac- Finally, two thoughts on the exercise of them; tions to improve health and become the the steering role by the health authori- full embodiment of all the competen- ties are worth considering: d) Furnish technical cooperation to cies of the national and subnational the decentralized or deconcen- health authorities, the ministries of First, the modern steering role in health trated service providers to guaran- health must consolidate their institu- is not simply the development of the tee a streamlined process for the tional capacity for the effective exercise ministry of health’s leadership in sec- transfer of authority and the devel- of the steering role. toral matters and advocacy to convince opment of the necessary institu- other sectors to take part in improving tional capacity for the full exercise This is not simply an issue of gover- health. Nowadays it is necessary to of their functions; nance in health, although that must be think in terms of shared leadership considered to understand the political among the different levels of govern- e) Define mechanisms for the redistri- economy involved in the exercise of the ment with responsibilities in health, es- bution of current and capital ex- sectoral steering role and, to a certain pecially in countries with a federal penditures to compensate for any point, develop it. It is a complex issue structure or in confederations of au- inequities that may be generated by that requires a clear will to action, tonomous communities. Increasingly, the decentralization processes; backed by political mandates and gov- what is involved is state health pacts ernment authority. whose corollary must be territorial f) Establish mechanisms for hiring or management and coordination of the for service management agree- Exercise of the steering role in health competencies of the local, intermediate, ments that will serve as the basis for demands an imaginative effort by the and central health authorities, both de resource allocation, based on a se- State, in an intense dialogue with civil jure and de facto. ries of performance measurements society, that will result in specific meas- expressed in terms of processes and ures to guide progress in the sector and Second, a neutral steering role is incon- outcomes. correct the imperfections of the health ceivable. Behind the act of governing, systems; that will make it possible to directing the efforts of the sector, con- The tasks enumerated above establish meet the basic objectives of protecting ducting activities in health, building a the national ministries of health as the and improving the health of individu- consensus between the State and civil harmonizers of the work of the decen- als; and that will guarantee equitable ac- society, are social values that plot the tralized or deconcentrated public agen- cess to health services, regardless of the course. These values are not personal in cies that act as service providers rather ability to pay. nature, but public and collective; they than the direct administrators of service have to do with the demands that soci- delivery—a definition that demands All of this requires good organization, ety places on the legitimate, constituted the rapid development of new institu- which often involves a profound reen- public authorities. In this regard, espe- tional capacities. gineering of the current national min- cially within the framework of the pro- 13 found social and economic inequities equities—in access to health care, in the have a redistributive function, anchored that characterize our Hemisphere, it is financial burdens that people must bear in solidarity and aimed at combating very difficult to conceive of an effective to gain access to health services, and in poverty and meeting the millennium steering role that does not seek to im- the health conditions of the population. development targets. prove social cohesion, that does not It is very difficult to conceive of an ex- make its goal the reduction of in- ercise of the steering role that does not

14 3 Origins and Current Scenarios

1. Health and Public between the spirit, soul, or mind and the chances for specific interventions, Health through the Ages the body. Another, and no less impor- while medicine became an area of tant one, is the notion of the relation- knowledge and a profession. Prevention The fear of death and of life-threatening ship between the health of the individ- took on greater relevance, as it became situations can be traced back to the very ual and that of the social group to possible to associate disease with impu- origins of society. Consequently, a tribe’s which he/she belongs. rity or dirtiness; thus, the concept of hy- need to defend and protect its members giene emerged as the first organized re- against multiple threats was what kept With the dawn of agriculture came new sponse in health protection. Moreover, it united. In a world without scientific patterns of material and social organiza- there was growing recognition of the en- knowledge, disease was explained as the tion that revolutionized public health: a vironment’s role in health and disease. punishment of gods and spirits for the more reliable food supply and better This idea helped give rise to the mias- sins of the individual or group, whereas protection against environmental fac- matic theory of disease, complemented health was regarded as a blessing or re- tors brought with it, no doubt, a spec- by the humoral theory of body func- ward for virtuous behavior. tacular improvement in health status tions. Individual and collective health over that of the pre-agriculture era. was improved through a kind of assimi- Prevention was achieved through virtue lation with beauty, art, and care of the and cure was the result of magic. This As humankind’s knowledge of nature body. period of magic and myth gave rise to increased so did its potential for ra- many health-related beliefs and values tional explanations and scientific health This model of development was already that have lasted, with some changes, for interventions. Beliefs begin to be sup- present in prehistoric societies, as evi- generations, centuries, and even millen- plemented with reason, and philosophy denced in the historical record of differ- nia. These are still significant today began to transform itself into the culti- ent civilizations. and, at times, fundamental. One of vation of knowledge. these inherited concepts with major According to the Etruscan inscriptions, repercussions for society has been the Natural explanations began to emerge dating back to the beginnings of histori- acceptance of the duality and the union for health and disease, thus increasing cal records (5000/6000 B.C.), the prac-

17 tice of curing was already established as corpses, thus precluding the develop- It is against this marvelous backdrop, a socially significant activity; the Code ment of knowledge in the areas of this explosion of human creative genius, of Hamurabi (3000 B.C.) mentioned anatomy and pathology. that Hippocrates (460–380 B.C.) and physicians, and in ancient Egypt, medi- his collaborators authored the wondrous cine acquired a defined position and its However, in Greece a true revolution in Hippocratic Collection (Corpus Hip- own social status, although linked to and knowledge occurred that also encom- pocratum) on medicine and health. The regulated by religion. Imhotep (2980– passed health. Building on Babylonian importance assigned to observation and 2900 B.C.) was the first physician to be and Egyptian foundations, and perhaps logic in diagnosis and treatment was far confirmed by history (18 centuries be- also those of China and India, Hellenis- more than just the basis of semiology fore Aesculapius) and the Ebers and tic civilization laid the groundwork for and remedy research; it was also the ori- Smith Papyri were the first known med- the transition from magic to science. In gin of epidemiology and the study of ical texts, the former consisting of a list health, this change began with the myth public health. Indeed, the text on Airs, of remedies and prayers and the latter a of Aesculapius (circa 1200 B.C.), the Waters, and Places explores human ecol- surgical textbook. Health was no longer god of medicine, who was also a physi- ogy and the relationship between health viewed as exclusively magic. The ancient cian. Temples doubled as therapeutic cen- and living conditions, laying the founda- Egyptian society’s food systems (silos ters where, in addition to the role of faith tion for the integral view of the patient in and distribution) and concerns about in curing the sick, health was restored his/her environment. This text also intro- the environment and the body can also through diet, therapeutic baths, and ex- duced the term’s epidemion and ende- be viewed as public health measures. ercises, often preventive in nature. Op- meion, referring to the presence of dis- portunities for observation began to be ease in the community. The reach of Meanwhile in the East, the Chinese fig- pursued, although primitively, as were Greek culture expanded with the cam- ure Fu Nsi (circa 2950 B.C.) was Im- attempts to make use of accumulated paigns of Alexander the Great and was hotep’s contemporary. The Nei Ching, knowledge. However, it was not until incorporated in Greco-Roman civiliza- the internal medicine classic of Yellow the 4th and 5th centuries B.C. that phi- tion. The medical school founded in Emperor Huang Ti (27th century B.C.) losophy, drawing on this greater individ- Alexandria (300 B.C.) was both a prod- was also written around the same time ual and institutional freedom of uct of and participant in that process, as the Egyptian papyri. The yin and thought, created the necessary climate which was already emphasizing the im- yang, or cosmic theory of complemen- for a qualitative leap in knowledge. portance of the basic sciences of medi- tary opposites, appearing proportion- Empedocles (5th century B.C.) built cine. Good examples in this regard in- ally in the human body and generating on the theory of the four basic elements clude Herophilus in the field of anatomy balance—health—and imbalance—dis- of the universe—fire, air, water and and Theophrastus in physiology. ease—emerged as the first known at- earth—with his hypothesis of the dif- tempt at a general and universal expla- ferent fluids or humors found in the Overall, the most specific contribution nation that was not strictly religious in human body. The grand contributions of ancient Greece to the field of public nature. of the different schools of philosophical health is found in the areas of hygiene thought, such as those of Socrates and and the physical culture of the human The sacred Vedas of ancient India (circa Plato, culminated in the work of Aristo- body. Health and beauty are confused 2000 B.C.), particularly in the Ayurveda tle (who was also a biologist), and cov- with one another and hygiene becomes system of medicine, include explanations ered almost all areas of knowledge. associated with well-being and physical of health and magical cures recorded by These contributions established the es- prowess. Dhanvantari, the god of medicine. How- sential characteristics of scientific knowl- ever, the Vedas also reflect an awareness edge as well as the intellectual and basic Rome succeeds Greece. Medicine was of the symptoms and signs of disease and instruments for its production and vali- expanded and affirmed by proponents prescribe treatments to cure them (espe- dation (the Organon). Moreover, they fa- such as Aulus Cornelius Celsius (30 cially herbal remedies). Moreover, reli- cilitated an understanding of the natural A.C.), Asclepiades (120 A.C., an oppo- gious customs in both China and India world and of man (physics and meta- nent of the humoral theory) and Galen prohibited any cutting or mutilation of physics), as well as his behavior (ethics). (160 A.C.), the latter of whom became

18 the prototype of the traditional physi- over social forces, filling the voids left by new scientific and productive transfor- cian. Rome’s contribution to public decadence and restricting freedom. mations. The revival or strengthening health is even more important. Prior to Magic once again prevailed over science; of values such as reasoning and free- that time public health had not been Providence over action, salvation of the dom, captured by illuminism, posi- distinguished from the field of medicine individual soul over cares of the body tivism, and subsequently, utilitarianism and only occasionally contemplated, and concern about the population. Con- and liberalism, broke down many of the most notably during health calamities, sequently, public health lost its recently barriers to human creation and led to a and was practiced by the same actors. acquired identity and medicine remained new social order that promoted the ex- Rome moved to differentiate the con- stagnant—or even lost ground—as it pansion of knowledge and the urban- tent of public health from that of medi- was relegated to isolated practice in a ization of agrarian societies due to in- cine. Thus, key measures, such as the handful of monasteries or by closely dustrialization. The ensuing impact on development of a common water sup- watched practitioners or the lower social health was impressive and multifaceted. ply, urban sanitation, hygiene and re- classes. fuses disposal systems, public baths, hos- The adverse effects of the grinding pitals, and public assistance to patients, Progress occurred under the relative lib- poverty in urban slums and mining was established to protect the health of eralism of Islam, including Avicenna’s towns during the initial stage of indus- the population. In many instances, such work in the field of chemistry and the trialization were widely offset by the as- measures became part of the legal frame- creation of modern public hospitals. sociated political advances and progress work, specific institutions were created Moreover, there was progress in the in the area of knowledge. for their development, and they were al- East: India’s Brahman period (800 most always adopted as social practices. B.C.–1000 A.C.) evidenced develop- With respect to the social sphere, the ment of the Caraka Samhita and the extremes of the new productive regime In each historical experience of the an- Susruta Samhita, which reinterpreted provided ample incentives for the emer- cient world, health was always associ- humoral theory by incorporating the gence of real socialism, social democ- ated with the values embraced by soci- spirit and made headway in dietary and racy, and the welfare state, and conse- ety and backed by the institutions medicinal treatments; in China, medical quently, for reforming capitalism, responsible for representing them, as materials, moxibustion, and acupunc- improving representative democracy, well as existing knowledge, in order to ture were developed. And by the end of and the rule of law. They also led to an explain and intervene in life. The the period (16th century), the Chinese understanding of the relationship be- progress resulting from the predomi- pharmacopeia, the “Ben Cao Gang tween health and living conditions. nance of positive values and the corre- Mo,” was published. However, in the Moreover, this expansion of productive sponding social institutions, from their West, advances were also being made forces encouraged a scientific revolution capacity to act (i.e. knowledge and with respect to health calamities and that is still under way, fueling the means), and from effective leadership, other critical situations, including the growth of knowledge and technology. was accelerated in situations of global leper’s code of the Third Lateran Coun- change. Thus in the historical context, cil (1179) and introduction of the con- The advent of microbiology reinforced progress occurred relatively slowly in cept of quarantine during the bubonic the foundations of hygiene, replaced ancient Egypt and civilizations of the plague epidemic of the 14th century, the miasma theory, established a direct East and faster in the Greek and Greco- which developed despite the predomi- causal relationship between disease and Roman civilizations. nance of miasmatic theory. its agents—etiology—and at the same time that the discoveries were being In the 1300 years that followed the 2nd The Renaissance and mercantilism, made in the physical sciences, paved the century, the prevalence of values aimed which revolutionized creativity in the way for the control of specific commu- at promoting conformity and limiting arts and “globalized” the world, also nicable diseases and the development of creativity limited the development of changed the social order, laying the medicine. Thus, microbiology ushered the field of health. In the West, reli- foundations for a new Cultural Revolu- in a new era of medicine and public gious dogmatism again exerted control tion for humankind, and by extension, health.

19 However, the most revolutionary changes and a desirable form of government. the first two international sanitary con- have occurred only in the past 300 These “suprastructural” manifestations gresses were held in Paris during 1851 years, as a culmination of the progress responded to accelerated transforma- and 1859, followed by others until the begun centuries earlier. The huge toll tions in the means of production, Office of Hygiene and Public Health exacted by the Black Plague of 1348 through transformations that upheld was finally created in 1907. In the Re- brought about the acceptance of natural the principles of the private ownership gion of the Americas, the first two in- causes for the disease and led to the in- of the means of production and the ternational sanitary conventions be- troduction of surveillance systems and bases of the market economy and in- tween Argentina, Brazil and Uruguay quarantine measures. With these steps, dustrialization, which were comple- were held in Montevideo in 1873 and public health started down a long road mented by liberal-democratic political 1884, respectively, while a third took toward reacquiring its identity. During regimes. The ideological context and place in Rio de Janeiro in 1887. These the 17th century, Girolamo Fracastoro productive basis stimulated creativity, meetings were the precursors to the first demonstrated the contagion principle, conflict and change. Pan American Sanitary Conference thus creating conditions for debate on (Washington, D.C. 1902), which created the idea of prevention. The closing This transformation continued and ex- the Pan American Sanitary Bureau. years of the 18th century witnessed the panded during the 19th century, result- development of the first vaccine (small- ing in a true health revolution. Scien- This process of constant, accelerated pox; Jenner, 1779) and the pioneering tific medicine was reaffirmed through change reached its climax during the brilliance of Johan Peter Frank and his experimentation (Claude Bernard) and 20th century. The opposing forces of method for a complete medical policy, microbiology (Pasteur and Koch). Eng- the capitalism that was dominant at the which states that governments should land’s Poor Law Commission submitted time gave rise to conflicts in the world be responsible for the health of their cit- its report in 1838, amending the Eliza- of socialism—such as uprisings, the izens. The exhaustive systematization bethan Poor Law of 1601. Moreover, cold war, and fiascos, as well as eco- that ensued laid the groundwork for the England created its own public health nomic crises and wars that shook the reforms carried out by Bismarck in institute, with other European coun- world. The ideas of people and civil so- 1884, which then became a model for tries following suit during the latter half ciety gradually gained acceptance in so- health services organization. Meanwhile of the century. Health care systems were cial areas such as human rights, citizen- in France, Dr. J.I. Guillotin (1792) suc- organized on more solid institutional ship, and the democratic rule of law. cessfully lobbied the National Conven- foundations, and public health acquired Liberal representative democracy was tion to create a health committee. Some definitive status. During this same pe- acknowledged as the dominant system decades earlier, in 1748, Sweden enacted riod, organizational models for health for legitimizing production based on the first law providing for the manda- and social security services emerged that the market and private initiative. Pro- tory collection of health data, followed have been guiding health care systems ductivity and production flourished, by similar initiatives in other countries. since (Bismarck model). fueled by technology and new forms of Improvements in health information, organization. Wealth, however, was the linking of health to a person’s social The 19th century ended with an explo- concentrated and social inequalities, status (Virchow, Villermé, Chadwick, et sion of progress in the knowledge of both between and within countries, be- al) and scientific advances in fields such communicable diseases (i.e. tuberculo- came more pronounced. as microbiology expanded the scope and sis, malaria, and yellow fever). These methods of epidemiological research, al- advances, together with the need to re- The end of old-style colonialism brought lowing even faster progress in the field duce health risks for international trade about a proliferation of the number of of public health. and the national elite, resulted in inter- independent countries at the periphery ventions targeting specific diseases. In of the exercise of world power. Interna- Generally speaking, the French and turn, these efforts led to improvements tional mechanisms for debate and con- American Revolutions transformed po- in sanitation and hygiene, and more- flict resolution, whether through treaties litical thinking around the world, usher over, underscored the need for interna- or organizations, succeeded in reducing in the return of democracy as an idea tional cooperation in health. Indeed, the chances of war with the potential for

20 world destruction, but by the same principles of the Washington Agreement, Public Health Service was created, from token, had the effect of maintaining a which have been carried out by numer- the Marine Hospital Service. large number of low intensity conflicts. ous countries over the past two decades. Scientific and technological output is Despite the successes, in the overall bal- World War I did not succeed in inter- both a driving force and result of the en- ance, the distance between what is possi- rupting this process, but instead offered tire process, providing—sometimes un- ble—not the ideal—and what has been opportunities to develop measures and expectedly—opportunities to satisfy or achieved has increased. This gap results enhance knowledge. In these opening create needs, while giving rise to impor- in the suffering, disability and avoidable decades of the century, the linkage be- tant ethical and social questions. As is deaths that make up the enormous and tween the reduction of poverty and san- the case with wealth and power, knowl- disgraceful social debt in health that, in itary improvements was strengthened, edge is also concentrated and selective, the Region of the Americas, is already and the first schools of public health so the breakdown and homogenization of adding up to approximately 1 million were founded in the U.S. (i.e. Johns culture clash head on with a multiethnic, unjustifiable and avoidable deaths annu- Hopkins and Harvard), and later in multicultural world. ally, as well as millions of years of life Latin America (i.e. São Paulo, Vene- lost. zuela, Chile and Mexico). With this, In terms of health and public health, the public health completed its institutional 20th century witnessed many sensational The history of public health in the 20th development cycle, creating mecha- successes, but also some painful failures. century has been full of ups and downs, nisms for the autonomous reproduction Spurred on by scientific advances, the especially in the Region of the Ameri- of knowledge, techniques and human predominance of positive values, and cas, which is the focus of this analysis. resources. Consequently, nongovern- more effective institutional organization The first three decades of that century mental organizations began to enter the and resources, health care experienced a were a continuation of the movement field of public health. Some even en- dramatic expansion, becoming at once under way at the close of the 19th cen- tered the international arena, exempli- more complex and effective. The health tury, in which the expansion of trade fied by the pioneering efforts of the of populations around the world im- and the capacity to intervene with the Rockefeller Foundation. The American proved rapidly, and we are now able to development of the science of etiology Public Health Association (APHA) was celebrate memorable victories in the stimulated efforts in the areas of sanita- founded in 1872, followed by a number struggle against disease, such as those tion, hygiene and disease control, espe- of other professional and scientific asso- over smallpox and poliomyelitis. How- cially with regard to malaria, cholera ciations with specific concerns, such as ever, enormous social inequalities remain and yellow fever, which held serious tuberculosis and cancer. Meanwhile in with respect to the level of health, expo- consequences for trade and immigra- Latin America, steps were taken to cre- sure to risks, and access to care. tion. Important successes were achieved ate the public ministries of health and in this regard, such as completion of the social security institutions, which con- Health care systems are expanding and Panama Canal (1914), rehabilitation of tinued developing until the 1950s. becoming more complex. Their organi- the Region’s major ports, and the eradi- zation has acquired more diversified ref- cation of yellow fever in Havana and The Russian Revolution (1918) and the erence points such as the state socialism Rio de Janeiro. During the second half arrival of bona fide state socialism altered models of Beveridge, and more recently, of the 20th century, major institutional the world’s political and ideological a number of innovations and combi- development occurred in the United landscape, thus introducing an element nations. Consequently, a great deal of States, where, from the time of the that would prove to be very important to progress is being made in public health, Shattuck Report (Massachusetts), pub- political development in the remaining but there are also failures. While public lic health services were created at the years of the 20th century. health has achieved importance and individual state level. This effectively prestige in some cases, in others it has marked a change in responsibility for The greatest failures of public health in been put aside and shows shameful health, which, up until that time had that period were the limitation of its omissions, such as those observed in the been almost exclusively the domain of practice to sanitary/hygiene conditions cycle of sectoral reforms based on the the local level. In 1912, the Federal and the control of communicable dis-

21 ease despite knowledge of the social di- Latin America experienced prolonged growth and activity in its sphere of ac- mensions of health, and its limited cov- growth and expanded its process of in- tion. By the end of the period, the erage, especially in Latin America. dustrialization and the State’s role in the “Health for All” initiative and its core economy; planning for development strategy of primary health care suc- The 1930s witnessed the rise of Nazism came into fashion. At the same time, de ceeded in increasing public health ex- and fascism, with their assaults on facto regimes replaced budding democ- pectations. However, the strategic vi- human rights, intolerance, and colonial- racies, prompted by the struggle against sion of transforming these efforts was ist aggression that ultimately led to con- communism—a trend that intensified minimized due to an exaggerated em- frontation with the major powers in with the Cuban Revolution. Meanwhile phasis on the first level of care, thus the World War II. This decade also began in the United States, there was a popu- transforming potential of these initia- with the worldwide recession of the lation explosion—the baby boom—and tives was not fully realized. 1930s (the Great Depression in the a great expansion of public health care United States began in 1929), which re- programs; public health services were By the end of the 1970s, the dynamic quired new economic thinking to cope consolidated and strengthened (i.e. factors that fueled growth in the previ- with the crisis, including a call for the NIH, CDC, EPA, and FDA), thus ous period began to lose steam, leading individual states to take on greater re- completing the epidemiological transi- first to the foreign debt crisis in Latin sponsibility, and pointed to the need for tion. In Latin America, a significant ex- America and then to “the lost decade” a new institutional order to improve fi- pansion in the supply of personal health of economic growth, the 1980s. During nancial stability. This provided the mo- care services was consolidated, thanks the 1970s and 1980s, the United States tivation for creating the institutions of to a major reorganization of health sys- and Canada experienced a turbulent the Bretton Woods system at the end tems. Public health consolidated the economic period with high rates of in- of WWII. The 1940s were witness to expansion of its objectives, although it flation, including downturns in invest- WWII, and afterwards, to the creation of remained a second-tier priority of gov- ment, production growth and employ- the United Nations and World Health ernments. Moreover, the most recog- ment, as well as clear signs of unrest Organization (WHO), as well as to a nized achievements of public health among some sectors of the U.S. popula- renaissance of humanism. During this continued to take place in the areas of tion with respect to the problems of period, the sciences experienced extreme communicable disease control and basic racial segregation and the Viet Nam growth, and economic production ac- sanitation, such as the failed effort to War. The failure of communism in the celerated its diversification—in terms eradicate malaria, smallpox eradication, Soviet Union and other countries in- of organization and products—which and the expansion of the coverage of the creasingly led to an easing of Cold War would continue throughout the rest of water supply as well as excreta and tensions, whose symbolic end was the the century and bring about profound waste disposal. Latin America’s popula- fall of the Berlin wall. In Latin America, changes in consumer behavior, living tion reached the apex of its natural health was hit by the economic crisis, conditions, and expectations of the pop- growth thanks to lower mortality and which led to cutbacks in health re- ulation. Although public health contin- high fertility rates, thus accelerating the sources and the negative effects of so- ued to develop, it was increasingly tak- urbanization process. The Region ad- cial injustice (i.e. the concentration of ing a back seat to health care. justed to the increase in chronic dis- wealth, and the unjust and avoidable eases, while coping with high incidences disparities that the previous growth pe- The period of the 1950s and 1960s began of communicable disease and vitamin riod had not significantly addressed). with a sense of peace and unity after the deficiency disorders. There was a prolif- Political violence reached critical pro- tragedy and barbarism of WWII, which eration of public health schools and in- portions in some areas and common were subsequently replaced or altered by stitutes, which began to work together violence rose. Then, public health took the ideologies of the Cold War. Neverthe- in efforts to coordinate and exchange on a new dimension: peace. Accord- less, it was a period of renewed Pan- information. ingly, emphasis centered on the social Americanism and regional cooperation, dimension of health, by demonstrating especially after the critical phase of Euro- The Pan American Health Organiza- its relationship to development. A host pean reconstruction. tion (PAHO) experienced continuous of other actors become concerned about

22 health, as did international cooperation profusion of ideas from illuminism, util- in this chapter, the current and future for health, particularly the international itarianism, and liberalism, which had challenges in the field of public health development banks such as the World such a big impact on politics (i.e. the will be examined, while Chapter 4 ad- Bank and the Inter-American Develop- French Revolution, the nature and or- dresses the new conceptual underpin- ment Bank, as well as NGOs and civil ganization of the State, the Napoleonic nings, with a view to achieving more ef- society associations. Code, representative democracy and fective practice in public health. capitalism, and other societal transfor- The failure of bona fide socialism and the mations) reached the sphere of public In short, in the past few centuries, the economic crisis of the 1980s prompted a health with considerable delay. The combination of values—although only return to liberalism—or neoliberalism— mechanisms responsible for transform- partially taken from humanism and sol- whose basic principles are reflected in ing general ideas into public health prac- idarity—with the expansion of knowl- the so-called “Washington consensus.” tice were developed slowly, whether edge and public institutional reorgani- This led to the promotion of a series of with respect to knowledge, techniques zation, has pushed health and public health sector reforms, which occurred or institutions. Public health remained health into a process of even more rapid simultaneously and/or complemented restricted to the miasmatic theory and, change, leading to spectacular suc- other economic and state reforms. Yet in practice, to limited actions targeting cesses. At the end of the last century these reforms did not show a great deal hygiene and the control of epidemics. and into the present, the control of en- of concern for public health; on the con- The Industrial Revolution and the ensu- demic disease has been pursued, with trary, in some cases the already weak in- ing urbanization process helped to speed the additional incentive of commercial stitutional infrastructure of public health up the change. The 19th century arrived interests and the concern of the elite services was further marginalized. How- with an expanded vision of health and about protection. This led to consider- ever, progress was made in several areas: its relationship to social conditions, un- able efforts in environmental sanitation the expansion of coverage for some ser- dermining the dominance of miasmatic and vector control, following the sani- vices; polio eradication; greater partici- theory, which was finally discarded, with tary model. pation by the health sector in the strug- the proof of microbial etiologic agents. gle for peace and social participation in Throughout the first half of the century, The scientific foundations of medicine the “redemocratization” of countries op- the main public health paradigms tar- have been strengthened and made more erating under totalitarian regimes dur- geted the social dimension, especially effective, and health care has expanded ing the previous period; emphasis on living and working conditions. By the rapidly, largely due to performance health promotion; and growing recogni- end of the century, the resulting social evaluation, the demands of workers, tion of the importance of health for sus- reforms and institutional reorganiza- and the growth of social security sys- tainable human development. The last tion—the State and insurance systems— tems. This expansion has brought med- decade of the century played out amid were superceded by the practice of spe- ical care closer to public health, also the new process of globalization and a cific etiology and its control. In practical understood as a process of organizing growing consensus on the need to re- terms, the new public health interven- health care delivery, whose costs and consider, review, or improve on the tions were, as in the past, centered on growing complexity demand a collec- “Washington consensus” and many of the definition of regulations and the tive response. However, the conflicts its effects, a topic that will be discussed monitoring of compliance and inspec- and injustices persisted, and even in- further on in this chapter. tion. The 20th century began under the creased, during the process. The State influence of the same paradigms, em- created and strengthened its health Beyond simply recovering its identity, phasizing concern about sanitation and agencies, yet the assistance it provided public health has undergone profound the control of specific diseases. Concern varied from country to country and changes in the last three centuries about society, as well as the organization over time. Scientific progress supplied (XVIII XIX and XX) years in terms of and management of health services, more and better intervention instru- its conceptual underpinnings and im- gained momentum in conceptual un- ments; however, most of these involved plementation. In the 18th century, the derstandings, with still more progress personal care. The international organi- “century of the Enlightenment,” the coming after World War II. Further on zations have committed themselves in-

23 creasingly to health. And more recently, 2. Present Context over, did not provide room for denial or global financing and regional institu- objection, since such acts would be con- tions have come on board. The concept The different components of social life sidered deviations from good behavior of health is becoming increasingly com- have never been as interconnected as and punished with exclusion from the prehensive and expansive, moving be- they are today. This interconnectivity is established order. These promises have yond the boundaries of medical care found in all aspects of human life and either not been kept or have been selec- and even those of the so-called health has increased with the development of tively kept—generally at the expense of sector. Although institutionalized prac- national societies and global society. An the developing countries. After 15 years tices do not adequately reflect this all-encompassing vision is increasingly of adjustments and reforms, most of knowledge, particularly in the develop- necessary in order to understand the these countries in Latin America and, ing world, the necessary conditions are parts in that unique space of what is generally, others throughout the world, nevertheless in place to evaluate these universal or abstract, of what is specific seem to find themselves in a relatively practices and the concepts implied with or concrete. Health, which is deter- worse situation today. In some cases, respect to the new realities. mined and also explained in this con- countries are absolutely worse off than text or contexts, is no exception. before. Globalization, however, has in- Some basic conclusions can be drawn Among the several approaches in this filtrated all dimensions of life, creating with respect to this overview of the his- regard, we have intentionally narrowed new situations and conditions that ap- tory of health and public health: our focus in this document to the fol- pear to be permanent, or at least, to lowing four sets of interrelated yet dif- have long-lasting effects. 1. Health and public health are social ferentiable phenomena that reflect the and historical constructs. immense complexity of the current real- Below are some aspects particularly rel- ity and its implications for health and evant to living conditions and health, 2. Their nature is cumulative and public health: globalization and its which primarily affect the Latin Ameri- changing throughout history. manifestations; political processes; the can and Caribbean countries. environment and the population; and 3. Progress in health is made through necessary development. a) Science and Technology the combination of values incorpo- rated into social practices, with the 2.1 Globalization and Its Globalization is based on unprece- expansion of knowledge and its ap- Manifestations dented progress in science and technol- plications and the creation of a pub- ogy. Productivity and competitiveness lic institutional infrastructure that Globalization stands as a substitute for are based largely on that progress, in- promotes synergy among them. the geopolitical bipolarity and ideologi- cluding improvements in management cal confrontation of the Cold War years. that have reduced the importance of the 4. The concurrence of politically signif- As a form of victorious expression, it is traditional comparative advantages as- icant interests (economics, groups, imposed in absolute terms as the indis- sociated with natural resources and etc.) during stages of expansion putable road to a new world order and as cheap labor, since the principal strategic and/or changes in the social produc- the sole doctrine for the organization of input is knowledge, technology, or in- tion process, together with adequate production, imposing market liberaliza- formation. This fact further encourages leadership, increase the power of this tion in all areas and on a global scale. the selective concentration of research combination of factors. The advantages and promises of adher- and technology development toward ing to the principles and guidelines of solving the problems of the core coun- The following sections provide more in- the “Washington consensus” implied a tries; toward market preferences, to- sight and detail regarding some of the new era of world progress, the fruits of ward fields that provide greater profit fundamental components of health at which were to be shared by all. Those potential, and it also favors the present, as well as the current and fu- promises appeared to be solidly rooted in strengthening of intellectual property ture challenges facing public health. a macroeconomic rationale that, more- protections. This hinders access by poor

24 countries to the resulting services and seminated universally, resulting in cul- expanding democracy and strengthen- technology products, thus increasing tural breakdown and promoting a cer- ing the rule of law. Thus, information their dependency on the core countries. tain degree of cultural homogenization. can be used to evaluate the cultural di- Moreover, all of this is sanctioned in This is a process of critical importance, versity and identity of nations, which is multilateral agreements. However, sci- although it has yet to be fully assessed. indispensable to their ability to build ence and technology are also promises their own futures, working together for of social redemption if put to the ser- The explosion of information and ad- a unified and just humanity. vice of human development and the val- vertising has broadened consumption ues that sustains it. Consequently, these habits, which are the expectations and c) The Market, the State, and Society inputs are critical factors for progress in behaviors required by markets. This is health and should be applied in ethi- accelerating the pace of a large-scale In keeping with the principles of the cally and socially correct ways. Informa- cultural breakdown, capable of destroy- new world order, the three entities listed tion and technology constitute essential ing or substituting values and diminish- in the title of this section appear in elements for the development of public ing cultural diversity and identity. The order of their importance. The market is health; since they expand its effective- result is a loss of moral and ethical pa- affirmed, despite its occasional imper- ness and capacity for intervention, pro- rameters for the sake of a materialistic fections, and has sufficient virtues to vided they are appropriate and used in a hedonism, whose models lie far beyond provide all the necessary answers. The rational manner. the reach of poor societies. Cultural role of the State is to facilitate market breakdown and unmet expectations are activities by creating favorable condi- b) Information and Culture important determinants in the origins tions for its full operation, while ab- or incentives of socially destabilizing staining from intervention, except when One of the basic instruments of global- behaviors, including self-aggression, ag- warranted by market interests or in very ization, in both the modern and post- gression toward others, and mistrust. specific situations. And society is the modern era, is the enormous expansion On a collective scale, the replacement of substratum through which the market of the information and communications positive values such as solidarity and co- and State exist and are justified, and media, including transport media. In operation by other interests contributes thus should be organized and act ac- fact, today’s economy and all the con- to the corruption, domination, and cordingly in the hope that in the final veniences of modern living are possible marginalization of the weak. In other analysis, the market-State alliance will due to the extraordinary capacity for words, freedom without control of the also prove to be socially beneficial. Nev- managing information—compiling it, powerful in society amounts to a denial ertheless, the obvious limits and the fail- processing it, using it, and disseminat- of justice and fundamental human ures of the extreme liberal—or neolib- ing it for different purposes and circum- rights for many. The risk of social frac- eral—model have led to the realization stances. Today’s virtual realities parallel tures increases with the development that there is a need to modify some of factual realities and are increasingly re- of the behavioral sciences, which offer its characteristics. placing them. More financial capital due more powerful analytical tools and in- to the speed of its universal circulation, terventions in that area. A strong State with the capacity for bal- the expansion of markets through the anced regulation reduces excessive in- marketing of expectations and represen- As in other fields of science and tech- stability, uncertainty, the undesirable tations of real, derivative, and future as- nology, information can also be the destructive effects of competition, and sets, and Internet transactions represent most powerful instrument of liberation, untempered private interests. Further- the very essence of current globalization. as well as of individual and social more, the State should also have the ca- The strength of that process reaches all progress; it can facilitate individual and pacity to effectively meet its state obli- sectors of human society, exerting influ- collective training and the building of gations (i.e. defense, public safety, and ence over culture, values, and the prac- citizenship, as well as social participa- justice), provide the necessary incen- tices that form society. Values that can tion and control in the public sphere, tives for private enterprise, and create be exploited for market purposes are dis- which are essential for deepening and the conditions to address complex so-

25 cial needs that involve major uncertain- privatization of public enterprises and markets—has still not been achieved in ties and externalities in circumstances delivery of services, often done with the most countries. where market mechanisms have serious immediate end of obtaining additional imperfections, such as in education and fiscal resources to subsidize financial d) Inequities and Injustice health. This contributes to stability, le- capital through debt servicing and con- gitimization of the political regime, tract guarantees. The reorientation of The inequities between countries and improvements in the distribution and the State toward fulfilling its own “spe- within developing countries themselves exercise of power, as well as the cific functions,” including its social re- are increasing visibly. The initial distrib- strengthening of the market itself, and sponsibilities as well as health, has ei- utive effects of successful stabilization by extension, the sustainability of the ther not been done or done with many policies are offset many times over by the process. But this review should go far- limitations. In many cases, in fact, the social injustice of regressive macroeco- ther and deeper. It is increasingly recog- capacity of the State has been under- nomic policies, and those that place spe- nized that a system of positive values, mined in these areas by the devaluation cial emphasis on capital. According to expressed in organized social relation- and demoralization of public service, the Wolfensohn,1 without taking China ships and practices and backed by solid, lack of incentives for public employees, into account, in the 10 years between effective institutions (social capital), is heightened uncertainty, and the slash- 1991 and 2001, the number of poor in essential for market expansion, well- ing of resources. It is interesting to note the world has increased by at least 100 being, and the development process. that the claims of a State with no role in million. Inadequate growth or recession production activities that private mar- increases unemployment and reduces Moreover, the management of goods ket initiative does a better job, do not wages; with the reduction in income, whose generation, use, benefits, and pro- apply to financial intervention: despite relative poverty (and in some cases, ab- duction are destined for regional or the resources obtained from privatiza- solute poverty) increases. This situation worldwide consumption—known as tion and an increased tax burden, the brings about an increase in the need and global public goods (i.e. knowledge, peace, public debt has swelled in most coun- demand for public services—including some natural resources, international tries; debt servicing has greatly reduced health services—precisely at a time when regulations and standards, and aspects of the power to allocate resources for social public response capacity has fallen. health)—requires international coopera- spending and has also compromised Poverty, inequality, and social exclusion tion, which is virtually impossible with- their economic futures, particularly as a threaten the stability of the new order out the input of capable governments. result of external dependence. and thus, gain priority in the discourse. Hence, the major social entities men- This increases possibilities for change tioned in the title are placed, at the very Another dimension, perhaps more im- with a social orientation and a human least, on equal footing, opening up the portant than scaling back the public face. Social inequalities between coun- possibility of their proper re-articulation: role of the State, is the decline in its in- tries are, for the most part, unjust and the primacy of the society served by its fluence as an agent of social cohesion avoidable and affect significant segments main instrument or institution (the and as a means of reinforcing a sense of of the population. Such inequalities are State), and by the principal mechanism national identity. In the case of periph- not only ethically inexcusable as an as- or form of production (the market). eral countries, once the State submits sault on human rights, but also impose to the rules of multilateral interdepen- severe restrictions on the possibilities of Nevertheless, the terms of this debate dence, thereby placing itself in a posi- expanding production and, indeed, on are still in the theoretical phase of de- tion of inferiority, it often gives up the all development. The poor living condi- velopment. For the most part in prac- sovereignty to defend the interests of its tions of those affected by these inequali- tice, the liberal—or neoliberal—concept own people. State reform that seeks to ties constitute the primary risks and still prevails in a more pure form, with safeguard the public interest, democ- health problems of public health. some incidental limitations. racy, justice, as well as national iden- tity—and therefore resist corruption 1President of the World Bank; prologue of For example, the modernization of the and its own “privatization,” and be able The Quality of Growth. PAHO; 2002. (Scien- State has largely been reduced to the to guarantee free enterprise and stable tific and Technical Publication No. 584)

26 e) Management Models includes the intensification of capital tance from central governments are, in and Organizational Tools flows and trade on a worldwide scale in most cases, only a fraction of the amount order to take advantage of productive promised (on average, 0.3 as opposed to Globalization also has an obvious im- opportunities everywhere and increase 0.7 of GDP) and appear to be declining. pact on behavior in all areas—from the production, with a more equitable dis- And worse still, the selective protection- “style” of governance to the managing tribution of profits and protecting our ism practiced by wealthy countries of the programs and productive units of common natural heritage now and in harms poor countries by reducing their social services. The undeniable contri- the future, respecting the essential di- income on the order of US$100–150 bution of business management tools to versity of cultures. This definitely em- million annually. This represents huge public administration is understood as a braces the idea of a single humanity losses—two to three times the volume substitute or universal solution for all with different cultures and complemen- of the cooperation assistance received, problems. In government, the situation tary ways of being and living. which additionally, is subject to diverse of ill-defined public and private func- conditions.2 tions leads to the uncritical adoption of On the other hand, the current model management methods and to a diverse of globalization, which is predomi- The use of global public goods, parti- mix of interests and actors, almost al- nantly geared toward financial and cularly environmental goods, involves ways with disastrous results: corruption, trade concerns, is not contributing to a regressive distribution of costs and privatization of public concerns, insti- this end, but instead seems to be widen- risks to the world’s population living in tutional weakening, social insensitivity ing gaps and divisions. Capital flows poverty. and ineffectiveness. The dogmatic ap- follow highly profitable immediate in- plication of market principles to the or- terests, sometimes with disastrous con- These, as well as other symptoms of the ganization of health care systems has sequences for the weak economies at asymmetrical world power structure resulted in costly and socially painful the periphery, as well as their customs, represent the loss of many opportuni- experiences in the Region of the Amer- social practices and government. Trade ties for reducing poverty, for supporting icas and worldwide. The sectoral re- is governed by a set of asymmetrical real development, for strengthening forms promoted by many Latin Ameri- rules and double standards. Transac- democracy, and for promoting respect can countries in recent decades have tions are liberalized on goods for which for human rights. They stand in the suffered the consequences of that ap- the rich countries have comparative ad- way of a world where all humankind proach, including distortions in health vantages, namely, those of the industrial can live in peace, freedom and safety. objectives, socially perverse subsidies, and service sectors, while transactions In short, globalization has ignored the increased inequalities and real social in markets that poor countries are able importance of social and human capi- costs and, as a result, reduced social ef- to compete in with some measure of tal in the poor countries, the strength of fectiveness of their health systems. In success are protected or restricted, such their cultures, the stability of their in- the case of such reforms, public health as agriculture and mining. Generally stitutions, and the requisite human has either been marginalized or over- speaking, the result in either case is an resources necessary for their compre- looked entirely. increase in the exposure and weakness hensive and sustainable development. of poor countries externally, hence the Consequently, these conditions create f) Missed Opportunities increase of dependency and reduction instability, uncertainty, fear and mis- of the possibilities of development. trust, which is exactly the opposite of There is no humanist who does not what is needed for investment decisions yearn for a united humanity in which Moreover, international cooperation is and a healthy market. opportunities to realize the human po- seriously distorted. At international fo- tential are available to all, where all hu- rums there is no shortage of promises or In addition, all of these aspects have a manity is free to exercise its fundamen- commitments. However, they are subse- negative impact on the development of tal human rights. Globalization, thus quently met only partially, generally only understood, would be an objective wor- when it is convenient for the core coun- 2 Alonso, J.A. “Sin respuestas de Monterrey”. thy of pursuit. Without a doubt, this tries. Flows, transfers, or voluntary assis- Madrid: El País; 3/22/2002.

27 health and public health. Nevertheless, hancing the legitimacy of representa- tire political process, corrupting the many people still adhere to the dogmatic tion and political institutions. representativeness of the representa- belief that the market is the primary tives, who, on numerous occasions, model for health system organization in However, there are troubling signs that literally purchase their mandates to all situations, and that the State should the political process is being affected defend their own interests. only intervene when the market fails or by distortions in current models and is not interested. This belief, which practices: • There is a growing popular percep- tends to overlook market deficiencies in tion that public institutions and the health and the need for public interven- • The totalitarianism inherent in mar- State exist only to serve a few; that tion, puts at risk the indisputable advan- ket ideology, like most ideologies, is the system places too much value on tages of market mechanisms for the pro- controlled neither by the liberal doc- the interests of capital and obeys the vision of many goods and health services trine nor by representative democ- dictates of the market at the expense and as a corrective complement of pub- racy—the political regime that legit- of society and country. That percep- lic action, although always under the di- imizes capitalism. It subordinates the tion includes the meting out of jus- rection, regulation and monitoring of political process to the economic ra- tice, which threatens democracy and the State. tionale and, frequently, to the special the rule of law. Moreover, examples interests that represents it. This inver- abound in this regard. 2.2 The Political Processes sion or subversion of hierarchy be- tween the two camps is facilitated • At the international level, interde- The phenomena mentioned in the pre- through a process of cultural break- pendence often operates asymmetri- vious section are also reflected in the down and the predominance of in- cally against the weak countries, es- political sphere. The great convergence terests over values. This natural cor- pecially at economic forums. The and common ground between eco- ruption affects not only policy, but mandatory or necessary surrender of nomic liberalism and liberal representa- management as well. national autonomy is not sufficiently tive democracy is the greatest strength accompanied by just and effective in- of both processes. Over the past two • Simultaneously, such distortions in- ternational mechanisms that offset decades, almost all countries of Latin crease the legitimacy gap or deficit the disadvantages to the weakest. The America and the Caribbean have up- of the political process to the point imbalance of power reinforces the in- held, returned to or acquired a repre- where there is no correlation between fluence, often directed, of the multi- sentative democratic regime, thus open- decisionmakers and the people af- nationals and financial capital. This is ing channels for mobilization and fected by their decisions. In such cir- a particularly important point in a participation that are indispensable for cumstances, the institutions, authori- “unipolar” world in which the unilat- effective social progress and for the as- ties and their decisions lose the public eral decisions of a dominant coun- sertion of democracy in the Region. trust and, at the same time, hinder try—which are difficult to foresee be- Growth of the non-State public sphere 3 development. Consequently, political cause they are frequently based on accelerated, resulting in a more pro- power becomes more concentrated, national interests and situations, or nounced presence of new and existing placing more distance between society under the nonnegotiable label of “na- social agents. The wide range of direct and the fulfillment of its real needs. tional security interests”—affect all; participation forums, mechanisms and the nonexistence of equitable, univer- initiatives of society and communities • The political parties of some coun- sal standards increases the insecurity reinforces the possibility of expanding tries are merely ad hoc groupings of of the weak and, consequently, of all. and intensifying democracy and of en- personal interests or alliances of convenience that are not guided by • Undoubtedly, all this is much more programs or principles and have a troubling because the normalcy and 3 The term non-State public sphere is under- stood as the nonprofit civil society organiza- vendor-client relationship with the strength of democracy, and of the tions that do not seek to defend special per- population. The social illegitimacy of rule of law, are fundamental for so- sonal or private group interests. their practices contaminates the en- cially responsible economic freedom

28 and for health, especially public “bads” or goods, has a great deal of con- ulation of the past will all but disappear. health. ceptual strength and enormous potential But perhaps the most significant demo- to influence multilateral development graphic change is the rapidly aging 2.3 The Environment policies and international cooperation. population of Latin America, and by ex- and the Population However, this will require extensive de- tension, of the entire Region. The com- velopment of instruments and institu- bined effect of the decrease in birth rates The role of the environment in health is tional reorganization, which the interna- and increase in life expectancy is invert- crucial and, consequently, has been rec- tional community has not demonstrated ing the proportion of young to old and ognized since ancient times. At the same any enthusiasm for taking on. In view economically active to inactive in the time, environmental conditions have of the foregoing, the environment will regional population. The population been priority and irrefutable objectives continue to be a primary source of pyramid of the recent past is rapidly of public health. The experiences of re- health hazards and a key concern both becoming pear-shaped: after one more cent decades have offered proof of the for public health and the international generation, the proportion of the popu- importance of the environment to sus- community. lation over 60 will exceed 15% of the tainable development and to solving total population, rising to 25% by mid- many environmental problems at the Because the population is the central century. In addition, declining fertility global and regional levels. This topic has concern of public health, demographic and the proportional reduction in the been debated at several international characteristics are strategic for its prac- number of women of childbearing age conventions (Oslo, 1968 and Rio de tice. The countries of the Region of the will lead to birth rates below the neces- Janeiro, 1992), which have approved rec- Americas are completing—although to sary minimum for maintaining the pop- ommendations and even a detailed plan different degrees and at different rates— ulation, as is already occurring in some of action (Agenda 21, Rio de Janeiro) for the final phase of the demographic tran- countries of Europe and Asia. The im- universal protection of the environment. sition, one of low fertility and mortality. pact of this new demographic revolution Accordingly, the natural increase rate is will be profound and affect all areas of At the national level, progress has been declining, although it remains high in human society. In fact, it is a significant made in the delivery of basic and general some countries. The total population of characteristic of the new society that is services. On the other hand, with regard the Region in 2001 was estimated at already taking shape, and constitutes to air, water and soil pollution, the ra- 841,254,000, some 317,195,000 of one of the principal challenges for pub- tional use and protection of biosphere which are found in the English-speaking lic health and for social security systems resources, and urban problems, less countries of the Americas, whereas in general. progress has been made and, in many 524,099,000 are distributed throughout cases, setbacks have been observed. Nu- Latin America and the Caribbean. In 2.4 Necessary Development merous and substantial threats to health spite of lower and declining rates of nat- persist, which end up becoming priority ural growth, by 2020 there will be 174 The backlash of societies against liberal public health concerns. At the interna- million more inhabitants in the Region: dogmatism or market fundamentalism tional level, the lack of action is frustrat- 52,600,000 in the English-speaking is growing and even welcomed by unex- ing. Ten years after the Rio de Janeiro Americas and 121,400,000 in Latin pected actors and authors. This is not a Summit, ratification of the primary in- America and the Caribbean.4 In the case matter of a return to previous situations; strument developed for implementation of Latin America, that additional popu- what is needed is to establish the nec- of Agenda 21—the Kyoto Protocol for lation represents more than 50% of its essary balances that will not only allow limiting the emission of greenhouse total population in 1950. The regional the creative capacity of individuals and gases—was undermined by the with- population is already mostly urban companies to flourish, but also ensure drawal of the United States, the main (>80%) and will be even more so in the their just contribution to social progress greenhouse gas polluter. However, the future. With regard to the need and de- through an achievable and essential proposal to consider the global aspects of mand for health services, the rural pop- complementary synergy. Thus, the de- such assaults and their environmental velopment of social capital is a funda- solutions as global and regional public 4 Encyclopedia Britannica, Yearbook, 2002. mental condition, and health is one of

29 its instruments: an essential component cides with changes in other external de- threats, to the general mechanisms for and a desirable outcome. The five guid- terminants of health, specifically in producing health and the risks that ing principles for necessary development health care systems, and thus, in the threaten it. These issues will be ad- are: an objective centered on human health problems and status of the pop- dressed in more detail, in the following well-being and security; equilibrium in ulation. Despite the spectacular ad- chapters, without being concerned with the concentration of all assets—physi- vances of recent decades in terms of the examining them categorically as yet. cal, financial, human, social and natural; usual health indicators, the health situ- equitable distribution of benefits that ation is still considered unsatisfactory in 3.2 Related Challenges also takes the intergenerational perspec- most countries of the Region. Conse- to Health Systems tive into account; participation; and an quently, this poses old, new and evens institutional framework for implement- some re-emerging challenges. In fact, Insomuch as the organization, policies ing these principles that includes guar- the countries of the Region show an and strategies, management, financing, antees of good governance. alarming gap between what has been supply and management of health care done and what could be done with the systems are matters of public interest, The search for a new concept of the available resources in terms of the levels they are also challenges for public State, including its functions and re- of development attained. For example, health. The public demands socially ef- sponsibilities and their relationship to unjustifiable and avoidable mortality fective health systems—capable of pro- civil society and the market, are funda- still accounts for more than 1 million ducing health—that generate social sat- mental tasks designed to strengthen the deaths annually. In addition, health isfaction, under the guidance of a rule of law, the distribution of justice services systems reveal several short- structured set of basic principles, ethics and security, and also to expand and comings and deficiencies, reinforced by and politics, and are established ration- deepen democracy. This is especially a context that is many times more ad- ally. Included among these principles, true with respect to guaranteeing levels verse than favorable. on which there is consensus in Latin of social justice and equity that are eth- America and the Caribbean, and possi- ically desirable and necessary for true Accordingly, the challenges for public bly throughout the Region, are equality human development. In this regard, the health are numerous and far-reaching; for the universality of care, social par- rhetoric of consensus should find its ex- they are found in the external factors ticipation, collective financing, effi- pression in public policy and through that can affect the context, in health ciency and decentralization. effective instruments of action that can care systems, in risks and threats, and in be fully implemented in the countries the health status of the population. One particularly significant aspect in- of the Region and worldwide. This is volves the adequate definition of func- development that links vital economic 3.1 Challenges in the Context tions and relations between the State growth under stable conditions with public, the non-State public, and the adequate social development, imple- Each topic discussed in the previous sec- private spheres, and preparing the State mented under conditions that ensure tion involves risks, problems or oppor- to exercise its functions, especially those social and environmental sustainability. tunities for public health. Generally it assumes as the steering authority of speaking, the contextual determinants the health sector. These functions in- All the foregoing should take place of health have collective dimensions clude regulation of the entire health under the basic principle of the preem- and, consequently, are inescapable issues care system, the identification of fi- inence of society, which is served by the for public health. The general proposal nancing mechanisms, providing insur- State and the market in a complemen- to effectively incorporate health into all ance coverage for care, performance of tary fashion. dimensions of the development process, EPHFs, and the organization and man- and the resulting intersectoral interven- agement functions associated with the 3. Health and Public tion, is the primary strategy for respond- generation of resources, knowledge, and Health in Today’s World ing to challenges from the context. This information. also entails expanding the field of public The change occurring in the economic, health, from concern over specific as- Also important is how public health is cultural, and political framework coin- pects of disease etiology and health defined in health and health care sys- 30 tems and the mechanisms through Table 1 Health Sector Reforms which it operates, which is the main focus of the next chapter. Shortcomings of Reform Processes • Incentives are centered on economic factors; • Equality and public health continue to be treated as second-tier priorities; Another challenge facing health systems • Quality of care and the redefinition of care models are marginal; and is how to make use of the potential of- • The role of the State is far too limited. fered by science and technology so as to Primary Lines of Action for a New Generation of Reforms Focusing on the Health of take maximum advantage of their prob- the Population lem-solving capacity in each situation, 1. Expand social protection in health and ensure universal access and equality; 2. Develop efficient forms of collective financing; while adhering to the ethical principles 3. Emphasize quality and effective care; of respect for human dignity and fun- 4. Incorporate health promotion as the primary focus of the comprehensive care damental human rights. model; 5. Strengthen public health through the reorganization of health systems; 6. Strengthen the steering role of the health authority; The ethical challenges involve much 7. Develop human resources; and more than the ones found in the fields 8. Promote social participation and control. of science and technology and include everything from basic research up through the application of knowledge and technology. These are present in all health care processes and activities. rizes definitions of current processes In addition, advances in science and These challenges are also considered and desirable lines of action for a new technology provide more and better in- beforehand, during decision-making generation of reforms. struments for intervention and new processes geared to the development of methods and possibilities for their use. public policy and other standards that 3.3 Health Status Progress is being made, from the pre- affect health. Yet they go much further; vention and diagnosis of diseases, to they are present in the behaviors and re- Due to changes in health determinants their treatment and control, to health lationships of persons and groups in so- at the individual country level, the promotion and the prediction of risks ciety, to the extent that the correspon- health of the population in the Region and, subsequently, to the actual creation ding social practices have an impact on of the Americas is in different stages of of healthy conditions. In fact, the pri- health. In short, the ethical considera- epidemiological transition. In many mary focus of health is promotion, tions reveal the human values attached countries, infectious diseases and ill- which is increasingly relevant to the or- to public health. nesses associated with poverty are still ganization and management of health significant problems, whereas the inci- care and corresponding systems, as well Furthermore, all of these challenges are dence of chronic degenerative diseases, as public health. linked to the greater challenge of in- generally associated with the developed corporating health into truly sustain- world, is also on the rise. Added to this 3.4 Need for Definitions able human development for the bene- are new health problems, including (or Redefinitions) fit of all peoples and countries, where AIDS; the resurgence of old problems, health must be at the same time both such as tuberculosis; and the serious Conventional public health by itself is component and purpose, and thus be- and growing risk of violence, drug no longer able to meet these challenges. comes one of the principal indicators of abuse, and environmental degradation. There can be no doubt that disease con- development. The repeated individual harm takes on trol, the recognition and production of collective dimensions and ends up by public goods, or those with significant It is also time to modify many of the reducing the differences between per- externalities, as well as the organization current sectoral reforms to make them sonal and population-based care—or, of activities recognized as responsibilities more responsive to these challenges, put differently, by revealing the collec- of the State, continue to be important which in itself poses a significant chal- tive potential of personal health care elements in the work of public health. lenge to public health. Table 1 summa- due to the cumulative effect. Strategically, they should even serve as 31 the platform from which public health tial public health services, which ciencia, y la oratoria. España. Editorial expansion is promoted, until it embraces have served as the basis for develop- Iberia S.A. 1965. other significant aspects, both within ing the methodological component Camdessus, M. Speech to UNCTAD-10. and outside the health sector, in order to of the SPA, with a view to evaluat- Bangkok. 12/02/2000. improve the health of the population. ing performance of the FESP; CEPAL y UNICEF. Panorama social de América Latina, 1998. Santiago, Chile. A review of public health concepts, its c) The Delphi study, coordinated by 1999. linkage with significant social practices WHO, on essential public health Chauí, M. A pastoral de Florença e a guerra for health, the identification of its es- functions; and de Seattle as fantasias da Terceira Via. sential functions, as well as the instru- Caderno Mais. Folha de S. Paulo. 19/12/ 1999. ments for carrying them out, will be an- d) A series of debates promoted by alyzed in Part II, Chapters 4 through 7. PAHO/WHO in the early 1990s Douglas, N. Globalization and Health. Washington, D.C.: Global Health Coun- These aspects, including their opera- that were taken up again in 1998, cil. 2000. tional characteristics, will be examined giving rise to this project in which in greater depth and detail in Parts III the Association of Schools of Pub- Douglas, WB. Sapirie S. y. Goon E. Essential Public Health Functions: Results of the and IV of the book. lic Health (ALAESP) has played an International Delphi Study. WHO, important role. World Health Statistics 51. 1998. 3.5 Recent Initiatives Drucker, P. The Next Society. The Economist. The Initiative is based on these earlier ef- Nov. 1, 2001. “Public Health in the Americas” is not forts and experiences and benefits from Encyclopedia Britannica, Macropaedia. Vol. the only initiative where effort has been the abundant and growing debate, as 11 History of Medicine. Pp 823–841. directed in this area. Many other initia- well as the work on necessary develop- 15th edition. 1980. tives with similar intentions have been ment, health promotion, equity, and the Encyclopedia Britannica, Macropaedia. Vol. formulated in recent years, and several struggle against poverty—especially 15 Public Health Services. Pp 202–209. are currently being implemented. Thus, from the agreements expressed in decla- 15th edition; 1980. there is a general need for this review. rations or resolutions of the international Evans, R., Barer, M. Marmor, T., De However, we will cite only the initia- community and its principal agencies. Grayter, A. eds. Why Are Some People tives that have more directly inspired Healthy and Others Not? New York. The or adopted the ideas that we wish to Determinants of Health of Populations. Bibliography 1994. analyze: Alonso, JA. Sin respuestas de Monterrey. Fee, E. The Origins and Development of a) Canada’s experience with the for- Madrid. El País; 22/03/2002. Public Health in the US. Chapter I of Oxford Textbook of Public Health. 2nd mulation of its health policies and Amartya, S. Address to the International Edition. Oxford Medical Publication. reorientation of health care and Labor Conference. 87th Session. Gine- 1991. health promotion systems; bra. In Decent Work, ILO. Fuentes, C. Democracia latinoamericana: Aristotle. Poética, Organon, Política e Con- anhelo, realidad y amenaza. Madrid. El b) The work currently under way in stituição de Atenas en Os Pensadores. São País. 15/05/2001. Paulo. Editora Nova Cultural Ltda. 1999. the United States, especially a study Fukuyama, F. The Great Rupture. The Free on the future of public health by Bambas, A. et al. (ed.) Health and Human Press. 1999. the National Institute of Medicine, Development in the New Global Econ- omy: The Contributions and Perspectives Garison, H. x fielding. Historia de la medi- and a project of the Centers for of Civil Society in the Americas. Wash- cina. 4a edición. México. Editorial Inter- Disease Control and Prevention5 to ington, D.C. PAHO 2000. americana. 1966. evaluate the performance of essen- Bezruchva, S. Is Globalization Dangerous to Gianotti, JA. Nossa Barbárie. Caderno Mais. our Health? West Journal of Medicine Folha de S. Paulo. 3/03/2002. 2000. 172: 332–334. 5 NPHPSP: National Public Health Perfor- Giddens, A. 5 clases: Globalization, Risk, mance Standards Program. CDC, Atlanta, Burckhart, J. Historia de la cultura griega. Tradition, Family and Democracy. Reith U.S.A. Vol. III. Parte VIII. Sobre la filosofía, la Lectures Home. BB.C. Homepage. 1999.

32 4 Foundations of the Conceptual Renewal

Public health is understood as the health versible disability. Public health, under- health cannot remain limited to govern- of the population and, hence, encom- stood as the health of the population, ment action. From an economic per- passes all collective dimensions of health. constitutes the fundamental reference spective it may be useful to view public This notion of public health stems from point for all efforts to improve health, health as the production of public the concept of health itself: the absence from which it derives its most complete health goods and services, or as the gen- of disease, injury and disability, as in a expression. erating of important and socially bene- complete state of well-being.1 However, ficial externalities, however, this defi- identifying health with well-being poses While the traditional cornerstones of nition falls short of covering all the operational difficulties in terms of delin- public health—the prevention and con- necessary aspects for achieving effective eating health sector responsibilities since trol of communicable diseases or envi- and efficient public health, which is un- at the same that it establishes the re- ronmental sanitation—continue to be derstood as the health of the population. sponsibilities of other sectors in health important areas of activity, the current and the need for intersectoral action. definition of public health includes In light of current public health chal- Viewed from a more sectoral and opera- much more. It is no longer sufficient to lenges, there is a need to further expand tional standpoint, health is the fulfill- define public health in terms of what the and clarify what public health means ment of the biopsychic potential of the government does. Although with the today. This chapter will focus on the individual and of populations in accor- premise that the State must serve the in- conceptual analysis of public health, dance with their particular living condi- terests of the population, there has been whereas subsequent chapters will discuss tions, without the limitations of injury, greater correlation between the actions its contents. disability or disease. However, when of governments in the health field and these limitations do exist, there must be public health activities. Government 1. Objective and Focus the possibility for prompt recovery or for should in fact play a central and funda- functional adaptation in cases of irre- mental role in public health today. The main objective and primary focus However, not everything that govern- of public health is the health of the 1 WHO, Constitution of the World Health ment does in terms of health can be re- population. This includes all elements Organization. garded as public health, just as public of collective interest that contribute to

35 improving people’s health. Conse- may sometimes be impossible, unless it and of itself. Furthermore, there is a quently, its specific focus should not be seeks to influence these conditions. Log- need for an instrument or method for limited to so-called public goods and ically, the function of public health with coordinating information, since public services, significant externalities, or ac- respect to many such factors is not to health draws on knowledge from diverse tions considered responsibilities of the decide or intervene directly but rather, disciplines, depending on the specific government or the State. As already to promote and coordinate, with the ex- focus of the public health practice that is mentioned, there is an existing consen- press aim of protecting the health of the required for a particular situation. How- sus that this constitutes an important population. Thus, for public health to ever, one discipline that appears to hold part of public health and it can and be effective, it must expand its focus as a great deal of potential for public health should be its overall strategic core. How- a function of its main objective. As for and which, likewise, frequently serves its ever, if public health is thus limited, it defining specific responsibilities, the purposes, is the field of epidemiology. cannot fully serve the public interest. problem can be solved by identifying This has to do with the kind of epi- Consequently, its reach and concern the direct and shared responsibilities of demiology that is broad enough to in- must extend much further, toward the public health and the different perfor- clude all the determinants of health and external determinants of health and the mance indicators for the two categories. aspects of health care, one that is not collective dimensions of the health care The first demands more precise in- limited solely to the study of disease. In systems, while never losing sight of its dicators for measuring the structure, fact, this combination of epidemiology main objective the health of the popula- processes, production capacity and out- and demography constitutes the science tion, even in circumstances where the comes related to health, whereas the in- of population; the focus and methods instruments of public health are in dicators in the second category focus on are consistent, in terms of structure and themselves insufficient to effectively measuring performance and evaluating outcome, with the concept and focus change these factors. Two primary con- processes and outcomes—that is, the of public health. Since epidemiology sequences reult from this concept: on impact on direct responsibilities, the evolves together with public health, it is the one hand, the need for joint action factors that determine public health, or not surprising that the history of epi- with other sectors; and on the other, the health of the population itself. demiology is sometimes confused with concern for the health of the individual, that of public health. Ultimately, the to the extent that some of these aspects 2. Sphere of Activity epidemiological method is the more take on a collective interest and are es- powerful and general instrument, but it sential to public health or that the oper- The objective and focus determine the is by no means the only one for coordi- ative tools, like health services and sphere or spheres of activity of public nating the inputs of the many disci- human resources, are shared. health. plines that contribute to public health.

The argument can be made, and justifi- First, it is important to note that public Inasmuch as public health involves both ably so, that such a broad understanding health implies a field of knowledge, and knowledge and practice, it also generates of the focus of public health could jeop- especially, a field of practice that can knowledge that enriches the various dis- ardize its effectiveness and the opera- be defined and organized. However, it ciplines that it draws from or that are tional definition of its responsibilities. is neither a science nor a discipline. specific to it. Thus, we are correct in Even though the main criterion for this Consequently, the body of knowledge speaking of public health knowledge, analysis, namely the health of popula- required for its exercise comes from a public health research, as well as the tions, should be the central objective of number of disciplines, articulated in functional fields that are specific to it. public, these arguments must also be terms of the objective and focus of pub- taken into consideration. Insofar as pub- lic health. This articulation of the The spheres of activity are a functional lic health—understood as the health of knowledge that the practice of public reflection of the focus of public health, the public—is determined by living health comprises an interdisciplinary di- namely, its main concerns, health deter- conditions for example, and that the ac- mension, is the epistemological essence minants, risks, etc. Accordingly, they tivities of public health itself are also de- of public health, which often transcends cover all facets of the social process asso- termined by the conditions of its con- the disciplines that contribute to it, even ciated with the production of public text, its activities cannot be effective and though it is not a specific discipline in health. Responsibility for the correspon- 36 ding public health activities lies with a Figure 1 Spheres of Health and Social Components specific actor or actors or is shared among several actors, as explained fur- ther on in section 4 of this chapter. Nev- Society ertheless, it is possible to identify a core Civil society State set of functions and responsibilities be- longing to the health authority, the ful- Health Care fillment of which is, without exception, or Health necessary in order to ensure good public Services System health. This set of basic public health functions make up what the initiative Private considers the “Essential Public Health Functions” (EPHFs), which are the pri- mary operational focus of the project. The EPHFs will be examined in subse- Health quent chapters, especially in Chapter 5 System and Parts III and IV.

3. Public Health, the Health System, non-State and Health Care public Public Health

Public health’s sphere of activities covers the field of health in general, encom- and it includes provision of the neces- contains the health care system (dotted passing all of its components from the sary means, resources and conditions to oval), both containing their State, pri- standpoint of the health of the popula- accomplish this. This definition also in- vate, and non-State public components. tion. Public health functions are carried cludes actions affecting the general de- The irregularly shaped shaded area rep- out within the broader context of terminants of health, undertaken to im- resents the field of public health, which health actions, so that no analysis of the prove health or facilitate care, regardless covers part of the health care system concept of public health is complete of the nature of the agents—whether area, but also some additional areas out- unless it is done within the context of public, State, non-State, or private— side of it. Thus, as will be seen in sec- the health system, health care and med- who carry them out. The health system tion 4.1 and subsequently in Chapter 5, ical care, with which it is so intrinsically is much broader than the health care the concept of public health encom- linked. system or health care services, which in- passes some aspects outside the health clude medical care. Figure 1 illustrates system that are important to the health Public health is an integral part of the these health areas and their relationship of the population. Nevertheless, it is ap- health system which is understood to be to the primary social components—civil propriate to limit its extension to the the interventions carried out in society society, the component with a basically health system. with health as the primary goal.2 This private operation that includes the mar- The operational side of the concept adds concept of the health system includes ket, the non-State public or “commu- 3 another dimension to the scheme—that care for people and the environment, nity” sector, and the State. of the health sector. In every institutional with the purpose of promoting, protect- The larger circle, which is society, rep- setting or political/legal/administrative ing and restoring health, or reducing or resents the health system, which in turn system, there are institutionally formal- compensating for irreversible disability, ized organizations whose main purpose is 3 Non-state public sector: non-profit public to advance health. This group of institu- 2 WHO, “The World Health Report and social services-oriented civil society or- 2000—Health Systems: Improving Perfor- ganizations, such as charities and commu- tions, including the relationships among mance”; 2000 nity organizations. themselves as well as between them and 37 other institutions, is conventionally brief analysis of the main objective, gen- Health systems are based on values, known as the health sector. The concept eral contents and universal basic func- some of which constitute the structural of the sector, to be conventional and util- tions of the health system is in order, in principles of these systems, influencing itarian in administrative terms, adjusts to an effort to link them with the objective their organization and operation, as each set of circumstances. In the case of and fields or functions of public health, well as their final goals. As such, they the health sector, it also generally in- with a view to establishing public health constitute complementary and/or inter- cludes the public State and public non- actions, responsibilities and relation- mediate objectives of the final goals State subsectors, as well as private sub- ships within the health system. and, in some cases, are justifiable and sectors of public or private interest sought after in their own right. Cur- associated with the market or other The basic purpose of the health system rently in the Americas, the following groups. The sector is ordinarily delimited and the health care system that com- values are included in this category: within the scope of the health system, prises it is to produce health in the best but rarely corresponds with it; it corre- possible way in keeping with each spe- a) Equity. Equity is viewed as an es- sponds more with the health care system, cific situation. This constitutes the pri- sential value for correcting the un- but is not consistent with the fields of mary focus of the social process of justifiable inequalities and social public health at the present time. More- health generation—to produce health injustice that exist in health, as well over, albeit designed for administrative for people, but especially for the popu- as for attaining effectiveness and purposes, in reality, a well-established, lation as a whole. The social effective- social satisfaction. Equity is also a functioning organizational structure ness of the system is, therefore, its main necessary and strategic condition does not necessarily exist. Often, certain performance indicator. However, it is for achieving universal access to health-related institutions and organiza- not enough to be effective and produce care, based on existing needs and tions are, from an administrative stand- health collectively; the system must do available resources. point, part of other sectors, such as basic so by generating individual and, espe- environmental sanitation, the produc- cially, social satisfaction. Satisfaction is b) Social participation. Social partici- tion of health equipment and supplies, not just an attribute or a result of the pation is considered the right and food security, and health insurance. quality of care but also something that capacity of the population to par- Thus, the nature of a productive organi- is necessary for its effectiveness. In dem- ticipate effectively and responsibly zation and not its purpose is the test for ocratic societies, governed by human in health care decisions and their determining which sector it belongs to. rights and real humanitarian values, sat- implementation. Social participa- isfaction is an essential value for enjoy- tion in health is one facet of general The proportions of the elements pre- ing a full quality of life and has signifi- civic participation, a condition for sented in Figure 1 do not reflect any cant political importance in terms of exercising freedom, for democracy, concrete situation nor are they intended legitimizing the political system and ex- for social control over public action to serve as a model. They do, however, ercising the rights of citizenship. Thus, and, hence, for equity. It is also an generally reflect the most common situ- the level of satisfaction constitutes the essential condition for ensuring ef- ation found in the Region of the Amer- second global performance indicator fectiveness and satisfaction, and, in icas, which is the fact that most health of health and health care systems, espe- terms of health actions, constitutes and health care systems are private, al- cially when complemented with an a desirable end in itself. though the State participates in these to evaluation of its primary factors—qual- a large extent, and that the field of pub- ity of care, as defined by problem-solv- c) Efficiency. Efficiency is understood lic health is largely public, where the ing capacity and the types of services; as the use of resources in terms of the State is the dominant contributor to the and response to the population’s expec- objectives and principles established. health system and only a small part tation in health or some other sphere. Efficiency is especially important, comes from the private sector. The two final goals—effectiveness and given the scarcity of resources. social satisfaction—are always present Given the above considerations on the in health and health care systems, d) Decentralization. This maintains the general organization of health actions, a whether explicitly or implicitly. most appropriate balance of com-

38 plementary responsibilities among they constitute immediate objectives for takes on special meaning. The fol- the different levels of government. It management. This situation leads to the lowing factors are important: the also helps to facilitate the aforemen- risk, which is quite commonplace, of level of financing in relation to the tioned principles, as well as the final disassociating these resources and condi- wealth of a country. which reveals goals of health systems and health tions from the objectives, values or prin- the extent of societal efforts and the care. ciples they should be serving and of degree of sufficiency or production being transformed into independent ob- that is possible; its origins or e) Comprehensive care. This means jectives themselves. This has certainly sources, which determine the level health care that attends to needs in been the critical mistake of many recent of solidarity—or absence thereof— keeping with the seriousness of the sectoral reforms. Among these resources and equity in the distribution of illness or harm and problems that and conditions, we will cite five that are that effort; and its use (process of require progressive care, which particularly important: allocation and distribution and constitutes a requirement for effec- production generated), which rep- tiveness, satisfaction and equity. a) Leadership. Leadership is understood resents the essence of the manage- as the capacity to formulate and im- ment model, its level of efficiency, f) Solidarity. There is a need for soli- plement plans and projects. This in- and the final destination of re- darity to counter the uncertainty cludes the ability to set up agree- sources—that is, which needs are and complexity of health problems ments and support mechanisms; met and who are the beneficiaries. associated with risks and diseases effectively bring opposing parties and to mount responses to these together; mobilize willpower and The objectives, basic principles, and the challenges. Solidarity is fundamen- resources; and ultimately, to bring required conditions and resources guide tal for balancing financing—de- about the most favorable conditions the definition of system functions, as fined as the distribution of financ- and situations for realizing system well as its organization and operation. In ing efforts based on fair criteria and objectives, principles and functions. this document, we only consider the collective coverage of costs for the Leadership, then, is the most essen- global functions as a frame of reference delivery of equitable, universally tial attribute for properly exercising for public health functions. WHO iden- accessible services. Solidarity is the the management function. tifies four global and universal functions recognition of common situations of health systems:4 stewardship; provi- and interests and organization for b) Information. Information is consid- sion of services; generation of resources joint efforts to protect health—that ered vital input for appropriate de- through investments and development is, for the organization and delivery cisions and actions, provided that of human resources; and financing, of necessary health services. Soli- the information is produced and which includes collection, incorporation darity is therefore a characteristic used properly to generate the intel- and purchasing. With respect to the di- that includes equity and partici- ligence required. mensions of the steering role in health, pation, and it contributes to effi- PAHO5 also identifies four global health ciency and productivity, which c) Sufficient human resources and ap- system functions: stewardship, service makes it a key factor in the effec- propriate physical capacity for pro- delivery, financing and health care insur- tiveness of and social satisfaction duction; ance. The EPHFs form part of the steer- with health systems. ing role, together with heath system d) Appropriate knowledge and tech- management and regulation, harmo- Health systems and health care must nology; nization in the delivery of services, the have resources and conditions in place distribution of financing, as well as over- to facilitate the realization of their final e) Financing. Because financing is an sight and insurance. goals, as well as to apply the structural instrument that makes all other re- 4 WHO, op. cit. principles adopted. Because the charac- sources and conditions feasible, and 5 PAHO, “Steering Role of the Ministers of teristics of such resources and condi- ordinarily depends on decisions Health in Health Sector Reform Processes,” tions are critical for system performance, made outside the health system, it 1996.

39 Among the functions subsumed under population as well. Global health system history of disease, according to the the steering role, and considered in part functions, as they relate to the health of phases of promotion, prevention, recov- an essential public health function, is the population, are references for public ery and rehabilitation. public information. This is not a matter health functions. Public health, through of information for management in the its essential functions (EPHFs), supports Consequently, it comes as no surprise broader sense, which would be part of and integrates the steering role, even di- that public health also acts through the the requirements of other functions, rectly assuming responsibility for some resources allocated to the operational el- nor does it have to do with the propa- of its tasks and transforming them into ements of personal health care and even gation of institutional information, as public health functions. Public health is through that same care system. In fact, called for by the steering role or other concerned with financing as a require- the nature of the two fields and their auxiliary functions. Rather it is a matter ment for collective health; it shares re- complementarity warrant the use of of information directed at the public for sponsibility for the creation of produc- common resources and taking advan- empowerment pusproses and to ensure tive capacity in order to ensure that it tage of the opportunities created by the public’s co-participation in taking addresses the health needs of the popu- health services and personal care to responsibility for health and taking lation; it is concerned with the collective carry out public health interventions. control over public action. It is infor- aspects of service delivery, with a view Physicians’ contact with patients, for mation for building citizenship, for af- to social effectiveness (i.e. organization, example, provides significant opportu- firming values and institutionalizing quality, coverage and access); and finally, nities for health promotion and disease them through the development of social it assumes responsibility for providing prevention, in addition to other public practices. All this is part of a wider the public with information, which is health activities geared to the individual process under the essential responsibil- a collective function par excellence. In and the family, as well as to their rela- ity of the public sector but is specifically this way, public health contributes to the tionship to the environment and the manifested as a basic function of health organization and execution of health communities in which they live. The systems. The concept of transparency in system functions; it is not simply a com- same holds true for other types of public administration is included here ponent, even though its limits and con- health workers. This joint action en- as well, which facilitates ongoing and tents can be delineated. hances personal health care, while ex- effective oversight by society. tending the social reach of public health This vision of public health makes it that would not otherwise be possible. In The foregoing analysis makes it possible possible to understand the interdepen- the case of environmental health, such to position public health within the dent relationships between it and med- action is more than a matter of articula- health system and to regard it as a part, ical care and, at the same time, their dif- tion or complementarity; it is public or rather, as a manifestation of the health ferences and complementary nature. health itself at work. system, from the perspective of popula- Medicine, then, becomes one of the sci- tion health. It is more than just a health ences that contribute to public health, 4. Actors system function; it is about its fulfill- but it neither defines it nor is confused ment in the collective and social dimen- with it. The practice of medicine itself is Many actors are involved in the work of sions. The final goals of the health sys- not part of public health, although the public health. Given its very broad and tem and health care, particularly those sum of its activities and contributions varied sphere of activity, public health pertaining to social effectiveness, are also to collective health are indeed. Thus, an demands the participation of practically public health objectives. Values and ba- individual vaccine may not be consid- all the actors. sic principles make up the parameters ered part of public health, whereas re- of public health, which are applied as a peated vaccinations aimed at protecting 4.1 Society specific focus to achieve to the main ob- the population and controlling disease jective—which is the health of the pop- certainly would be. This same kind of The population, organized into society, ulation. The essential conditions and re- relationship can also be seen if the basic is the fundamental and permanent focus sources of health systems are also a health system or health care functions of public health. The public constitutes public health concern to the extent that are defined from the most narrow and not only the main focus of public health they are necessary for the health of the traditional standpoint of the natural but also its primary actor. Public health 40 is the health of the population, for the legal use of force or the implementation be used in special situations or to correct population, and by the population. So- of formal international commitments; certain shortcomings in public adminis- ciety’s activities to promote health are or with the defense of national sover- tration. However, some market agents, reflected in its institutions and social eignty and integrity. In other cases, its such as companies and corporations, can practices, and are represented in socially functions are carried out by means of assume responsibility for issues of public recognized values that shape the atti- delegation, promotion, complementar- interest that are in keeping with their na- tudes and social behavior in support of ity, or subsidiarity. The primary respon- ture and can even achieve social legiti- life and health. These are also reflected sibilities of the State in public health macy, and at the same time make im- in the recognition of health needs and include mobilizing, coordinating, ori- portant contributions to public health. demands, and in collective efforts aimed enting, and supporting the actions of There are some situations that offer op- at satisfying them. The activities of the society—particularly those of its non- portunities even for typically private en- population as a public health actor are State public sector actors. This synergy tities, like companies, to act as public reflected through the work of organized between the State and civil society is the health actors—for example, in the field groups in society, informal or formal key to achieving effective public health. of occupational health, environmental public support networks, community protection, or in a voluntary capacity in interest groups, and even specific or The action of private social agents helps other fields. vague feelings of satisfaction or dissatis- to further expand the reach of public faction. All these manifestations of the health, as well as the capacity of the As mentioned earlier, this societal vision population in society and of the non- State, and is consistent with the concept of public health draws individual care State public sphere constitute the social of public health that is being studied. and collective care closer together. In foundation of public health and its re- Notably, the role played by social or- fact, many collective public health ac- cipients, as well as its instruments of ac- ganizations, the non-State public sector, tions stem from individual care. For ex- tion, inspiration and strength. offers undeniable opportunities for the ample, the entire population can be health system in general, and for public protected by protecting a number of in- 4.2 The State, the Non-State health in particular. These public inter- dividuals or by common individual be- Public Sphere, and the Private est organizations are not limited by haviors. Personal care also requires con- Sphere some of the shortcomings of State ac- ditions that are public in nature, such as tion, their behavior does not follow the financing, organization and regulation. Societies establish legally recognized in- rules of the market, and they tend to Adopting a public health perspective stitutions to perform functions of com- operate at the grassroots and commu- in personal health care complements it mon interest or of interest for socially nity levels. This is not, however, an al- and promotes greater quality and effec- significant groups. The State constitutes ternative to State action and does not tiveness while expanding the capacity of the most important of these institu- excuse the State from its public health public health by offering opportunities tions, and one of its priority responsi- responsibilities. for action at all levels of care. bilities is to monitor the performance of public functions, including those per- Moreover, private agents also have func- 4.3 Professions and taining to public health. The State, act- tions, although limited, in public health. Professionals ing on behalf of the population, plays a Generally, the shortcomings or imper- central role as a public health actor, fections in the health market are magni- Public health, as a separate field of given its direct responsibility for ensur- fied when it comes to public health, knowledge, depends on the services of ing that its functions are carried out. In where, by definition, public goods or specifically trained agents, namely, pro- some cases, the State performs these di- goods with significant externalities pre- fessions and professionals. The public rectly and exclusively—for example, the vail and where there is greater asymme- health professions consist of disciplines functions associated with formal politi- try of information, complexity, and un- that contribute to its realization, whose cal power (i.e. mandatory observance of certainty, and where moral hazard and exercise is differentiated according to legal values through legislation and adverse selection are even more inexcus- their specific purpose—the health of the other general regulations); with the co- able. The market is an additional mech- population. Some of these professions ercive power of justice, through the anism available to public health that can are more widely identified with public 41 health insofar as their respective disci- of different organizations and particu- society to join the efforts of its members plines are more committed to the objec- larly the State—in its role as the domi- in solidarity in order to fulfill that re- tive and focus of public health. Such is nant social institution in the public sponsibility in favor of health for all— the case with epidemiology, which is sphere. The key to success in the practice i.e. public health. As society’s main in- closely integrated into all facets of public of public health lies in understanding stitution, it is also the duty of the State health, running the gamut from etiolog- how all the different actors contribute to to lead the way towards that social aspi- ical research to communicable disease the common goal and in facilitating ration. Arising from these fundamental control, and from policy formulation to these contributions in an articulated and values are others such as solidarity, the health systems and services management synergistic manner so that they respond efficient use of available resources, social and evaluation. It can even be argued efficiently, responsibly and in a socially participation, social control and equi- that the quality of public health is di- controllable way to the needs of the pop- table access to health-generating goods rectly proportional to the quality of the ulation. This is also fundamentally a task and services. epidemiology practiced, and vice versa. of the public authorities. In addition, it is possible to identify pro- This concept seems too obvious, since it fessionals working in the contributing 5. Construction Process would be difficult for anyone to dare to disciplines who are committed to the dispute it. However, it has conceptual task of coordinating knowledge to fur- With such deep roots in the social and operational implications, and de- ther the objective and focus of public sphere, health and public health are the fines, albeit in general terms, the final health. These professionals devote them- result of a complex social process that goals for action, for the development selves exclusively to the exercise of pub- has been constructed over the ages—a of knowledge and technology, and of lic health and can be characterized as process that entails the generation and course, for public health. From the per- “holistic” public health professionals. regeneration of values, as expressed ception and identification of needs, to That fact exemplifies the scientific, tech- through public health institutions and the definition and implementation of re- nical and professional nature of public organizations or through those that sponses to address them, values should health, which is essential for its exercise, contribute to its practice. This fact is es- precede the rationale; in other words, the although the field is always immersed in sential for understanding public health rationale must be constructed on the the context that shapes it and is at the in each situation and culture, and also foundation of those values. Accordingly, service of the values which sustain it. for understanding general aspects re- public health as a scientific and technical However, scientific and technical excel- lated to its theory and practice. exercise places value on identifiable and lence is strategically important to the measurable evidence and endeavors to quality of public health and can only be 6. Values and Principles base its decisions and interventions on achieved by taking all the other dimen- such evidence. However, there is aware- sions into account. The work of public As a sociocultural and historical process, ness in public health of the limitations of health cannot be limited to the work of and as a humanistic activity par excel- scientific evidence when it comes to so- public health professionals, but must be lence, public health is the union of cial realities, especially in conditions of expanded to incorporate the work of all knowledge and technology in a practice underdevelopment, and the importance workers in health and related sectors, es- that is at once subordinate to and based of values in shaping public health. Like- pecially at the primary level of care. In on certain values. At the extreme of wise, public health will always try to rec- fact, one of the main challenges for pub- these values is the concept of health and oncile scientific evidence with values, lic health workers is to make others un- life as the supreme goods of human be- while recognizing, in principle, the ori- derstand the focus and actions of public ings who are endowed with rights and gin of those values. health and to incorporate them into responsibilities, including among oth- their own behavior. ers, the higher right to social protection Viewed from another perspective, the of their supreme goods and the shared erosion of values undermines consider- In short, there are many actors in public responsibility to take care of them. ation of the final goals of human prac- health, and its core lines of action are There is also acceptance of the concept tices and, ultimately, of the nature of found within society itself, in the form that it is the function of an organized humankind and the value of life and its

42 protection through health. Under these cas—that of equity—actually acquires nant of public health and the social circumstances, science ceases to be an significant importance and serves to in- conventions that shape it. The socially “episystem” and basically shifts its focus tegrate the value-added dimension of legitimate political process and institu- to building real world models, without public health. In the context of health tions are in turn the prerequisite and examining the valueswhich would legit- care, the concept of equity calls atten- the result of effective democracy and imize them and which should shape the tion to the value of human life and the salutary public policies that adequately practices promoted by the models, a absurdity of rules of conduct that allow respond to the health needs of the pop- shift that runs counter to the objective privileges based on ethnic differences, ulation. In essence, these elements are of public health. economic status, gender, culture or place related to the characteristics of the of residence. Thus, equity works towards process and the political system, and to The risk of abuse in the name of values and calls for universal access to health the democratization of power through is always less than the risk of abuse posed care and demands that the State fulfill the empowerment and participation of by formal rationality that has the appear- its social obligation to see that this is citizens, thus legitimizing the process ance of science in order to justify opin- extended, especially to disadvantaged and conferring on it the capacity for so- ions and even interests (i.e. imposing groups. Equity also demands compre- cially correct public action. values on others). The assertion of un- hensive, quality health care and, ulti- questionable truths has frequently been mately, the most efficient use of available From this perspective, public health im- observed in the social sphere, only to be resources. In public health, the equity proves with democracy and civic partic- proven false or altered by the real condi- principle is the core line of action for ipation. It is this context that makes it tions later on. Deficiencies in the defini- modeling health financing, the organiza- possible to have genuine social integra- tion of objectives and methods of obser- tion and management of the health care tion of public health values with real vation in the data compiled, in the system, and the generation of real re- empowerment (even political empower- observation itself or in the observer, are sources to ensure full exercise of health ment) of the people, enabling them to all too obvious in the social sphere. As a system and public health functions. Eq- assume co-responsibility in matters per- result, it is difficult to have complete uity is more critical since reality reflects taining to the health of everyone in so- confidence in such evidence, especially if major inequalities and injustice in the ciety, and to the actual socially charged it is divorced from the basic purpose and health situations of and between coun- role of the State in the health of the principles that should govern health sys- tries. Moreover, it has been demon- population. This essential condition tems and especially public health. This strated that a lack of equality in the way compels health systems to incorporate warning call is not meant to belittle the people are treated is one of the main the strengthening of the process of de- importance of evidence; on the contrary, contributors to the unsatisfactory social mocratization and social participation it aims to increase its importance by al- performance of health systems. as part of their global functions, as set lowing values to place conditions on it. down especially in the steering role, and 7. Politics and Legislation which must be assumed operationally In an approach that emphasizes the im- by public health. portance of values, public health is asso- To a large extent, public health is sub- ciated and inspired with ethics, and servient to and depends on politics, and All of this lays the foundation for the spreads it out in all its spheres of ac- in many ways the corresponding actors formulation, adoption and implementa- tion—throughout society, the State, for need to operate with reference to it. tion of healthier public policies. Public specific and shared tasks, and even in health is responsible specifically for pro- the consideration of individual needs. 7.1 Democracy, Participation, moting and advocating these healthy This is an ethical framework with social and Healthy Public Policies public policies in all the sectors, and for dimensions that reinforces the primacy evaluating projects related to these poli- of society and the population. The expansion and deepening of both cies in order to determine the impact of democracy as a frame of reference and adopted or implemented policies on the From this perspective, one value that has the actualization of civic participation population. Likewise, it is incumbent been especially lacking in the Ameri- constitutes the main political determi- upon public health to promote and pre-

43 pare the necessary legal instruments for ous state institutions and the health sys- d) Contributing to citizenship-build- organizing its functions and to promote tem itself. The effort required is part of ing and the capacity for social par- behaviors aimed at their adoption and the steering role function of the health ticipation, especially through infor- implementation. system and is especially important for mation, health education, and the public health. organization of community partic- 7.2 Legislation and ipation; and Democracy The viability of public health practice is assured with the viability of the condi- e) Building alliances and mobilizing Public health is the recognition and im- tions and resources that are necessary politically significant support. plementation of socially accepted values for carrying out its functions. Thus, for protecting life and health, and the achieving political and cultural viability If we understand politics as the exercise promotion of health-related values in is of practical significance. of power, both real power exercised by society. This effort requires legal norms society with its capacity to influence, and their compliance by a lawful society 7.4 Public Health and Politics and formal or institutional power that is in which the monopoly of institutional substantively on a par with the powers political power exercised by the State The importance of politics in public of the State, then the essence of the po- produces the necessary laws and ensure health can be deduced from the above. litical process consists of channeling the their equal enforcement for all. Only Obviously, it is not a matter of politi- demands of society to the State for con- under such conditions can the neutral- cizing public health in the sense of sub- sideration and fulfillment. This is not to ity of the law and its impartial applica- ordinating it to political ideologies or ignore the importance of the private de- tion for the health of all be guaranteed. partisan interests, although the impor- cisions of some actors in civil society, The work of preparing, proposing and tance of some ideologies and interests but these decisions are voluntary, and advocating the necessary legislation for should not be discounted. What is their effects are hardly evident for those health protection, of ensuring that it needed is deliberate and consistent ac- who believe that these decisions belong complements the health authority’s tion, with a view to achieving the de- to the restricted domain where they op- sphere of competence and is appropri- sired political results. At the very least, erate and are respected, without forget- ately applied—even going as far as using this requires: ting that some of these decisions indi- supervisory powers conferred by legisla- rectly affect other actors found outside tion—constitutes the essential regula- a) Understanding the political process this domain. The State is the only insti- tory component of the steering function and its relevant aspects and actors tution that society entrusts with the of the health system, and public health with respect to the decisions de- power to decide for all. Nevertheless, serves as its main beneficiary as well as sired and the capacity to prepare ef- the problem lies in the enormous con- executor. fective strategies in this regard; centration of real power in society, which distorts the political process, 7.3 Viability of Public b) Analyzing policies from the stand- causing governments to make socially Health Practice point of the health of the popula- detrimental and non-salutary decisions tion in terms of their merits, defects at times. Hence, one important task of The viability of public health practice is and contribution toward develop- public health is to actively contribute to determined by the degree of acceptance ing healthy policies; citizenship-building and the democrati- and support for the proposed measures zation of power in society. This is based that culminate in effective fulfillment. c) Promoting public health interests on the principle that a well-informed Creating that viability is essentially a by using the power of science and citizenry, conscious of its rights and re- political process that entails the creation technology and the capacity for sponsibilities and organized for demo- of consensus-building, the forging of mobilizing society and the most ef- cratic participation, is the most effective partnerships and the neutralization of fective alliances according to the guarantee of a democratic and socially opposition in civil society, in the vari- situation and the moment; beneficial exercise of real power as well

44 as political or formal power, including Public health is not only a multidisci- and solidarity between countries and in the sphere of health. Accordingly, the plinary and interdisciplinary field of peoples, regional and universal agree- main political instrument of public knowledge, but also a social practice ments, international organizations— health consists of having at one’s dis- that is necessarily intersectoral. All pub- whether intergovernmental or private, posal a reform process that can strategi- lic health functions require cooperation all working to analyze the problems of cally mobilize society and be supported with other sectors to one extent or an- humanity and to find solutions. by it, and which can, as occasions arise, other. Hence, ensuring this type of co- help to develop alliances and political operation is one of the challenges facing The aspects mentioned in the preceding support that would make it viable. In public health. paragraph constitute public goods or addition, it is crucial to be able to “bads” that affect the global or regional demonstrate the capacity for effectively 10. International population with a supranational scope. implementing reforms and realizing the Dimension of Public This necessitates that their production benefits that can be obtained as a result. Health and many of their regulatory considera- tions be managed at the international 8. Social Practices and The risks and determinants associated level, which requires an institutional Public Health with health are not confined to national framework that ensures the requisite borders. The fact that disease has no re- decision-making capacity for their im- plementation. Moreover, the profound All of this underscores the close link spect for borders was established long differences between countries in terms between public health and health- ago. In a world immersed in globaliza- of development and the capacity to ex- promoting social practices. As already tion, the threats and possibilities for so- ercise essential public functions—in- mentioned, this relationship can be lutions in the matter of health related to cluding those in public health—require used as a matrix for identifying essential this phenomenon are more likely to be- a growing level of international cooper- public health functions, which is the come important issues than those re- ation in health, based on the develop- topic of Chapter 5. lated to the transmission of disease. Many of the key decisions regarding ment of public health. health determinants are often made or 9. Intersectoral Approach developed abroad, especially in the case The world has become integrated, and and Public Health of developing countries. Some of these the health of populations is increasingly global influences were mentioned in influenced by events and processes oc- It makes sense that the multisectoral na- Chapter 1, where we examined global- curring outside countries, or that are ture of the factors that determine health ization, its manifestations, and modern common to some or all countries. In- also affects public health, while the im- public health networks. Examples in- ternational health is thus a universal portance of intersectoral action is re- clude the global effects of environmen- component of a public health that is inforced by the diverse facets of the tal pollution, the AIDS pandemic, the also becoming increasingly universal, or concept of public health that we have resurgence of tuberculosis, the commer- “the health of humankind”. analyzed. Indeed, areas such as nutri- cial interests of transnational corpora- tion, environmental health, citizen par- tions in the health industry, as well as a 11. Toward a Definition ticipation, and ultimately the creation socially perverse concentration of the of better living conditions and healthy means of production in the areas of It is impossible to synthesize in a brief public policies, depend on cooperation knowledge and technology. There are definition all the conceptual aspects with other sectors. However, even spe- also natural and man-made catastro- that have been analyzed. This means cific aspects of health care services such phes, as well as criminal organizations that a consensus on the notion of pub- as inputs, transportation services, com- linked to drug abuse and other forms of lic health is virtually inconceivable. munication, etc., are contingent on sup- violence. On the other hand are the Nevertheless, the reality is that a defini- port from other sectors for accomplish- promises of science and technology, the tion that aims to integrate these con- ment or quality improvement. intense and progressive interdependence ceptual components will facilitate the

45 dissemination of the concepts and help community’s inhabitants. This definition mon elements from the many previous strengthen public health practice. at once simplifies and expands the sphere definitions and tries to adjust for the of public health activity, specifically in- concepts analyzed in this chapter: Several definitions can be found in the corporating the area of restoring health. literature, all of which have positive and Nevertheless, the emphasis on the collec- “Public health is an organized effort by negative aspects. Perhaps the most ac- tive is connected more to the method of society, primarily through its public in- cepted and complete of all is the defi- operation through collective efforts than stitutions, to improve, promote, protect nition offered by Winslow in 1920: to the targeted goals of that action. and restore the health of the population “Public health is the science and art through collective action.” of preventing disease, prolonging life, The idea of basing the concept of pub- and promoting health and efficiency lic health on the health of the popula- Bibliography through the organized effort of the com- tion has been gaining strength and con- munity for: 1) the improvement of envi- sensus and is contributing a lot to the Berkman L and Lochner K. Social Determi- ronmental sanitation; 2) the control of new conceptual framework in this re- nants of Health; Meeting at the Cross- community infections; 3) the education gard. This concept includes all the es- roads, Health Affairs, Book Review Essay; March/April, 2002. of the individual in the principles of per- sential elements of the previous defini- sonal hygiene; 4) the organization of tions, is compatible with the current Claeson M et al. Public Health and World medical and nursing services for the understanding of the course of health Bank Operations. Washington: HNP/ World Bank; 2002. early diagnosis and treatment of disease; and disease, and has the potential for and 5) the development of social mech- addressing the complexity of public Cordeiro H. “Sistema Único de Saúde,” Ayuri Editorial Ltda., Rio de Janeiro; anisms that will guarantee everyone a health in today’s world as well as 1991. standard of living adequate for the demonstrating how it can be put into maintenance of health, organizing these practice in response to the challenges Escuela de Salud Pública del Ecuador y OPS. “Salud pública — Ciencia, política y ac- benefits such that each individual will be that all this entails. ción,” Quito; 1993. in a position to enjoy his innate right to Frenk J. “The New Public Health,” in: An- health and longevity”.6 The concept of public health has been nual Review of Public Health, Vol. 14, evolving throughout the history of hu- pp. 469–490; 1993 This is a very broad definition and cov- manity in accordance with our under- Frenk J. “La salud de la población — Hacia ers most contemporary elements of standing of reality and the instruments una nueva salud pública,” Fondo de Cul- public health, even though it was pro- available for intervention. The necessary tura Económica, México; 1994. posed more than 80 years ago. Its em- complexity of public health in today’s Glonberman S. “Towards a New Perspective phasis, however, is still on disease and world has turned it into a multifaceted on Health Policy,” CPRN Study no. based on the dominant hygienic/sani- concept that is in constant flux. All the H/03, Renouf Publishing Co, Lrd, tary paradigm of the day, although it different facets of this concept deserve Ottwawa; 2001. incorporates the social dimension of to be examined carefully from all possi- Granda E. “Salud pública e identidad,” pre- health and the collective nature of pub- ble angles, as they manifest themselves sentación en el Foro “Modelos de Desa- lic health action. through the many different ways in rrollo, Espacio Urbano y Salud,” Santafé de Bogotá; April 1999. which they are defined and acted on. In- A more recent definition (Piédrola Gil deed this also includes the use of alter- Guimarães R e Tavares R. “Saúde e Sociedade et al, 1991), which further simplifies native or complementary expressions in no Brasil — Anos 80,” Relume Dumará, Rio de Janeiro; 1994. Winslow’s, holds that public health is the reference to tn the use of terms like so- science and art of organizing and direct- cial medicine and community health. Hanlon JJ. “Principios de administración ing collective efforts designed to protect, sanitaria,” Parte I — Introducción, 2ª edición, La Prensa Médica Mexicana, promote, and restore the health of a Therefore, as already pointed out, México; 1963. building a definition that might be con- Hartge P. “Epidemiologic Tools for Today 6 Winslow, C.E.A. “The Untilled Field of sidered appropriate and unanimous is and Tomorrow,” Anal of the New York Public Health,” Modern Medicine, 2: 183, not possible. As such, the definition Academy of Sciences, 954: 295–310; March; 1920. that we propose below combines com- 2001. 46 5 Social Practices and Public Health

1. Culture, Social Capital, as a group, and results from its actions health is then strengthened and im- and Social Practices and interactions in society. proved. The most communal societies are geared more toward sociability and The concept of public health encom- The actions and interactions of a society association, have higher levels of trust passes not only a population’s health, are usually a reflection of its values, cus- among its members and organizations, but also the health generated by a pop- toms, beliefs and standards, which gov- and thus exhibit a greater degree of co- ulation. Society, understood as an or- ern the attitudes and behaviors of its operation. Hence, these communal so- ganized population, is the principal members. These values and standards cieties are more inclined to expand pub- actor in public health and, in the final guide and condition individual behavior lic forums in social activities and to analysis, is responsible for the collective through explicit and implicit rewards favor the development of civic spirit and means to protect the health of its mem- and punishments. Moreover, they also the value of common goods. By exten- bers, including the actions of the State, define the organizational structure of sion, they develop human resources and its main institutional structure. How- the society and the relationships be- protect the environment through the ra- ever, the population’s role in public tween it and other groups, as well as the tional use of natural resources and better health is not exercised solely through relationships within the society. In other utilization of artificial capital, both fi- the formal organizations in its society. It words, institutionalized values shape the nancial and technological. In these soci- is also exercised through society’s actions social organizations and relational net- eties, sustainable human development is and interactions, formally organized or works through which a society func- more likely to engender greater equity, not, which may have a positive or nega- tions and meets the needs of its mem- well being, and health for all. tive, direct or indirect impact on health. bers. This is also the principal means of To be effective, these actions and inter- societal renewal and creation, which de- This set of positive values converted actions do not have to be guided by or termine the form, capacity for self-gen- into social institutions and manifested have goals specifically related to health, eration, and sustainability of societies. in active social organizations and rela- but their positive impact increases when When the dominant values place special tional networks is what current thinking they are carried out conscientiously for importance on life and lead to the es- on development has called social capital. this purpose. Health is part of a popula- tablishment of conditions, situations, Its importance is being increasingly rec- tion’s daily life, both as individuals and and behaviors that favor health, public ognized as fundamental to development 49 itself. Social capital is built on culture plete state of law, is the political system the health potential of people and pop- and consists of values or institutions and needed in this situation. Political repre- ulations and the capacity and effective- other cultural components such as be- sentations and governments, whose le- ness of the social response to health liefs, the arts, and language that define gitimacy is a true reflection of the will of needs. Promoting the development of the identity of peoples and nations and the people, adhere to the mandates and these favorable conditions and of sustain the desired cohesion, stability, expectations of the people by means of healthy and the subsequent health-gen- and change in a society. These condi- ongoing and effective social control car- erating behaviors is at the core of public tions are essential to dynamic and sus- ried out using multiple and convergent health. There is sufficient evidence, ex- tainable integral development. instruments and mechanisms. The trust periences, and analyses showing that provided by the awareness of its identi- communities or populations with simi- In theory, social capital and culture de- fication as a society, solidarity among its lar material resources can differ with re- fine the social processes of decision mak- members, and procurement of future gard to health conditions as a result of ing and, by extension, the orientation projects give a society the willingness their culture and especially of their spe- and characteristics of development. A and ability to make the changes needed cific values, beliefs, institutions, organi- well-structured society with a high level for renewal and sustainability. zations, and social processes. We will of social capital and a strong cultural not analyze this evidence and examples identity will be cohesive enough to de- This summary is provided merely to here; suffice it to state that public health fine its needs and the means to meet emphasize how beneficial social capital is very dependent on culture-based so- them to reach a consensus on its own can be when it is based on its own pos- cial capital. Technical interventions, development projects. This consensus, itive culture. In reality, it is nearly im- doubtlessly very valuable, provide op- based on effective social contracts, will possible to achieve this utopia in mar- portunities and specific solutions whose extend to controlling the distribution ginalized countries where there is a full benefit and effectiveness depend on and exercise of political power, including stronger trend toward heterogeneity how a society uses them. The integrity of course the State, its principal instru- than toward cultural autonomy. Social and sustainability of public health can ment. The public policies formulated capital is weak and can even have neg- only be achieved when a population under these circumstances will necessar- ative manifestations. The basic values permanently incorporates health pro- ily be healthy and generate health and of trust, solidarity and civic spirit are tection measures into its everyday rou- be geared toward making the best use of drowned out. Society disintegrates, and tines, including the appropriate use of development potential in a sustainable uncertainty and insecurity increase, health care through interventions based manner that benefits all. Assertion of the weakening basic institutions, such as on science and technology. basic values of social solidarity and re- the family and religion. Social and po- sponsibility will help create stability and litical organizations lose credibility and Culture is an amalgam of the values, tra- reduce uncertainty, stimulate creativity, legitimacy. The modern world is com- ditions, customs, beliefs, and social stan- and reduce transaction costs, among promising the chance to achieve the de- dards formed throughout history, and it other things. These conditions are essen- velopment needed precisely because it makes it possible for use to perceive re- tial to increasing production in regulated does not take into account the impor- ality, interpret it, and act on it. It is the markets and employing a certain degree tance of social capital and culture. perspective through which we see life of social responsibility. The balance and and take part in it. Culture is also the re- complementary relationship among so- In public health, culture and social cap- sult of its application throughout his- ciety, the State, and the market will be ital are even more important, because, tory incorporated into the lives we lead the foundation and, thus, the reference in addition to the impact of their gen- and into the future we build. In turn, point and purpose of the entire process. eral importance and consequent devel- social capital is the established capacity opment, they directly affect health. Fa- to take action, built on the foundation Democracy, expanding into everyday voring the development of conditions of culture. It is a structure composed of life, borne out in the permanent partic- and behaviors that reduce public health the key values, institutions, organiza- ipation of citizens, and based on a com- risks, culture and social capital increase tions, and relationships that shape soci-

50 eties’ nature and capacity for action. combination is increased by powerful, is used to produce illegal weapons or This type of social action provides pop- convergent interests, favorable political drugs. In addition, negative values and ulations with the sense and purpose of circumstances and adequate leadership. standards can promote unnecessary culture and social capital. It is this type conflict, violence, and destruction. of social action, reflected in the practices Like human and physical capital, social that characterize social processes, that capital can be produced and accumu- These initial theoretical reflections are truly shows the dynamism or inertia of lated, as well as produced in an eco- geared toward facilitating compre- accumulated culture and social capital. nomic sense. The production of social hension of the two following sections, Ultimately, it is what really defines a so- capital, however, is essentially indirect which address social practices with re- ciety’s possibilities in public health. and normally is expressed in externali- gard to health and public health. ties and public property, such as a gen- In other words, the social values attrib- eral reduction of production costs, 2. Social Practices uted to culture set the guidelines for un- shared knowledge, trust, association, and Health derstanding and building reality, and and cooperation. Social capital thus be- guide or determine the behavior of indi- comes a public good and the produc- Given the nature of health, the social viduals or social groups. In essence, they tion of it tends to be spontaneous practices that affect it are multiple and define the means by which societies and within a society and to be the result of encompass the broad spectrum of its their components endeavor to meet the social interaction, imitation, and cul- determining and deciding factors, as needs of all and of each of its members, tural continuity by means of socializa- well as health care itself. Thus, specific including the formation of institutions, tion. It is slow in forming, but its exis- health practices are not the only factors organizations, and social relationships, tence and effects tend to be lasting. that should be identified. The scope and the use of social capital in their gen- of this document, however, does not al- eral operations. This set of facts and ac- From another perspective, social capital low for an exhaustive study of all the tions that are socially recognized and is very important for governance and social practices relevant to health. We carried out by societies, whether individ- the social performance of governments, have limited ourselves to a set of social 2 ually or collectively but always for the as demonstrated by R. Putman in his practices pertinent to health in broad public, is what have come to be known extensive study on the process of re- spheres of action, defined in terms of as social practices. In other words, there gionalization in Italy. In many ways, so- the large general goals on which soci- is an obvious manifestation of culture cial capital mingles with the concept of eties base their efforts to improve the and social capital in action; Social prac- citizenship, an indispensable condition health of populations. tices encompass all aspects of life in a so- for creating a full democracy and state ciety, and serve their different reasons for of law. It is in opposition to political Four groups of social practices are set existing, including the improvement of corruption, and to the subordination of forth according to their main goals. the health of populations. the State to private interests. Instead, it promotes the renewal and social legit- • Development and strengthening of a culture of life and health. As can be seen, public health achieves imization of the significance and ac- countability of public organizations and its full potential when its purposes and • Attention to health needs and de- practices are accepted by society and in- governmental authorities. Social capi- tal, however, can also be used to nega- mands. corporated into social practices. As was tive ends, as is the case with human cap- pointed out in chapter 3, the combina- • Development of healthy environ- ital when it is used for oppression and tion of positive values that are geared ments and control of risks and threats torture or with physical capital when it toward health and institutionalized by a to public health. society, and the availability of socially • Development of citizenship and the effective knowledge and technology has 2 Putman, R. Comunidade e Democracia — a been the driving force for public health experiência da Itália moderna. Rio de Janeiro: capacity for social participation and progress. Moreover, the effect of this Editora Fundação Getúlio Vargas; 1996. control.

51 The four groups and the end goals that to improve it, as well as with the well- In addition to positive values and beliefs, define them also correspond to a possi- being of individuals, groups, and the a culture of life and health requires ap- ble system for classifying the challenges entire population. A culture of life de- propriate institutions, organizations, and affecting health today and in the imme- mands true human development, which social relationships, i.e. adequate social diate future. ultimately have the same objectives. In capital that will be reflected through the many ways, quality of life and well- healthy and health-generating behaviors Various practices within each group and being determine health and, at the same of individuals and societies. Some insti- among groups continually complement time, are shaped by health. In essence, tutions that can promote a culture of and reinforce each other, blurring the health, in the broader meaning given by health and life include, among others, boundaries among them. Moreover, a WHO, mingles with well-being and is the family in particular, religion, general social practice can serve more than one indispensable to quality of life and so- education, and other socialization mech- end goal, but will be included in the cial development. anisms. These organizations play a key most relevant group. role. In particular, they transmit the val- A culture of life is necessarily also a cul- ues that reinforce life and health as basic 2.1 Development and ture of health, and thus becomes the human rights and, moreover, they instill Strengthening of a Culture main condition for the protection and life with a transcendental aspect that of Life and Health quality of life. It is not merely a matter goes beyond the simple results of biolog- of survival, but of living a full and ical processes and, therefore, has a higher The purpose of the practices in this healthy life. The culture of health adds value than material things. The trans- group is to make life and health funda- other values to the culture of life that are mission of this concept, be it a matter of mental human values, rights, and re- linked to the promotion and protection faith and ethical principles or the simple sponsibilities in a society. A culture of of health, recovery of health if it is lost belief in the special destiny of humanity, life guarantees the sustainability and de- or affected, and the elimination or mit- is essential to strengthening a culture of velopment of the society where it flour- igation of all disabilities. A culture of life and health. ishes. The culture of life includes values health is a permanent and basic founda- essential for coexistence, mutual respect, tion for fully developing public health. The culture of life is the most basic ex- and cooperation among social actors. It pression of humanism, and is the con- is also the source of certain related val- In addition to its importance in the vergence of faith, beliefs, and hope in the ues, such as peace, solidarity, and demo- structure and functioning of societies future of humankind. In this context, cratic participation. A culture of life and in the health of populations, a cul- the agents of public health are not does not negate the concept of self, but ture of life and health is one of the high- merely instruments that contribute tech- rather demands an awareness of others, est universally recognized ethical man- nical solutions. Above all, they should be in the same way that the projection of dates. The rights to protection of life the transmitters of values and hope, co- the self in the existence of the other is and to health are part of basic and uni- builders and even Quixotes of projects needed to protect the development of versal human rights, and are recognized designed to protect and improve life. life in the community. This clears the as the first of all rights. Unfortunately, way for recognizing the unity of life and reality is far from reflecting this recog- The social practices of and for a culture the codependence of all life forms, nition, and human life from economic of life and health precede and are the where death is only a contingency of bi- and political perspectives has different root and basis for other groups of prac- ological necessity or the imposition of values depending on national or social tices; they inspire these other practices the survival of the species. Within this situations. Moreover, the lives of many that complement and strengthen them. perspective, the structure is built for people, sometimes even the majority of peaceful coexistence based on coopera- people, have very little value. Today’s 2.2 Attention to Health Needs tion among all members of society. basic rejection of the culture of life and and Demands health should not, however, be an ob- The culture of life is associated with stacle to defending and promoting it, This group comprises the specific social quality of life and the constant attempt but rather an incentive. practices needed for health care. It in-

52 cludes the way in which society and its extension, to make use of the deci- those geared toward meeting basic needs. members recognize health problems and sions that have been made and of re- They include the production of goods the need for care, which are the basis for sources that have been allocated. In and services, their distribution and use, the demand for health services, includ- many respects, it is also a matter of reg- and, consequently, income generation ing informal and alternative services. It ulating the operation of health markets and distribution, and social protection also encompasses efforts to create, or- and of the spontaneous generation of mechanisms, i.e. the model for and dy- ganize, and implement health care ser- demands. namism of the development process. vices. Basically this group deals with the social demand and supply of services These observations are not intended to This group of social practices is the junc- that respond to the problems, needs, downplay the importance of specific so- ture of the other three. The culture of and the demands of health care. At the cial practices in the health care field that life encompasses a culture that favors the convergence of these two actions are the are truly vital to public health. How- natural and social environment, and its practices of self-care, the demand for ever, the importance of specific social values require that basic levels of social and use of organized health services, practices is related to their dependency equity and solidarity be met in a society, and, in general, the ways in which a so- on other groups of practices. If the lat- thus preventing extreme need among ciety shapes and uses health systems and ter were not taken into account, under- the population. Essentially, public well- heath care. standing of the former and of their role being is the principal raison d’être of so- in public health would be seriously cieties and their institutions, especially The practices of this group are largely prejudiced. the State. This becomes a basic political derived from the practices of other matter, which is dependent on the dis- groups. The culture of life and health is 2.3 Development of Healthy tribution, relationships, and the exercise the main determinant of the way health Environments and Control of political power. This matter is re- is understood, how disease and the need of Risks and Threats solved through effective citizenship and for care are recognized and the demand to Public Health the existence of true democracy and a for health care, including self-care. state of law. Finally, a clear demand for Sickness and disease are the result of liv- The origin of society is the need for col- health needs, which garners the most at- ing conditions, environment, and the lective protection of life in order to en- tention and the best possible response, is risks in and with which a population sure the survival of society’s members. an essential part of living conditions and lives. Thus, the needs, perception, and This same motivation still holds sway a healthy environment. Social practices demands basically stem from ways of in today’s societies and is even more related to health care share the same goal life and living conditions. Even when pronounced when the culture of life is of controlling risks and harm. Reduced the extent of health services, specifically stronger and more structured. Adher- risks and harm as a result of healthy en- the offer of health services, is largely ence to this principle and the conse- vironments go hand in hand with spe- based on science and technology and quences of doing so are what lead to the cific actions to protect individual, group, the rational use of available resources, protection of public health, which ne- or environmental health. the use of these services is very depen- cessitates non-aggressive environments dent on culture. Moreover, the same and favorable living conditions. Although the social practices in this rationality based on science and tech- group almost always relate to health, nology, particularly in regards to the al- In analyzing health and public health, they are of interest in other sectors, rein- location of resources and of public re- all social practices should be taken into forcing in a society the multi and inter- sources in particular, are also political in account if they help improve living con- sectoral nature of the process of health nature. Thus, they are dependent on ditions and protect the environment, production, especially in the communal the distribution and use of power in a as should any actions of and within the aspect of public health. society and on the values that regulate society if they modify external health the use of power. Essentially it is a ques- conditions and determinants. Of par- Within this group of social practices, tion of the social capacity to participate ticular importance are social practices acculturation and socialization mecha- in and control political power and, by related to environmental health and nisms play a key role, particularly educa-

53 tion and social communication, organi- Effective, aware, and participatory citi- the government as a means of legitimiz- zations related to production and labor, zenship is the basis of real democracy ing processes, authority, and decisions. networks stemming from social and sol- and of the creative or regenerative However, citizenship and citizen partic- idarity movements, and, logically, the in- power of a society. Actually, citizen par- ipation go much further; they are the stitutions of the State through public ticipation expands a society’s power of permanent source for creating and ex- policies in particular. Actually, the role cultural assertion, and makes use of panding the social capital needed to in- and responsibility of the State as the strong and effective institutions and or- crease the productivity, stability, and basic driving force behind and guarantor ganizations through which its values are predictability needed for the sound op- of these practices are even more impor- implemented. It modulates the distri- eration of markets. At the same time, tant and decisive than in other groups. bution and exercise of power, keeping they automatically regulate market op- the State faithful to its social commit- erations and correct many related short- The practices in this group are almost al- ments. It can be said that citizenship, as comings. In turn, the market can be a ways carried out with regard to public reflected in participation, is the deter- permanent means of learning about cit- goods (or evils), making them particu- mining factor of integrated develop- izenship, with regard to the economic larly relevant to public health. Many ment that necessarily encompasses pub- rationality needed to make decisions phenomena, such as the disappear- lic health or health in general at both about consumption and investment. ing ozone layer, the greenhouse effect, the individual and collective levels. pollution in oceans, the conservation Thus, citizenship is the expression of Citizenship and participation also have of species, hazardous waste, peace and and a factor in culture and social capi- an extensive and profound impact on world security, drug consumption, inter- tal. It is the driving force behind health public management, from the approval national terrorism, and equity in world and health-generating social practices. of policies and plans to the management trade, are international public goods and If culture is the foundation and social of services, through demands, contribu- evils. Addressing them necessitates a capital is the productive structure, then tions, and requirements for transparency great deal of cooperation among coun- citizenship is the motor for healthy so- and regulation that limit unwanted and tries and true international regulation, cial practices. socially detrimental deviations. In the i.e. the need for universal healthy, social final analysis, citizenship and the capac- practices. Development of citizenship results from ity for participation must be developed knowledge- and experience-based train- to completely achieve democracy and 2.4 Development of ing, contributing to learning-by-doing. the dominance of a state of law, in turn Citizenship and of the It is also a product of the cultural her- guaranteeing social cohesion and stabil- Capacity for Social itage that shapes social learning. The ex- ity and creating real possibilities for true Participation and Control istence of effective mechanisms of par- human development. ticipation within social organizations This group of practices is fundamental and the State translates into measurable In health and particularly in public for endogenous social strategies or those citizenship, while at the same time fa- health, citizenship and social participa- imposed on societies, is the principal vors its development. tion are the foundation for best meeting driving force of a society in movement, the goals of health and ensuring that it and lends dynamism to the creation Mechanisms of information and educa- is sustainable. and development of the organizations tion, and community organizations are and institutions through which the so- very important in this process. Ex- 3. Development of ciety operates. Most important, these changes with formal political powers are Healthy Social Practices social practices are able to preside over indispensable in two ways: toward civil and control these organizations and in- society as a conduit for demands that Social practices are the result of the so- stitutions, and can even prevent specific strengthen participation by establishing cial process and, at the same time, one groups from owning them and thereby channels to make them more effective; of its manifestations, which implies that reducing their social character. and toward political representation and they simultaneously act as an instru-

54 ment for consolidating culture and for creased importance of basic institutions tion among cultures to initiate endoge- changing and renewing it. The slow, like the family and religion, and the ero- nous and indigenous, and therefore so- repetitive, and evolutionary process of sion of the meaning of “public” or “so- cially legitimate, processes of change. history, as seen in concrete social prac- cial.” In the structurally most mature so- The appropriate balance between au- tices, also creates the stimuli, needs, and cieties, the cradle of globalized culture, tonomy and heteronomy will result in changes in values, standards, beliefs, and the extensive, complex, and stable net- societies that are more sustainable and institutions that set the guidelines for work of institutions and social organi- have a greater capacity for self-renewal, these same practices. Essentially, this zations has softened the impact of cul- within a culture and social capital that process is endogenous to a society. Still tural rupture, guaranteeing the stability produce healthy and health-generating changes can be introduced and acceler- needed for their social renewal and for social practices. ated by what begin as external factors the formation of the required new values and eventually lead to cultural ruptures and standards. In marginalized societies, In the four groups mentioned, specific and even cultural revolutions. Social cultural rupture without substitutes and practices can be exercised by organized practices are not actually constructed, without strong established social capital groups or by individuals that reproduce rather they are elements of the culture often implies a loss of their ethical refer- socially established models. But what is and social capital that produce them. ents, manifested by increased uncer- important for public health is the pres- Social practices are the same actions tainty, insecurity, and all forms of cor- ence of a collective meaning, even in re- made possible by social capital within a ruption and violence. In these cases, the peated and aggregate individual actions. cultural context. However, changes in societies are less communal, in terms of The link between the social practices culture and social capital are manifested having common shared goals and values, of a population and those of the indi- through social action, that is, through in spite of the recent surge in social vidual lends a social dimension to the social practices. So completes the practi- organizations. The rate of decomposi- aggregation and organization of indi- cal and conceptual unity of this trinity. tion is greater than efforts to develop or vidual practices and justifies the actions maintain goals and values. The social of individuals or groups in promoting In other words, the culture and social practices resulting from this process are healthy social practices and their contri- capital that serve as a foundation and often not healthy and the construction bution to public health. structure of social practices can be delib- of social capital does not meet the needs erately constructed or destroyed, giving of the development needed and in cer- The construction and development of rise to new practices that in turn will tain instances or situations yields a nega- social practices can be analyzed in the change the culture and social capital. tive balance. In this way, public health is following phases, which are always pres- Today, a market-based, globalized cul- developed to a much lesser degree than ent in society and continuously occur ture is imposing itself on national cul- would otherwise be possible. and complement each other: a) the con- tures and changing them in fundamen- struction, accumulation or assertion of tal ways. The strength of modern However, the mechanisms used in this values and knowledge, and of the oper- communication technology, especially cultural downgrading can also be used ational contents that sustain them and marketing and the effects of demonstra- to assert the values of a culture of life through which they are manifested; b) tion and imitation, has universalized and of health in order to develop con- the formation of the institutions, or- consumption and social organization ditions and situations, which, taking ganizations, and actors that apply the patterns, changing expectations and be- into account the cultural identity of values and knowledge, and the relation- havior and favoring material hedonism, populations, instill the trust needed to ships they establish among themselves, exaggerated individualism, destructive create social capital through solidarity ranging from the most simple to the competition, and the objectification of and cooperation. In turn, they sustain most complex; c) the mobilization of human life. The negative results of this true human development to the benefit efforts within and by means of social phenomenon are the marginalization or of all. The goal is not cultural isolation practices as such; and d) the strengthen- exclusion of the weak, neglect of the val- or intractability, rather it is a matter of ing, expansion, renewal, and modifica- ues of solidarity and cooperation, the de- using the external stimulus of interac- tion of the entire process.

55 This overview of the construction of so- possibilities, so that each actor can par- is, without a doubt, their most impor- cial practices shows the importance of ticipate in the formulation and execu- tant mission in public health. the combination of values, knowledge, tion of shared projects, while maintain- and institutions that influence the de- ing the specific, individual goals of the The process is simultaneously dynamic, velopment of social practices and their individual or group. Developing citizen- thanks to the continuous evolution of importance in public health. Educa- ship in a less than ideal social context society, and sufficiently stable, thanks tion, in all its forms, as a means of citi- generally implies working to change and to the values of sustainability, making zenship training is one of the main driv- transform. By extension, the resulting it possible to develop strategies within ing forces in the process. Essentially, it social practices are geared toward the reasonable time frames. In all of this, is an instrument for transferring train- same goal. Developing citizenship and and particularly in public health, the ing information, which should be com- the capacity for participation also means role of the State is fundamental as the plemented by the creation of mecha- building and accumulating positive so- principal social institution. Despite nisms to use it effectively. The fourth cial capital. At the same time, it means the basically endogenous character of group of practices, the development of creating socially endogenous mecha- the process, the State can stimulate and citizenship and of the capacity for social nisms to correct distortions or problems promote it by recognizing its impor- participation, thus becomes the princi- within social and collective acts: nega- tance for governance, all levels of edu- pal strategy for promoting the desired tive opportunism seen in the personal cation, information for public training, social practices. gain of individuals or of closed groups, and the creation of adequate institu- corporatism, and antiquated political tional mechanisms. The last item not The construction of citizenship is, in practices, such as political patronage or only makes participation effective, it essence, the process of procuring power nepotism, passivity, and corruption. also makes it possible to view participa- and the conditions for effectively exer- tion in terms of quantifiable results and cising it. Accordingly, it is basically a Logically, social practices are not consis- benefits. Perhaps the most important of political process where preparation is tently uniform among themselves; nor the State’s specific roles, in this field and needed to consciously select individual are they always associated with common in today’s world, is expanding public ac- yet shared projects that thus have a cer- and good purposes. In the vast complex- tions by mobilizing and bringing to- tain potential to create change. Accord- ity and diversity of social processes, gether social actors from the non-State ing to the definition of Savater, it is the there are divergent and conflicting public arena so that they can play a syn- capacity to do, more than simply to be.3 processes. What matters is the possibil- ergistic role in achieving common pur- In other words, it is the capacity to as- ity of establishing viable courses of ac- poses. Nonetheless, it should be borne sert cultural, group, and community tion to meet the goals accepted by the in mind that the State has certain direct identity and ownership (the being) as majority of a society and shaped by responsibilities that cannot and should the basis for participation (the doing), good, socially hegemonic practices. Pub- not be delegated, or that would be very which becomes the main goal of the lic health can and should take advantage difficult to delegate in practice. When entire process. Citizenship can only be of the high degree of consensus about the State fulfills this role, power over complete through participation by shar- the value of health and life in order to the state reverts to society, and state in- ing values, rights, and responsibilities, take part in the necessarily intersectoral terventions are subject to social control and action projects to build the future, effort of promoting the development of through citizenship. In terms of public i.e. to change the present. conditions that produce healthy social health, this means expanding its reach practices. In this regard, the human ac- and making it more effective by sharing The foregoing does not imply only ideas tors especially, i.e. public health profes- responsibility with its principal actor— and thoughts. On the contrary, it means sionals, should also act as messengers the population. strengthening multiplicity through the and promoters of cultural change and of homogenization of rights, duties, and the formation of social capital that leads Bibliography to healthy and health-generating prac- Borsoti CA. In: Planificación social en 3 Savater, F. “Elegir la Política”, Letras Libres, tices—the development of citizenship América Latina y el Caribe. Chile: ILPES- Spain, 2002. and the capacity for participation. This UNICEF; 1981. pp. 47–117.

56 6 Essential Public Health Functions

In this chapter we begin the transition justify and even necessitate arriving at state functions carried out by the health from the concept of public health to its this conclusion. First, the State is the authority as the starting point not only implementation. This idea will be ex- main institutional actor in public makes it possible to reach all other ac- plored further in the next chapter for health, and is an individualized entity tors and the entire public health field, it the same purpose: to define how the from an operational point of view, with is also the most appropriate and, strate- conceptual elements and aspects ana- legal status and its own powerful means gically, the most powerful way to do so. lyzed in chapters 3, 4, and 5 can be re- for carrying out actions. Identifying op- Using the State’s instruments for taking flected in operational instruments and erations, particularly the delegation of actions is the mandatory and best foun- in their application in the practice of responsibilities and the idea of account- dation for the most effective practice of public health. ability, is easier if it is centered on insti- public health. tutions of the State that are directly re- As per our analysis, the breadth of the sponsible for the health sector (the Parts III and IV will analyze certain op- concept of public health, and the result- health ministry or secretariat); these will erational aspects of this approach in de- ing complexity of this field, as well as be denoted as the national health au- tail. This chapter will focus on more the many and varied aspects taken into thority (NHA), the regional/provincial general considerations of public health account, make it difficult to implement. health authority (RHA), and the local functions from the point of view of the An operational proposal needs to be health authority (LHA). Second, the responsibilities of the health authority. adopted based on a well-defined func- objects of public health are largely pub- The goal is to specify the concept and tional core that is well-designed and lic in nature, e.g. public or socially mer- make it more operational with regard to manageable, but of sufficient breadth itorious goods, and therefore are also the following four points: and trategic significance to address all the responsibility of the State. Lastly, as public health comprehensively. Fortu- we have already seen, one of the State’s • The concept of essential public nately, it is easy to identify this strategic most important functions in public health functions (EPHF). functional core of public health in the health is the mobilization of civil society Americas: the functions under the direct and the training of the population for • Essential public health functions and responsibility of the State. Three reasons social participation. Thus, using the social practices in health.

59 • Institutional responsibilities in public Based on the conceptual framework de- health planning, follow-up, and evalua- health. scribed in chapter 4 and on the reasons tion. The concept of responsibility as mentioned at the beginning of this being “responsible for” is articulated • The essential public health functions chapter, we have adopted as the opera- with the idea of assuming responsibility in the Americas. tional definition the responsibilities in the sense of being “responsible to” or that the State should undertake in pub- being “accountable through responsibil- 1. The Concept of lic health, or, more precisely, the re- ity.” Diffuse general social responsibility Essential Public Health sponsibilities of official health authori- and impractical “accountability” are Functions ties within governments, i.e. the group substituted with the specific and exten- we generically refer to as the health au- sive operational responsibility of the By virtue of its objects, actors, and thority. This includes not only the re- health authority, which is manifested as fields of knowledge and practice, public sponsibilities for directly carrying out a public health indicator. Basic public health is an identifiable functional and specific public health activities and ac- health functions viewed as being the re- operational part of the health system tions, but also the strategic priority sponsibility of the health authority are with a specific operational and func- areas of mobilizing, promoting, orient- thus functional indicators for the entire tional identity. Thus, not only is it pos- ing, and articulating other social agents public health field. Thus, these func- sible, it also necessary to identify public and the support needed from them in tions need to be identified and defined. health functions to view them as an op- public health actions. In other words, it erational part of the health system and is a matter of making other agents carry However, even with the operational lim- to optimize their performance. out these actions, rather than doing so itation discussed, public health actions directly. In this regard, promoting can help identify numerous functions, Public health functions are understood healthy social practices is particularly depending on the criteria used. The as the set of actions that should be car- important. The work of promoting greater the number of functions, the ried out specifically to achieve the cen- these practices as the principal means more complex it is to articulate putting tral objective of public health: improv- for promoting and protecting health is them into operation to achieve the ulti- ing the health of populations. In other a basic structural component of good mate objective of public health. Exag- words, within the set of public health public health. gerated aggregation decreases the speci- actions and responsibilities, it is possi- ficity of the function in terms of its own ble and advisable to define more homo- In this way, the State acts through the determined and quantifiable objectives, geneous specific subsets—public health health authority to mobilize the general meaning that certain important, practi- functions—based on the objectives or public and various social agents in all cal referents are ignored. The concept of tasks needed to achieve the end goal of pertinent sectors to ensure that public the essential public health function of- public health. health functions are carried out. Public fers a very useful alternative. Thus, the health is thus perceived as a social obli- focus is on grouping public health inter- The operation of a function depends gation, which, nonetheless, is particu- ventions into limited and defined func- primarily on a sufficient definition of its larly manifest in the realm of the spe- tional groups from the operational point contents, objectives, and activities and cific responsibilities and operational of view, with the identification of their on assigning responsibility for imple- definition of the health authority. The the end goals, objectives, activities, re- menting it. If responsibilities are not latter is the institutional instrument ca- sources, and organizational forms that precisely identified, it is impossible to pable of mobilizing all the relevant ac- are essential to the overriding goal of verify, monitor, and assess operations, tors and carrying out its own executive public health, i.e. the health of popula- and to plan or program strategies and functions. tions, and are sufficient for addressing activities. Hence, an operational defini- public health as a whole. tion is needed, which identifies public The broad and social nature of public health contents and responsibilities in health thus is channeled into specific Essential is understood as being funda- concrete situations. operations that make possible public mental and even indispensable to meet-

60 ing public health goals and to defining tive”, and the main criteria that were Actually, there will always be a balance public health. This term is also makes used to identify them. Part III of the between these two types of action, even reference to the definition of the respon- book details the characteristics of each though structural functions dominate. sibilities of the State, through health au- EPHF as a base from which to evaluate This balance generally depends on the thorities, considered essential to the de- their completion or performance. scope and importance of the specific velopment and practice of public health. problems addressed by public health Consequently, the EPHF are at the core The main goal of the initiative is to de- and on the level of societal development of the functional definition of the entire velop the institutional capacities of and institutional public health struc- public health field and, in turn, are in- health authorities to carry out sound ture. In well-structured societies, that dispensable to improving the health of public health practices. The leading cri- have a consolidated and effective health populations. Other functions may or terion for identifying EPHF is the func- infrastructure, the generic or structural may not be added, but the essential func- tions that make these capacities possi- functions that make up the necessary tions should always be present. The latter ble. Public health actions are carried out public health infrastructure are, gener- also shape the matrix for building an op- through the substantive aspects of its ally, sufficient for responding to the erational infrastructure, within the cir- field of action, including environmental needs of specific interventions to solve cumstances and possibilities of each envi- health, occupational health, child and public health problems. In societies fac- ronment: national, regional and local. maternal health, and chronic diseases. ing major and priority public health Applying the generic functions to the risks and harm and that have a weak The complexity and variety of social sit- diverse field of specific or programmatic and ineffective institutional base, the uations and health systems help identify actions makes it possible to intervene in generic or structural functions are the many public health functions. Different these actions. These generic functions core of the public health infrastructure perspectives and situations will give rise are thus the core of the capacity for ac- and are generally sufficient for meeting to different lists of public health func- tion in public health. Examples of these the need for specific interventions to re- tions. However, the previously agreed- functions include monitoring health solve public health problems. In these upon criteria can be used to identify a status, public health surveillance, and societies, there may be a need for more limited number of essential public regulation and control. When these es- of the specific or programming func- health functions, which are manageable sential functions are properly defined tions that shape the direct response ca- from an operational perspective, fulfill and encompass the capacities needed pacity of public health to meet the pri- the characteristics previously noted, and for the sound practice of public health, ority needs of the population. Some of are based on a large enough consensus appropriate operations are assured in all these aspects will be addressed in greater to be applied internationally, like in the and each of the work areas. Table 1 pro- detail in chapter 7. case of the Americas, particularly in the vides a schematic. countries in Latin America and the In terms of the end goals of the health Caribbean. A list of this type makes it The distinction between structural func- and public health systems, functions can possible to develop common instru- tions and programming or areas of ac- be considered final or instrumental. Fi- ments to analyze the situation of public tion is very useful in selecting the essen- nal functions directly assist in meeting health in the Region and even to carry tial functions to develop institutional these goals, including the promotion of out a comparative analysis of compli- capacities in public health. However, this health, the control of risks and threats, ance with these functions, as well as to does not imply absolute mutually exclu- the protection of the environment, and design the necessary corresponding in- sive concepts. Rather structural func- the quality of care. Instrumental func- terventions, always bearing in mind a tions also have their own programming tions are the means to meet these goals, country’s specific situation. areas of action, and specific fields of ac- creating or contributing to the creation tion have an obvious functional signifi- of the conditions or other elements for Section 4 of this chapter provides a list cance. Some of them are so important to meeting the final goals, such as monitor- of the EPHF, adopted as part of the public health in concrete situations that ing and analyzing the health status, de- “Public Health in the Americas Initia- they are deemed to be essential. veloping human resources and public in-

61 Table 1 Essential functions and spheres of activity of the public health

Areas EPHF Etc. are applied

EPHF Environmental Occupational Maternal and Chronic health health child health diseases

1. Monitoring of health Monitoring of Monitoring of Monitoring of Monitoring of status environmental risks in the health risks to health risks for risks workplace mothers and chronic diseases children

2. Regulation and control Establishment Monitoring of Monitoring of Monitoring of of regulations legislation on compliance with compliance with and monitoring workers’ health laws to protect regulations compliance with mothers and promoting them children healthy behaviors 3. Etc.

formation, and regulating public health but delivery of such services is not part also as being geared toward promoting matters. of the essential functions. and reinforcing healthy social practices. They integrate and promote social prac- Another dimension of the concept of 2. Essential Public Health tices at the same time. One of the main essential public health functions relates Functions and Social strategic goals of public health is spe- to the collective aspect of personal Practices in Health cific comprehension of social practices health care. It is difficult to establish a and how their benefits aid in develop- clear separation between the health au- Essential public health functions are ing health. The practice of public health thority’s public health responsibilities in not synonymous with the social prac- through its essential functions thus has disease prevention and health promo- tices that affect health. Social practices become part of the social practices in tion among population groups and in shape much broader areas than do es- health, which ultimately determine and, its responsibilities in the organization of sential public health functions and are at the same time, are affected by it. individual care services. This last item is the actions of an entire society, even obviously important in a different way, though they are specifically carried out Earlier in this chapter, analysis of the but the essential responsibility of public by certain sectors or actors. The essen- operative concept of the essential func- health is to focus on the first of the tial functions are the actions of a spe- tions showed that the EPHF are instru- functions previously mentioned. In cific and functional segment of the ments and indicators of social practices, terms of the second function, essential health system. Social practices in health understood as social responsibilities to- public health functions point more to- and essential public health functions are ward public health. Thus, essential pub- ward concern for equitable access to closely linked, however. Both are part of lic health functions need to be consid- services, the guarantee of their quality, the society, and social practices are the ered in relation with groups of social and the incorporation of a public health principal matrix for shaping the func- practices, regardless of whether corre- perspective into individual health ser- tions that in turn should act as an in- spondence between the two is exact or vices. Thus, one of the EPHF is geared strument for developing the former. In unique. It depends on the criteria and toward reinforcing the capacity of the effect, essential public health functions conventional limits employed; they do health authority to ensure the popula- need to be viewed and identified as not eliminate overlapping or obscure tion’s equitable access to health services, functions born of social practices and the extensive, common and comple-

62 mentary areas that exist. Below are 2.4 Attention to Health Needs sponsibility is to serve society. On the some examples of these relationships for and Demands contrary, meeting this responsibility in each of the groups of social practices. the best possible way necessitates the mo- The EPHF related to this group of bilization, orientation, articulation, and practices could include quality assur- support of various social agents and of so- 2.1 Development of a Culture ance in health care, promotion of access ciety itself. Adherence to this idea is justi- of Life and Health to health services, and regulation and fied by its importance to public health. enforcement. It should be borne in mind that this This responsibility is distributed among group of social practices, in keeping Some EPHFs are directly related to a set the various powers that constitute the with its end goal, has the task of incor- of social practices. This particularly true State and among the sectors of the gov- porating knowledge and forming so- in the case of generic or structural es- ernment covering public health-related cially shared cultural values reflected in sential functions. Examples might in- areas, but is concentrated in the health the institutions, organizations, and so- clude monitoring and analysis of health sector and more precisely in the institu- cial relationships that comprise social status, human resources development, tion or organization with the responsi- capital and form the basis for generat- and fostering research and developing bility for the steering role in the sector— ing social behaviors with regard to life technology in public health. the ministry or secretariat of health, and health. what we have called the national health Public health in the context of healthy authority (NHA). The State confers on The EPHF most typically related to this social practices seems have an extra- the NHA, as part of the government, the group are the fostering and promotion ordinary potential for developing pub- legal responsibility to monitor public of health and social participation. lic health, especially under the condi- health. But, it is much more than a for- tions seen in Latin America and the mal responsibility; it is also the moral Caribbean. However, comprehending 2.2 Development of a Healthy and ethical commitment to attend to the and managing it are still in the begin- Environment and Control interests of society and of the population ning stages. Increasing systematic ef- of Risks and Threats in the area of health and the obligation forts to implement the functions and to Public Health to make them its own. This commit- better manage them is one of the objec- ment implies seeking the best results The EPHF related to this group of so- tives of the Public Health in the Amer- from the direct actions for which the icas Initiative. cial practices could be health promo- NHA is responsible and maximizing the tion, public health surveillance and con- effectiveness of various social actors to trol of risks and threats to public health, 3. Institutional improve public health. Thus, it is a com- reducing the impact of emergencies and Responsibilities in Public mitment to technology and science, as disasters on health, and regulation and Health well as to management. However, it is enforcement in public health. primarily a political and social commit- The State has the primary institutional ment originating from the agreement responsibility in public health. It is the that infuses life into and supports a soci- 2.3 Development of basic social institution that should inter- ety and the State representing it. In car- Citizenship and the Capacity pret the needs of a society, respond to rying out its responsibility, the NHA an- for Social Participation them, and work to meet them in the swers to the government under which it most effective way possible. The State’s operates and in whose name it acts, in- Examples of the corresponding EPHF responsibility should not eliminate or in- cluding other non-executive powers, and would be social participation and train- hibit the responsibilities and actions of above all to the society it serves. ing in health, health promotion, and other social institutions or organizations. development of policies, planning, and The State should not look to monopolize However, the main public health re- management in public health. public health, even though its main re- sponsibility of the NHA is not a mo-

63 nopoly within the State. Each branch of scope of the health authority’s responsi- and acceptance of control exercised the State has its own specific province bilities set out in the EPHF. by the people. of responsibility where it exercises non- transferable functions. The legislative The health authority’s functions are 5) Optimizing use of the scientific and branch is responsible for legislation, variables related to corresponding na- technical instruments designed for regulating policies, and general man- tional and subregional situations. How- better recognition of the realities and agement of the government in name of ever, certain generic conditions seem to the selection and implementation of the people it politically represents. The be common to the majority of these sit- the best possible solutions. As already judicial branch is responsible for com- uations and can be considered as refer- pointed out, this is the basic strategy pliance with laws. The public ministry ents for specifying the conditions of for taking maximum advantage of or its equivalent (e.g. prosecutor’s of- each case. We will now briefly review the NHA’s ability to facilitate creating fices) is responsible for other mecha- the most important characteristics and other conditions, because it lends the nisms to defend rights; more and more will address this matter in greater detail NHA recognition, prestige, and au- often, this is the fourth branch in mod- in chapter 7. thority in its actions. This also implies ern democracies and its responsibility is developing the institutional capacity to monitor respect for legally recog- 1) Complementary relationships among to strengthen public health practices. nized rights. Within the executive relevant state sectors in accordance branch, i.e. government in the strict with the legal framework needed, in- A simple review of these conditions sense of the word and of which the cluding the definition of interven- highlights the complexity of the NHA’s NHA is a part, other sectors have a very tions, NHA regulations, and inter- mission in meeting its responsibilities in significant presence in public health, sectoral actions in comprehensive public health and its essential functions. even though their specific or overriding health care for the population. Aside from availability of resources and goal is not to protect the health of the legal instruments, there are four basic population. Within the so-called health 2) Effective inclusion of public health requirements for satisfactorily carrying sector, there are normally institutions in an integrated development proj- out this mission. and organizations that do not formally ect, thereby favoring effective and answer to the NHA, but that carry out very politically significant actions a) Optimization of the inherent or public health interventions. All these for public health and the NHA. specific functions that form the actors and institutions should be coor- basis for recognizing the NHA’s ca- dinated to promote public health 3) Distribution of responsibilities among pacities and promoting the com- through synergistic actions; this is an the levels and components within pletion of related functions (also important part of the NHA’s mission the health authority, among the po- see requirement (5)). and responsibility. litical/administrative levels in the State, and the organizational com- b) Capacity to understand the reality The actions of the State, coordinated by ponents of the NHA, and their ef- and base its proposals on irrefu- the NHA, are geared toward civil soci- fective articulation in a common table tests. ety and articulated with and comple- project. The result of this is integra- mented by the intervention of non- tion of public health as an essential c) Ownership of a consistent project governmental social agents, such as component of health systems. that is never finished and always institutions and organizations, in the ef- changing, even though there are suf- fort to mobilize all of society to pro- 4) Development of effective capacities ficiently stable and executable basic mote public health, as subsequently re- for the real participation of the pop- referents such as the purpose, strate- flected in healthy and health-generating ulation, which implies, among other gies, and operational structure. social practices. This brief description things, development of adequate so- of the process once again highlights its cial capital, transparency, communi- d) A capacity for dialogue, persuasion, integrated, social nature and the broad cation, participatory management, and negotiation, making it possible

64 to mobilize support and neutralize and they help carry out specific func- organized manifestation of civil society opposition, i.e. a true capacity for tions of this task, including manage- that completes and even shapes the ac- political action. ment, the organization of the delivery tions of the State and the NHA. Mobi- of health services, regulation of financ- lizing and articulating this group effec- The four requirements demand effec- ing, guarantee of the social protection tively are fundamental to the essential tive and productive leadership. It is not of health, and regulation of public public health functions so that, under merely a matter of personal or charis- health. They also act as criteria for ori- the responsibility of the NHA, they matic leadership in the Weberian sense, enting the other global functions of the reach society, are effectively linked with but rather of a capacity extending be- health system, which were mentioned social practices, and comprise indicators yond this. It is leadership multiplied in Chapter 4. Actually, the health of a suitable for the entire social sphere of through the actions of various leaders population and health promotion and public health. and sustained by common values and protection should be a basic guiding goals. Charisma, authority, and tradi- criterion for the entire health system 4. Essential Public Health tion do not disappear, but neither is and especially for the health care model Functions in the Americas there an exclusive or overriding depen- comprising it, which is definitely the dence on them. Based on shared ideas, principal referent of its organization The Public Health in the Americas Ini- values, and the participation of many and operation. tiative has prepared a list of 11 essential actors, it is even possible to renew lead- public health functions. The number of ers in positions of power without inter- In civil society, the public health respon- functions was not determined a priori, fering with the process. It is the leader- sibilities of private or nongovernmental but rather is the result of the analysis, def- ship of a true democracy, which is also social institutions can be specific, i.e. inition of basic criteria, discussion, and reflected in permanent participation. their main facet, or secondary and can field tests carried out to establish them. be either formal or informal. The main Institutional responsibilities in public responsibility of specific private, social Below is a summary of the basic criteria health are part of the aggregate respon- health organizations is the health of adopted to identify the EPHF, which sibility toward the well-being of a popu- people or of a population. Other social would best respond to circumstances lation. This holds true not only because organizations with broader goals or that in the Americas, and to validate these health is the product of living condi- are related to health assist in the field of functions. The entire process will be de- tions and quality of life, but also because public health as part of these responsi- scribed in greater detail in chapters 8, 9, public health is a component and strat- bilities. Both are formally bound by the and 10 of part III. egy for improving them. In this way, the society’s legal strictures not to threaten responsibility for public health implies health, but the activities they carry out 1) Since the principal goal of the initia- being part of the greater responsibility are basically the result of voluntary deci- tive is to promote the permanent in- for comprehensive human develop- sions. These institutions and organiza- frastructure of public health, priority ment, which becomes a basic aspect for tions can make a profound contribution has been placed on selecting generic developing public health policies and to public health. From the family to the or structural functions from a purely strategies that are very dependent on de- community or nongovernmental organ- functional view of specific functions velopment policies and strategies. izations working in health or related to in determined fields of action. The it, from religion or churches to the press, generic or structural functions are the The NHA’s institutional responsibility and from schools to unions and political basis of a functional public health in- in public health and its essential func- parties, all these organizations comprise frastructure and are applied in vari- tions are part of its overall steering role an expanding universe of actors that ous spheres of activity. in public health. This does not mean bond together forming relationships that the NHA directly carries out each and action networks that make a deci- 2) Comparing the three previous stud- function. The EPHF are the instru- sive contribution to improving public ies that specifically addressed identi- ments the NHA uses to oversee health, health. This variety of social agents is the fying essential public health shows

65 Figure 1 EPHF defined in the NPHPSP,2 the WHO Delphi Study,3 and the PAHO position paper4

NPHPSP PAHO Human resources development

• Monitoring health status • Epidemiological surveillance • Health promotion and personal empowerment • Social and intersectoral participation • Strategic public health planning • Regulation and financing • Guarantee of health planning • Evaluation of the effectiveness, access to, and quality of health services • Environment • Research and development in public • Disasters • Occupational health

Delphi Study Public Health Management

WHO

that there is a high degree of conflu- process culminated a meeting of the net- processes that could be verified and ence among the functions identified. work of institutions and experts, con- evaluated, and responsible operating The following schematic reflects this vened by PAHO.1 mechanisms for accountability. idea. (Figure 1) 3) It was also important to define the 4) The initial list of 12 functions set Nine of the functions appear in all three functions as groups of actions that forth in an instrument to measure the studies. One of them, human resources, could be carried out adequately. performance of essential public appears in both NPHSP and PAHO This necessitated a certain degree health functions was pilot-tested in documents. Three appear in both of homogeneity to identify specific Colombia, Jamaica, and Bolivia. PAHO and WHO documents. Only goals, components, and production These tests were analyzed, resulting one function appears solely in the WHO in a list of 11 essential functions. study. This overlapping helped indentify 1 Expert consultation on the performance (Table 2.) Obviously, this list it is functions and was used to prepare the measurement of essential public health func- subject to improvements. It was not rough draft on an instrument for mea- tions, Washington, D.C., September 9 and designed to cover all the public health 10, 1999. suring the performance of the EPHF. 2 National Public Health Performance Stan- perspectives in the world; nonethe- This draft also includes the definition dards Program, Centros para el Control y Pre- less, efforts have been made to mini- of all the 12 essential functions selected vención de Enfermedades (CDC), EE.UU. mize biases and include the relevant 3 and the indicators and standards for WHO. “Essentials Public Health Func- aspects determined by the experts tions: results of The International Delphi evaluating their performance. Different and actors that help make health pol- Study”, World Health Statistics 51, 1998. groups of experts and public health pro- 4 OPS. “Las Funciones Esenciales de la Salud icy decisions. Their opinions were fessionals evaluated the draft, and this Pública: documento de posición”, 1998. taken into account in all instances. 66 • A public health services infrastruc- Table 2 Essential Public Health Functions ture designed to conduct population EPHF 1 Monitoring, Evaluation, and Analysis of Health Status screenings, case-finding and general EPHF 2 Public Health Surveillance, Research, and Control of Risks and Threats to epidemiological research. Public Health EPHF 3 Health Promotion • Public health laboratories capable of EPHF 4 Social Participation in Health conducting rapid screening and pro- EPHF 5 Development of Policies and Institutional Capacity for Planning and Management in Public Health cessing of a high volume of tests nec- EPHF 6 Strengthening of Institutional Capacity for Regulation and Enforcement in essary for identifying and controlling Public Health emerging threats to health. EPHF 7 Evaluation and Promotion of Equitable Access to Necessary Health Services • The development of active programs EPHF 8 Human Resources Development and Training in Public Health for epidemiological surveillance and EPHF 9 Quality Assurance in Personal and Population-based Health Services control of infectious diseases. EPHF 10 Research in Public Health EPHF 11 Reduction of the Impact of Emergencies and Disasters on Health • The capacity to develop links with international networks that permit better management of relevant health problems. Defining the EPHF is the first step in • Identification of those nonsectoral re- measuring public health performance sources that support health promo- • Preparedness of the NHA and in the Region of the Americas, and tion and improvements in the quality strengthening of local health surveil- this activity will doubtlessly be per- of life. lance to initiate a rapid response for fected in the future. the control of health problems or spe- • Development of technology, expert- cific risks. EPHF 1: Monitoring, Evaluation, ise and methodologies for manage- and Analysis of Health Status ment, analysis and communication of EPHF 3: Health Promotion5 Definition: information to those responsible for public health (including key players Definition: This function includes: from other sectors, health care pro- • The promotion of changes in lifestyle viders and civil society). • Up-to-date evaluation of the country’s and environmental conditions to fa- health situation and trends including cilitate the development of a “culture their determinants with special em- • Identifying and establishing agencies of health.” phasis on identifying inequities in that evaluate and accurately analyze risks, threats, and access to services. the quality of collected data. • The strengthening of intersectoral partnerships for more effective health • Identification of the population’s EPHF 2: Public Health Surveil- promotion activities. health needs including an assessment lance, Research, and Control of of health risks and the demand for Risks and Threats to Public Health health services. 5 This function encompasses the definition Definition: of the capacities specifically required to im- plement, from the perspective of the NHA, • Management of vital statistics and • The capacity to conduct research and the components of health promotion defined the status of special groups or groups surveillance of epidemic outbreaks, in the Ottawa Charter and reaffirmed in the at greater risk. patterns of communicable and non- recent Global Conference on Health Promo- communicable disease, behavioral fac- tion in Mexico. Since it has been considered necessary to define another essential function • Generation of useful information for tors, accidents, and exposure to toxic to cover social participation, this latter has the assessment of the performance of substances or environmental agents concentrated on defining capacities that health services. harmful to health. largely facilitate health promotion. 67 • Assessment of the impact of public lic health through a participatory EPHF 7: Valuation and Promotion policies on health. process that is consistent with the po- of Equitable Access to Necessary litical and economic context in which Health Services • Educational and social communica- the decisions are made. Definition: tion activities aimed at promoting healthy conditions, lifestyles, behav- • The institutional capacity for the • The promotion of equity of access iors and environments. management of public health sys- by civil society to necessary health tems, including strategic planning services. • Reorientation of the health services with emphasis on building, imple- to develop models of care that en- menting and evaluating initiatives de- • The development of actions designed courage health promotion. signed to focus on health problems of to overcome barriers when accessing the population. public health interventions and help EPHF 4: Social Participation link vulnerable groups to necessary in Health • The development of competencies health services (does not include the for evidence-based decision-making, financing of health care). Definition: planning and evaluation, leadership • Strengthening the power of civil soci- capacity and effective communica- • The monitoring and evaluation of ety to change their lifestyles and play tion, organizational development and access to necessary health services of- an active role in the development of resource management. fered by public and/or private pro- healthy behaviors and environments viders and using a multisectoral, mul- in order to influence the decisions • Capacity-building for securing inter- tiethnic and multicultural approach that affect their health and their ac- national cooperation in public health. to facilitate working with diverse cess to adequate health services. agencies and institutions to reduce EPHF 6: Strengthening of injustices and inequities in use of • Facilitating the participation of the Institutional Capacity for Planning necessary health services. community in decisions and actions and Management in Public Health with regard to programs for disease • Close collaboration with governmen- Definition: prevention, diagnosis, treatment and tal and nongovernmental institutions restoration of health in order to im- • The institutional capacity to develop to promote equity able access to nec- prove the health status of the popula- the regulatory and enforcement essary health services. tion and promote environments that frameworks that protect public health foster healthy lifestyles. and monitor compliance within these EPHF 8: Human Resources frameworks. Development and Training EPHF 5: Development of Policies and in Public Health Institutional Capacity for Regulation • The capacity to generate new laws Definition: and Enforcement in Public Health and regulations aimed at improving public health, as well as promoting • The development of a public health Definition: healthy environments. workforce profile in public health • The definition of national and subna- that is adequate for carrying out pub- tional public health objectives which • Consumer protection as it relates to lic health services. should be measurable and consistent health services. with a values-based framework that • Educating, training, developing and favors equity. • Carrying out all of these activities to evaluating the public health work- ensure full, proper, consistent and force to identify the needs of public • The development, monitoring and timely compliance with the regula- health services and health care, effi- evaluation of policy decisions in pub- tory and enforcement frameworks. ciently address priority public health

68 problems and adequately evaluate pub- making process at all levels and con- • An integrated approach with respect lic health activities. tributes to quality improvement. to the damage and etiology of any and all emergencies and disasters that • The definition of licensure require- • Using the scientific method to evalu- can affect the country. ments for health professionals in ate health interventions of varying general and the adoption of ongoing degrees of complexity. • Involvement of the entire health sys- programs that improve the quality of tem and the broadest possible inter- public health services. • Systems to evaluate user satisfaction sectoral and inter-institutional col- and application of its results to im- laboration to reduce the impact of • Formation of active partnerships with prove the quality of health services. emergencies and disasters. programs for professional develop- ment to ensure that all students have EPHF 10: Research in Public Health • The procurement of intersectoral and relevant public health experience and Definition: international collaboration to re- receive continuing education in the spond to health problems resulting management of human resources and • Rigorous research aimed at increasing from emergencies and disasters. leadership development in public knowledge to support decision-mak- health. ing at the various levels. Bibliography • The development of skills necessary for • The implementation and develop- interdisciplinary, multicultural work in ment of innovative solutions in pub- CDC/CLAISS/OPS. La salud pública en las Américas. Instrumento para la medición public health. lic health whose impact can be mea- de las funciones esenciales de la salud sured and assessed. pública — Prueba piloto (working docu- • Bioethics training for public health ment); April 2000. personnel, emphasizing the principles • The establishment of partnerships Bettcher DW, Saprie S, Goon EH. Essential and values of solidarity, equity, and with research centers and academic public health functions: results of the respect for human dignity. institutions from within and outside international Delphi Study. Geneva: the health sector to conduct timely WHO, World Health Statistics, n.º 51; 1998. EPHF 9: Quality Assurance in studies that support decision-making Personal and Population-based of the NHA at all its levels and in all OPS. Funciones esenciales de salud pública: documento de posición. División de De- Health Services its fields of action. sarrollo de Sistemas y Servicios de Salud, Definition: (draft); May 1998. EPHF 11: Reduction of the impact OPS. Funciones esenciales de salud pública • The promotion of systems that evalu- of the emergencies and disasters on (doc.). CE126/17 (Esp.), April 2000. ate and improve quality. the health6 Secretary of State for Social Services. Public Definition: Health in England. The Report of the • Facilitating the development of stan- Committee of Inquiring into the Future dards required for a quality assurance • Policy development, planning and Development of the Public Health Func- and improvement system and over- execution of activities in the preven- tion. Londres: Her Majesty’s Stationary Office; 1988. sight of compliance of service pro- tion, mitigation, preparedness, early viders with this obligation. response and rehabilitation programs The Core Functions Project. Health Care to reduce the impact of disasters on Perform and Public Health: a paper on Population-based Core Functions. Jour- • The definition, explanation, and as- public health. nal of Public Health Policy, Vol. 19, n.º 4, surance of user rights. 294–418. 6 Emergency and disaster reduction in health U.S, Institute of Medicine. The Future of • A system for health technology as- includes prevention, mitigation, prepared- Public Health. National Academy Press; sessment that supports the decision- ness, early response and rehabilitation. 1988.

69 7 Framework for Action to Improve Public Health Practice

This chapter outlines the principal fea- of effective strategies for action. There- they know that theory and practice, tures of the interventions aimed at im- fore, the groups of factors will be ana- concepts and action, are interdepen- proving public health practice in accor- lyzed sequentially, the aim being to re- dent. Indeed, theory that does not lead dance with the concepts and operational produce the reality as closely as possible, to practice is sterile, and all practice strategy of the essential public health although this approach will entail some is, in turn, the manifestation of a con- functions. Although it seeks to cover the redundancy, which is unavoidable and ceptual representation of reality. The most important aspects of public health at times may even be desirable. The last concepts that justify practice may not practice, the exposition hereby pre- section will summarize the entire chap- be explicitly stated, or they may not be sented is more conceptual than opera- ter, presenting a comprehensive over- perceived by the actors, who simply act tional. It identifies and provides a char- view of the process needed to develop on the basis of unanalyzed experience or acterization of the factors that are public health practice. they merely apply procedures and rou- important for good public health prac- tines established by others. However, tice, without dwelling on how they are 1. Concepts and Practice while an exercise carried out under such to be applied. Parts III and IV of the conditions may be effective in a specific book delve further into operational is- Unfortunately, evidence of a false con- instance—provided the conditions of sues and specifications for the applica- tradiction between theory and practice the previous experience are replicated tion of some of these factors. continues to abound in the social and the established rules followed—if sphere. Many who consider themselves it does not include some element of Given the number and variety of factors pragmatic reject theory and theorists, self-evaluation or cannot be adapted to that must be taken into account it is rec- whom they consider to be out of touch different or changing circumstances, it ommended to group them within the with reality and whom they label as ac- will ultimately become less effective, if sections that identify them. It is recog- ademics or dreamers. On the contrary, indeed it ever was. Practice, especially nized, however, that the components some of the so-called theorists view the in the social realm, and in public overlap, both between and within pragmatists with arrogance and even health, in particular, both tests and val- groups. This calls for a holistic and contempt. In general, the latter recog- idates theory. Most importantly, prac- comprehensive approach to the design nize their views as misleading because tice serves as the most effective mecha-

71 nism for enhancing and broadening through the use of technology and the means, in essence, the ability to ascer- theory. organization of production. In other tain the reality and to intervene to words, real or potential unmet demand change it. It means, having the neces- A similar situation may occur, but with a becomes the incentive to transform basic sary information and intelligence and different argumentation: Concepts may knowledge into the means to apply tech- the ability to implement—i.e., actual be negated for ideological reasons. This nology for the production of goods. It resources, especially human resources, occurs frequently in the area of health, also encourages entrepreneurs to organ- and adequate organizational and mana- especially in regards to its social determi- ize the production and sale of goods in gerial capacity. nants. There are no longer those who the market to potential consumers. Pub- dare to deny that health and public lic policies may help or hinder this Public health practice is strongly influ- health are influenced by social factors, process through fiscal incentives, credit, enced by the culture in which it takes but when the negative impact of the technical assistance, training, etc. How- place. The value placed on public health dominant economic models or political ever, in the field of public health, a very is an important factor in the application processes that lead to unhealthy public different process occurs. A significant of technical instruments and limits or policies are analyzed, it is often argued portion of theoretical knowledge is the encourages their application, depend- that public health should confine itself result of an analysis of reality and experi- ing on the circumstances. The charac- to its own area of scientific inquiry—i.e., ence, and is therefore, to some extent teristics of social processes, including the biological and related sciences (clas- already being manifested in practice. economic and political processes, deter- sical epidemiology, statistics, etc.)—and What needs to be done, then, is mainly mine the possibilities and opportunities not get mixed up in politics and eco- to compile this knowledge, to organize it for intervention. On the other hand, nomics. This risk involved in this type of and make it more consistent, and to ex- the availability and quality of resources argument is that it is used as justification pand its application. In the case of pub- will also influence the possibilities for for inaction in the social sphere under lic health, the goods in question are usu- action. It is therefore essential to con- the guise of biomedical sciences which, ally public goods or goods with great sider specific factors that may affect in- in the final analysis, is an ideologically social value, which have high externali- terventions in the short term, structural motivated political position that mas- ties and cannot be individually owned, factors in the broader context, and fac- querades one of scientific neutrality. In leading to insufficient demand and tors related to public health itself, as it advanced societies, in which basic social scarce market supply. Thus public health relates to national and even intrana- needs have been satisfied such position is a State responsibility. tional situations. Thus, implementation has negative effects mitigated by the fact modalities are always specific and take that there is relatively little need for so- Hence, essential public health functions place in a concrete situation. However, cial change. This is so, particularly, with are a fundamental responsibility of the this does not negate the validity of gen- regard to political processes and prac- NHA, from the generation of knowl- eral knowledge and the possibility of tices. On the other hand, in those soci- edge to the development of technology generalizing the use of some well-de- eties in which such changes are impera- and its appropriate implementation signed operational instruments in com- tive for public health development the through the organization of its produc- parable situations, as long as care is consequences are appalling. tion. Similarly, the transition from con- taken to identify differences and varia- cepts to action is basically an institu- tions in order to make the necessary In summary, a solid and well-defined tional process in which the NHA adaptations. The possibility of general- conceptual framework—to guide ac- manages the participation of other ac- izing may prove to be a very significant tion and which is validated and im- tors. Accordingly, the essential require- advantage for progress, given its poten- proved by it—is crucial starting point ment for carrying out this process is the tial usefulness for comparisons, mutual for public health development. institutional capacity to undertake such support, learning and shared develop- endeavor, the development and exercise ment, etc. Hence, the process of devel- The transition from theory to practice in of which will be discussed in the sec- oping public health practice will be the production of goods is accomplished tions that follow. Institutional capacity based on national ownership and the

72 willingness to cooperate and share related to all these steering functions, stewardship that the political and inter- achievements at the international level. sometimes overlapping or complement- sectoral dimensions of health, the ing them with regard to the objectives of health system, and public health are Chapter 6 described the basic functional public health—i.e., everything that has manifested most fully and obviously, strategy for public health develop- to do with the health of the population. and it is in stewardship that these di- ment—i.e., performance of the essential The EPHF and public health are thus mensions are addressed in ways that will public health functions for which the more than simply a component of the have repercussions and be replicated, to national health authority is responsible. steering role and the health system; they differing degrees, in other sectoral areas. This strategy is justified, not only be- are general reference frameworks and in- cause it represents a manageable func- tervention instruments present in all ac- It is also in the stewardship that alliances tional interest in the field of public tions that help enhance the health of are forged and support is enlisted for the health, but also because of its potential populations. They are also, because of implementation of the vision and pro- to achieve overall health development of their objectives, necessary outcomes. In- posed objectives, that the tasks of mobi- the population. Public health practice deed, the steering role of the health sys- lization and cooperation are defined and through the EPHF is the best way to ad- tem should be guided, first and fore- organized, and that the greatest capacity dress all aspects of public health, includ- most, by the fundamental objective of for leadership and promotion should ing health-promoting social practices. In public health: the health of the popula- reside. It is here that general strategies this manner, the practical application of tion, which is also the principal and ul- for action are developed and articulated, the concepts of public health will occur timate objective of the health system, that sectoral policies are formulated and as a natural outgrowth of the adequate and the EPHF, may be the best instru- negotiated, and that the characteristics performance of the essential public ment to achieve such objective. of the planning, organization, and man- health functions. The operational ap- agement processes are defined. Finally, it proach for assuring that this happens Stewardship is the central function of is in exercising the steward role that de- will be performance evaluation and de- the steering role and defines it as such. cisions are made about the general con- velopment of the national health au- Stewardship means guiding the health ditions that will lead to the effective thority’s capacity as an institution which system from a given situation, which is execution of programs and activities enables carrying out the essential public considered partially or wholly unsatis- within the health system—decisions health functions as effectively as possi- factory, to a better situation in the fu- about institutional organization, financ- ble, including the mobilization and in- ture, which is established as the objec- ing, assignment of responsibilities and volvement of other actors from the State tive to be achieved. In accordance with allocation of resources, and monitoring and civil society. this view, stewardship entails an evalua- and evaluation throughout the process. tion of the existing situation and the Without effective stewardship, it will be 2. Managerial Capacity as definition of the situation established as impossible to achieve good public health a Prerequisite a goal—the vision of what is desired and the entire steering role and overall and possible—including the health ob- performance of the health system will be As was explained in Chapter 4, public jectives and determinants, which im- compromised. health is part of the overall health sys- plies the design, implementation, and tem, and essential public health func- execution of strategies for achieving the The steering role should recognize and tions are part of the global steering func- proposed change. In the exercise of the adopt public health as the basis for tion exercised by the NHA. This steering role, stewardship performs or stewardship, with performance of the steering role includes, in addition to oversees other functions, including the essential public health functions as its EPHF, management of financing, health EPHF, which are carried out so that the principal instrument, to be applied in care, and general organization of the de- process of management can be accom- the design of models of care, in insur- livery of services, as well as regulation plished effectively. Stewardship is thus ance and quality assurance in the deliv- and management of the entire system. central to the decision-making process ery of care, in the organization of sys- The essential public health functions are that is part of the steering role. It is in tems of services, and in health systems

73 performance assessment. Stewardship identify differences between the existing the variety of objectives or spheres of is, therefore, a prerequisite for—and, at situation and the possible and desirable action, it requires an analytical vision. the same time, benefits from—good situation and determine the causal fac- The results of the overall action of pub- public health practice. tors that explain the discrepancies. lic health are manifested in the specific outputs of its parts and in their joint 3. Systemic and Specific The situation assessment will serve to contribution to the health of the popu- Aspects of the Essential identify weaknesses or deficiencies that lation, which may be much greater than Public Health Functions need to be corrected, including their the mere sum of the partial results if the causes, as well as strengths that should actions of the various components are The previous chapter, in analyzing the be reinforced. The resulting strategies guided by a common objective. concept of essential public health func- and programs for action will initially be tion, a differentiation was made be- centered on the essential public health Essential public health functions, as the tween systemic or structural functions functions as the structural matrix of the core of public health action, share indi- and specific or programming functions capacity for action in public health and vidual and complementary traits as and the relationships between the two as the basis for improving interventions parts of the whole that is public health. categories were established in a graph. in the specific spheres of action through Every EPHF has its own functional This distinction is very useful for im- public health programs. Later, or if pos- identity and specific processes and each proving public health practice, and the sible simultaneously, the particular situ- generates specific outputs and results. At selection of EPHF As noted earlier, if ations of those programs will be as- the same time, however, they share com- essential public health functions in- sessed and the necessary corrective or mon resources and complement one an- clude all significant interventions of a strengthening measures will be defined. other. There is also a question of effi- systemic nature that define the essential Then, an effort will be made to deepen ciency involved: sharing resources and capacity for public health action, and if knowledge in regard to certain specific taking full advantage of the opportuni- those interventions are carried out satis- or complementary issues and expand ties for synergy will increase benefits in factorily, practice in the various specific the capacity for action with respect to relation to cost for each cost unit added. or programmatic spheres of action will social practices in public health. Optimizing the balance between the also be satisfactory. specificity of each function and achiev- Interventions aimed at improving the ing the most effective integration of Hence, a requirement for achieving EPHF performance will involve specific their common aspects is thus the golden good public health practice is proper actions for each function, but should rule for the management of essential selection of the essential functions and, place special emphasis on aspects com- public health functions. The selection of especially, a clear definition of each mon to several or all of them. These functions (Chapter 6) was made to fa- function that identifies the principal ac- common aspects will frequently appear cilitate the achievement of that balance. tivities involved and includes a compre- as features in the situation assessment hensive range of activities within the and will usually reveal deficiencies in The EPHF 1 (monitoring, evaluation, overall set of functions. A clear defini- the overall public health infrastructure and analysis of the health situation), tion of the functions will make it possi- that are affecting some or all of the es- EPHF 5 (development of policies and in- ble to select the best indicators to meas- sential functions. The sections that fol- stitutional capacity for planning and ure their performance.1 The first step is low will focus on this topic. management in public health), EPHF 8 to assess the situation, as measured by (human resources development and performance of the EPHF, which is done 4. Complementarity training in public health), and EPHF 10 by comparing it against optimal stan- and Comprehensive (research in public health) are examples dards, established by consensus for the Development of the EPHF of systemic functions that support or entire Region. This makes it possible to complement the others and constitute Because its fundamental objective is the areas that share capabilities common to 1 See Part III for more detail on the measur- health of the population, public health all public health actions. EPHF 3 (health ing instrument and process developed in the requires a comprehensive vision. At the promotion) and EPHF 4 (social partici- framework of the Initiative. same time, owing to its complexity and pation in health) require the contribu- 74 tion of some of the other functions but, public health infrastructure and its artic- gence for action. Section 6 below ana- especially through their results, they are ulation with the other functions associ- lyzes this element in greater detail. also capable of changing the operational ated with the steering role and with the conditions of the entire health system related resources and activities of the • Skilled human resources and satisfac- and public health, amplifying the impact health system. Thus, the principal strat- tory working conditions. Section 8 of their specific activities. EPHF 6 egy for developing public health and discusses this matter further and (strengthening of the institutional capac- improving its practice will also be part of Chapter 15 (Part IV) explores the ity for regulation and enforcement in the strategies for making public health a subject in depth. public health) is instrumental and essen- fundamental instrument for strengthen- tial for ensuring adequate operation of ing the steering role with regard to • Organization, as the element that ties the whole health system in its collective health and enhancing the overall health the resources together, endowing or public health dimensions. At the same system. In other words, another aim of them with functional unity and en- time, the contribution of the other essen- the improvement of public health prac- abling public health action. Organi- tial public health functions is needed tice, or the integral development of pub- zation, like infrastructure, defines the to fulfill this function. Similarly, perfor- lic health, is to develop the steering role institutional characteristics of public mance of EPHF 2 (public health surveil- as an essential function for bettering the health, specifically, those relating to lance, research, and control of risks and health system and increasing its effec- the performance of essential public threats to public health), EPHF 7 (evalu- tiveness and raising the population’s sat- health functions. It comprises the ation and promotion of the equitable ac- isfaction with its services. If this aim is legal basis for public health—i.e., the cess to necessary health services), and achieved, public health will be strength- national authority responsible for EPHF 9 (quality assurance in personal ened and its effectiveness in attaining public health, its functions and du- and population-based health services), its fundamental objective—the health of ties, the assignment of those func- which are directly linked to the ultimate the population—will be enhanced. tions and duties to the various ele- objectives of public health, is aided by ments and levels of the organization, the other functions. Finally, EPHF 11 5. Public Health and the mechanisms and processes (reducing the impact of emergencies and Infrastructure and for ensuring accountability and eval- disasters on health) is an example of a Development of Capacity uation, among other things. Organi- more specific function with a defined for Action zation defines, in short, how the in- sphere of action, which receives support frastructure is configured and how it from the more systemic functions. The infrastructure for public health is can be managed to carry out public the set of stable and interconnected health actions. Organization also in- The foregoing examples point out the means by which its activities are organ- cludes the fundamental technical interrelationship between the individ- ized. In the broad sense, it is the perma- processes through which scientific ual essential public health functions, on nent base of resources organized for and technical activities are carried out the one hand, and between the EPHF action and defines NHA’s capacity for in order to perform the essential pub- and other areas of intervention in performance of the essential public lic health essential functions and exe- health systems. The specific approach, health functions. Accordingly, it is by es- cute basic administrative and mana- though necessary given the specificity of tablishing a sound infrastructure that in- gerial processes. They are not each function, entails significant risk of stitutional capacity for action in public technical manuals, but they do pro- a loss of the synergism among them, health can be increased and the practice vide the basic parameters for the unjustifiable duplication of effort, and, of public health can thus be improved. preparation of such manuals. The consequently, lack or reduction of effec- distinction between administrative tiveness in public health. The fundamental elements that make processes and scientific and technical up the infrastructure are: processes is important for the im- The strategy that will achieve the best provement of public health practice balance between specificity and integra- • Information, which implies the exis- because it singles out scientific and tion of the essential public health func- tence of adequate information systems technical tasks, differentiating them tions is the development of a common and the capacity to turn it into intelli- from management and administra- 75 tion, which makes it possible to tailor structure. In this case, the infrastructure of other sectors or are carried out by the infrastructure for these tasks to is of a social nature, which corresponds them. For this reason, intersectoral ac- their specific characteristics. to and is complemented by the institu- tion is also a means of expanding the ca- tional infrastructure that is the focus of pacity for action in public health beyond These three functional elements operate this section. Section 12 will deal with the possibilities of its own infrastructure. on the basis of indispensable physical the social infrastructure. resources and essential support or auxil- The situation assessment and, especially, iary services. These support or auxiliary Articulation of the concepts and prac- the evaluation of the performance of es- services are public health laboratories tice of public health is accomplished sential public health functions should and, special research and training units. mainly by means of the institutional be used to identify the weaknesses in the Public health laboratories, however, are capacity for intervention, which is deter- institutional infrastructure of public essential structural elements for public mined by the infrastructure, or by the health. It will then be possible to design health and for the performance of es- social capacity for positive action, which specific interventions to correct them sential public health functions. In some in turn is determined by the social capi- within the conceptual framework pre- situations, special research and training tal that is formed in the culture and sented here, which is the principal frame units may be so essential to the overall manifested in healthy social practices of reference for guiding the efforts development of public health and serve and social participation. Creation or im- needed in each case to strengthen the as key structural elements for interven- provement of the institutional and social public health infrastructure. Use of the tion in public health and for the effec- infrastructures for public health is there- findings of the EPHF performance eval- tive performance of essential public fore the principal condition and funda- uation, coupled with a conceptual un- health functions. mental factor for achieving effective derstanding of the characteristics and re- practice. quirements of public health, will enable Functional infrastructure requires physi- the development and implementation of cal space, instruments and equipment The institutional infrastructure is spe- strategies and plans to strengthen the in order to operate. This becomes even cific to public health, but public health infrastructure as needed and enhance in- more necessary the more public health action would be severely limited if it stitutional capacity for intervention in functions are not being performed. The were restricted to the capacity of its own public health, in accordance with the most obvious examples are computer infrastructure. Therefore, the NHA possibilities and needs in each situation. and communications systems for infor- should utilize the capacity of other areas Moreover, it will be possible to articulate mation management, laboratory facilities of the health system and other sectors— institutional capacity with the contribu- and equipment, and workspaces in especially those that have a hand in the tion of the society. Chapter 13 in Part IV which managerial personnel and public steering function and in the delivery of will address this subject in more detail. health workers can carry out their func- care—to expand the capacity for action tions. In many countries these require- in public health. In fact, at one extreme In essence, the process of strengthening ments are not being met, or the condi- of the health care system, public health infrastructure and the consequent devel- tion of the physical resources is extremely activities are part of general health care opment of institutional capacity for ac- precarious. Public health development for the population and often they are tion is the result of decisions made by and practice require that these physical carried out by the same agents, especially the national health authority in the exer- instruments and resources exist at least at at the primary care level. Similarly, the cise of the steering role, through its a basic minimal level, which must be de- essential public health functions overlap stewardship function. Such decisions are fined in each case. with and complement all the functions political in nature and represent the ex- of the steering role and depend deci- ercise of institutional power. In the na- In accordance with the conceptual basis sively on the management function. tional arena, these decisions will have adopted, the positive social capital that Moreover, some important public health greater force and sustainability if the is produced by healthy and health-pro- activities, including some of a systemic government assumes responsibility for moting social practices and manifested nature, such as regulation, risk and them and if they become the responsi- in citizen participation in health is, threat control, and human resources de- bility of the State. Not only will the de- without a doubt, another kind of infra- velopment, depend on the intervention cisions themselves be reinforced, but all 76 of public health, as much as it will be en- fine not only the use or purpose of the based information and qualitative infor- dowed with greater importance. The information, but the users as well. The mation with a less rigorous formal basis. NHA, too, will be strengthened as its matrix also shows the variety of subject It is derived, preferably, from objectively authority to exercise the global steering areas with which public health is con- observed and recorded facts, but it is role in the health system will be aug- cerned, including both areas related also based on the perceptions and opin- mented. Once a policy decision has been to specific public health objectives and ions of reliable actors. Fortunately, there made, the process of implementing it essential functions, health risks and are techniques for analyzing and mini- becomes mainly a management respon- threats, and human resources for public mizing inaccuracies, variations, and er- sibility with fewer political implications. health, as well as broader objectives, rors in such information, which makes In any case, it will be a slow and com- with information for exclusive public it possible to reach reliable or acceptable plex process, which will always depend health use and for shared use in the per- conclusions on the actions to be taken. on the existence of good sectoral man- formance of other functions related to For example, to measure and evaluate agement and the use that is made of it. the steering role and the health system. the performance of essential public In general, the use to be made of the in- health functions in the countries, an in- 6. Information and formation will serve as a guide for the strument based on the opinions of Intelligence in Public selection of the subject areas. Based on groups with expert knowledge of the sit- Health this simple and imaginary exercise, it is uation has been designed and utilized obvious that public health practice and successfully. The limitations of evidence Information is the most generic input the essential public health functions re- and the observations that produce it in into the infrastructure of public health. quire information on both the specific the field of public health should be It is also an indispensable input, since areas of concern for public health and noted here, as should the importance good public health practice cannot more general information, nonspecific of qualitative evidence, due in part to occur without information or if the in- to public health but essential to its ca- the limitations that may result from fail- formation available is ineffective or in- pacity for action. ure to include important variables that sufficient. Indisputably, the improve- should be considered. Nevertheless, it ment of public health practice depends Nevertheless, it is not enough simply should be reaffirmed that it is preferable on the availability of information, and to have information; the information to base public health intelligence on in- it will only be as good as the quality of available must be of satisfactory quality, disputable scientific evidence. Accord- that information. it must be timely, and it must be ingly, there should be an ongoing effort processed correctly in order to generate to expand the evidence base. The information required for good pub- intelligence. Mechanisms and processes lic health practice is extremely varied and for evaluating and assuring information Notwithstanding these considerations, is related to a wide variety of topics, in- quality are just as, or even more, impor- the question of ownership of informa- cluding objectives and areas of concern tant than primary information collec- tion systems in public health remains for public health, context, and external tion, transmission, and processing sys- to be answered: Are they exclusive or determining factors. Consequently, the tems. Intelligence is the parameter for shared? There seems to be no doubt processes by which the information is measuring the use and valid of informa- that the answer is “both.” To attain in- collected, analyzed, and used will also tion. Knowledge of subject areas and formation that has to do specifically vary. To obtain an overview of all the situations is the first stage of intelli- with the areas of concern of public complex processes involved in informa- gence gathering in public health, which health, there will be specific informa- tion management, it might be useful to facilitates or complements the wisdom tion systems that can delve into the par- construct a matrix indicating the rela- and capacity to choose, carry out, or ticular area and components of each tionship between the various categories promote the most effective actions in EPHF. For more general information, of information, the principal subject relation to given objectives. public health will coordinate with other areas, and the EPHF. systems to gain access to the necessary The concept of information used in this information. The guiding criterion for The suggested categories have great instance is quite broad, encompassing decision-making in this regard is to seek strategic importance because they de- both objective, quantifiable, evidence- the most appropriate balance between 77 specificity and integration in the steer- alyzed in detail here,2 although they are compasses some personal health care ac- ing role and in the health system. The essential for the improvement of public tivities and is carried out through them, ideal would be to design a health in- health practice. which blurs the distinction between the formation system that is comprehensive two fields. In the case of environmental in nature, but has components that In conclusion, the initial situation as- health, the distinction disappears alto- will produce specialized information for sessment of the essential public health gether because interventions aimed at the particular uses, as well as a common in- functions through the measurement and environment always have a public health formation base for shared use. In such a evaluation of their performance also connotation, whether or not they are car- system, public health and essential pub- serves as a starting point for the man- ried out within the health sector or under lic health functions will have a special- agement of public health information. the responsibility of the NHA. Environ- ized component, tailored specially to Performance indicators are excellent mental health, in all its practical manifes- their needs, which will feed the infor- guides for identifying the information tations, falls within the sphere of action mation generated into the shared sys- needed, and application of the measure- of public health, owing to the public na- tem in previously agreed formats. Such ment instrument reveals gaps in the ex- ture of the services rendered and the a system would permit access to the isting information, deficiencies in the scope of their coverage in the population. common information base and to other available information, and even, in some specialized components for the acquisi- cases, the fact that the available infor- Definition and coordination of institu- tion of necessary data and information, mation is unusable or useless. It also re- tional responsibilities are basically the all of which would be available in usable veals the strengths and weaknesses of the only issues that have to be addressed in formats. health services infrastructure in regard relation to public health practice and to information production. On the basis the essential public functions. The rela- of this knowledge, interventions can be tionship between public health and per- In any case, public health should always designed to remedy the weaknesses or sonal health care at all levels of the care have the capacity to analyze data for reinforce the strengths and devise and delivery system, but especially the pri- specific purposes and generate its own promote strategies for the structuring, mary care level, has already been dis- intelligence, although access to this in- expansion, and enhancement of the cor- cussed, as have the simultaneous execu- telligence should not be restricted or responding systems. tion of public health activities in the exclusive. One precaution that is fre- course of caring for individuals, the quently overlooked but that should be shared support systems, and the com- exercised in regard to information is not 7. Public Health Practice plementarity of information. All these to go overboard in terms of the volume and Personal Health Care connections are crucial for public health or variety of data and information pro- Services practice and performance of the EPHF. duced, so that it does not exceed the Here, the focus will be on the influence capacity for use, which would not only As has been noted above, there is a close of public health in the organization and waste resources, but could entail a risk and complementary relationship be- operation of the personal health care of seriously biasing the entire process tween public health and personal health system and the total health system, and, possibly, jeopardizing the genera- care activities, and this relationship is which may be a critical factor in the ori- tion of intelligence. manifested in a variety of ways. entation of health sector reforms and Both public health and personal health also, be of great importance for the gen- Information about public health proves care are integral parts of the health eral orientation of public health. its usefulness and becomes real intelli- system and share responsibility for con- gence when it serves for the formulation tributing to the achievement of its The ultimate objective of a health sys- of plans and policies, planning, and ef- objectives. Moreover, public health en- tem is to improve the health of the pop- fective and efficient management, in- ulation and ensure that care provided cluding evaluations of sufficient breadth 2 See Chapter 13 in Part IV for more infor- provides social satisfaction. Both objec- and depth. These matters will not be an- mation on this subject. tives—social effectiveness and satisfac-

78 tion—have collective significance; they will be consequential from a political cial effectiveness of personal health care; are related to the health of populations, standpoint. they also benefit from the opportunities and they are, therefore, public health that personal health care creates and objectives. The vision of public health Disregard for or failure to recognize the from its resources to expand the scope should be the underlying criterion or importance of public health in the or- and also the effectiveness of public basis for the formation, steering, and ganization and the operation of health health activities, without this implying management of health systems and the care systems and health services has been, any loss or weakening of the necessary delivery of personal health care. It is perhaps, the leading cause of the low so- specificity of these two spheres of action. within the perspective of public health, cial effectiveness of health systems, low understood as population health, which levels of satisfaction among the popula- 8. Human Resources3 global health objectives and the desired tion with the care received, and the fail- health situation can be properly defined ure of some of the sectoral reforms car- Human resources are a fundamental and and the system and its resources and ried out in the last two decades. Now, essential element for public health prac- processes can be organized to produce however, a new generation of reforms de- tice and constitute one of the pillars of the services that will make it possible to signed to correct this deficiency is antici- its infrastructure; in reality, the practice achieve those objectives. pated. It is not a question of reducing the of public health is no more than the sum importance of personal health care, since of the practices of the personnel who The instruments of public health ac- such care responds to perceived needs work in public health. Nevertheless, tion, which are made manifested basi- and urgent demands of the population the public health workforce is one of cally through the essential public health and will always be a central priority in the the most neglected and least valued re- functions, also serve to achieve overall health sector and, indeed, a specific re- sources within the health sector in the health objectives and fulfill the guiding sponse to the recognition of a fundamen- Americas, which is a reflection of the principles of personal health care. For tal human right: the recovery of lost lack of regard for the importance of example, equity and universality of care health. Rather, what ought to be done is public health itself. Indeed, in most of are objectives of EPHF 7; quality of to organize the provision of this care in the countries, the distinct nature of pub- care and, therefore, its effectiveness and accordance with social effectiveness crite- lic health work is not recognized to the generation of satisfaction, are objectives ria in order to take maximum advantage extent that would give rise to a differen- of EPHF 9; and models of care that em- of its contribution to the improvement of tial approach to the development and phasize health promotion and disease population health. Public health practice, management of public health workers. prevention are objectives of EPHF 2 from this perspective, takes on broader and EPHF 3. Public health and the es- and more socially significant dimensions The specific characteristics of the field sential public health functions, as has as it is situated at the center of decision- and objectives of public health and the already been pointed out, are essential making and action by the sectoral leader- nature of its activities and relationships instruments for the NHA’s exercise of ship and is considered an integral part of give the public health workforce differ- its steering role in the health system, es- the health care and health systems. ential characteristics within the health pecially its management. Beyond the system. Because they deal with the col- specific area of health care as such, pub- In short, public health and the essential lective dimensions of health, public lic health, as it is understood here, is public health functions, in particular, health professionals utilize knowledge fundamental for the promotion of so- should never be considered in isolation from multiple fields and employ inter- cial participation in health (EPHF 4), from or in opposition to personal health vention instruments that reach the entire not only for the protection of health care, including medical care. On the population and address specific health and the appropriate use of health care contrary, public health and EPHF co- risks and impairments, their direct services by the population, but also for exist and their concepts and practices are causes and general determinants, social the exercise of social control over public intertwined with personal health care in and instrumental responses for meeting actions and for the promotion of social health systems. They contribute deci- 3 See Chapter 15 in Part IV for a more thor- demands for healthy public policies that sively to the relevance, quality, and so- ough discussion of this subject.

79 collective health needs, health systems thus creating a group of professionals de- which mean that one of the principal and social practices, political and man- voted specifically to the practice of pub- tasks of such training is to teach public agement processes, and, ultimately, all lic health in its various manifestations. health workers to continue to learn on the myriad, interrelated, and changing While this variety of manifestations re- their own. If this objective is achieved, factors that have an effect on the health quires professional specialization in the the necessary continuing education will of the population. They are constantly various spheres of activity within public be assured, thanks to access to educa- combining various forms of knowledge health, it also requires an ongoing effort tional information and the creation of and information and applying and revis- to link and integrate the various disci- opportunities and environments for ing the instruments available to them to plines—which, in turn, requires special collective reflection, which will multi- solve public health problems. Owing to skills—in order to avoid the fragmenta- ply individual ability to learn and col- the variety of skills needed to cope with tion and lack of focus that may result lective capacity to create and produce. the complexity, diversity, and variability from an exaggerated division of public It should also be considerd, for all the of the issues to be addressed, public health into operational compartments foregoing reasons, emotional intelli- health work—which relies on the man- and specialties. gence, a sense of social ethics, and the agement of knowledge—is basically an ability to work as a member of a team interdisciplinary field that calls for team- Public health is not, however, restricted are often more important qualities in a work and requires the unique contribu- to the work of public health profession- public health worker than isolated tech- tions of many professions and disci- als or specialized workers. Because pub- nical skills. plines. Hence, public health work not lic health practice has repercussions on only has objectives of a collective nature, the work of other health professionals, Public health workers deal mainly with it is collective in and of itself, and public especially those who care for people and goods of a public nature or goods with health workers not only work with the environment, and even the work of high social value, and their work there- knowledge, they create knowledge and other sectors, one can speak of a joint fore earns very little recognition in the develop ways of applying it as part of work force, which should receive the labor market. The organization and their collective action. necessary training and support to en- management of the public health work- able it to carry out its public health re- force are an eminently public issue and a The foregoing paragraphs underscore sponsibilities in a satisfactory manner. responsibility of the State. In general, the need for a public health workforce Indeed, one of the skills or competen- public health work, especially in the case composed of professionals from various cies that public health workers should of public health professionals per se, re- fields. Although it continues to be as- have is the ability to raise awareness that quires total, full-time dedication, owing sumed that training in the basic health public health is the responsibility of all, to the nature of the functions, the lim- professions, especially medicine, is ad- including both general health profes- ited opportunities that exist on the mar- vantageous for public health workers. sionals and those who work in related ket, and the numerous conflicts of inter- Medical education, because of its bio- activities and, ultimately, of all citizens. ests that may arise. These circumstances medical orientation, can no longer nec- Public health workers are thus more require special management of the per- essarily be considered an indispensable than technical agents responsible for sonnel who work in public health, in- requirement for public health work. In applying their knowledge; they are mes- cluding the creation of new occupa- some spheres of activity and for some sengers who convey the social message tional categories and careers specific to essential public health functions, train- of public health and promoters of public health. In addition, incentives ing in other professions may be more healthy social practices and participa- that will balance individual benefits helpful. tion by all in the shared work of im- with collective worth and incentives, so proving the health and well-being of the that individual performance and team- However, it is clear that specific training population. work will be promoted simultaneously in public health, as a specialization, must and there will be well-structured evalua- take precedence over training in other Training in public health should there- tion processes and general working con- professions in order to succeed in form- fore be tailored to these characteristics ditions suited to the characteristics of ing a distinct public health workforce, of its workers, its human resources, public health interventions.

80 In sum, good public health practice de- public health programs are more pre- defined objectives. Some of these pro- pends on adequate consideration of the cisely defined, but they are also scattered grams, or parts of them, constitute an human resources who carry it out. throughout the institutional structure of essential public health function, as the health sector or, sometimes, outside is the case with programs on disaster The instrument used to measure and the sector. Reorganizing the essential preparedness (EPHF 11), health or evaluate performance of the essential public health functions as needed to give epidemiological surveillance (EPHF public health functions in the Region of them functional identity and unity is a 2), health promotion (EPHF 3), and the Americas includes indicators relating complex and difficult undertaking. In health information (EPHF 1), etc. to the availability of key human re- some cases, functional identity may be sources for each of the essential func- achieved without operational unity— • Practice incorporated into others tions, in addition to the specific indica- that is, without a specific structural or- areas of health care, particularly per- tors used to assess the performance of ganization for all the EPHF. In other sonal health care services at the pri- EPHF 8 (human resources development cases, a virtual structure may serve as a mary level. and training in public health). The re- temporary solution. In either case, it will sults of this initial exercise can be used be imperative to carry out the process of • Public health practice carried out by to move ahead in this area and to signif- functional identification and delimita- other institutions but subject to regu- icantly strengthen the work that PAHO tion in order to improve performance. lation and oversight by the NHA. is currently carrying out in support of In this regard, it should be recognized the countries. that although the measurement and The fact of belonging to a structure or evaluation instrument and its applica- organization is part of the definition of 9. Public Health, EPHF, tion have led to progress, a great deal re- the last two. Public health practice that is and Programs mains to be done. incorporated into personal health care is thus part and parcel of the delivery of Public health practice and performance Public health practice within the steer- those services, and only the support ac- of the essential public health functions, ing institution of the health system (the tivities performed, and their respective and the organization thereof, require a ministry or health secretariat) can be costs, are counted as part of the corre- precise delimitation of each EPHF in examined from the standpoint of four sponding EPHF. Similarly, public health order to identify the desired outcomes, different components with structural activities carried out by other institutions the activities needed to achieve them and significance: are incorporated into the functions of the necessary resources and organization those institutions, and only the regula- to carry out the work. This, in turn, will • Specific practice of the essential pub- tion and oversight exercised by the NHA make it possible to estimate expenditures lic health functions—individually are part of the corresponding EPHF(s). and costs, establish the amount of fi- and together—which form the struc- The process of functional organization nancing and budget needed, and man- tural core of public health. of public health thus remains limited to age the financial aspects of public health the essential public health functions work.4 • Practice carried out in specific spheres themselves and to specific public health of activity, usually structured in the programs, which constitute the sphere of In almost all the countries of the Region form of public health programs, such action for public health. of the Americas, the essential public as those pertaining to environmental health functions are not identified as health, health surveillance, control of In the case of programs, the task of eval- such. Their components, or some of diseases (AIDS, tuberculosis, malaria, uating performance is relatively easy. them, are mixed in with other activities etc.), and others. ). It must be recog- The objectives and outcomes are de- and are carried out by various agencies nized that public health outcomes are fined, as are the activities, processes, and or institutions with little or no linkage achieved through the execution of resource needed to achieve them. It is among them. However, some typical programs, which are defined as a set thus easy to assign responsibilities, estab- of resources organized to carry out lish monitoring and evaluation mecha- 4 See Chapter 14 in Part IV for more details. certain activities in order to achieve nisms, determine costs and expendi-

81 Table 1 Organization of public health in the health system

Steering limits Intersectoral Action

FRAMEWORK PUBLIC HEALTH OTHER FUNCTIONS Programs5 EPHF6 CARF 1 2F1n Fn A BCN

Common infrastructure

HEALTH SYSTEM

tures, and prepare specific budgets, such the organization and management of be impossible to carry out public health that the requirements for good practice public health and of the EPHF should activities, a situation that is politically or good performance are known or at be included in the organization and untenable. least discernable. However, the situation management of the steering role, under is a good deal more complicated in the the control of the NHA, with the neces- Financing for public health is basically a case of essential public health functions sary linkages and interaction with other matter of allocating resources, because it that do not correspond to programs or areas of the health system, other sectors, normally comes from the public budget, are not organized as well-defined func- and social participation mechanisms. especially in the case of essential public tional units. First, it is necessary to es- Table 1 attempts to illustrate this situa- health functions. There are exceptions, tablish that functional unity so that the tion with regard to the health system such as financing for the delivery of EPHF can be carried out and, as men- and the steering role. public services for which users pay in the tioned earlier, this is not an easy, espe- form of charges, fees, or fines, as is the cially when it is necessary or desirable to case with basic and urban sanitation have a common infrastructure for two or 10. Financing, services and those for enforcement of more functions. One of the crucial as- Intersectoral Action, regulations on market goods. However, pects that should be developed in public and Political Viability the majority of public health activities health practice is organization and man- carried out in connection with the agement, for which the ideas presented These three major areas of action are EPHF is the responsibility of the State, in this book are only the beginning of a decisive for public health development and attempts at cost recovery are inef- long process that will be refined through and practice. There can be no practice fective because it is difficult and expen- experience. However, it seems clear that without real resources to carry it out sive to exclude some from the benefits. and there can be no real resources with- Moreover, such exclusion affects the ef- out financing. Solving public health fectiveness of interventions. There is 5 Specific programs that do not correspond problems almost always involves some also the possibility of external financing to an EPHF are instrument for delivering care and as such are not part of the global degree of intervention by other sectors, through loans or grants, which can sub- steering function. without which the effectiveness of pub- stitute for or complement the resources 6 F1 and Fn can be organized as programs. lic health will be jeopardized and it will of the State in some specific cases, but

82 this is an alternative that should be con- possibility of raising the priority of pub- rhetorically. Among the many issues and sidered only in exceptional national sit- lic health and the EPHF, allocating to interests that affect the living conditions uations or circumstances. In any case, them resources from other areas, bear- of populations, public health is also the participation of the State is always ing in mind the constraints imposed by deemed very important by public opin- crucial—even in cases in which the de- the availability of a finite amount of ion. However, the importance attached livery of public services such as basic resources. The NHA, in exercising the to public health in the rhetoric and in sanitation has been privatized—since it sectoral steering role, should spearhead public opinion is not necessarily ex- is the State that determines and ap- efforts to win an increase in the re- pressed in concrete action, even within proves the structure of rates and regu- sources allocated to the sector, especially the health sector and among health au- lates and controls quality and other mat- those intended specifically for public thorities. Obviously, this constitutes a se- ters related to the provision of services. health functions. This is an eminently rious obstacle when it comes to making political process, which can be facili- public health activities politically viable. Financing for public health and the tated by technical arguments to support EPHF is, in the final analysis, a govern- the proposal. Assuring the viability of strategies and ment decision. In the Region of the plans for strengthening public health Americas, the general impression is that Intersectoral action can be encouraged and improving its practice implies the EPHF and public health are insuffi- and carried out at all levels of the health development of a political strategy that ciently financed. The available studies, system, but it is facilitated when those includes direct activities, as well as the though they are few or incomplete, in- responsible for the steering function creation of favorable conditions articu- dicate that spending on activities associ- and sectoral leadership embrace it as a lated among them. To this end, it is ated with the EPHF is less than 1% of preferential strategy. There are also necessary, first, to convince the NHA to total public expenditure on health. more general ways of fostering an inter- lead and oversee the process and, then, When spending on specific public sectoral approach, such as coordination to build and project an image of effec- health programs or programs for care of of sectoral strategies and policies, shar- tiveness and efficiency and develop the the population is added to that figure, ing institutional conditions, etc., which capacity to gain support from political the percentage increases, but it is still must be dealt with at the national level. institutions and leaders, as well as civil very low. In reality, the true situation is Promotion of the necessary intersec- society and the authorities of the State. not accurately known, because itemized toral approach in public health is thus Strategic instruments for achieving this accounts are not kept for basic activities also a responsibility associated with the must be chosen on the basis of specific (EPHF) and their exact costs therefore steering role, especially with respect to situations, but the following seem to cannot be determined. As was noted in the exercise of the management func- have universal application: the previous section, this is a task that tion. Public health plays a key role in remains to be carried out,7 and estimat- this regard, especially in identifying the • Information on decision-making pro- ing financing needs is still an exercise in areas in which an intersectoral approach cesses and on significant stakeholders approximation. It may be possible ini- is required and indicating how to apply and development of the capacity to tially to utilize standardized costs ad- such an approach. Public health can utilize the information intelligently. justed to the local price structure to ob- also support the process of negotiating tain a more exact estimate of financing and developing proposals for shared or • Superior technical quality in the de- needs. Within the NHA’s sphere of ac- complementary action and promote velopment of proposals and projects, tion, it is recommended that there be a and support initiatives at the local or carried out with the broadest possi- reallocation of the available resources to sub-national levels. ble constructive participation, but whatever new organization is adopted, without detriment to the quality and at least as regards current expenditure Public health, like health in general, timeliness of the outputs, such that for EPHF activities. There is also the enjoys a high level of consensus with maximum benefit is derived from the regard to the values that underpin it identification of the stakeholders of 7 Part IV, suggests some methodologies for and the objectives it pursues. On these political significance to the process this purpose. points, there is virtual unanimity, at least and the outputs.

83 • Capacity to negotiate and build im- 11. International • Coordination of this strategy with the portant alliances. Cooperation development of the steering capacity and with the rectification of the sec- • Demonstration of ability to perform International cooperation can play a toral reform processes still under way. effectively and efficiently, so that re- vital role in the development of public sults and benefits are perceived and health practice and the performance of • Construction of alliances among inter- recognized. essential public health functions the in national cooperation organizations, es- the Region of the Americas. From the pecially the banks, as well as bilateral • Forging of relationships of trust and formalization and promotion of ideas, agencies, through joint or compatible solidarity that will enable cooperation to the development of concepts and op- projects in keeping with the internal and support, which implies trans- erational instruments and the provision positions adopted within each organi- parency, dedication, and productivity. of support for countries and coopera- zation. tion among countries, there is ample • And, perhaps most important, capac- room for effective cooperation. The • Promotion of the Initiative in each ity for social mobilization and creation contribution of public health to the im- country, as a fundamental and indis- of conditions that foster effective so- provement of overall health and de- pensable requirement for its success, cial participation. The population will velopment is now widely recognized in so that the countries will take owner- thus feel ownership of the proposal international circles. The progressive ship of the Initiative, make it viable, and demand formal political support restoration of the essential functions of and extend it to other sectors, as well from its representatives. the State, relative freedom in regard to as social practices and participation. the pressure of demand for medical Clearly, building viability is a political care, and the failure of previous initia- The combination of good ideas and process that is aided and strengthened by tives all necessitate the consideration of suitable instruments for implementing general technical and social aspects. It is sectoral cooperation strategies that in- them, with quality technical coopera- also an ongoing process, since its princi- clude public health as an important tion and appropriate and well-oriented pal purpose is not the approval of a sin- component. The “Public Health in the supplementary financing, has great po- gle proposal or document, but the over- Americas” initiative thus is timely. tential for success. This potential can be all development of public health and increased by means of promotion and public health practice. An important Cooperation strategies must take ac- support through cooperation among part of this process is the creation of sus- count of all possible factors and contin- countries, taking advantage of their re- tainable and ever renewable structural gencies and must be adapted to national spective strengths and ability to com- conditions to enable full performance of situations. Several strategies, however, plement one another, and intensifying public health functions, in particular are worth serious consideration: the exchange of information and mu- conditions of an institutional and legal tual support, especially among subre- nature. The process is also ongoing be- • Enhancement and progressive expan- gional groups. Advantage should also be cause the conditions in which it occurs sion of the operational strategy of the taken of the public health-related con- and the actors involved are constantly essential public health functions, cerns that currently occupy a priority evolving and changing. It requires, more- which include the improvement of in- place on the international agenda. The over, formal and logical capacity, but also struments for deepening knowledge of debate on global public goods and in- a special sensitivity to the variety and the situation and for remedying any ternational cooperation, for example, mutability of motivations and human deficiencies detected, emphasizing can be a useful vehicle for promoting behavior. This is, therefore, the most in- their functional delimitation and public health, which is an area that un- teresting of the dimensions of health and characterization and strengthening of questionably deals in public goods. public health and the most remarkable the infrastructure of public health Analysis of the issue at the international of the institutional capabilities that en- services and the capacity for institu- level underscores the importance of sure good public health practice. tional action. public health as a field of cooperation

84 and also strengthens the importance at- shapes and guides them, giving them a and facilitate projects for develop- tached in the countries to public goods true social dimension by transforming ment and progress. But without or- as a responsibility of the State and, by them into real instruments at the serv- ganization, there can be no effective extension, public health. The increase ice of the population. The practice of social will and participation. in cooperation resources for control of public health and the EPHF, in particu- preventable diseases—especially AIDS, lar, is strengthened in terms of its sphere • It is not enough, however, to train and tuberculosis, and malaria—reflects a of action, its purposes, and its social im- organize. It is also necessary to create shift in priorities that affords opportu- portance. Without doubt, approaching institutional mechanisms for partici- nities for highlighting the crucial im- the essential public health functions pation that link health and public portance of public health in controlling from the perspective of social practices health institutions to the organized such diseases and, therefore, its impor- will increase their effectiveness as a pref- and involved society. Specific mecha- tance for health in general. erential strategy for public health. nisms for participation in health should be articulated with other forms In short, international cooperation can The considerations presented in Chapter of participation, both in other sectors have a decisive influence on the devel- 5 and expanded on in Chapter 6 provide and in general, and these mechanisms opment of public health practice in the a general idea of the concept of social should allow for real participation in Region of the Americas. practices and their application in public decision-making. This implies a sub- health, but we are only just beginning to stantive change in management mod- 12. Towards Social understand the process and explore its els to open them up to participatory Practices Centered potential for public health practice. Nev- processes and at the same time benefit on Public Health ertheless, some modes of intervention from their productive potential. Par- are currently available to facilitate insti- ticipation mechanisms should be rep- Public health achieves its pinnacle when tutional action in public health in order resentative of the diversity of society there is ownership by the people and to implement the process: and should be organized and operate communities, and when it is incorpo- democratically, with the capacity to rated into social practices—i.e., when • Training and empowering the popu- recognize and process the diverse in- it is manifested in healthy and health- lation for participation can be acceler- terests and opinions represented, min- promoting practices. Accordingly, this ated through information and organ- imize corporate distortions, and resist is one of the aims of the operational ization, in which health institutions manipulations of all types, so that strategy of the essential public health can play a key role. Health and public they are subject to the interests of functions, which also offers the best health, thanks to widespread consen- groups, parties, authorities, or ideolo- means of achieving it. Each EPHF, in sus about their value, enjoy an unde- gies. The process of promoting partic- practice, contributes something towards niable social acceptance that can be ipation is complex, slow, and often that aim, and it is the fundamental pur- an advantageous platform for mass frustrating, but it has potential that pose of EPHF 3 (health promotion) communication and transfer of infor- goes beyond health to the construc- and EPHF 4 (social participation in mation and knowledge. It can also tion of a future characterized by health). Through these functions, insti- serve as the starting point for encour- greater well-being, freedom, and true tutional action is directed towards aging and supporting social organiza- democracy. training and empowering people to par- tion processes, especially in commu- ticipate in health and public health and nities, which can be utilized to join • Social participation has costs, of in the exercise of their rights and re- forces and actions, expand social rela- which the least and easiest to defray is sponsibilities as the principal stakehold- tions, manifest collective demands, the institutional cost of promotion ers, while also exercising control over and consolidate the values of confi- and support. The cost to the popula- the actions of the State. This does not dence, solidarity, and cooperation, tion—in time, thwarted expectations, eliminate or diminish the responsibili- thus increasing the social capital that disillusion, etc.—is the social price ties and actions of the State, but it can nurture public health practices paid in advance, which must be com-

85 pensated for in the form of responses in this area. Two types of informa- purpose educational information, effec- and results that reward the effort tion, in particular, are essential: tive communication, promotion of so- made. Indeed, the process of partici- cial organization, and creation of effec- pation will not be sustainable if the • Educational information that en- tive participation mechanisms are the stakeholders and the population do courages citizen participation and principal intervention instruments. not acknowledge its usefulness. prepares individuals, families, and Consideration of social practices shapes communities to care for their own and strengthens the practice of public • Promotion of participation and train- health and the environment in health and the essential public health ing of citizens as a strategy for foster- which they live, so as to enable functions, while at the same time intro- ing healthy social practices in public them to make the best use of avail- ducing extraordinary possibilities for health is part of a broader process, as able health care services, monitor progress that, beyond their contribu- it is in regard to health in general. In- the performance of public authori- tion to health, will help foster sustain- deed, citizenship is a broad attribute ties, and take part in the develop- able human development. that has specific manifestations in the ment and execution of joint proj- various fields of human endeavor, ects to improve living and health 13. Summary which means that it cannot be limited conditions. to one of those fields. Although pub- The ideas presented in this chapter are • Information on institutional activi- lic health should take responsibility, elements that should be taken into ac- ties that ensures the transparency through its essential functions, for count when developing a strategy for of public action, enables social con- promoting the process in the field of the improvement of public health prac- trol, and provides greater safeguards health, this task, in order to be truly tice. They constitute, as the title of the against deviation or distortion of effective, should be accompanied by chapter indicates, a framework for ac- public functions. tion to that end. a solid attitude of support, political will, and intervention by the State, in- • Communication that transmits infor- The process begins with recognition volving all sectors, or at least those mation and thus makes it real, utiliz- of the importance of public health and with the greatest potential in this re- ing all kinds of media, from specific the need to improve its practice. This gard (education, labor, social develop- personal communication at the time should be manifested in a firm commit- ment, public prosecutor, etc.). In ad- care is delivered to mass communica- ment by the NHA to adopt the strategy dition, as a process of empowering the tion, with emphasis on those media of essential public health functions for population—that is, the transfer or that will have the greatest reach and the development of public health and creation of power—the development impact in each situation, and adjust- make those functions a fundamental of citizenship and social participation ing the format of messages to the tar- tool for carrying out its steering role in is a political process in that it changes get audience. the health system. Such a commitment the distribution and exercise of power implies the use of its stewardship func- in society. For that reason, social par- The summary provided in the preced- tion, especially to create the necessary ticipation mechanisms should be in- ing paragraphs gives an idea of the im- conditions for the development of pub- corporated into the formal political portance and the nature of the action lic health and for better fulfillment and process, through these they can find needed to incorporate health into social performance of the EPHF and their use appropriate channels for conveying practices and encourage public health in the management of the entire health social demands to the State and have social practices. It also gives an idea of system. a better chance of obtaining a reply. the complexity of the process and the means available for carrying it out, em- The next step is to understand the cur- • Information and communication phasizing the development of social rent situation, which can be accom- comprise the principal input and capital by building citizenship and so- plished, at least initially, by measuring most powerful instrument of action cial capacity for participation, for which and evaluating performance of the

86 EPHF. Such an assessment will point ing the assignment of responsibilities Claeson M. et al. Public Health and World out the weaknesses and strengths in the and allocation of resources such as fi- Bank Operations. Washington, D.C.: World Bank; 2002. existing infrastructure and the way it nancing and budget, as well as mecha- works. The information obtained will nisms and processes for monitoring and Leppo K. Strengthening Capacities for Policy guide the development of interventions evaluation. The process also includes si- Development and Strategic Management in National Health Systems. Geneva: targeting the strategy’s fundamental multaneous and ongoing political ac- WHO; 2001. component, which is to build institu- tion to enable intersectoral action. In- tional capacity for action by developing ternational cooperation helps catalyze Macedo C. Desarrollo de la capacidad de conducción sectorial en salud. Washing- and strengthening the infrastructure of and extend the process. ton, D.C.: OPS; 1998. (Serie Organi- public health services and the compo- zación y gestión de sistemas y servicios de nents of that infrastructure: information From the strategic standpoint, it is also salud 6). and strategy, human resources, organi- important to incorporate the perspective Macedo C. Modelo de gestión y eficacia de zation, and basic support processes and of social practices from the outset, ex- las reformas de salud en América Latina. essential support services. To do this, it panding the sphere of action of EPHF 3 In: Solimano, G. Isaacs, S. De la reforma is necessary to deepen the analysis, ex- and EPHF 4 to the utmost and marking para unos a la reforma para todos. San- tiago, Chile: Editorial Sudamericana; panding it to include other aspects, such the course of future development. as the study of relevant stakeholders, 2002. costs and expenditures, etc. The result- Doing all these things will set in motion Milen A. What Do We Know about Capacity Building? An Overview of Existing Knowl- ing proposal will be comprehensive in a process of public health development, nature, encompassing the whole set of edge and Good Practice. Geneva: WHO; based on performance of the essential 2001. essential public health functions and the public health functions, that will lead to Organización Panamericana de la Salud. De- shared infrastructure of public health progressive and sustainable improve- and their applications in specific spheres safíos para la educación en salud pública. ment of public health practice and en- La reforma sectorial y las funciones esen- of action through programs, relation- hance its contribution to the improve- ciales de la salud pública. Washington, ships within the steering role and the ment of population health and the D.C.: OPS; 2000. health system, requirements for inter- overall performance of the health system. sectoral action, etc., but it will have as a Organización Panamericana de la Salud. Edu- cación en salud pública: nuevas perspectivas unifying and supporting principle the Bibliography para las Américas. Washington, D.C.: development of institutional infrastruc- OPS; 2000. ture and institutional capacity-building. Atchison C. et al. The quest for an accurate U.S. Department of Health and Human Ser- The cycle is completed with the estab- accounting of public health expenditures. vices. Public Health Infrastructure. In: lishment of the functional organization Journal of Public Health Management Healthy People—2010 Objectives. Wash- for management and execution, includ- Practice 2000; 6(5): 93–102. ington, D.C.;1998. (Preliminary report).

87 PART III Performance Measurement of the Essential Public Health Functions 8 Rationale for the Performance Measurement of EPHF

The processes of State modernization 1. Assessment and management decision-making by the and health sector reform have high- improvement of health health system and should not be con- lighted the importance of evaluating systems performance ceived as a simple academic exercise. Ad- the performance of social systems and, ditionally, it should be linked to the def- in particular, of health systems, to make The regional consultations in the Re- inition of desired changes included in them more transparent and useful while gion of the Americas on health systems current programs of health sector re- providing a public accounting of their performance assessment included a con- form, as well as to the real possibility of actions with respect to the allocation, certed effort to orient the debate toward putting these changes into practice. utilization, and development of re- the future and to contribute to the de- sources that society provides for the ful- velopment of a clear definition of per- At both the national and international fillment of social objectives and public formance assessment and to improve- levels, the criteria for evaluating the per- policies, including health policies. ments in the reliability and usefulness of formance of health systems as well as the the data collected for the participating indicators used should be established by In this context, a variety of actions and countries. These consultations resulted consensus. Otherwise, polemics on cri- debates have unfolded regarding the di- in several conclusions that are summa- teria and indicators will tend to cloud rection, purpose, process, and utiliza- rized below.1 the assessment results and limit their tion of health systems performance as- possible use by policy makers and other sessment in recent years, including, in Health systems performance assessment interested actors. the Region of the Americas, a series of should be linked to political, social, and consultations on the subject among Similarly, performance assessment should participating countries. Performance be seen as a “quantitative and qualita- 1 Pan American Health Organization. Health measurement of the EPHF by national tive appraisal that shows the degree of Systems Performance Assessment and Improve- authorities fits within the framework of ment in the Region of the Americas. Washing- achievement of the objectives and the those interventions and debates. ton, D.C.: PAHO/WHO, 2001. goals.”

91 Better health is the ultimate goal that to serve as a stimulus to the formulation Furthermore, it was considered im- societies seek to achieve with their of health policies in the participating portant to define procedures to meas- health systems, but the delivery of indi- countries, the terms of the compari- ure the performance by health authori- vidual and collective services, along with son—the conceptual framework, the ties of their steering role, taking into intersectoral actions, is only one way of variables that operationalize it, and the account the functions assumed in the improving the health of the population. measurement indicators—must be sub- majority of the countries by the cen- Factors linked to socioeconomic condi- ject to consensus among the countries to tral, intermediate, and local levels of tions, the environment, genetics, and be compared. government. collective and individual behavior also have a powerful influence on health. Ac- In this regard, as part of rethinking and Therefore, performance measurement cordingly, it is necessary to improve our improving health systems performance of the essential public health functions, understanding of how these factors in- assessment, it was considered appropri- as carried out in the Region of the teract, how they influence the health ate to advance a framework that takes Americas, illustrates the potential of a status of individuals and populations, into account four dimensions: inputs tool for evaluating the institutional ca- and how they contribute to achieving and resources, functions, results or in- pacities of health authorities. In the first the ultimate goal of the health system, termediate objectives, and final objec- place, it measures a specific aspect of over and above the performance of the tives of the system. their steering role. It can also be used system itself. for continuous improvement of public Performance evaluation should incorpo- health practice and for reorienting re- All of the above also emphasizes the im- rate the different levels of analysis, that source allocation toward specific public portance of paying particular attention is, national, intermediate, and local, as health interventions. It does this through to the intermediate objectives of health well as the different functions of the a participatory and transparent process systems, that is, to what the systems are systems. It should also consider several within each country involving a self- actually doing and what they could do potential audiences: political decision evaluation of the performance of the better, rather than focusing performance makers, other interested actors, the pub- health authority in relation to the 11 es- assessment only on some distant final lic, etc. sential public health functions. Finally, objectives, that is, what should be done. it should be noted that the results are However, operational and performance Accordingly, it was agreed in the consul- not reduced to a global indicator, nor assessment of intermediate objectives tations that health systems performance are they aimed at development of a should always be related to the final ob- assessment should include a broad range summary measure for comparing differ- jectives of the system—that is, to im- of areas and levels of intervention, ent countries. provement of the health and quality of rather than simply equating the concept life of individuals and societies, the ulti- of performance with that of efficiency. mate reason for the existence and oper- This will allow users of the performance 2. Purpose of measuring ation of the health system. This also assessment to consider whether progress the EPHF in the countries raises the debate about the relationship is being made toward specific goals and of the Region of the between the boundaries of the health whether appropriate activities are being Americas system and accountability of health au- undertaken to promote the achievement thorities for its performance. of these goals. Health sector reforms face the challenge of strengthening the steering role of Unlike the comparison of health system The value of this would be in the ca- the health authorities, and an impor- performance over time in the same pacity to identify problem areas that tant part of that role consists of moni- country, the comparison of health sys- may need special attention, as well as toring the fulfillment of the EPHF that tem performance among different coun- best practices that can serve as models. are the responsibility of the State at its tries is seen as something desirable but Thus, performance assessment can also central, intermediate, and local levels. It difficult to carry out for technical and be a tool for regulation and for resource is therefore critical to improve public political reasons. For such a comparison allocation. health practice and the instruments for

92 assessing its current status and identify- to support the implementation role of functions for developing public health ing areas that should be strengthened. the health authority. This is essential for practice, leading to an operational diag- defining health policies in a manner nosis of the areas of institutional practice Measuring the degree to which the consistent with the underlying princi- that require greater support and develop- EPHF are fulfilled by the health au- ples of the health systems (equity, effi- ment. The development of the proposed thorities in the countries of the Region ciency, and responsiveness to citizens’ measurement is aimed at strengthening should enable the ministries or secre- expectations, for example), as well as for public health infrastructure, understood tariats of health to identify critical fac- ensuring implementation and develop- in its broadest sense to include the tors to be considered when developing ment of the policies in line with those human, material, and organizational ca- plans or strategies to strengthen public same principles. Thus, precise measure- pacities necessary for good performance, health infrastructure, understood as the ment of current deficiencies is very im- as analyzed in chapter 8. ensemble of human resources, manage- portant for governments as well as for ment practices, and material resources technical and financial cooperation In order to move forward in the achieve- that are needed to enable the health au- agencies involved in health. ment of this objective, it is important thorities at different levels to carry out that the decision to measure perfor- their responsibilities optimally. An emphasis present today in all reform mance be followed by the development processes is the introduction of a cul- of a measurement instrument that can This measurement is even more rele- ture of outcomes assessment, looking at be used to analyze the situation of each vant in periods such as the current one, the outcomes derived from use of the country, as well as of the subregions and marked by determination to reform ever-increasing resources allocated to the entire Region of the Americas. This health systems to enable them to better health care for the population. The instrument will undoubtedly require respond to current health needs. Public measurement instrument proposed by continuous enhancement until it reaches health plays a fundamental role in these the “Public Health in the Americas” ini- a reasonably optimal level that permits reform processes, since the potential to tiative is geared fundamentally to meas- its systematic utilization at the different achieve greater equity of access to better uring the performance of the health au- levels of public health practice in the health conditions lies within its arena of thorities in regard to public health. Its Region. activity. application should result in a diagnosis that does not just present a static image The set of indicators, variables, and Given that the majority of the countries of the current situation but permits a measures defined in the instrument is in the Region now make decisions on dynamic analysis of the results being subject to error and, obviously, cannot how to allocate the resources aimed at achieved currently and those that would pretend to satisfy every possible view- supporting their reform processes, hav- be possible in the future if investments point on the subject among public ing an accurate diagnosis of the areas are made to close the identified gaps in health specialists. Decisions to include, with the greatest needs in relation to resources, capacities, procedures, and for example, empowerment or stimulus public health development will be very results. of an intersectoral approach in the func- valuable when it comes to mobilizing tions of health promotion or social par- and directing the resources for strength- The heterogeneity of the responsibilities ticipation imply a certain degree of arbi- ening these areas, as the World Bank that come under the rubric of public trary agreement. This means that it is recognizes.2 health make it a social practice that, not possible to avoid repetition of areas often, can be equated with the full range that are included, with different em- As indicated earlier, strengthening pub- of functions and activities of a health phases, in more than one function. It is lic health is of fundamental importance system. obvious that the reality of daily public health practice does not allow for draw- In conclusion, the purpose of perform- ing clear distinctions between the times 2 The World Bank. Public Health and World Bank Operations. Washington, D.C.: The ance measurement is to identify strengths when the work is fulfilling one or an- Human Development Network: Health, Nu- and weaknesses in how the health au- other function, not even in the practice trition, and Population Series; 2002. thorities perform essential and necessary of a single individual.

93 It is important to mention here the fre- mainly on ensuring equitable access to services and lead to more precise defini- quent confusion between the State’s role services, guaranteeing the quality of tions of institutional responsibilities in in health, normally exercised by the service, and incorporating public health the delivery of these interventions. Pub- ministry of health or an equivalent perspectives in national health policies. lic health’s accountability to citizens for health authority, and the responsibility This does not prevent public health its performance should start with the of the State in overseeing and guarantee- professionals from undertaking to man- areas for which it is exclusively responsi- ing proper performance of the EPHF. age health services for individuals. On ble, that is, the EPHF. Furthermore, Although the State has a non delegable the contrary, it is desirable that they do public health’s legitimacy and its capac- role in the direct delivery or guarantee of so, especially in order to incorporate the ity to call on the cooperation of other the EPHF, this still represents only a public health vision in the operation of health-related sectors will be heightened fraction of its responsibilities in health. such organizations. The latter activity, by a more precise measurement of the It is a very important fraction, of course, however, utilizes disciplines that go be- essential components of its work. and proper fulfillment of these responsi- yond the social practice that has come bilities is not only fundamental for im- to be known as public health. In no case is measurement intended to proving the health status and quality of serve as a method of external evaluation life of the population, but is also needed The common concept of public health of the work of ministries or ministers, to give greater legitimacy to the State’s as embracing all work carried out in the nor is its purpose to rank countries on execution of its steering role and its re- health field contributes to a dilution of their commitment to public health. sponsibilities for regulation, financial responsibilities among areas distinct Nonetheless, in accordance with the control, supervision, and expansion of from public health and can lead to inef- mandate of the Directing Council, social security coverage in health and ficient use of health resources. Measur- PAHO has taken responsibility for facil- other areas. To clarify the point with an ing the degree to which essential public itating application of the instrument in example, a public health agency that health functions are being fulfilled and all the countries of the Region of the does not have a minimally comprehen- evaluating the performance of min- Americas. This has permitted a diagno- sive and reliable health surveillance sys- istries and public health agencies should sis of areas of weakness and strength in tem can hardly expect to be credible help to avoid this risk. the participating countries as a group, when it decides or acts to allocate finan- which is presented in the following cial capital to the different components With a view to strengthening the insti- chapter. or sectors of the health system. tutional capacity of the national health authority with respect to public health, The purpose of this measurement, then, One should also mention the difficulty it is important that the decision to is to present a self-evaluation of coun- in drawing a clear distinction between measure performance of the EPHF be tries at different points in time, allowing the responsibilities of public health for supported by the development of pro- for internal comparisons within an over- the management of disease prevention grams to ensure continuous improve- all analysis of the evolution of public and health promotion services for de- ments in infrastructure and practice at health in the Americas. As noted by the 3 fined population groups and those the different levels of public health in Executive Committee of PAHO, this functions related to the organization of the Region of the Americas. instrument will not achieve its objective services for individual curative care. unless measurement is carried out peri- Defining and measuring the EPHF are odically and the instrument is used on a The emphases here are undoubtedly conceived as a way of contributing to continuing basis. For this reason, both different. The first of these functions is the institutional development of public this measurement exercise and those to part of the basic heritage of public health practice and improving the dia- be carried out in the future will require health, since the public health authority logue between public health and other is the only one that performs it. As for health-related disciplines. Moreover, the second function, the essential re- better definition of what is essential 3 126th Session of the Executive Committee sponsibilities of public health focus should help to improve the quality of of PAHO, June 2000.

94 close collaboration among the partici- the development of this initiative, in development of the institutional pating countries and PAHO. which they consider an important con- capacities of the NHA, including in- tribution to the development of public frastructure, technology, human re- The instrument provides a common health teaching and research. sources, financial resources, inputs, framework for measuring performance etc. with respect to the EPHF, applicable to Measurement of the EPHF, understood all countries, that respects the organiza- as the capacities and competencies of As can be seen, each country made a tional structure of the health system of the national health authority (NHA) very substantial effort and there was a each country. In countries with a federal necessary for improving public health broad range of actors involved in the structure, for example, it will be neces- practice, is intended to: measurement effort, including officials sary to orient the measurement process at different levels of the NHA (both na- in accordance with the decentralized ex- 1. Help improve the quality of public tional and subnational), as well as rep- ercise of authority by each of the agen- health practice by strengthening criti- resentatives of other sectors, of non- cies involved. cal performance areas in the NHA. governmental organizations, and of the general public. This broad and repre- Finally, defining the EPHF and measur- 2. Promote accountability in public sentative participation made it possible ing their level of performance in the Re- health practice, bolstering the com- to achieve a comprehensive evaluation gion are fundamental for strengthening mitment of the NHA to carry out of the performance of the EPHF by the public health education in the Ameri- public programs aimed at strength- NHA. cas, an activity whose current crisis has ening the EPHF. much to do with the lack of a more pre- Given the difficulties involved in carry- cise definition of its task. This measure- 3. Promote the development of public ing out the measurement exercise in all ment effort also contributes to honing health relevant to the current situa- the countries of the Region, it is impor- such a definition, although its purpose tion, improving the quality and con- tant to note the short time period in is not really to define the scope of pub- tent of information available to those which this entire process was com- lic health as an academic discipline or who make decisions about health pleted, which again confirms the coun- interdisciplinary field. In this regard, re- policies. tries’ interest and commitment to meet- cent agreements of the Latin American ing this challenge. and Caribbean Association for Public 4. Strengthen public health infrastruc- Health Education (ALAESP) support ture in its broadest sense by investing

95 9 Development of the Measurement Instrument

The development of instruments to 1. Participate in a regional exercise, try, an exercise in performance meas- measure the performance of the EPHF sponsored by PAHO, to measure urement with respect to the essential entailed a long process aimed at defin- performance with regard to the es- public health functions, making use ing the functions to be measured, as sential public health functions to of the methodology designed; noted in chapter 6, as well as to define permit an analysis of the state of the performance indicators, variables, public health in the Americas; 3. Conduct a regional analysis of the and measures that would serve to verify state of public health in the Ameri- performance. 2. Use performance measurement with cas, based on a performance mea- regard to the essential public health surement exercise targeting the essen- 1. Definition of the EPHF functions to improve public health tial public health functions in each for the Region of the practice, develop the necessary infra- country; Americas structure for this purpose, and strengthen the steering role of the 4. Promote the reorientation of public The EPHF were defined operationally, in health authority at all levels of the health education in the Region of the accordance with the conceptual frame- State. Americas in line with the develop- work set forth in chapter 6, as the con- ment of the essential public health ditions that allow better public health In the same resolution, the ministers functions; practice. urged the Director General of PAHO to: 5. Incorporate the line of work on the The ministers of health in attendance at 1. Disseminate widely in the countries essential public health functions into the 2000 meeting of the Directing of the region the conceptual and cooperation activities linked with Council of PAHO unanimously adopted a resolution that, in essence, recom- methodological documentation on sectoral reform and the strengthen- mended1 urging the Member States to: the definition and measurement of ing of the steering role of the health the essential public health functions; authority. 1 Resolution CD42.R14. Essential Public Health Functions. 42nd Directing Council of PAHO. Washington, D.C.; 25–29 Sep- 2. Carry out, in close coordination with Furthermore, the XVI Special Meeting tember 2000. the national authorities of each coun- of the Health Sector of Central America 97 and the Dominican Republic (RESS- that can undoubtedly be improved on in jective of upgrading the public health CAD) agreed to support the proposal to the future, especially if the countries take services infrastructure within the short- carry out the measurement of the responsibility for the instrument. est possible time frame. EPHF and strengthen the steering role of the ministries of health in the coun- 2. Definition of Based on the selection of the EPHF, the tries of the subregion, as part of the performance standards next step was to determine the optimum process of PAHO/WHO technical co- for the EPHF standard for their general performance operation for institutional and sectoral in order to facilitate the elaboration of strengthening of public health.2 The information obtained with meas- that objective by the evaluation group as urement instruments of this type, which regards the expected performance of Based on these normative precedents, are intended to help the NHA more ef- each function. one of the most important decisions fectively define and evaluate the func- adopted in the course of developing the tion of public health in the health sector, Next, the identification and allocation Public Health in the Americas initia- should reflect a vision of the objective to of priorities for the indicators was one tive, related specifically to design of the be achieved. of the most complex and difficult steps measurement instrument, had to do in the design of the instrument. The in- with the need to adopt definitions of in- As in other performance measurement dicators, used as summary performance dicators and standards for performance processes, a choice had to be made be- measures of each function, are the most measurement of the EPHF. The inten- tween acceptable and optimum stan- important component of the instru- tion was to make it possible to guide the dards. Defining acceptable levels was ment and determine its quality and use- strengthening of public health practice difficult and necessarily arbitrary, since fulness. Ultimately, they constitute the by building up the institutional capaci- it implied either choosing a level com- heart of the measurement. ties of the health authority. parable to the hypothetical average cur- rently existing in the Region or defining For determining the indicators, one The list of the EPHF that are defined in the minimum requirements for per- proceeded with the identification of the instrument is based on an exhaustive forming a function based on the judg- variables that should be measured and process of collective analysis and reflec- ment of a group of experts. The choice the description of the measures and tion, as described in chapter 7. How- of optimal standards was considered submeasures, in the form of questions, ever, all the definitions are, obviously, more appropriate whenever, obviously, which made it possible to characterize subject to improvement and are not in- this fit the general situation of the Re- the performance of the functions. For tended to represent all the views on this gion, since such a definition identifies the purpose of enhancing measurement subject in the field of public health. gaps in the current situation with re- objectivity, the measurements included spect to an optimal level. This should were, insofar as possible, those that Nevertheless, there have been efforts to lead to continuous improvement, which served to verify proper performance. minimize disagreements and to incorpo- is precisely what is to be promoted. rate the most important aspects as laid The objective of this task is to obtain, out by experts and actors involved in Given the heterogeneous practice of the through the country’s response to sev- health policy decisions, whenever they EPHF in the Region, the optimum eral measures and submeasures, as com- have offered their opinions. It should be standards were defined to reflect the plete a profile as possible of the state of noted that this instrument represents the best conditions that could be attained in public health practice from the national first effort on performance measurement all the countries of the Region within perspective with respect to structure, in- of public health in the countries of the reasonable time periods; this implied stitutional capacities, processes, and Region of the Americas, an endeavour the need to rely on expert opinion to specific outcomes. When the indicators determine what those conditions are. and the associated variables are evalu- 2 Agreement 14 of the XVI Special Meeting of the Health Sector of Central America and Aside from this, opting for these reason- ated through the measurements, it is the Dominican Republic. Tegucigalpa, Hon- able optimum standards seemed more important to take into account the duras; 12–13 September 2000. appropriate and consistent with the ob- source of information on which the re-

98 sponse is based. This information lic health. Those exercises made it pos- ions are not unanimous, in order to should come from the core group of sible to enhance the measurement in- facilitate a more exhaustive analysis people interviewed and selected to carry strument based on the experiences and later to identify gaps with respect to out the evaluation, as well as from avail- opinions of the participants. the expected optimal level. able and easily accessible information sources for both quantitative and quali- 3. The instrument for 3.1 Sections of the instrument tative data. measuring the EPHF in the Region of the The instrument is divided into 11 sec- In the final analysis, the key indicators Americas tions, one for each essential public are capable of relating the results to the health function. Each function is pre- decision-making processes of the sys- The performance measurement instru- ceded by a definition of a selected set of tem. Thus, the validity of the indicators ment for the EPHF in the Region (see capacities necessary for performing that will make it possible to ensure contin- Annex I) is organized as follows: function, from which the indicators ued use of the instrument and future and related variables and measurements improvements in quality assurance in • A brief introduction explaining the are derived. public health practice. basics of the Initiative and describing the instrument. Utilizing this definition, indicators for A first draft of the instrument, includ- each function have been constructed ing definitions of the functions to be • The 11 essential public health func- and are used to measure the infrastruc- measured and definitions of the opti- tions, each with its corresponding ture, institutional capacities, key pro- mum standards for indicators, was dis- definition, are presented in a table cesses, and related results, as well as the seminated by the interinstitutional containing the practices that identify decentralized exercise of the function. In team in charge of elaborating the in- the work associated with each EPHF, general, all functions begin with inter- strument with various groups of public with three to five indicators for each mediate result indicators, such as: health professionals and experts, a function. Each indicator consists of : process that culminated formally in a • EPHF 1: The indicator “Guidelines meeting of a network of institutions • A standard that describes the opti- and processes for monitoring health and experts convened by PAHO for this mal level of performance for the status”. purpose.3 indicator. • EPHF 2: The indicator “Surveillance Subsequently, the instrument, contain- • A set of variables that identify the system to identify threats to public ing the indicators, variables and meas- operational characteristics of the in- health”. urements for each indicator, was vali- dicator that are the object of the dated in four countries of the Region: measurement, and are expressed as • EPHF 3: The indicators “Building Bolivia, Colombia, Jamaica, and Chile. the percentage of accomplishment sectoral and extrasectoral partner- The validation was carried out with of the function, based on the an- ships for health promotion” and “Re- groups of key informants who included swers given to the measurements. orientation of health services toward managers at different levels of the health promotion”. health authority (central, intermediate, • A set of measures and submeasures and local), researchers, and representa- that serve to verify performance for • EPHF 4: The indicators “Empower- tives of public health associations or each variable within each indicator, ing civil society for decision-making other institutions concerned with pub- and that allow for a dichotomous in public health” and “Strengthening “yes” or “no” response. Based on of social participation in health”. the methodology of response by 3 Expert Consultation. Essential Public Health Functions and Performance Measure- consensus of the evaluation group, Below are indicators for processes con- ment in Public Health Practice. 9–10 Sep- it was suggested that the country sidered critical for good performance of tember 1999. Washington, D.C. respond in the negative when opin- each essential function, such as:

99 • EPHF 1: The indicator “Evaluation principal processes for achieving these • The development of actions designed of the quality of information”. results; 3) the institutional capacities to to overcome barriers when accessing carry out the processes; 4) the necessary public health interventions and help • EPHF 2: The indicator “Capacity of basic infrastructure, and 5) the compe- link vulnerable groups to necessary public health laboratories”. tencies delegated to subnational levels health services (does not include the for the decentralized exercise of the func- financing of health care). • EPHF 3: The indicator “Support tion. For some functions it was not con- for health promotion activities, devel- sidered relevant or easy to identify sensi- • The monitoring and evaluation of opment of norms and interventions tive indicators within each of these five access to necessary health services of- to promote healthy behaviors and areas; but for all the functions, the meas- fered by public and/or private pro- environments”. urements cover at least outcomes and viders, using a multisectoral, multieth- processes, capacities and infrastructure, nic, and multicultural approach to • EPHF 5: The indicator “Develop- and also decentralized competencies. facilitate working with diverse agencies ment, monitoring and evaluation of and institutions to reduce inequities in public health policies”. Each indicator has, in turn, a standard access to necessary health services. model that describes in detail the pa- All the functions include indicators that rameters for optimum performance of • Close collaboration with governmen- measure institutional capacity for the the function. tal and nongovernmental agencies to performance of the EPHF, as well as promote equitable access to necessary those that measure technical support to Finally, for each of the indicators, vari- health services. the subnational levels. These make it ables to be measured have been identi- possible to evaluate efforts to strengthen fied and measures and submeasures de- Indicator decentralization, and are usually the last signed in the form of questions that indicators for each function. Examples further detail the specific capacities de- 7.1 Monitoring and evaluation of of indicators designed to evaluate insti- scribed in the standard for each meas- access to necessary health services tutional capacity are: urement. Those measurements ulti- mately reveal the degree of development Standard of the indicator EPHF 5: The indicators “Development or the degree to which performance ap- The NHA: of institutional capacity for the manage- proaches the expected optimum level. ment of public health” and “Manage- • Monitors and evaluates access to per- ment of international cooperation in As described in previous paragraphs and sonal and public health services by public health”. illustrated below, the format of the in- the inhabitants of a territorial juris- strument is as follows: diction at least once every two years. EPHF 6: The indicator “Knowledge, skills, and mechanisms for reviewing, The example below shows this with • Conducts the evaluation in collabora- improving, and enforcing regulations”. greater clarity: tion with subnational levels in public health, clinical care delivery systems, EPHF 7: The indicator “Knowledge, Essential function 7: Evaluation and and other points of entry into the skills, and mechanisms to improve ac- promotion of equitable access to neces- health system. cess to necessary health services by the sary health services population”. • Determines the causes and effects of Definition barriers to access, gathering informa- As a general rule, indicators for each tion on the individuals affected by This function includes: function were established such that they these barriers, and identifies best prac- would cover the five areas that would de- • The promotion of equity in the effec- tices to reduce those barriers and in- termine performance: 1) the results of tive access of all citizens to necessary crease equity of access to necessary the application of the function; 2) the health services. health services

100 7.1.1.4.2 Is the national evaluation Figure 1 Format for the Performance Measurement conducted in collaboration with the Instrument local levels?

ESSENTIAL FUNCTION 7.1.1.4.3 Is the national evaluation conducted in collaboration with other governmental entities?

7.1.1.4.4 Is the national evaluation conducted in collaboration with non- Indicator governmental entities?

3.2 Limitations of the instrument

Variable The task of developing a common in- strument for performance measurement of the EPHF faces a set of self-imposed limits in the design and selection of in- dicators and variables. While represen- Measure tative of the work of the NHA, these variables cannot possibly reflect the full Submeasure scope of the functions and activities of the NHA with regard to public health. Submeasure In order to design a viable measurement process, a choice was made to concen- trate on a small set of indicators that • Uses the results of this evaluation to 7.1.1.2 Is the national evaluation based would adequately characterize perfor- promote equitable access to necessary on a collection of population-based ser- mance of the 11 essential functions and health services for the population of vices accessible to the entire population? guide efforts to strengthen infrastructure the country and significant public health processes 7.1.1.3 Is information available from • Collaborates with other agencies to in relation to the role of the NHA. The the subnational levels to implement the ensure the monitoring of access to selection of indicators took into account national evaluation? necessary health services by vulnera- significant aspects concerned with the ble or underserved population groups direct results or key processes related to 7.1.1.4 Is the evaluation conducted in each EPHF, the institutional capacity or Variable collaboration with the subnational lev- infrastructure needed for proper per- formance of each EPHF, and the degree 7.1.1 The NHA conducts a national els and different entities of the NHA? of support to subnational levels for evaluation of access to necessary pop- strengthening the decentralized exercise ulation-based health services. Submeasures of each EPHF. Measures If so, In addition, for each indicator, a lim- Evaluation 7.1.1.4.1 Is the national evaluation ited subset of variables to be measured 7.1.1.1 Do indicators exist to evaluate conducted in collaboration with the in- was defined; these are also representa- access? termediate levels? tive of performance, but under no cir-

101 cumstances do they provide a detailed the national authorities understand it, analysis of the performance of the NHA picture of everything needed for good and offer the most accurate reflection of with respect to the EPHF. The meas- fulfillment of public health objectives. a self-evaluation of performance of the urement exercise and subsequent initia- EPHF as recommended by the minis- tives by the countries to develop actions Moreover, it is important to take into ters of health in the Governing Bodies aimed at addressing the major critical account restrictions imposed by the of PAHO. Beyond the specific score ob- areas encountered demonstrate that these methodology used for measurement, tained on each EPHF and each indica- objectives were fully achieved. based on the consensus opinion of a tor, what is important is that significant group of key experts that represented trends were identified within critical These problems could have been solved adequately the reality of national public areas for each country and, accordingly, through external evaluation carried out health, and who were selected by the provide an acceptable basis for efforts by a single evaluation agency in all the NHA to participate in the evaluation toward improvement. countries of the Region of the Americas. process. The selection of national evalu- However, the value of the self-evaluation ation groups was not exempt from the Furthermore, the instrument design and processes, especially in terms of the com- problems that contributed to the cur- the evaluation methodology are not in- mitment of national authorities to rent political and institutional environ- tended to have validity in the strict sci- strengthening the critical areas diag- ment, nor from the cultural dynamics entific sense of the term, given the pos- nosed, reinforces the methodological de- related to the performance evaluation of sibility of error in specific responses if sign chosen. government work in general. In this re- they are contrasted with the reality as gard, distortions due to selection of the depicted by another observer or by in- Moreover, it was decided not to prepare evaluation groups can be identified, and dependent arbitration. The responses re- a composite indicator encompassing all it is also quite possible that the level of flect the opinion of the participants with the EPHF, given that each function has success achieved by each country—not respect to the exercise in which they value in itself and includes significant the trends shown in the global profile— took part, which means that other read- capacities necessary for the develop- may differ depending on when the eval- ers of the results, who believe they know ment of public health in the participat- uation was carried out, whether at the the national situation, could make dif- ing countries. It would not be particu- beginning, middle, or end of a govern- ferent judgments. larly appropriate to calculate a unified ment’s term. It can also vary depending score for all the EPHF and present this on the breadth and complementarity of However, despite these limitations with as an expression of the reality of public the perspectives of the participants, who respect to validity, the instrument pre- health as a whole within each country are mainly representatives of the central sents a reasonably credible panorama of or in the entire Region. levels of the NHA and, to a greater or critical areas. Although it is possible that lesser extent, of subnational levels and of specific responses would vary if another The scores achieved by the countries are some entities outside the NHA. group of participants were constituted, qualitative and cannot be compared it is likely that the critical areas would quantitatively among themselves, since It is therefore important to regard the be the same, which confirms the valid- they depend on a great variety of factors measurement results as reflecting the set ity of the overall diagnosis put forward. linked to the reality of each country, as of capacities currently characterizing noted above. In addition, it is desirable public health in each of the countries The design of the instrument for mea- to stimulate cooperation among differ- involved, based on the consensus of the suring the EPHF, the methodology for ent countries to improve public health expert group selected by the govern- which is eminently qualitative, is aimed performance. For these reasons, no at- ment health authority at the time of at constructing a picture of the state of tempt was made to classify countries ac- measurement. Although these results the EPHF within each country. The cording to their level of commitment to might differ from those that would have great advantage of this measurement public health. Rather, the presentation been obtained by a different group of lies precisely in its capacity to retain the of results illuminates areas of greatest national experts, it is clear that they do peculiar characteristics of each country weakness, providing evidence to sup- faithfully reflect the national reality as and, potentially, to initiate a deeper port policies and plans for developing

102 public health in national and regional The questions for the measures and sub- tive weight, although this can be modi- contexts. measures permit only “yes” or “no” re- fied in the future. This decision was sponses. If the consensus response was based on the difficulty of determining a Notwithstanding these considerations, “yes,” a value of “1” was assigned for the priori different relative weights for each presentation of the overall panorama measure or submeasure in question; if function or for different indicators and also makes it possible for decision mak- the response was “no,” a value of “0” was variables. It is more logical to attempt ers to compare their national situation assigned. Partial responses were not ac- this in the context of the situation in with those of other countries, as well as cepted. For this reason, how to obtain each country, once the measurement has to define areas of collaboration for the the collective response for each measure been carried out without differentiating improvement of public health in their and submeasure was a significant issue. the relative weights of the questions. areas of responsibility. As a methodological guide for this mea- surement exercise, it was proposed to In the first stage, the analysis of the re- 4. Analysis of results the countries that in cases where a con- sults for each country that undertook of the measurement sensus of the entire group could not be the measurement was carried out by the achieved, at least 60% of the partici- country team, which had the support of For presentation and analysis of the pants should be in favor of the “yes” op- the instruments that were made avail- results of the measurement, a scoring tion in order to count the collective re- able to the country and that are at- system was devised that makes it possible sponse to the question as positive. tached in an annex. to quantify the qualitative responses from the measures and submeasures. At The score for each indicator and its The following scale was proposed as the same time, criteria were developed variables has been calculated using the a conventional guide for overall inter- for classification of the scores obtained percentage of positive responses to the pretation of the performance of each from the indicators as either strengths or measures and submeasures. This score is country: weaknesses, and, finally, for identifica- assigned to each indicator and, finally, tion of priority areas for attention and is used to calculate the average perfor- • 76–100% (0.76 to 1.0) intervention in subsequent efforts to mance level of each essential public Quartile of optimal performance strengthen institutional capacity in order health function. to improve performance of the EPHF. • 51–75% (0.51 to 0.75) In order to facilitate measurement, the Quartile of above average 4.1 Scoring of the instrument was supported by a com- performance measurement puter program that performs direct calculation of the final score for each • 26–50% (0.26 to 0.50) This section describes the methodology variable based on the responses to its Quartile of below average that was used to prepare the scoring sys- measures and submeasures. This facili- performance tem based on the responses, and that tates automatic calculation of the scores constitutes the quantitative basis for the for indicators and functions, and their • 0–25% (0.0 to 0.25) analysis of results of the measurement. graphic representation. Utilization of Quartile of minimum performance the same computer program in all the The scoring of each indicator that is part measurement exercises made it possible Although it is recognized that the scor- of the measurement of each function is to compile the information instanta- ing mechanism is not yet fully refined, based on the scores obtained for the dif- neously and using the same criteria. it is sufficient for identifying strengths ferent variables. The value of these vari- and weaknesses of the system, as well as ables can range between 0.00 and 1.00, For this first measurement exercise in for SWOT (strengths, weaknesses, op- given that they are prepared on the basis the countries of the Region of the Amer- portunities, and threats) analysis of the of the average value of positive responses icas, a method of scoring was chosen in public health systems of the countries, on the measures and submeasures that which all the functions, indicators, vari- especially from the perspective of a sys- are detailed under each function. ables, and measures have the same rela- tematic and continuous development

103 process. Moreover, application of the Based on the characteristics of the indi- spaces free from threats or harm to instrument in successive measurement cators used for measurement of the public health, and development of exercises will help to identify the evolu- EPHF in the five aspects that determine citizenship and of the capacity for tion of weaknesses in the public health the performance level, that is, outcomes, participation and social control. system infrastructure, making it possi- processes, capacities, infrastructure, and ble to improve the orientation of inter- decentralization, it was possible to iden- • Ensuring equitable access and quality ventions recommended for strengthen- tify three large groups of indicators that of necessary health services for the ing institutional capacity. represent strategic intervention areas entire population, and improving that can be included in programs for user satisfaction. 4.2 Identification of strengthening public health. These intervention areas strategic areas are the following: • Promoting recognition of the inter- sectoral character of health services In preparing plans to develop the insti- 1) Intervention for final achievement of and building partnerships to increase tutional capacity of the health authori- outcomes and key processes, the funda- the success of public health initia- ties in order to improve the exercise of mental component of the work of the tives. the EPHF pertaining to them, which is health authority in public health and, the immediate objective of this exercise thus, the primary goal of interventions 2) Intervention for development of in- in performance measurement, two basic to improve performance. It is related to stitutional capacities and infrastructure, premises have been observed: effectiveness, that is to results, and also understood as the qualitative and quan- to the efficiency—or the processes— titative sufficiency of human, techno- a) Development efforts should be in- with which the health authority carries logical, knowledge, and resource capac- stitutional in nature. This implies a out the public health functions that ities necessary for optimal performance comprehensive approach, rather pertain to it. Accordingly, proper per- of the public health functions that are than isolated interventions target- formance of the key processes will lead the responsibility of the health author- ing the actors and areas of each to success in terms of expected results ity. Adequate provision and develop- function. To this end, all the func- of the work of the NHA in public ment of such capacities and resources tions have been merged into strate- health. To this end, this area concen- condition performance of the functions gic intervention areas. trates mainly on critical areas that re- and achievement of desired results quire managerial interventions and within the public health work carried b) Interventions for institutional de- monitoring to improve performance of out by the NHA. In addition, this type velopment must seek to overcome the EPHF in the countries, such as: of intervention is basically investment, weaknesses by taking advantage of in its broader sense, and includes as- strengths. In order to rate perfor- • Articulating public health with pub- pects such as: mance in the different indicators as lic policies through definition of strengths or weaknesses, a reference health objectives and through under- • Strengthening of institutional organi- value is needed; this needs to be standing, analysis, promotion, con- zation. identified for each country at dif- tribution, and negotiation of policies, ferent points in the process, as a as well as their translation into laws • Strengthening of management capac- function of the level of perfor- and regulations. ity. mance and development goals. The basic criteria for establishing the • Facilitating the role of the population • Human resources development. reference values are: a) that the not only as object—the health of the weaknesses diagnosed not be ac- population—but also as active subject • Budget allocation and organization cepted or consolidated, and b) that of public health, that is, health for the based on performance of the EPHF. they represent an achievable chal- population. This includes develop- lenge and a reasonable incentive for ment and strengthening of health • Strengthening of institutional infra- continuing efforts at improvement. promotion, construction of healthy structure capacity.

104 Table 1 Indicators for each EPHF according to area of strategic intervention

Achievement of Development of Development of results and capacities and decentralized EPHF key processes infrastructure competencies

1. Monitoring, evaluation, 1.1 Guidelines and 1.3 Expert support and 1.5 Technical assistance and analysis of health processes for resources for and support to the status monitoring health monitoring health subnational levels of status status public health in monitoring, evaluating, 1.2 Evaluation of the 1.4 Technical support for and analysis of health quality of information monitoring and status evaluating health status

2. Public health 2.1 Surveillance system to 2.2 Capacities and 2.5 Technical assistance surveillance, research, identify threats to expertise in public and support for the and control of risks and public health health surveillance subnational levels in threats to public health public health 2.4. Capacity for timely and 2.3 Capacity of public surveillance, research, effective response to health laboratories and control of risks and control public health threats to public health problems

3. Health promotion 3.1 Support for health 3.5 Technical assistance promotion activities, and support to the development of norms, subnational levels to and interventions to strengthen health promote healthy promotion activities behaviors and environments 3.2 Building sectoral and extrasectoral partnerships for health promotion 3.3 National planning and coordination of information, education, and social communication strategies for health promotion 3.4 Reorientation of the health services toward health promotion

4. Social participation in 4.1 Empowering civil 4.3 Technical assistance health society for decision- and support to the making in public health subnational levels to strengthen social 4.2 Strengthening of social participation in health participation in health

5. Development of policies 5.1 Definition of national 5.3 Development of 5.5 Technical assistance and institutional capacity and subnational health institutional capacity for and support to the for planning and objectives the management of subnational levels for management in public public health systems policy development, health 5.2 Development, planning, and monitoring, and 5.4 Managment of management in public evaluation of public international health health policies cooperation in public health (continued)

105 Table 1 (continued)

Achievement of Development of Development of results and capacities and decentralized EPHF key processes infrastructure competencies

6. Strengthening of 6.1 Periodic monitoring, 6.3 Knowledge, skills, and 6.4 Support and technical institutional capacity for evaluation, and revision mechanisms for assistance to the regulation and of the regulatory reviewing, improving, subnational levels of enforcement in public framework and enforcing public health in health regulations developing and 6.2 Enforcement of laws enforcing laws and and regulations regulations

7. Evaluation and 7.1 Monitoring and 7.2 Knowledge, skills, and 7.4 Support and technical promotion of equitable evaluation of access mechanisms to improve assistance to the access to necessary to necessary health access to necessary subnational levels of health services services health services by the public health to population promote equitable 7.3 Advocacy and action access to necessary to improve access to health services necessary health services

8. Human resources 8.2 Improving the quality of 8.1 Description of the 8.5 Technical assistance development and training the workforce public health workforce and support to the in public health profile subnational levels in 8.4 Improving the human resources workforce to ensure 8.3 Continuing education development culturally appropriate and graduate training in delivery of services public health

9. Quality assurance in 9.1 Definition of standards 9.3 Systems for technology 9.4 Technical assistance personal and population- and evaluation of the management and and support to the based health services quality of population- health technology subnational levels to based and personal assessment that ensure quality health services support decision- improvement in making in public health personal and 9.2 Improving user population-based satisfaction with health health services services

10. Research in public health 10.1 Development of a 10.2 Development of 10.3 Technical assistance public health research institutional research and support to the agenda capacity subnational levels for research in public health

11. Reducing the impact of 11.1 Emergency 11.4 Technical assistance and support to the emergencies and preparedness and subnational levels to disasters on health disaster management in reduce the impact of health emergencies and 11.2 Development of disasters on health standards and guidelines that support emergency preparedness and disaster management in health 11.3 Coordination and partnerships with other agencies and/or institutions in emergencies and disasters

106 • Development and technological up- pally, interventions aimed at reorganiza- pared, a choice was made to use as the grading of information, manage- tion of the authority in conjunction conventional reference the median of ment, and operational systems. with national decentralization policy. the global results in the 11 functions, so that half the indicators are classified as 3) Intervention for development of decen- Table 1 details the indicators selected weaknesses to be overcome. However, tralized competencies, related to actions for each area of strategic intervention. despite the uniform use of this criterion aimed at transferring faculties, compe- for the regional evaluation, it was possi- tencies, capacities, and resources to the In order to classify strengths or weak- ble for national authorities to set a dif- subnational levels, and supporting them nesses based on the measurements ob- ferent reference level that could be more so as to strengthen the decentralized tained in these first evaluations, and or less exacting for the purpose of guid- exercise of the health authority with re- with a view to consolidating the results ing national efforts to improve perfor- gard to public health, consistent with of the different evaluations in the coun- mance of the EPHF. the requirements of State and health sec- tries of the Region of the Americas so tor modernization. This requires, princi- that a regional action plan can be pre-

107 10 Measurement Process

It must be emphasized that the measure- country, utilizing a practical guide to areas of collaboration, such as education ment instrument was designed by standardize the measurement process. and the environment—measurement of groups of experts from different coun- the performance of the EPHF has been tries of the Region and by staff of the Consideration must be given to the fact carried out by a group of key actors that Pan American Health Organization that in this first exercise the main pur- represent as faithfully as possible the (PAHO), the U.S. Centers for Disease pose of measuring the EPHF has been broad, diverse picture of public health in Control and Prevention (CDC), and the self-evaluation of the performance of the each national context. Latin American Center for Health Sys- NHA. Such institution is responsible for tems Research (CLAISS) to be utilized the steering role, which implies, as men- Due to the complexity involved in self- by key national actors. By developing tioned in Part I of the book, responsibil- evaluation and the building of consen- consensus-based responses to the mea- ity for fulfilling other major functions, sus for measuring the performance of surement instrument, actors would be such as the definition of health policies, the EPHF, it was necessary to begin by able to report on the EPHF performance financing arrangements, insurance for sensitizing the ministries of health to the profile in their respective countries. health care, and regulation of the health importance of the subject and introduce sector. As pointed out earlier, in most of them to the methodology. This was fol- It should be noted that throughout the the countries of the Region that institu- lowed by the training of a group of fa- process, the backing and support of each tion is the Ministry of Health. cilitators that would have the knowledge of the aforementioned participating in- and capacity to support the national stitutions was provided, in addition to Since the work of the NHA in public measurement exercise to ensure proper the input and guidance given by the na- health implies the collaboration of a implementation and greater control tional health authorities, which have broad range of governmental and non- over the process, thus making it possible been invaluable to the achievement of governmental institutions—consider- to obtain reliable results. the measurement objectives. It was ing, naturally, universities, health re- through the collaboration among multi- search centers, and public and private In general, the steps followed in the ap- ple institutions that the measurement of service providers, not to mention the plication of the instrument in each coun- the EPHF could be carried out in each government sectors devoted to other try were as follows:

109 a) Upholding a political agreement e) Selection of participants in the exer- the Region of the Americas fell within between PAHO and the govern- cise as an exclusive domain of the the realm of the Division of Health Sys- ment for the implementation of national health authority. The par- tems and Services Development (HSP) the exercise. ticipant profile that was suggested of PAHO, whose main functions were: indicated that the Ministry could b) Formalization of an agreement be- select the group, making it as repre- a) To promote application of the in- tween PAHO and the Ministry of sentative and interdisciplinary as strument in all the countries of the Health to carry out the exercise. possible, ensuring the broad-based Region, in close collaboration with origin of its members in accordance the national health authorities; c) Identification of the Ministry of with their relevance to the central Health personnel who would as- or subnational level of the NHA b) To support the national measure- sume responsibility for the prepara- or their affiliation with nongovern- ment processes through the PAHO tion and execution of the exercise. mental or academic institutions. delegations in each country;

f) Preparation of the managerial as- d) Holding of a cycle of meetings be- c) To collaborate in training the pects of the exercise. These included tween the two counterparts in group of facilitators who would activities such as selecting the place which the following was discussed: participate in the application of the and dates, convening the partici- instrument; pants, financing travel and lodging • The underlying philosophy of for participants who lived far from the “Public Health in the Ameri- d) To compile the evaluations from the meetings, provision of secretarial cas Initiative”. each country; and, finally support, supplies, and a computer infrastructure. • The characteristics and details of e) To systematize and analyze the in- the development of the measure- g) Execution of the measurement ex- formation received, as well as pre- ment instrument. ercise. Using the workshop method- pare the reports on the results of the ology and the application guide, all EPHF performance measurement in • The need to stay on top of prob- the participants met to respond to the Region of the Americas. lems to control potential risks the measurement instrument in an that might be incurred during exclusive and intensive fashion. It should be emphasized that the process the preparation and execution of Thus, once the teams were formed, has implied an effort to communicate the exercise, such as: for three days on average, the par- in different languages. This involved an ticipants focused on the measure- exercise involving much interaction to – Unfounded fear of what ment exercise, structuring a consen- obtain linguistic and conceptual consis- might be implied by a suppos- sus-based response to each of the tency in English, French, Portuguese, edly “external evaluation” of questions contained in the indica- and Dutch for the formulation and ap- the upper levels of health tors of the 11 essential functions. plication of the measurement instru- management and of each per- ment, as well as for the execution of the son responsible for the areas computer program, the analysis of re- addressed specifically by the 1. Description of the sults, and the preparation of the final instrument. Preparation Process and report. EPHF Performance – Apprehension that the “evalua- Measurement in the Thus, using the agreements of the Di- tion” would lead to a classifica- Countries of the Region recting Council of PAHO as the basis, tion of the countries of the Re- after developing and validating the gion according to their degree The responsibility for organizing sup- measurement instrument, the self-eval- of support for public health. port for the measurement exercise in uation was carried out in each country

110 of the Region. It consisted of the fol- Table 1 Workshops for Training Facilitators in the Application lowing stages: of the Instrument

1.1 Training of facilitators Subregion Workshop date Participants 1.2 Formation of the group of par- Central America/Costa Rica 6–8 March 2001 57 professionals ticipants South America/Argentina 29–31 May 2001 59 professionals 1.3 Organization and implementa- English-speaking Caribbean/Jamaica 16–20 October 2001 24 professionals tion of the measurement exer- French-speaking cises Caribbean/Haiti 29–31 May 2002 14 professionals Total number of trained facilitators 154 professionals 1.1 Training of Facilitators

The first step comprised the selection and training of facilitators who exhibited the leadership and appropriate knowl- Table 2 Additional Workshops for Training Facilitators in the edge to support the application of the Application of the Instrument instrument. To that end, account was taken of the fact that the work would be Country Workshop date Participants carried out in the context of an innova- Puerto Rico 1–4 August 2001 15 professionals tive measurement process. This would Brazil 9–12 January 2002 15 professionals involve highly complex deliberations be- Paraguay 3–7 October 2001 50 professionals Curaçao 14–16 November 2001 7 professionals cause of the need to arrive at consensus. In addition, the groups of informants were heterogeneous, since their mem- bers were trained in different disciplines and had various levels of knowledge, ex- preparations for the measurement of the recommendation submitted,1 and perience, responsibility, and interest, all the EPHF. the technical and political considera- of which would result in their being suf- tions that were their exclusive responsi- ficiently representative of the realities of To expand this central group of facilita- bility. With this, the task aimed at the public health service in each country. tors, other national staff members were achieving effective appropriation of the subsequently added. They were trained instrument and the measurement pro- Under these premises subregional work- at new workshops in Brazil, Puerto Rico, cess by each NHA, and consequently shops were held in Argentina, Costa and Paraguay, as detailed in the follow- the results obtained, take on greater di- Rica, Haiti, and Jamaica, resulting in ing table 2: mensions, making it possible to ensure the formation of a team of at least three subsequent implementation of strategies experts from the ministries of health of 1.2 Formation of the Group and actions designed to attend to the each country, who had the distinction of Participants critical areas revealed in the performance of being named by the corresponding profile. minister or secretary of health. (Table Taking into consideration the mandate 1). It should be pointed out that this of the Directing Council of the Pan Consequently, the participating min- work and the entire measurement pro- American Health Organization (PAHO), istries of health in each country of the cess up through the conclusion of the which stressed the importance of this Region selected technical and profes- reports was supported by the staff of the measurement as a self-evaluation exer- sional staff from a variety of institu- PAHO Representative Offices in the cise, it is necessary to emphasize the countries that were part of the principal meticulous care given to safeguarding 1 The team responsible for the initiative de- nucleus in charge of formulating the the autonomy of the NHA in terms of veloped a participant profile, which was rec- work program and carrying out the selecting the participants, formulating ommended to each NHA.

111 tions representative of the public health- Table 3 National Workshops and Participants in the EPHF related sectors, establishing working Performance Measurement groups that assumed responsibility for answering the questions contained in Number of the measurement instrument, with a Country Dates participants view to honest collaboration within a Anguilla 29–31 January 2002 19 process of active, orderly participation. Antigua and Bermuda 20–22 February 2002 30 Argentina 13–15 November 2001 35 Aruba 20–21 March 2002 25 In each of the 41 countries special atten- Bahamas 23 May 2002 71 Barbados 25–27 March 2002 36 tion was given to ensuring the balanced Belize 25–27 July 2001 31 participation of NHA professionals Bolivia 15–16 November 2001 54 from the national and subnational levels. Brazil 15–17 April 2002 60 Colombia 19–21 September 2001 66 There was emphasis on the need for in- Costa Rica 25–26 April 2001 48 formants representative of the interme- Cuba 19–22 November 2001 56 Curaçao 12–14 November 2001 16 diate levels—that is, departmental, state, Chile 13–15 December 2000 40 or provincial—and even, at times, from Dominica 10–12 December 2001 25 the local level. Efforts were made to in- Ecuador 10–11 October 2001 56 El Salvador 21–23 May 2001 55 clude representatives from the academic Grenada 18–20 February 2002 35 sector and research groups, as well as Guatemala 17–21 May 2001 30 Guyana 6–7 December 2001 24 from the public and private organiza- Haiti 24–26 June 2002 29 tions that provide health care and ad- Honduras 6–8 June 2001 24 minister social security, including non- Virgin Islands 5–7 March 2002 27 Cayman Islands 11–13 December 2001 27 governmental organizations and other Jamaica 10–11 December 2001 31 actors in national public health. Mexico 19–20 February 2002 40 Montserrat 5–7 February 2002 25 Nicaragua 28–29 May 2001 46 With the assistance and coordination of Panama 27–29 June 2001 93 the PAHO delegations, the participation Paraguay 13–15 February 2002 108 Peru 28–29 November 2001 155 of a representative set of key actors in the Puerto Rico 17–19 October 2001 154 application of the instrument, which Dominican Republic 7–10 June 2001 102 Saint Kitts and Nevis 12–14 February 2002 41 covered the 11 functions, was achieved. Saint Lucia 13–15 February 2002 27 This effort made by the countries of the Saint Vincent Region to ensure the intended results is and the Grenadines 28 January–1 February 2002 28 Suriname 24–26 April 2002 36 revealed in the following list. The num- Trinidad and Tobago 27 February–1 March 2002 42 bers and the profile may at first glance Turks and Caicos Islands 31 April–1 May 2002 23 Uruguay 24–25 May 2002 45 appear inconsistent, but this is due to Venezuela 6–8 February 2002 83 the unique features of each country and Total Number of Participants in the Measurement of the Region 1,998 the exclusive decisions of the ministries to carry out the exercise.

Complementing the above description propriately concerning the performance cial participation, health information with respect to representativeness, the of the different public health functions. systems, public health laboratories, table below summarizes the types of human resources, communications and participants in the EPHF performance In addition, it should be recalled that the public relations, environmental health, measurement. Although the nature of goal was broad representation from the emergencies and disasters, planning, and the participants varied among the dif- various disciplines linked to public others. At the same time, an effort was ferent countries, it should be noted that health: epidemiologists, public health made to ensure intersectoral representa- in all cases there was a broad range of professionals, health economists, lawyers, tiveness in accordance with the structure professionals capable of responding ap- and specialists in health promotion, so- and organizaton of each country. 112 Table 4 Profile of Participants who Evaluated EPHF Performance in the Countries of the Region

Category Type of participants

NHA: representatives from the Ministers or Secretaries of Health national level Advisers to Ministers Health Policy Secretary 54% of the participants from the NHA Secretary of Health Investment Management National Health Council Members Members of National Boards of Municipal Health Secretariats Directors of Administrative Departments Directors-General Of Health and Environment Programs Directors of Promotion Directors of Health Services Development Directors of National Health Surveillance Programs Directors of Human Resources Development Directors of Planning and Institutional Development Directors of National Epidemiology Centers Mass Communication Unit Members

NHA: representatives from the Provincial or state ministries of health subnational levels Directors of Health Regions Subregional Delegates 46% of the participants from the NHA Regional or Provincial Coordinators PHC Directors Municipal Health Directors National Hospital Directors Provincial Hospital Directors Clinical Unit Heads

Other institutions Ministry of Social Action Ministry of Labor 15% of all participants Ministry of Agriculture And Livestock Ministry of Finance Or Its Equivalent Social Welfare Secretaries Unions Representatives of professional associations (physicians, other health professionals, lawyers, etc.) Nongovernmental organizations Red Cross, UNICEF German Agency for Technical Cooperation (GTZ) Governors Mayors Representatives of Indigenous Peoples Schools of Public Health Representatives of Universities In The Country Representatives of Institutes of Vital Statistics Institutes of Science and Technology Churches National Nursing Schools Social Insurance, Social Insurance Institutes Offices of People’s or Citizens’ Advocates Army, Navy, and Air Force Medical Centers National Institutes of Diabetes, Cardiology, Aids, Drug and Addiction Control, etc.

Organization and Development of EPHF were held. In all of them there groups as a whole were able to respond the Measurement Exercises was broad participation from the group to the different sections of the measure- Between April 2001 and June 2002— selected for the exercise. It is worth clar- ment instrument, identified by the 11 that is, during 15 months of continu- ifying that in some cases, when the essential functions. In general, the re- ous work—a total of 41 national work- groups were very large, they were di- sponding groups had similar configura- shops to measure the performance of the vided into subgroups to ensure that the tions, with each of them having repre- 113 sentation from the various sectors and strument would not become a tool di- The development of consensus made it disciplines that are part of or related to rected exclusively toward the experts of possible for those with different opin- public health, and were convened on a each of the EPHF, but instead yielded a ions on the degree of public health de- timely basis. picture that was as representative as pos- velopment in their country to make sible of the different national and subna- their contribution and inform those It is necessary to point out that the tional areas and that provided a compre- who were not familiar with a specific Ministers of Health, who were totally hensive view of national performance. function. However, it should be noted supportive, strongly backed the initia- that all the participants were able to tive. It should be noted that a team of It is important to emphasize the contribute to a collective response to two or three experts from the institu- achievement of one of the main objec- the entire instrument and had the op- tions participating in the design of the tives of this measurement, to have each portunity to contribute their knowl- measurement instrument served as ex- country claim the instrument as its own edge to the contents and aspects impli- ternal facilitators to provide support to and to improve it, if it deems that nec- cated in the process. each exercise. essary, for later monitoring exercises in its territory. For that purpose the desig- As a result, it was recognized in all cases To begin the process, the Ministers of nation and training of national facilita- that the greatest effort had been made Health of the countries convened a tors that could subsequently make use so that the measurement exercise made working meeting to obtain responses to of the instrument for follow-up was it possible to obtain the most realistic the questions contained in the measure- basic. To this end, in several countries a representation of public health function ment instrument. Because of the nature series of meetings was held to enable the performance in each country and iden- of self-measurement of the performance local facilitators to take charge of the tify the areas of weakness that required of the essential public health functions, initiative and be responsible for carry- strengthening. and in order to familiarize the partici- ing out the measurement. pants with the instruments, the basic To record and process the responses of documents for the exercise were annexed It is important to note that, in most ap- the evaluation group, computer software to the notice of the meeting. In addition, plications, the participants brought in- was used that permitted direct instanta- an effort was made to select a site with formation to the meeting that they con- neous calculation of the final scoring for the suitable characteristics and environ- sidered supportive of their responses to each variable, using the responses to the ment so that the self-evaluation group the questions in the instrument. This questions and subquestions, and the dis- could concentrate exclusively on the information could be made available play of the results in tabular form. To measurement of the EPHF during the to the team responsible for measuring utilize this instrument the only require- course of the workshop, which lasted the EPHF, especially whatever was re- ment was working knowledge of Mi- from two to three days. lated to the specific questions aimed at crosoft Excel. verification. For the measurement process a coordi- After completion of the exhaustive nating group was established in each As a general rule, given the limited time measurement of each function in each country to prepare the response to the available for the application of the en- country, the workshop continued with general and specific aspects of the instru- tire instrument, whenever a majority a presentation of the summary of results ment. Furthermore, as mentioned ear- was not obtained an effort was made to obtained and an analysis of the deficient lier, key actors and experts or specialists achieve consensus through a couple of areas in public health, with the purpose in the area and in the process were able rounds of voting and presentations. If, of drawing preliminary conclusions to participate and provided complemen- at the end of the group discussion, there from the measurements. Thus, based on tary information of both a general and was still no majority agreement, the re- the presentation and the analysis of the specific nature that was of special value sponse was considered to be negative; performance profiles for each function in the measurement of each function. A when there were doubts about the per- and to counteract the shortcomings de- salient aspect of the measurement was formance, it was considered preferable tected, the participants made comments the effort to reach a consensus among to assume it as a deficiency that had to and suggestions for possible future ac- the different actors, to ensure that the in- be overcome. tion; these were compiled for the prepa- 114 ration of the final reports from the re- and, as appropriate, the resolution de- 2. Participant Evaluation spective countries. This was the most fined by the countries, both specific and of the Application of the significant moment of the exercise be- subregional. Performance Measurement cause, based on the presentation of the Instrument weaknesses and the strengths, progress Despite the difficulties involved in was made toward the development of a completing the measurement in all the To enrich this section in which each common vision of the state of public countries of the Region, the entire pro- stage of the measurement process has health in each country. Very significant cess was carried out within a brief pe- been described, reference will finally be elements contributed to the develop- riod, which demonstrates the interest made to a very important component, ment of a plan for the interventions re- and commitment of the countries in namely, evaluation of the entire exercise quired to improve the institutional per- the face of this challenge. by the participants from the different formance of the EPHF. countries. For this purpose, the Centers It is worth noting that various countries for Disease Control and Prevention At the end of the exercise, each country in the Region have begun to plan the (CDC) and the Pan American Health summarized the results of the measure- development of institutional capabilities Organization (PAHO) developed a ment in a document with standard to overcome identified deficiencies and questionnaire to evaluate the applica- characteristics and format, like the one consolidate the progress and achieve- tion of the methodology and instru- prepared by the national coordinators ments obtained. Others are in the pro- ment used to measure performance. and outside experts who supported each cess of adapting the instrument for use This questionnaire was used to compile exercise. This report contained a de- in the measurement of the EPHF at the data on the measurement process scription of the measurement process subnational levels, which confirms the carried out through the aforementioned and the results of the application of the motivation generated by the measure- workshops. Accordingly, the evaluation instrument, based on the scores ob- ment exercise. questionnaire was distributed the last tained for the EPHF and the values of day of the workshop in order to: the indicators considered. It also in- Meriting special mention is the fact that cluded possible interpretations of the in the subregion, made up of the coun- • Obtain feedback from the partici- results and identification of priority tries participating in the Special Meet- pants concerning their impressions of areas for intervention. Some of those ing of the Health Sector of Central the experience. reports have been published by the America and the Dominican Republic national authorities. Several countries (RESSCAD), adopted a resolution2 de- • Receive suggestions for improving have already made a commitment to signed to formulate a subregional proj- the measurement process as well as measure the performance of the EPHF ect to support the countries with joint the content of the instrument. again within two or three years and interventions in those functions whose identify the concrete progress, general performance received a lower score • Ask the participants to provide rat- and specific, that has been made (see ex- (Functions 8, 9, and 10). To this end ings on a scale analogous to that in ample in Annex B). a meeting specifically for building sub- the instrument, from the perspective regional consensus3 was held, and the of the national health authority. During the workshop, all the partici- project was formulated with a high de- pants were given an opportunity to pro- gree of participation. In order to begin this evaluation process, vide feedback in writing to the team in all participants were asked to answer the charge of the project on the content, questionnaire anonymously and return methodology, and other aspects of the it before leaving the session. This survey measurement process that they felt could 2 Agreement XVII, RESSCAD-NIC-6. Ma- was administered to practically all the be improved. The evaluation forms used nagua, Nicaragua; 29 and 30 August 2001. participants with the exception of two were subsequently analyzed and the 3 Subregional meeting on functions essen- countries. A total of 891 adequately an- results can be found later on in this tial to public health as a continuation of swered questionnaires were returned and Agreement No. 6, XVII RESSCAD. Santo chapter. Finally, it is important to sum- Domingo, Dominican Republic; 15–17 of these 882, which correspond to 45% marize the principal lines of continuity April 2002. of the 1,998 participants, that could be 115 processed and analyzed. The results pre- Table 5 Countries with Return Rates that Could be Calculated sented below refer to that universe. No. of participants Results Country Return rate registered Return rate Grenada 95% 22 Jamaica 89% 27 Honduras 88% 27 The evaluation forms were obtained in Antigua and Barbuda 81% 32 time to complete the analysis of the data Belize 80% 20 for 30 countries; evaluation data from Saint Lucia 77% 27 Nicaragua 72% 40 the other countries is not available since Ecuador 70% 39 they did not complete the exercise. Fur- Venezuela 69% 93 Barbados 67% 36 thermore, it was possible to calculate Saint Vincent and the Grenadines 65% 29 the return rates for only 23 countries Dominican Republic 64% 81 (see Table 5). Data from seven countries Saint Kitts and Nevis 64% 30 Guyana 63% 19 could not be calculated because there Dominica 61% 18 was insufficient information on the num- Cayman Islands 58% 31 Brazil 54% 55 ber of registered participants. In many Montserrat 52% 21 cases a list of the invited participants, di- Anguilla 50% 18 vided into groups, was available, but it British Virgin Islands 50% 27 Guatemala 48% 31 could not be used as a list of those who Colombia 42% 64 actually registered (actual participants). Trinidad and Tobago 41% 41

In addition, there was the possibility Note: These are the countries that responded completely and in a timely manner to that, in the dynamic of the workshops, the questionnaire. The rate of return could not be calculated for Argentina, Bolivia, people may have been moved from Cuba, El Salvador, Paraguay, Peru, and Puerto Rico. one group to another to respond to specific functions, so that using this list would not yield the exact number of provide this information. Some partici- In addition to their primary responsibil- participants. pants believed, without sound reasons, ities to the health authority, a limited that revealing that information would number of participants (1%) also had Based on the available data from the make it possible to determine their iden- responsibilities in other public health countries that conducted a strict regis- tity; however, they were simply asked if organizations, including schools of pub- tration process, the following infor- they were affiliated with the national lic health and environmental protection. mation was obtained on the number health authority, to what level they were of registered participants and the rates assigned, and if their primary specialty Perception of the respondents about the of return. The average return rate was was health or something else. Of the level of their training for participation 66%. forms containing this information, 54% in the process indicated the national level and 46%, In general terms, 37% of the respon- Affiliation with the National the subnational level. Of the 768 forms dents reported that they did not feel Health Authority that included such information, 84% well-prepared; 40% felt reasonably well- Of the 882 forms returned, only 768 indicated “health” as their primary spe- prepared; and 23%, well-prepared. (93%) contained general information cialty; the rest, who indicated “other,” Although “adequately prepared” and on the type of institution to which the were from the national health authority, “well-prepared” represented 63% of the participants belonged and the level of the army medical corps, international responses, the observations of the re- their work; this was because the page re- agencies, universities, churches, and spondents that did not feel well-prepared questing this data had not been in- human rights organizations, as well as were significant. The principal concern cluded in some forms, while in other health service providers from the private expressed was the lack of standardized cases the participants decided not to sector. instructions and the inability of facilita-

116 tors to explain concisely the objective hand and understood better. The follow- been designed to measure what already and methodology of the application. ing factors contributed to this delay: existed in fact and not what was poten- They indicated that the instructions var- tial or planned, the lack of an option of ied with the occasion and the process • Little preparation time before the an intermediate or partial response was appear inconsistent. These observations workshops were held. not considered to be so significant. were even repeated by respondents who said that they felt sufficiently prepared. • Insufficient notice to the participants Number of questions It should be noted that at the beginning of the dates and contents of the work- Sixty-two percent of the respondents of the application process there were a shops. indicated that the number of questions large number of such observations. was sufficient, while 34% considered However, as greater experience was • Late distribution of the materials. that it was too high. It should be noted gained and the list of more frequently that certain areas of redundancy were asked questions was expanded, the ex- Clarity of the instrument format identified and, accordingly, an examina- pressions of skepticism and negative The results were very encouraging: 89% tion of the instrument is being planned attitudes became less frequent and, at of participants considered the format with a view to simplifying and elimi- the same time, the presentations in the understandable or easy to understand; nating the possible duplications. workshops were better directed, the only 11% found it difficult. The most strategies improved, and the participants common reason given for the lack of Clarity of the standards for the indicators understood the process better. clarity was related to the way in which The results in this regard were also very the questions were formulated, includ- encouraging. Some 56% of the respon- Ninety percent of the respondents indi- ing the language utilized. This was true dents thought that the standards were cated that they received adequate direc- for both the Spanish and the English appropriate but needed further clarifica- tions from the facilitators on how to an- versions. In both cases people felt that tion; 42% thought that they were well- swer the questions. some questions were ambiguous and written, clear, and understandable; and would have preferred the use of clearer, only 2% felt that they were inadequate. Clarity of the instructions more concise language. The last group were generally from the Some 94% of the respondents reported very small island nations. The partici- that the instructions were adequate or In the Spanish-speaking countries, dif- pants from those countries suggested sufficiently clear; 6% indicated that the ferences in the meanings of words that the standards be reviewed and made instructions were not clear, because: played a decisive role in determining more applicable to small countries. In whether the instrument would be ap- view of these responses, the standards • The facilitators had not presented the propriate for local use. A small percent- and their drafting will be examined. methodology clearly. age also indicated that it would be use- This should be done in cooperation ful to have other options, rather than with the smaller countries themselves in • There had been a change in the in- just yes or no: perhaps a partial or ana- order to better respond to local needs. structions. log scale for the response so that works in process, plans, or signaled changes Difficulty in responding to questions Again, these observations related more could be included. This proposal would, on functions and measurements to the initial applications. of course, eliminate the instrument’s Seventy-six percent of the respondents capacity to measure conditions as they indicated that they had difficulty an- Distribution of course materials were at the time. It was not accepted, swering some questions and subques- Fifty-four percent of the participants since the purpose of the exercise was to tions. Of this group, 63% gave as their stated that it was necessary to improve take a snapshot of the current situation, reason the fact that the subject was out- this aspect of the process by allowing with no concern for what it might be side their area of specialization, while more time between the circulation of the with the partial option. It should be 37% of those experiencing the diffi- materials and the holding of the work- noted that once it was explained to the culty when the subject was not outside shop so that they could be read before- participants that the instrument had their specialty indicated that they did

117 not understand the questions because • Promote self-evaluation in other areas, useful. This indicates very clearly that they were ambiguous or unclear, some- for quality analysis. the type of report that most countries times due to the type of language uti- would consider useful would include a lized. Although the evaluation form • Work with other sections of govern- graphic analysis of the strong and weak allowed the participants to make unre- ment, especially in the formulation of points of the system, together with ap- stricted observations on the content of interinstitutional agreements. propriate recommendations of inter- the instrument, the participants pre- ventions that would improve system ferred to do that during the workshop • Strengthen organizational and mana- performance. itself. The observations were recorded gerial capacity at every level. for use in the iterative development of Use of the results: reports generated based the instrument. • Continuously improve quality. on this activity The options presented in the question- Linkage of this instrument for use with • Seek to develop a better fit between naire were: other national quality improvement human resources and system needs. or evaluation activities a) Use the results to improve devel- In regard to this point the respondents • Provide training in leadership and opment of the public health work offered three options: management. force. a) Validate other, existing national and • Use the data to train personnel at all b) Improve the accountability of the subnational efforts. levels of the system. system. b) Provide data that can be used in • Link the data to the standards and ac- c) Determine and strengthen the weak conjunction with those from other creditation of the organizations in the areas in the system. activities to improve planning at public health system. the national and subnational levels. d) General strategic planning to im- Types of reports that would be of greater prove the system at all levels. c) Both a and b. usefulness to the respondents e) Policy evaluation. The options presented were: Of the 825 respondents, 767 (93%) an- f) Capacity development. swered this question; 71% selected Op- a) Graphs that indicate the degree of tion a; 87.5%, Option b; and 59%, success achieved, by function or g) Use the results to strengthen the ca- Option c. Those selecting Option c felt indicator. pacity to manage the organization. that the data derived from this instru- ment played a broader, more significant b) Analyses of strengths, weaknesses, h) Use the results to promote change role, since they could be used to vali- opportunities, and threats (SWOT). within the system, eliminating pro- date existing data and also could be cesses that no longer work. combined with the existing data from c) Recommendations and interven- other activities to improve planning at tions to improve system perfor- i) Promote greater adherence to the the national and subnational levels. mance, based on the results of the standards by the national health Some participants pointed out the need process. authority. for a mechanism to objectively validate the recorded data. With respect to the d) All the above options. j) Modify existing programs and cur- request for other areas of possible link- ricula in public health to make age, the respondents answered: Option c was selected in 73% of the them better adapted to the needs of cases and Option b in 70%. Only 61% the health sector. • Provide data to lawmakers to improve felt that Option a by itself would be the redefinition and formulation of useful, while 61% felt that a report that k) Use the results to better define policies and laws. included the three options would be what the public health products 118 should be, depending on the situa- levels (chi square = 0.025, P = 0.8). The Classification of the usefulness of the tion in the country. 23% of the participants who did not instrument in daily practice believe the instrument would measure The analog scale used by the respon- l) Evaluate the national health au- the performance of the national health dents to classify the usefulness of the in- thority’s capacity for effective lead- authority indicated that: strument in daily practice was as fol- ership. lows: 0 = of no use, 1 = of little use, 2 = • The opinions expressed by the partic- of some use, 3 = of average use, 4 = very m) All of the options above. ipants were not consistent with real- useful, 5 = highly useful. ity and expressed only an imprecise idea of the system. The respondents could select one or all The lack of scatter in the responses in- the options that they considered appro- • There was no way of validating the dicated that most of the participants priate. The options most commonly se- responses. The questions were too assigned a high value to the use of the lected were a, c, d, and h: in more than subjective. instrument for evaluating the public 75% of the responses. Options a and c health service: 70% thought that the in- were the most common, which indicates • The indicators were not applicable to strument was “very useful” or “highly that the respondents considered the in- certain countries. useful.” Fewer than the 10% of the par- strument and the methodology useful ticipants judged the instrument to be of for the analysis of gaps in the evaluation • Lack of participants with experience little use. Figure 1 illustrates the distri- of the system. It was significant that Op- to answer the questions, inappropri- bution of the responses. tion l was selected in only 54% of the re- ate composition of the groups, not sponses, which means that the partici- representative of the system. Frequency of application pants did not seem to link the process Seventy-three percent of the partici- and the instrument with evaluation of • Only certain areas of activity were pants said that the instrument and the the national health authority’s capacity measured. measurement process should be used for effective leadership. Only 33% of • The national health authorities in every one or two years, with 48% opt- the respondents recognized the useful- some countries did not use the EPHF ing for annual application. The results ness of reports applicable to all areas. framework. can be observed in the following table. This indicates the need for guaranteeing that the presentations offered before- hand provide pertinent information that Figure 1 Classification of the Usefulness of the Instrument allows the participants to establish a 350 connection between the type of report generated and the work of the national 300 health authority. Making the linkage more evident will make it possible for 250 the participants to better understand the 200 relevance and suitability of applying the instruments to their own work. 150

Use of the instrument for evaluating 100 Number of participants national health authority performance Seventy-seven percent of the respon- 50 dents indicated that they thought the 0 instrument could accurately measure Little = 1 Some = 2 Average = 3 Very = 4 High = 5 the performance of the NHA. There Levels of Usefulness was no significant difference in this per- centage between the participants who Average = 4 Standard deviation = 4 Variance = 4 came from the national and subnational 119 that they better understood the objec- Table 6 Recommended Frequency of Application tives of the exercise and the methodol- Frequency of Number of Percentage of ogy. In most of the countries, the local application responses responses facilitators held a series of meetings Annually = A 288 35 prior to the workshop to familiarize 2 years = B 313 38 them with the workshop methodology 3–5 years = C 190 23 5–10 years = D 33 4 and guarantee that the workshops were held without problems. Unfortunately, this was not done in all the countries. The selection and training of the facili- Suggestions from the respondents every year or two. The main concerns tators is of the utmost importance, and to improve future workshops were focused on the need for reformulat- it is essential to select people with the This open-ended question solicited ob- ing the questions, using more concise profile, experience, and responsibility servations from the participants, based language to avoid ambiguities or misin- required to being a facilitator. As princi- on their experience in responding to the terpretations. Instruments of this type pal factors in the preparation and plan- instrument and participating in the work- constantly evolve as they go through an ning of the countries that wish to use shop. The observations are very insight- iterative refining process. Despite a rig- this instrument and this methodology, ful and should be taken into account to orous phase of pilot studies, certain the following should be emphasized: help make future workshops more ef- problems did not become evident until fective and efficient. the instrument was used in the field. For a) Be sure that the political will exists these reasons, the drafting and content and that those in charge will accept • Guarantee diversity in the composi- of the standards, questions, and sub- and adopt key “in-country” deci- tion of the group and appropriate questions are currently undergoing in- sions through preliminary meet- representation of all levels for each tensive examination before the next ver- ings and workshops function. sion of the instrument is produced. b) Make sure that effective strategies • Have the support documents in hand A stricter approach must be integrated are in place that guarantee timely to validate the responses. into the application process, so that the receipt of the documents prior to facilitators can carry out the evaluation the workshops and data collection • Hold preliminary workshops in the (especially the collection of the com- exercises. country to explain the objectives and pleted forms) and guarantee that an methodology, so that the participants exact list of all the participants registered c) Educate facilitators and promote can be well-prepared. is available from the start. This way, the more effective distribution of the return rate can be calculated. This com- materials by them and by the focal • Make sure that the practical guide is ponent of the application process should points prior to the workshop. concise and the glossary broad enough be emphasized. Even though return to cover all the terminology used. rates are not available for all the coun- d) Support the holding of introduc- tries, information from 825 participants tory workshops in each country to • Improve orientation and standards. was obtained. The qualitative informa- promote a better understanding of tion obtained by feedback from the par- the concept, goals, and objectives Discussion, conclusions, and lessons ticipants was very useful, as it con- of the evaluation. This will also derived from the evaluation tributed data on their perception of the encourage better acceptance by the From the perspective of the participants, instrument and the application process. participants. the instrument and the methodology have proven to be very useful. This is ob- It was clear that it would have been use- Emphasis must be placed on the impor- served in the high rating given to useful- ful to have better strategies “at the coun- tance of assigning the participants so ness and the desire to repeat the process try level” to prepare the participants so that the groups are well-balanced, rep-

120 resentative of the issue under analysis, the success of the exercise and, as stated Thus, the relativity of the results of spe- and foster harmony and collaboration earlier in this chapter, some countries cific measurements should not lead to among the attendees. Although all par- have already analyzed this information hasty conclusions, but to a more in- ticipants were not experts in all mea- and used it to prepare their own coun- depth diagnosis, through the use of surements, that was positive, for it try reports and plans of action. It must more objective instruments and more caused the groups to coalesce, with each be reiterated that regional meetings detailed analysis of the critical areas participant having a specific area of spe- have already been held to explore the identified. Only in this manner will it be cialization and making significant con- development of regional plans of action possible to guarantee the development tributions in that area. Although it is and interregional cooperation plans for of programs to improve public health necessary to guarantee that the respon- the formulation of strategic interven- that effectively meet the needs of each dents selected match the function mea- tions; all of them were geared to boost country. sured, it also is important to avoid in- the institutional capacity of the infra- troducing biases by having too many structure, which will give rise to an im- Similarly, given the differences in the se- “experts” in a particular group. provement in the delivery of public lection of the national evaluation groups health services at the regional level. and the asymmetry of the information As can be observed in the information available to the participants, it is likely obtained, there is no doubt about the that the evaluation of some functions or need for some type of objective valida- 3. General Lessons indicators will not be entirely acceptable tion of the responses, to ensure that the derived from the to them or to other national experts. In data collected are scientifically valid. The Measurement that case, complementary mechanisms application form used in some countries should be activated to improve the diag- did not give participants access to the in- For the group of Member States, the re- nosis to ensure reliable responses that strument as a whole but only to the sec- sults presented in Chapter 11, as well as will assist in the recognition and accept- tions or functions for which their group the individual country reports, provide ance of the national challenges to public was responsible. Thus, the participants a significant quantity of information health. Here, this diagnostic measure- did not have an overview of the instru- that they can use to define their own ment can also serve as a frame of refer- ment. A balanced mixture of partici- plans for strengthening public health. ence for all institutions interested in co- pants from the different levels of the sys- operating in the improvement of public tem sometimes acted as a control on the The identification of common areas of health in the Americas. responses themselves and avoided the in- weakness and strength can serve as a troduction of excessive bias from domi- very useful supporting argument when For this reason, based on the first mea- nant individuals in the group. In light of ministries of health in the Region at- surement exercise at the regional level, the situations in which there was a lack tempt to pressure those responsible for it can be concluded that the instrument of objective validation, the balance—or decision-making in their governments and its application are in need of im- “self-validation”—introduced by the to provide the help needed to develop provement. The number of questions composition of the group made a differ- their health capacities. and subquestions can be reduced signif- ence. It also is useful to ask the partici- icantly depending on their explanatory pants to study the instrument before- However, although there may be con- power, a conclusion that could not be hand and to bring to the workshop any tinued emphasis on the importance of reached prior to the completion of this document that would help validate their the measurement process and interest in first iteration in each country. Similarly, responses to the questions. the results obtained as a faithful repre- it is also possible to balance the order sentation of the overall situation at the and the number of questions and sub- Although the participants recognized national, subregional, and regional lev- questions for each indicator. However, some deficiencies in the last version of els, the limitations of the methodology even though the instrument does not the instrument and methodology, they and measurement instrument indicated pretend to have the validity required in were able to use the instrument and the in the previous chapter should not be a typical diagnosis, it is important to data to analyze gaps. This underscores overlooked. recognize the possibility of improving

121 the questions to ensure greater reliabil- tional health authorities and by the in- the measurement can be improved, a ity and, consequently, greater reprodu- ternational cooperation institutions that process to which participants in the ex- cibility of the national responses, thus make this instrument a tool for change ercise have contributed with an enthusi- providing greater value and more objec- and adapt it to their particular needs. asm that makes future improvements tivity to the measurements, regardless of Since this first evaluation, initiatives di- imperative. However, perhaps the most who the evaluator is. rected toward adapting the instrument important aspect of the whole experi- for subnational measurements have al- ence has been witnessing the adoption Furthermore, in response to requests ready appeared, along with proposals de- of the measurement instrument and the from the countries of the Region, prog- signed to require stricter standards, all of methodology for its application by the ress is now possible in improving the which confirm the recognition that this participating countries. design of instruments used to measure is, in fact, a useful instrument and that it the EPHF at the subnational levels or in is undergoing continuous improvement. Finally, the EPHF performance mea- specific spheres of public health activity, surement contributes to the develop- allowing greater utilization of the con- From the perspective of the institutions ment of a baseline for the analysis of the clusions obtained. in charge of the measurement process in state of public health in the Region of the Region, the exercise has elicited very the Americas and provides a point of The development of this measurement significant contributions. The main sat- departure for future evaluation of the instrument is thus the starting point of isfaction lies in the verification that the progress made by the countries in im- an evaluation process that will allow the instrument and measurement method- proving their performance. It also un- countries to better direct their efforts to ology developed are useful and mean- derscores the strategic value of self-eval- the improvement of the public health ingful to those responsible for public uation as it applies to the institutional service. Thus, that improvement and health services in each country. The ex- performance of the NHA. evolution will be determined by the na- ercise has also revealed areas in which

122 Results of the Measurement of the 11 Essential Public Health Functions in the Americas

Introduction ica, the Caribbean, the Andean subre- summary was chosen because the results gion and the Southern Cone and Mex- in each country do not make it possible The following chapter presents the re- ico. Finally, the chapter closes with a to dispense with the normal distribu- sults of the performance measurement section on conclusions, that far from tion as an explanatory model of the of the Essential Public Health Func- being a final discussion and analysis— country’s performance for any of the tions. To facilitate the presentation and product of many work sessions with the EPHF. allow for analysis, the results are ex- groups of participants and experts in plained in detail for the Region as a the field, both from the countries and In general, a low-intermediate perfor- whole and for each of the subregions. In the participating institutions—repre- mance profile was observed for the this manner the reader has at his dis- sent an open door for communication group of 11 EPHF. The best relative posal a summary of what has been an and continued discussion to advance in performance was observed in the func- enormous effort of professional and the purpose of promoting the develop- tions of reducing the impact of emer- highly participatory work, where as was ment of the EPHF, starting from the gencies and disasters (EPHF 11) and in observed in the previous chapter, the ef- foundation of the self-evaluations of the public health surveillance (EPHF 2), al- forts of 1,997 qualified public health countries which has always had the in- though neither of these exceeded a 70% workers that participated in the meas- tention of being objective and integral. fulfillment rate with respect to the stan- urement exercise that took place in 41 dard used for this assessment. countries and territories in the Region, 1. Regional Analysis are gathered. The functions of human resources de- 1.1 General results of the velopment and training in public health First, the average results for the 11 Es- measurement (EPHF 8), quality assurance in health sential Public Health Functions for the services (EPHF 9), and research in pub- countries of the Region that partici- As an example of the results obtained in lic health (EPHF 10) performed more pated in the exercise are examined; sec- the Region concerning the performance poorly. ondly the results of the performance of of the EPHF, the following chart pro- the EPHF are presented by subregions vides the median values for this group High-intermediate performance was in the following order: Central Amer- of countries (Figure 1). This type of observed in the functions of monitor- 123 Figure 1 Performance of EPHF Regional of the Americas1

1.00

0.90

0.80 0.71 0.70 0.63 0.60 0.57 0.56 0.54 0.52 0.46 0.50 0.44 0.40 0.36 0.35

0.30 0.21 0.20

0.10

0.00 EPHF1 EPHF2 EPHF3 EPHF4 EPHF5 EPHF6 EPHF7 EPHF8 EPHF9 EPHF10 EPHF11

ing, evaluation, and analysis of health capacity in order to address new health solidating the experiences of a number status (EPHF 1), evaluation and pro- and management challenges. of countries which, within the Region, motion of equitable access to necessary are performing better. health services (EPHF 7), development An important area of concern is the low of policies and institutional capacity for performance observed in the function of An average dispersion is observed for the planning and management in public human resources development (EPHF remaining functions. Generally speak- health (EPHF 5), and health promo- 8). This fact must be taken into account, ing, this also indicates that there are tion (EPHF 3). Finally, low-intermedi- given that an essential part of the future groups of countries with relative strengths ate performance was observed in social strengthening of public health is devel- that could contribute to improving the participation in health (EPHF 4) and oping the abilities of the human resources situations of other countries in the Re- the strengthening of the institutional on which the institutional strength of the gion that are performing at an insuffi- capacity for regulation and enforcement NHA depend. cient level and need to improve. This in public health (EPHF 6). indicates that, except for several excep- An analysis of the dispersion of the re- tional cases in which a country is show- In general, this EPHF profile shows that sults obtained for the Region (Figure 2) ing generally better performance for the functions that can be considered part of indicates that function 1 (monitoring, set of EPHF, the vast majority of the Re- the “tradition” of public health develop- evaluation, and analysis of health status), gion’s countries have areas in which they ment (EPHF 2 and 11) performed bet- function 2 (public health surveillance), are performing well and others that are ter, while more recent functions, such as function 6 (regarding regulation and en- more critical. quality assurance (EPHF 9), performed forcement), and function 9 (quality as- more poorly. This requires the Region to surance in the health services) are more The results in terms of the median undertake a profound review of its pub- homogeneous in the various countries. value, the first standard deviation (rep- lic health activities, particularly with a resenting 66% of the countries), and view toward developing its institutional On the other hand, functions 7 (pro- the maximum and minimum values2 motion of equitable access to necessary for each function are provided in the 1 For more details on the overall results with health services), 10 (research in public regard to each of the EPHF, all of the sum- mary measurements—median, standard de- health), and 4 (participation in public 2 In this analysis, several results that were viation, 25th and 75th percentiles—are given health) show the greatest degree of vari- identified as outliers in the statistical analysis at the end of the chapter. ability, indicating the possibility of con- were excluded. 124 and evaluating health status in the Figure 2 Distribution of the performance of each EPHF in the countries of the Region (Indicator 1) Countries of the Region and evaluating the quality of the data 1.0 (Indicator 2) with which the profile of health status is drafted, as shown in the following table (Figure 4). .8

Indicators: .6 1. Guidelines and processes for moni- toring health status .4 2. Evaluation of the quality of informa- .2 tion

3. Expert support and resources for 0.0 monitoring health status EPHF_1 EPHF_3 EPHF_5 EPHF_7 EPHF_9 EPHF_11 EPHF_2 EPHF_4 EPHF_6 EPHF_8 EPHF_10 4. Technical support for monitoring and evaluating health status following table. As can be seen, most with respect to the technical support 5. Technical assistance and support to countries fall within in a similar per- needed to discharge this function (Indi- the subnational levels of public health formance range. A wider range of vari- cator 4) and NHA assistance to subna- ability can only be seen for EPHF 7. tional levels (Indicator 5). The most Upon analyzing the dispersion of the critical areas with those concerning the performance of these indicators for the 1.2 Results of the existence of guidelines for monitoring Region of the Americas, it can be con- measurement by function

An analysis of the performance of each EPHF is presented below. Figure 3 Distribution of the performance level of EPHF 1 in the Countries of the Region EPHF 1: Monitoring, Evaluation, and 10 Analysis of Health Status Standard deviation = .17 Mean = .58 Although high-intermediate perfor- 8 N = 41.00 mance was demonstrated with respect to this function in the Region, it continues to be an area in need of strengthening in 6 some countries. A frequency histogram of the performance of the countries 4 studied is shown below (see Figure 3), showing a median for the Region of 2 0.58 and a range from 0.24 to 0.97.

The greatest strength was found in the 0 institutional capacity of the NHA to .25.38 .50 .63.75 .88 1.00 perform this function (Indicator 3). Moderate strength was demonstrated 125 Indicator 3, with respect to which the Figure 4 Performance of the Indicators for EPHF 1 strongest performance was shown, had 1.00 a low level of variability, leading to the 0.94 0.90 conclusion that institutional capacities and competencies are a strength for per- 0.80 formance of this function. 0.70 0.62 0.60 0.52 0.54 The remaining indicators, that is, guide- 0.50 lines and processes for monitoring health 0.40 status (indicator 1) and technical sup- port (indicator 4), should be reviewed by 0.30 0.25 each country, given that they constitute 0.20 significant weaknesses for some. 0.10 0.00 The results in terms of the median 12345 value, the first standard deviation (rep- Indicators resenting 66% of the countries), and the maximum and minimum values3 for each indicator are provided in the cluded that there is a high degree of area, others demonstrated adequate per- following table (Figure 5). variability between the countries of the formance. A similar situation was found Region, particularly with respect to the with respect to the variability of Indica- The primary factors determining per- indicator for which the poorest per- tor 5. In contrast to the previous case, formance of this function, which were formance was shown (evaluation of the Indicator 5 was a strength for the ma- common to all or the majority of the quality of information). However, de- jority of the countries, although it con- countries are as follows: spite the fact that the majority of the tinued to be an important weakness for countries showed weaknesses in this others. • Roughly 70% of the participating countries have guidelines for measur- ing health status on the national and intermediate levels, and a somewhat Figure 5 Distribution of the performance of the Indicators of EPHF 1 in the Countries of the Region higher percentage have guidelines for the local level. 1.0 • In the majority of the countries, the

.8 health status profile is updated every year and provides information about the use of health services by individu- .6 als and groups. It is also used to mon- itor trends and formulate national .4 goals and objectives. However, the profiles still display shortcomings with regard to using the data to reveal in- .2 equalities in access to health services,

0.0 3 In this analysis, several results that were IND1 IND2 IND3 IND4 IND5 identified as outliers in the statistical analysis were excluded.

126 guiding activities aimed at improving Figure 6 Distribution of the performance level of EPHF 2 in the effectiveness of the services, and the Countries of the Region providing information on changes in risk factor profiles and the determi- 10 nants of health status. Standard deviation = .17 8 Mean = .58 • The primary data used to measure N = 41.00 health status are mortality, socioeco- nomic indicators, and use of health 6 services. In general, barriers to access- ing health services are not monitored, 4 less than 30% of the countries moni- tor risk factors for the most impor- tant pathologies, and data on mor- 2 bidity are inconsistently recorded. 0 • With regard to the quality of the data, .25 .31.38 .44 .50 .56 .63 .69 .75 .81 .88 .94 only 16% of the countries have an oversight agency that is independent of the ministry of health. Roughly 30% of the countries replied that they had carried out audits in order to evaluate have at least one professional with the • In general, it was acknowledged that the quality of the data. A common title of doctor at the central level. the NHA advises subnational levels critical area is the lack of procedures with respect to data collection, how- for continually improving information • The majority of the countries have ever, the NHA exhibited greater weak- systems. It was also acknowledged that staff trained in designing plans for nesses with respect to providing sup- there are no procedures for distribut- sampling and collecting general and port for the interpretation of results. ing information concerning the health specific data on health status. These status of the population to the com- professionals can consolidate data EPHF 2: Public Health Surveillance, munications media and to the general from various sources, perform inte- Research, and Control of Risks and public (half of the countries permit grated data analyses, interpret results, Threats to Public Health public access to the information). Fi- formulate valid conclusions, and com- This is one of the better performing nally, very few countries periodically municate pertinent information on functions for the countries of the Re- evaluate how the distributed health the country’s health status and related gion, with a median of 0.63. A consis- status information is used by the recip- trends to decision-makers. tent profile was exhibited by the major- ients of that information. ity of the countries studied,4 as shown • Approximately 76% of the countries in Figure 6 which provides the median • Although national bodies responsible use computer resources is order to distribution histogram of the countries for coordinating health statistics exist, carry out this function at the interme- for this function. fewer than a third meet at least once a diate level, while only 27% of the year to analyze and evaluate their per- countries use them at the local level. As can be seen, the performance of the formance and coordinating activities. Approximately 43% of the countries majority of the indicators was higher use electronic communication systems than 50%. The primary areas of strength • In human resources education, 80% to disseminate data to subnational lev- els. A common critical area is the lack of the countries have qualified public 4 Fewer than 25% of the countries per- health professionals at the intermedi- of fast access to specialized computer formed at less than 50%, according to the ate level, and half of the countries systems and equipment maintenance. standards determined for this function.

127 results for indicator 1 (public health sur- Figure 7 Performance of the Indicators for EPHF 2 veillance system), which can be identi- 1.00 fied as a strength in the Region.

0.90 0.83 0.82 The results for the remaining indicators 0.80 0.75 exhibited an intermediate dispersion, as 0.70 shown in Figure 8. 0.60 0.51 0.50 The primary factors determining per- 0.40 formance of this function are as follows: 0.33 0.30 • The surveillance systems make it pos- 0.20 sible to identify the magnitude and 0.10 the nature of the threats, to follow ad- 0.00 verse circumstances and risks over 12345 time, to identify threats requiring a re- Indicators sponse, and to study trends in diseases determined to be national priorities. The surveillance systems are made up were adequate surveillance systems for Of the results obtained from the coun- of the subnational levels and are also identifying public health threats, the ca- tries, the indicator concerning the ca- integrated into supranational surveil- pacities of public health laboratories, pacity for timely and effective response lance systems. However, they do not and support for subnational levels. The exhibited the greatest dispersion. How- integrate information generated by primary weakness was an insufficient ca- ever, although this was a critical area for other actors (private health providers, pacity to provide a timely and effective the Region of the Americas as a whole, NGOs, etc.) response to control public health prob- it was a strength for some countries. lems, as it shown in the following Figure The least variability in the countries’ • The majority of the countries have (Figure 7). performance was demonstrated by the established the functions and respon-

Indicators: Figure 8 Distribution of the performance of the Indicators for 1. Surveillance system to identify threats EPHF 2 in the Countries of the Region

and harm to public health 1.0

2. Capacities and expertise in public health surveillance .8

3. Capacity of public health laborato- .6 ries

.4 4. Capacity for timely and effective response to control public health problems .2

5. Technical assistance and technical 0.0 support for the subnational levels of IND1 IND2 IND3 IND4 IND5 public health.

128 sibilities of the various levels, particu- • The countries maintain up-to-date eral deviated from the average perfor- larly at the local level. registries of public health laboratories, mance of the Region and exhibited bet- have formal coordination and refer- ter or worse performance, as shown in • Again, weaknesses are manifested in ence mechanisms, and periodically Figure 9. evaluating the quality of the data pro- evaluate the quality of diagnoses using duced by the surveillance systems, international laboratories as reference A fundamental objective of health pro- and few countries have established, parameters. However, weaknesses in motion is to improve access to available formal mechanisms for providing evaluating the public health laborato- protective factors, such as social sup- feedback on how the surveillance sys- ries were acknowledged with respect port, safe communities, job opportuni- tems are operating. to how the coordination and reference ties, and better education, which can procedures function, and the majority help reduce some of the health inequal- • The majority of the countries have of the countries do not comply with ities associated with low or disadvan- developed protocols for purposes of regulations directed toward guaran- taged socioeconomic level. To this end, identifying the primary public health teeing the quality of their laboratories. the countries of the Region must take threats in each country. necessary actions to improve the critical • In all of the countries, the NHA ad- weaknesses that the performance of this • The majority of the countries have vises and supports the subnational function revealed. qualified personnel to monitor basic levels in order to help them develop sanitation and infectious diseases, as and strengthen their surveillance ca- Very similar, intermediate performance well as to handle evaluation and fast pacity to an optimal degree. was observed for all of the indicators of screening techniques. They are also in this function (see Figure 10). a position to design new surveillance EPHF 3: Health Promotion systems for potential problems. A Indicators: This function exhibited high-interme- smaller number of countries (24%) diate performance, with a median for 1. Support for health promotion activ- support surveillance with geofigureic the Region of 0.53. Although the ma- ities, the development of norms, and information systems. The greatest jority of the countries fell near the in- interventions to promote healthy weaknesses are personnel knowledge termediate values, one can see that sev- behaviors and environments. and experience is epidemiological re- search on chronic diseases, accidents, and occupational mental health. These Figure 9 Distribution of the performance level of EPHF 3 in constitute the primary health chal- the Countries of the Region lenges for the Region of the Americas. 10

• One critical area is the lack of incen- Standard deviation = .19 tive mechanisms or recognition in Mean = .52 8 N = 41.00 order to promote good performance by public health monitoring teams. 6 • Although the vast majority of the countries can give examples of threats 4 to public health that were detected in a timely fashion in the last two years, 2 only a third of the countries evaluate the response capacity of the surveil- lance system, communicate results, 0 and supervise the implementation of .13 .19 .25 .31 .38 .44 .50 .56 .63 .69 .75 .81 .88 .94 corrective measures.

129 health promotion goals and carry out Figure 10 Performance of the Indicators for EPHF 3 “healthy municipality”-type actions

1.00 on the local level.

0.90 • One critical area is the poor develop- 0.80 ment of systems for supporting health 0.70 0.65 promotion at subnational levels. Only 0.60 0.58 23% of the countries have systems 0.50 0.50 0.50 0.50 for recognizing and rewarding health

0.40 promotion, 35% have “competition” 0.33 funds designated for stimulating 0.30 health promotion, and 76% finance 0.20 health promotion training activities. 0.10 0.00 • Although policies and standards aimed 12345 at promoting healthy behavior and Indicators environments are in place and efforts have been made to advocate for the development of health-sensitive pub- lic policies (especially with regard to the environment), only 43% of the 2. Building of sectoral and extrasectoral • The majority of the countries are countries plan actions in this area partnerships for health promotion. aware of the recommendations of in- each year, which may explain the lim- ternational conferences on health ited observed results. 3. National planning and coordination promotion and have incorporated of information, education, and so- them into their action plans. Roughly • In general, the NHA do not carry out cial communication strategies for 49% of the countries have established systematic studies of the impact of health promotion.

4. Reorientation of the health services Figure 11 Distribution of the performance of the Indicators toward health promotion. for EPHF 3 in the Countries of the Region

5. Technical assistance and support to 1.0 the subnational levels to strengthen

health promotion activities. .8

The results for Indicators 2, 3 and 5 were less variable. Greater dispersion .6 was observed for the remaining indica- tors, which confirms that health pro- .4 motion is a strength for some countries and a weakness for others. .2 The primary factors determining per- formance of this function, which were 0.0 generally shared by all countries, are as IND1 IND2 IND3 IND4 IND5 follows:

130 public policies on the health of the health promotion approach in pri- • The primary critical areas with respect population, a practice which would mary health care. to NHA support for subnational lev- make it possible to proactively sup- els are the lack of plans for strength- port healthy behavior and environ- • The countries pointed out that obsta- ening health promotion at subna- ments. Only 22% of the countries cles to reorienting health services to- tional levels, and the need to improve allocate resources for measuring the ward promotion include the fact that evaluation and support activities di- impact of public policies on health. only 5% of the countries have estab- rected toward subnational levels. lished payment mechanisms that sup- • Approximately 35% of the countries port health promotion, that no coun- EPHF 4: Social Participation in Health try has promoted health insurance stated that they have specific actions This function exhibited intermediate payment mechanisms that encourage plans for the purpose of establishing performance for the Region, with a me- health promotion, and that the ma- partnerships with other actors and dian of 0.49. The performance profile jority of the countries do not include sectors, and less than half of them pe- of the countries is quite homogeneous, activities in support of health promo- riodically evaluate the results of these with the exception of several countries tion in health plans. It was also stated actions and correct how they are im- that deviated from the intermediate that training in health promotion is plemented. range, as is shown in Figure 12. not a recognized part of the profes- sional accreditation process. • Throughout the Region, the NHA ac- As with the previous function, the indi- tively support health promotion activ- cators measured revealed intermediate • The countries stated that they have ities, particularly local health educa- performance, although the indicator for trained staff in health promotion. tion. They collaborate with other strengthening social participation in Around 59% of the countries encour- actors, but do not evaluate the results health was somewhat higher (Figure 13). of this collaboration. The use of tele- age training centers to include health promotion in academic training cur- vision, radio, and the press is common Indicators: in the majority of the nationally-spon- ricula, and 78% have included it in sored campaigns. Only 14% of the their own human resources training 1. Empowering citizens for decision- countries stated that they have used programs. making in public health the Internet to carry out campaigns. Figure 12 Distribution of the performance level of EPHF 4 in • There are few agencies specifically de- the Countries of the Region voted to providing public health in- formation and education, and the 7 agencies that do exist are not evalu- Standard deviation = .20 6 Mean = .48 ated. Less than a third of the coun- N = 41.00 tries use web pages and telephone 5 lines devoted to this purpose. 4 • Roughly 70% of the countries pro- mote the implementation of models 3

under which the primary strategy for 2 reorienting the health services toward health promotion is the provision of 1 public health services by teams with training in health promotion. How- 0 ever, only 35% of the countries state .13 .19 .25 .31 .38 .44 .50 .56 .63 .69 .75 .81 .88 .94 1.00 that they have developed mechanisms for encouraging and fostering the

131 2 years, although only 24% dissemi- Figure 13 Performance of the Indicators for EPHF 4 nate its results through the communi- 1.00 cations media. Only a few countries 0.90 have formal channels for receiving

0.80 public comments on these reports.

0.70 • Procedures and formal channels for re- 0.60 0.54 ceiving and responding to public com- 0.50 0.44 0.42 ments on health issues do not exist. 0.40

0.30 • Approximately 65% of the countries

0.20 stated that they have carried out pub- lic consultations that were helpful in 0.10 determining national health goals 0.00 and objectives and can mention spe- 123 cific examples of citizen contribu- Indicators tions in this regard.

• Weaknesses were acknowledged in 2. Strengthening of social participation • Half of the countries have an inde- the development of strategies for in- in health pendent “public defense” office, with forming the public of their rights legal and governmental powers, charged with respect to health. Only 32% of 3. Technical assistance and support to with protecting the public’s interest the countries stated that they had car- the subnational levels to strengthen in the area of health. ried out specific actions to this end. social participation in health. • Approximately 62% of the countries • Personnel trained in promoting com- The Region’s results for indicator 2 stated that they issue a public national munity participation in health pro- (strengthening of social participation in report on health status at least every grams are available, although there are health) were less variable, while indica- tor 3 (support for subnational levels) exhibited the greatest dispersion. The Figure 14 Distribution of the performance of the Indicators fact that some countries exhibited gen- for EPHF 4 in the Countries of the Region erally better or worse performance is manifested by the existence of extreme 1.0 values, as can be seen in Figure 14.

.8 The primary factors determining per- formance of this function in the Region are as follows: .6

• Approximately 84% of the countries .4 have formal agencies for receiving public comments on health issues, and 57% have formal forums for con- .2 sulting with the public on health is- sues. However, fewer than a third of 0.0 the countries ensure that comments IND1 IND2 IND3 are answered. 132 weaknesses in the areas of leadership, Figure 15 Distribution of the performance level of EPHF 5 in teamwork, and conflict resolution. the Countries of the Region

• The countries promote the develop- 14 ment of good practices with regard to Standard deviation = .18 12 Mean = .56 community participation. Roughly N = 41.00 49% of the countries disseminate these good practices to other coun- 10

tries, and 70% have access to re- 8 sources (sectoral and extrasectoral) in order to promote community partici- 6 pation activities. 4 • The majority of the countries have 2 formal mechanisms for promoting social participation in health at the 0 local and intermediate levels, includ- .19 .25 .31 .38 .44 .50 .56 .63 .69 .75 .81 .88 .94 1.00 ing organization directories and pro- moting meetings, forums, work- shops, and other activities in order to promote participation in health- related subjects. The indicators measured for this func- Indicators: tion revealed that the areas of lowest per- 1. Definition of national and subna- • In general, the capacity to promote so- formance are the definition of national tional health objectives cial participation with respect to health health objectives (Indicator 1) and NHA and the capacity to use the results of support to subnational levels for the per- 2. Development, monitoring, and eval- such efforts were not evaluated. formance of this function (Indicator 5). uation of public health policies The areas of highest performance are the • With regard to support for subna- development of public health policies tional levels, the primary weaknesses (Indicator 2) and the capacity for negoti- 3. Development of institutional ca- were found in evaluating the results of ating international cooperation (Indica- pacity for the management of public participation, designing mechanisms tor 4). Intermediate performance was health systems for receiving and responding to public shown in development of institutional comments, designing systems for ex- capacity for the management of public 4. Negotiation of international cooper- plaining health status, and designing health (Indicator 3), as can be observed ation in public health mechanisms for conflict resolution. in Figure 16. 5. Technical assistance and support to The greatest weaknesses in public health the subnational levels for policy de- EPHF 5: Development of Policies and management should alert health author- velopment, planning, and manage- Institutional Capacity for Planning and ities to formulate policies, and the NHA ment in public health. Management in Public Health in general, on the basis of the current This function exhibited intermediate and future challenges facing public Of the indicators that revealed the high- performance, with a median of 0.56 for health management. In addition, efforts est performance, the low dispersion of the Region. In general, it can be ob- should be made to identify measures that development, monitoring, and evalua- served that the majority of the countries health authorities should take in order to tion of public health policies (Indicator exhibited intermediate performance, increase institutional capacities, with the 2) makes it possible to conclude that and only one country exhibited optimal ultimate objective of improving public this is an area of strength for the Re- performance, as shown in Figure 15. health. gion. This is not the case with regard to 133 tent (68% of the countries), by the Figure 16 Performance of the Indicators for EPHF 5 legislative branch. The majority of the 1.00 countries follow through with legal

0.90 instruments and needed legislation in 0.80 order to implement these policies. 0.80 0.72 0.70 • Fewer than half of the countries con- 0.60 sult current and potential allies in 0.50 0.50 order to determine the degree of sup- 0.40 0.40 0.37 port for developing, implementing, and evaluating the process of improv- 0.30 ing national health policy. However, 0.20 the private sector and the public are 0.10 rarely included in these processes. 0.00 12345 • All of the countries have personnel Indicators trained in policy development, the preparation of legal documents, and the indicator management of interna- nent actors, such as civil society, do the prioritization of public health tional cooperation (Indicator 4), which not always participate in formulating policies. In addition, the majority of exhibited the greatest variability among these objectives. Roughly 51% of the the countries have qualified person- the countries of the Region; although countries stated that indicators had nel and resources for managing inter- it generally revealed adequate perfor- been developed to measure the effec- national cooperation projects and mance, it continues to be an area of tive performance of established health programs. weakness for some countries. objectives. • With regard to institutional manage- The indicators that presented low and • By and large, the countries have ment capacity, strengths were ob- intermediate performance (the defini- health policy plans supported by the served in strategic planning and lead- tion of public health objectives, the pub- executive branch and, to a lesser ex- ership in the area of health. The lic health management, and support for subnational levels) reveal optimal per- Figure 17 Distribution of the performance of the indicators of formance by some countries and weak EPHF 5 in the Countries of the Region performance by many others, as shown in Figure 17. 1.0

The primary factors determining per- .8 formance of this function in the Region are as follows: .6 • In the majority of the countries, the NHA spearheads the process of defin- .4 ing health goals and objectives, which are based on each country’s health .2 priorities. However, the countries ac- knowledged weaknesses in updating health priorities, and 43% stated that 0.0 health objectives and social policy ob- IND1 IND2 IND3 IND4 IND5 jectives are directly related. The perti- 134 majority of the countries stated that order to achieve the desired public Except for better performance concern- they have skilled and knowledgeable health objectives. Some 43% of the ing the development of public health personnel in strategic planning; 64% countries stated that they did not have regulatory frameworks (Indicator 1), stated that they have carried out a a clear organizational vision to guide the remaining indicators revealed poor planning exercise in the last year and management; only 32% of the coun- performance, particularly with regard that the greatest weakness in this area tries learn from changes, and 27% to the enforcement of regulations (Indi- is evaluating and monitoring the evaluate institutional performance. cator 2), as shown in Figure 19. strategic planning process. With re- gard to leadership, the majority of the • The areas of weakness in support Health legislation is regarded as an in- countries stated that they have the ca- to subnational levels coincide with strument for the implementation of pacity to generate consensus and pro- the areas of weakness in the NHA. It health policy, taking into account the mote inter-institutional collaboration was acknowledged that a widely- evolving role of the State and its rela- with regard to public health, and shared weakness in the majority of tionship to civil society. In this regard, 65% have used this experience to the countries is difficulty in deter- the countries’ efforts to reformulate ex- channel resources toward health. The mining necessary actions for support- isting legal frameworks for the regula- greatest weaknesses were observed in ing management at subnational levels tion of health-related rights and respon- the areas of conflict resolution and and responding in a timely and ap- sibilities demand that the NHA assist communications skills. propriate manner. the public, the State, and the private sector in effectively exercising these • The countries indicated that ade- EPHF 6: Strengthening of Institutional rights and responsibilities. quate financing mechanisms that Capacity for Regulation and Enforce- might help achieve health objectives ment in Public Health Indicators: are unavailable. In general, the majority of the countries 1. Periodic monitoring, evaluation, and performed this function at the low- modification of the regulatory frame- • In addition, weaknesses were ob- intermediate level, with a median of work served in the development of per- 0.47 and quite homogeneous results, as formance indicators for measuring shown in Figure 18. 2. Enforcement of laws and regulations the achievement of the defined health objectives. Only 51% of the coun- tries have indicators, and 38% de- Figure 18 Distribution of the performance level of EPHF 6 in velop the evaluation through partici- the Countries of the Region patory processes. The majority of the countries do not consult the private 12 Standard deviation = .18 sector with regard to this evaluation. Mean = .46 10 N = 41.00 • The NHA has difficulty in establish- ing alliances in order to implement 8 health policies. In general, they do not work with private sector health 6 services providers, insurers, authori- ties responsible for health social secu- 4 rity, or consumers. 2 • The primary weaknesses in institu- tional capacity for public health man- 0 agement are found in the decision .19 .25 .31 .38 .44 .50 .56 .63 .69 .75 .81 .88 .94 1.00 making process, based on evidence and organizational development, in 135 in legislative procedures and public Figure 19 Performance of the Indicators for EPHF 6 health regulations, sufficient health 1.00 advisory services from international

0.90 organizations, and sufficient institu- tional competencies and resources to 0.80 0.75 draft health regulations. 0.70 0.60 • The countries review existing regu- 0.50 lations for purposes of producing 0.41 0.40 and modifying draft legislation. 0.31 0.30 However, only 11% of the partici- 0.30 pating countries stated that they per- 0.20 form reviews in a timely manner (an- 0.10 ticipating problems); 24% perform 0.00 them periodically. Rather than the 1234 above, action is taken in response to Indicators pressures external to the NHA, both from the governments and from other actors.

3. Knowledge, skills, and mechanisms The primary factors determining per- • The NHA leads the process of modi- for reviewing, improving, and en- formance of this function in the Region fying the regulatory framework, of- forcing the regulations are as follows: fering technical assistance directly to lawmakers and seeking to persuade 4. Technical assistance and support to • The majority of the countries have the pertinent actors involved in mak- the subnational levels of public competent personnel knowledgeable ing the suggested legal modifications. health in developing and enforcing laws and regulations. Figure 20 Distribution of the performance of the indicators of The variability of the results obtained EPHF 6 in the Countries of the Region for each country demonstrates lower dispersion with respect to the weak- 1.0 nesses concerning enforcement of regu- lations (Indicator 2), and lower disper- .8 sion with respect to the regulatory framework (indicator 1). The highest variability index was observed in sup- .6 port for subnational levels. This leads to the conclusion that weak enforcement .4 of regulations is common to the major- ity of the countries. Although institu- tional competencies and aptitudes, as .2 well as support for decentralized levels, constitute strengths for some countries, 0.0 they continue to be critical areas for IND1 IND2 IND3 IND4 others (see Figure 20).

136 • Although most of the countries iden- countries stated that they evaluate tries exhibited performance higher than tified personnel responsible for en- their training programs. 70% with respect to the indicators used, forcement, only 30% stated that they which, in some way, reflects the empha- supervise enforcement procedures, • In the majority of the countries, sub- sis placed on this health objective. while a lower percentage stated that national levels are provided with sup- they monitor the timeliness and ef- port in implementing enforcement The lowest performance was for evalua- fectiveness of enforcement efforts. procedures and complex enforcement tion of access to services (Indicator 1). Roughly 80% do not supervise the operations. However, the technical as- The remaining indicators—namely, in- abuse or misuse of authority by en- sistance that is provided is not period- stitutional capacities and skills for de- forcement agencies, and the countries ically evaluated, and subnational levels veloping actions to improve access by generally do not have systems for are not provided with information on the population to health services (Indi- promoting the proper use of author- the development of local regulations. cator 2), advocacy and action to im- ity by personnel. prove access to necessary health services EPHF 7: Evaluation and Promotion (Indicator 3), and NHA technical assis- • Approximately 51% of the countries of Equitable Access to Necessary Health tance and support to subnational levels stated that they have mechanisms for Services to promote performance of this func- educating the public about the im- tion (Indicator 4)—revealed intermedi- This function exhibited intermediate portance of following existing regula- ate performance. performance for the Region, with a me- tions, and only 11% have incentives dian of 0.55. The performance profile is aimed at encouraging the public to Indicators: quite heterogeneous, and some groups comply with regulations. of countries were found to have differ- 1. Monitoring and evaluation of access ent levels of development for this func- to necessary health services • Another critical area concerns the tion, as shown in the Figure 21. Al- promotion of plans and actions aimed though some countries exhibited lower 2. Knowledge, skills, and mechanisms at preventing corruption. Although performance, it is important to point for improving access by the popula- some countries have anti-corruption out that a considerable number of coun- tion to necessary health services measures, these are not evaluated, and actions aimed at preventing the in- fluence of power groups are not even Figure 21 Distribution of the performance level of EPHF 7 in considered. Roughly 46% of the the Countries of the Region countries have warning and punish- ment systems for illegal practices, and 6 the public is aware of these systems in Standard deviation = .25 Mean = .55 35%. 5 N = 41.00

• In general, the countries do not have 4 enough personnel or resources to strengthen enforcement efforts, which 3 is the primary critical area for perfor- mance of this function in the Region. 2

• Although new personnel are trained 1 in enforcement issues and training courses are offered, only 24% of the 0 countries ensure ongoing training in .13 .19 .25 .31 .38 .44 .50 .56 .63 .69 .75 .81 .88 .94 1.00 this area. Approximately 40% of the

137 common to the entire Region is the Figure 22 Performance of the Indicators for EPHF 7 failure to identify and disseminate

1.00 good practices aimed at removing bar- riers to access. In general, few coun- 0.90 tries use the results of these evalua- 0.80 0.72 tions to implement strategies aimed at 0.70 0.66 reducing barriers to access. 0.60 0.58

0.50 • It is noteworthy that a low percentage of the participants identified barriers 0.40 0.30 related to ethnic groups, cultural or 0.30 religious barriers, or barriers based 0.20 on sexual orientation. Approximately 0.10 46% of the countries stated that they 0.00 included gender differences as a crite- 1234 rion in this analysis. Indicators • The greatest weaknesses in develop- ing strategies and actions aimed at 3. Advocacy and action to improve ac- better than evaluation of access to per- improving access to health services cess to necessary health services sonal health services (especially due for people without access to these to the absence of information from services are related to the extent to 4. Technical assistance and support to private health services and from the which personnel have knowledge and the subnational levels to promote social security institutions). Roughly experience in orienting users when equitable access to health services. 57% of the countries stated that they linguistic barriers exist, as well as to have indicators to objectively evaluate designing actions aimed at improving With regard to the variability of the per- access to health services. A critical area access to services for the most vulner- formance revealed by the indicators in the various countries of the Region, it can be seen that Indicator 7.3 revealed Figure 23 Distribution of the performance of the Indicators better overall performance and exhib- for EPHF 7 in the Countries of the Region ited lower dispersion, essentially con- firming that this is an area of strength 1.0 for the Region. The remaining indica- tors exhibited maximum dispersion. .8 This implies that there is one group of countries with relatively better perfor- mance, and another group of countries .6 for which these indicators are critical areas in need of improvement (see Figure 23). .4

The primary factors determining per- .2 formance of this function in all or the majority of the countries are as follows: 0.0 • In general, the evaluation of access IND1 IND2 IND3 IND4 to population-based health services is

138 able populations. Another weakness Figure 24 Distribution of the performance level of EPHF 8 in is insufficient systematic evaluations the Countries of the Region of efforts to reduce barriers to access. On the other hand, the majority of 6 the countries have the institutional Standard deviation = .20 capacity to develop early detection 5 Mean = .38 N = 41.00 programs and to implement innova- tive methods for improving access 4 (mobile clinics, fairs, etc.) 3 • The countries performed well with respect to developing laws and regu- 2 lations aimed at improving access for the neediest and with respect to car- 1 rying out actions directed toward re- ducing barriers to access, especially 0 for vulnerable groups. Half of the .06 .13 .19 .25 .31 .38 .44 .50 .56 .63 .69 .75 .81 .88 .94 countries advocate incorporating this knowledge into human resources ed- ucation and inform decision-makers of findings concerning barriers to ac- cess. In general, the greatest weak- mining a basic package of individual health, and increasing concern about nesses of the NHA were in develop- and collective services that should be educating personnel in issues that pro- ing actions designed to enable other available to the entire population. mote the culturally appropriate delivery actors responsible for providing health However, the performance of those of services to the populations of these services to reduce barriers to access responsible for providing this basic countries (see Figure 25). (private organizations and social secu- package of pre-established services is rity institutions). not regularly evaluated, particularly Indicators: with regard to the most vulnerable or 1. Description of the public health • In terms of actions directed toward underserved populations. workforce reducing existing gaps, all of the countries exhibited strength in their EPHF 8: Human Resources 2. Improving the quality of the work- capacity to inform the public of how Development and Training force to access health services. in Public Health

• Major weaknesses exist in the devel- This function exhibited low perfor- 3. Continuing education and graduate opment of incentive systems for ser- mance, with a median of 0.38 for the training in public health vice providers (public and private) Region. In general, it can be said that the aimed at reducing the access gaps that majority of the countries exhibited low 4. Upgrading human resources to en- were found. Approximately 46% of and intermediate performance; however, sure culturally appropriate delivery the countries indicated that they have a limited number exhibited better per- of services local measures for encouraging the formance, as shown in Figure 24. development of actions aimed at pro- 5. Technical assistance and support to moting more equitable access to Although all of the indicators revealed the subnational levels in human re- health services. low performance, the following areas sources development. are critical for the Region: improving • All of the countries provide subna- quality, promoting continuing educa- In general, the results for this function tional levels with assistance in deter- tion and graduate training in public exhibit little variability for Indicators

139 to those who graduate from training Figure 25 Performance of the Indicators for EPHF 8 centers. In addition, one of the greatest 1.00 weaknesses was found to be criteria for

0.90 determining needs for future growth.

0.80 • As for improving the quality of the 0.70 workforce, although guidelines for 0.60 personnel accreditation do exist, ad- 0.50 herence to these guidelines in hiring is 0.40 0.40 0.40 0.40 not evaluated. Strategies for selecting and retaining workers are evaluated in 0.30 0.28 only a few countries. Approximately 0.17 0.20 19% of the participating countries 0.10 stated that their training programs 0.00 include ethics as a pertinent field of 12345 study. Incentives for strengthening Indicators leadership among public health per- sonnel do not exist, and only 11% of 8.3 (continuing education) and 8.2 • Although the participating countries the participating countries promote (Improving the quality of the work- evaluate the characteristics of the the retention of leaders. Although half force). The remaining indicators (8.1, workforce, only 50% define personnel of the countries have performance 8.4 and 8.5) exhibit greater dispersion, needs for public health functions, evaluation systems, only 32% estab- which indicates that some countries ex- including determining the size, pro- lish measurable results, and few use hibit better performance in comparison file, and required competencies of the the results for allocating responsibility to the rest of the Region (Figure 26). staff. This hinders NHA efforts to and incentives for retaining workers strengthen appropriate human re- on the basis of demonstrated merits. The primary factors determining per- sources development for public health, formance of this function in all or the both with regard to the individuals • In the majority of the countries, par- majority of the countries are as follows: they train themselves and with regard ticipation in continuing education is encouraged, training for less-experi- Figure 26 Distribution of the performance of the Indicators enced personnel is offered, and agree- for EPHF 8 in the Countries of the Region ments have been reached with training centers for this purpose. However, 1.0 none of the countries have clear poli- cies and regulations for ensuring that

.8 human resources education is of an appropriate level, none have systems for evaluating the results of human re- .6 sources education and training, and none have mechanisms for retaining .4 the most qualified personnel, resulting in an ongoing loss of the potential benefits of these education and train- .2 ing activities.

0.0 • With regard to support for subna- IND1 IND2 IND3 IND4 IND5 tional levels in the performance of this function, less than a third provide sup- 140 port for the identification of human Figure 27 Distribution of the performance level of EPHF 9 in resources appropriate to the sociocul- the Countries of the Region tural and linguistic characteristics of

the users, while 51% of the countries 8 do not promote decentralized strate- Standard deviation = .21 gies for improving human resources Mean = .26 N = 41.00 management in accordance with the 6 needs of local and intermediate levels.

EPHF 9: Quality Assurance in Personal 4 and Population-based Health Services This function exhibited the lowest per- 2 formance for the Region, with a median of 0.26. The profile of the participating countries reveals similar results; all of 0 the countries exhibiting low-to-interme- 0.00 .06 .13 .19 .25 .31 .38 .44 .50 .56 .63 .69 .75 .81 .88 diate performance, with the exception of one country that exhibited better per- formance and clearly distanced itself from the group, as shown in Figure 27. 4. Technical assistance and support to health services (Indicator 9.1), and in Although all of the indicators revealed the subnational levels to ensure support for the subnational levels (Indi- very low performance, it is worth not- quality improvement in the services. cator 9.4), which, despite being a weak- ing that there were small advances with ness for the Region, is an area in which regard to health technology assessment The greatest variability in the results ob- there was considerable progress in some to support decision-making in public tained by the participating countries countries. On the other hand, concern health (Indicator 3) and the improve- was found in the definition of standards for improving user satisfaction with ment of user satisfaction with health and evaluation to improve the quality of health services is a critical area for all of services (Indicator 2). The low support for the subnational levels (Indicator 4) is due to the low development of this Figure 28 Performance of the Indicators for EPHF 9 function in general (see Figure 28). 1.00

0.90 Indicators: 0.80

1. Definition of standards and evalua- 0.70

tion to improve the quality of popu- 0.60 lation-based and personal health 0.50 services 0.40 0.31 2. Improving user satisfaction with the 0.30 0.25 health services 0.20 0.17 0.10 0.10 3. Systems for technological manage- 0.00 ment and health technology assess- 1234 ment to support decision-making in Indicators public health 141 porting decision-making in this area, Figure 29 Distribution of the performance of the Indicators of although no evidence was provided of EPHF 9 in the Countries of the Region any major successes related to sup- 1.0 porting the health policy decision- making process or delivering recom- mendations on technology use to .8 health services authorities. Although insufficient, the countries acknowl- .6 edged some progress in evaluating the safety and effectiveness of technology.

.4 • In keeping with the low level of per- formance exhibited for this function, it .2 was observed that the NHA provides partial support to subnational levels,

0.0 particularly with respect to evaluating IND1 IND2 IND3 IND4 the quality of personal health services.

EPHF 10: Research in Public Health Public health research is another func- the participating countries and exhib- evaluating processes and, less fre- tion exhibiting low performance, with a ited the least dispersion. It was con- quently, results) than in those aimed median of 0.42. Based on the results firmed that a third of the Region’s coun- at evaluating the quality of popula- obtained, the distribution profile of the tries failed to exhibit any progress with tion-based health services. participating countries indicates that a respect to Indicator 9.3 (see Figure 29). majority exhibited low-to-intermediate • In general, national systematic and performance, with the exception of sev- The primary factors determining per- periodic strategies for evaluating user eral countries that exhibited higher per- formance of this function in the major- satisfaction with health services (both formance, as shown in Figure 30. ity of the countries are as follows: personal and population-based health services) have been developed by very With regard to the performance re- • Approximately 49% of the countries limited degree; however, the partici- vealed by the indicators used in this promote policies aimed at continu- pating countries described several iso- measurement, the Region’s primary ously improving the quality of health lated experiences at the local and in- weakness is the lack of national public services. Some 43% apply quality termediate levels. Approximately 41% health research agendas. Better relative performance standards, and 27% of the countries use the results to en- performance was exhibited in develop- have measured their progress in this hance strategies for improving health ing the institutional research capacity of area. In general, few countries evalu- services quality, but it was acknowl- the NHA (Figure 31). ate the quality of services, and even edged that these results are not used fewer disseminate results to the pub- to guide decision-making in this area Indicators: lic. Only 22% of the countries have and that the results are not communi- 1. Development of a public health re- autonomous agencies that accredit cated to users. In general, the majority search agenda and evaluate the quality of health of the countries do not have mecha- services providers. nisms for ensuring the confidentiality 2. Development of institutional re- of information provided by users. search capacity • By and large, a greater increase was observed in actions aimed at evaluat- • Approximately 30% of the countries 3. Technical assistance and support for ing the quality of personal health have an agency responsible for tech- research in public health at the sub- services (particularly those aimed at nological management and for sup- national levels 142 countries stated that public health re- Figure 30 Distribution of the performance level of EPHF 10 in search does not consider the current lack the Countries of the Region of knowledge with regard to managing 10 health priorities, does not conduct tests Standard deviation = .25 in order to improve health services man- Mean = .55 agement, does not ensure the economic 8 N = 41.00 feasibility and sustainability of innova- tions in public health, and does not pro- 6 vide support for making important po- litical decisions with regard to public health. 4

• Progress in fulfilling the public health 2 research agenda is not periodically evaluated; if it is evaluated, the results 0 are not communicated to the parties 0.00 .06 .13 .19 .25 .31 .38 .44 .50 .56 .63 .69 .75 .81 .88 .94 1.00 involved.

• Weakness exists in the relationship with researchers, particularly re- As for dispersion, low variability was gen- The primary factors determining per- searchers who come from outside the erally observed for indicator 10.1, indicat- formance of this function in all or the NHA (e.g., from academia), and the ing that the lack of national public health majority of the countries are as follows: results of NHA research are only par- research agenda is a weakness for the Re- tially disseminated to the rest of the gion. The other indicators exhibit greater • Although 49% of the countries stated scientific community. variability; while the majority of the that they have an agency in charge of countries did not demonstrate sufficient the national agenda, significant weak- • No mechanisms exist for ensuring development in these areas, other coun- nesses were observed in the prepara- that public health research corre- tries exhibited strengths (see Figure 32). tion of these agenda. In general, the sponds to national priorities. Al- though half of the countries have pro- Figure 31 Performance of the Indicators for EPHF 10 cedures for approving research, only 19% evaluate the importance of the 1.00 subject. Few countries stated that 0.90 they have formal, transparent mecha- 0.80 nisms for assigning research funds.

0.70

0.60 • The availability of tools and experts 0.50 for the promotion of public health re- 0.50 0.47 search, as well as the fact that the 0.40 NHA tend to use research results, are 0.30 strengths in all of the countries. The 0.20 vast majority of the countries can give 0.10 0.05 examples of public health research in

0.00 the last two years. 123 Indicators • The primary research strengths are epidemiology and food poisoning; 143 gency and disaster management efforts Figure 32 Distribution of the performance level of EPHF 10 in are insufficient. the Countries of the Region

1.0 Indicators: 1. Reducing the impact of emergencies .8 and disasters

2. Development of standards and guide- .6 lines that support emergency pre- paredness and disaster management .4 in health

3. Coordination and partnerships with .2 other agencies and/or institutions

0.0 4. Technical assistance and support to IND1 IND2 IND3 the subnational levels to reduce the impact of emergencies and disasters on health. the primary weaknesses are research mance of the NHA in the area of man- on risk factors for chronic diseases agement for reducing the impact of The greatest variability among the coun- and research on collective interven- emergencies and disasters (Indicator 1). tries was observed for Indicators 11.1 tions and community health. This profile of the Region demonstrates and 11.2. Several countries acknowl- that, despite the existence of institu- edged that they had made no progress in • The countries provide subnational tional mechanisms, the results of emer- these areas, particularly in the develop- levels with partial support for re- search, and the majority promotes the participation of subnational level pro- fessionals in research. In addition, Figure 33 Distribution of the performance level of EPHF 11 in 32% of the participating countries in- the Countries of the Region dicated that they disseminate the re- sults of this research. 8 Standard deviation = .19 Mean = .68 EPHF 11: Reducing the Impact of N = 41.00 Emergencies and Disasters on Health 6

This is one of the best-performing func- tions for the Region, with a median of 4 0.69. The distribution profile indicates low dispersion in the specific results for each country, with the exception of sev- 2 eral countries for which this continues to be a critical area, as shown in Figure 33. 0 Although the majority of the indicators .31 .38 .44 .50 .56 .63 .69 .75 .81 .88 .94 1.00 revealed good performance, shortcom- ings were still observed in the perfor-

144 • The countries acknowledged that Figure 34 Performance of the Indicators for EPHF 11 one of the critical areas concerning

1.00 NHA management of emergencies and disasters is insufficient coordina- 0.90 0.85 0.84 tion within the health sector in the 0.77 0.80 event of emergencies and disasters. 0.70

0.60 • The health sector’s primary weak- 0.49 0.50 nesses in the management of emer- gencies and disasters are in addressing 0.40 mental health problems, managing 0.30 health services under these circum- 0.20 stances, and periodically carrying out 0.10 simulation exercises. However, with 0.00 regard to human resources education, 1234 it was acknowledged that adequate Indicators institutional capacity exists to address subjects such as basic sanitation, vec- tors, and infectious and communica- ment of standards and guidelines. This • Approximately 80% of the countries ble diseases. indicates that although this function is, have sectoral plans integrated into a for the most part, performed acceptably national emergency program, and • The greatest weakness in current reg- well throughout the Region, some coun- 50% have maps of hazards and risks ulations concerns treatment of mental tries still exhibit significant weaknesses. for emergencies and disasters. Ap- health problems; 50% of the coun- proximately 70% of the countries tries acknowledged weakness with The primary factors determining per- have a specialized body devoted to respect to the vulnerability of health formance of this function in the Region the subject, and 30% indicated that infrastructure. are as follows: this body has an allocated budget.

• The countries stated that there is Figure 35 Distribution of the performance level good coordination between the re- of the Indicators of EPHF 11 in the Countries of the Region maining institutions, and between na- tional institutions and international 1.0 organizations, in these cases. In gen- eral, the countries maintain relation- ships with the vast majority of the or- .8 ganizations concerned with disaster response issues, and they collaborate .6 with neighboring nations and other bodies in the event of emergencies.

.4 • In general, the NHA provide a high level of support and assistance to the .2 subnational levels. Roughly 70% of the participating countries stated that 0.0 they periodically assess the needs of IND1 IND2 IND3 IND4 subnational levels in the event of emergencies and disasters, although

145 this does not necessarily mean that In addition, the evaluation of the qual- lishing alliances with other agencies the shortcomings that are uncovered ity of information in order to subse- and/or institutions for this purpose. are corrected, given the limited avail- quently evaluate health status, the mon- ability of resources for this purpose. itoring of equitable access to necessary • The development of public health in- health services, and the generation of stitutional capacities and infrastruc- 1.3 Identification of priority timely responses to public health threats ture; monitoring and evaluating intervention areas in order are all common critical areas in need of health status; the capacities of public to prepare a program for improvement. health laboratories; and the capacity strengthening the EPHF in the to manage international cooperation. Region of the Americas Finally, a critical issue concerning the role of the NHA and regulation is the • With regard to developing the com- 1.3.1 Profile of all indicators low performance exhibited with regard petencies of decentralized bodies in to compliance with existing regulations. performing public health functions, In order to provide a guide for the prepa- subnational levels must continue to ration of national and Regional plans for 1.3.2 Analysis of the be supported in the areas of public developing the institutional capacities of Indicators by Area health monitoring, research, control- the national health authorities of the par- of Intervention ling risks and threats, and reducing ticipating countries, as well as for struc- damage caused by emergencies and turing a program for strengthening pub- The profile of all of the indicators de- disasters. lic health in the Region, the indicators termined to be strengths or weaknesses have been ordered so as to facilitate an for the Region appears below, organized Based on a level of success equal to or integrated analysis. For the majority of according to the three intervention lower than 40% of the established stan- the countries, the analysis will cover in- areas described in the previous chapter. dard, the primary weaknesses exhibited dicators representing strengths that must In order to facilitate the analysis, the in- by the Region, and which should be in- be maintained and strengthened, and dicators for each function have been cluded in a program for the improve- other areas of poorer performance that given a different color. ment of public health, are as follows: should be strengthened. Based on a level of success equal to or • In order to strengthen important pro- The Region exhibited the lowest per- higher than 70% of the established stan- cesses, progress should be made in: formance in the development of na- dard, the primary strengths exhibited by evaluating the quality of information tional public health research programs. the majority of the countries of the Re- available for monitoring the health gion in performing the essential public status of the population; enforcing Reflecting the low performance of the health functions, and which should be health regulations; improving user function, all of the indicators related to maintained in the programs of the per- satisfaction; and developing national health service quality assurance (defini- tinent countries, are as follows: public health research programs. tion of standards, monitoring health ser- vice quality, improving user satisfaction, • Intervention and action in the most • With respect to investing in institu- health technology assessment) constitute important processes for achieving re- tional capacities and infrastructure, as critical areas that should be strengthened. sults; surveillance systems aimed at was pointed out earlier, it is necessary identifying public health risks and to: improve the quality of human re- The development of human resources in threats; developing, monitoring, eval- sources; develop actions for promot- public health and, in particular, efforts uating health policies; reviewing, ing continuing education, life-long aimed at improving the quality of evaluating, and modifying the regula- education, and graduate education in human resources, also constitute a major tory framework; developing standards public health; and to train human re- challenge in ensuring the improvement and guidelines for reducing the im- sources to provide services in ways of public health in the countries of the pact of emergencies and disasters on that take into account the sociocultu- Region. health; and collaborating and estab- ral backgrounds of the users. Finally,

146 Figure 36 Performance of all Indicators of the EPHF in the Countries of the Region by quartiles

10.1 9.3 8.4 9.2 9.4 1.2

8.2 Low 9.1 6.4 2.4 7.1 6.2 5.1 5.5 8.3 8.1 8.5 6.3 4.3 4.1 10.2 11.1 Fairly Low 3.3 10.3 3.2 5.3 3.4 1.1 2.2 4.2 1.5 7.2 3.1

1.4 Fairly High 3.5 7.3 7.4 5.2 2.3 6.1 11.3 5.4 2.5 High 2.1 11.2 11.4 1.3

0.00 0.10 0.20 0.30 0.40 0.50 0.60 0.70 0.80 0.90 1.00

EPHF 1 EPHF 5 EPHF 2 EPHF 6 EPHF 9 EPHF 3 EPHF 7 EPHF 10 EPHF 4 EPHF 8 EPHF 11

147 Figure 37 Performance of all the indicators of the EPHF according to priority areas of intervention

10.1 8.4 9.2 1.2 7.1 2.4 6.2 9.1 5.1 4.1 11.1 3.2 3.4 1.1 Key processes 4.2 3.1 7.3 5.2 6.1 2.1 11.2 9.3 8.2 8.3 8.1 6.3 10.2 3.3 5.3 2.2 7.2 1.4 2.3 11.3 Capacities and infrastructure 5.4 1.3 9.4 6.4 8.5 5.5 4.3 10.3 1.5

3.5 Support to

7.4 Decentralization 2.5 11.4

0.000.10 0.200.30 0.40 0.50 0.60 0.70 0.80 0.90 1.00

EPHF 1 EPHF 5 EPHF 2 EPHF 6 EPHF 9 EPHF 3 EPHF 7 EPHF 10 EPHF 4 EPHF 8 EPHF 11

148 the primary weakness of the Region is These categories enable one to give pri- time. Although the countries have the the insufficient development of tech- ority to public health actions in the knowledge and institutional capacity to nological management and health health policy and financing debate, mak- monitor and evaluate health policies, technology assessment systems to sup- ing it possible to define health improve- these efforts are still focused on the ac- port decision-making. ment goals on the basis of the character- tions of the public sector, without taking istics of the health system, infrastructure, into account the existence and potential • The primary weaknesses with respect and institutional capacity to respond to policy contributions of other actors (the to NHA support for subnational lev- public needs, rather than on the basis of private sector, social security institu- els in the performance of public the specific health problems. tions, and others). A critical area in the health functions are enforcement of Region is the insufficient capacity of the health laws and regulations, and guar- The level of EPHF performance makes it NHA to ensure the quality of both per- anteeing and improving the quality of possible to test the effects of health poli- sonal and population-based health ser- personal and population-based health cies and programs, which helps to deter- vices; the capacity to define standards in services. mine how and why particular efforts fail order to subsequently evaluate quality is to achieve the expected level of perfor- particularly weak. Another current chal- 1.3.3 Performance Profile mance. As a result, policies and action lenge is the development of strategies According to the Action programs can be adjusted as necessary. aimed at including user satisfaction as Priorities of the World Bank key element in actions designed to im- It is also possible to use the results of prove health systems. Finally, the indicators have been re- the EPHF measurement to monitor grouped in order to make the results of and evaluate the formulation and im- Collection and dissemination of the measurement useful within the plementation of health strategies de- evidence to guide public health framework of the cooperation strategies signed to reduce poverty, particularly policies, strategies, and actions of the World Bank. This will make it those aimed at guaranteeing equitable easier to identify action priorities that access and health services quality. A critical area that must be strength- correspond to the significant gaps in the ened is defining a priority health research public health profiles of the countries in Measuring the EPHF makes it possible agenda for the countries of the Region question, as well as to identify invest- to identify the countries’ gaps in knowl- and promoting greater interaction with ment needs. The proposed categories5 edge, resources, human capital, and in- the scientific community and other actors are: stitutional capacity to respond to health capable of providing data that could challenges, making it easier to quantify support the decision-making process. 1. Development of health policies. what resources are needed to ensure an The Region is beginning to develop adequate public health infrastructure. technological management and health 2. Collection and dissemination of evi- technology assessment strategies and ac- dence to guide public health poli- Development of health policies tions that could help to improve public cies, strategies, and actions. health policies. It should also be noted The areas in need of strengthening must that many countries have not developed 3. Disease prevention and control. be seen in relation to the ability to define a systematic practice of evaluating the national health objectives in cooperation quality of information compiled by na- 4. Intersectoral intervention to improve with the actors involved in improving tional health authorities. This weakness health. health; these objectives must also be must be corrected in light of the fact consistent with decisions concerning the that changing national priorities make 5. Human resources development and structure of the health system. It is par- it necessary to continually address the building public health institutional ticularly important to point out that one need for new data with respect to dam- capacity of the most significant weaknesses is the age and risk factors, as well as with re- 5 The indicators assigned to each of these cat- lack of indicators for evaluating the spect to the use of, and access to, health egories are defined at the end of the chapter. achievement of national objectives over services. In many countries, the moni-

149 Figure 38 Performance of all the indicators of the EPHF according to priority areas of intervention Proposed by the World Bank

9.2 9.1 6.2 Public health 5.1 policy development 4.1 3.4 5.2 6.1 10.1 9.3 1.2 Collection and dissemination of 10.2 3.3 evidence for public health policy 1.1 8.4 2.4 7.1 Disease prevention 11.1 and control 7.2 3.1 2.3 2.1 3.2 4.2 Intersectoral action 7.3 11.3 9.4 8.2 6.4 5.5 Human resources development 8.3 and institutional capacity-building 8.1 8.5 6.3 4.3 10.3 5.3 2.2 1.5 1.4 3.5 7.4 5.4 2.5 11.4 1.3

0.000.10 0.200.30 0.40 0.50 0.60 0.70 0.80 0.90 1.00

EPHF 1 EPHF 5 EPHF 2 EPHF 6 EPHF 9 EPHF 3 EPHF 7 EPHF 10 EPHF 4 EPHF 8 EPHF 11

150 toring and evaluation of health status “emerging” public health functions, DemoFigureic and socioeconomic does not include analysis of risk factors, such as quality assurance, developing features of the countries. These vari- which are important variables for new strategies designed to improve public ables are understood to be independent diseases and for identifying trends in access to health services, and providing of the performance of public health and current priority epidemiological prob- support to subnational levels in order to may be determinants of the results ex- lems. Particular weakness was noted in increase health promotion and social hibited by the countries in this meas- the areas of mental health, risk factors participation in health. As was men- urement. for chronic diseases, and occupational tioned earlier, the majority of the coun- health, among others. tries generally exhibit low performance • Population with regard to developing public health • Rural population percentage Disease prevention and control human resources, which constitutes a • Per capita gross domestic product serious obstacle to improving the EPHF It is important to point out that short- in the Region. • Population income equity: 20% higher comings were observed in more than income/20% lower income half of the participating countries in the • Total per capita health expenditure integrity of the sources of information for 1.4 Initial Exploratory disease prevention and control. The data Analysis of the Country organization. This refers par- continue to focus on the public sector, Performance of the EPHF ticularly to how the governments and despite the growing role of the private and Their Relationship to health systems are organized. sector (nonprofit and for-profit) in de- Other Indicators livering services and the fact that this • Federal states/unitary states information must therefore be included An initial exploratory analysis of the re- • Type of health system: integrated pub- in order to monitor public health lationship between the performance of lic, mixed regulated, and segmented. threats. With regard to new areas of de- the essential public health functions, and velopment, the principal deficiencies some relevant characteristics of the par- Health and quality-of-life outcome were observed in the monitoring of ticipating countries, are provided below. indicators. These are variables that can threats to mental health, threats deriving be influenced by the performance of the from the work environment, and chronic Although not the primary purpose of public health functions. disease or risk factors for chronic disease. this evaluation, it is interesting to ana- With regard to the health services, it is lyze the performance of the EPHF in • Infant mortality troubling that evaluations of public ac- relation to some of the indicators in cess to services are barely used to correct • Maternal mortality order to determine whether differences policies and plans aimed at improving • Mortality due to infectious diseases exist between the EPHF profiles associ- the ability of poorly-served populations ated with these variables. • Life expectancy at birth to access services. In the majority of the • Human development index countries, the NHA addresses priorities It is important to note that this analysis through direct actions aimed at correct- only attempts to show that such relation- In the analysis presented below, the me- ing the gaps in the populations at great- ships exist; it does not attempt to explain dian performance of the various country est risk, and less effort is made to en- the observed relationships, let alone es- groups has been used as a measure of the courage other pertinent actors to tablish cause-and-effect, since such ef- overall performance of the EPHF for assume their roles and responsibilities forts would go beyond the purpose of purposes of evaluating performance.6 with regard to this problem. this evaluation. However, it is hoped that new lines of research based on the results Human resources development and given below will make it possible to building institutional capacity achieve advances in this regard. 6 The countries of the Region have been In this area, it is necessary to strengthen grouped by quartiles and terciles in order to institutional capacity for performing The chosen indicators are as follows: analyze groups with more or less indicators.

151 1.4.1 The EPHF Figure 39 Performance of the EPHF according to Population and the demoFigureic and Size of the Countries of the Region socioeconomic features of the countries 0.8 Smaller population Larger population The EPHF and the population 0.7 A comparison of the performance of 0.6 each essential function for groups of 0.5 countries with smaller populations (fewer than 120,000 inhabitants) and 0.4 groups of countries with larger popula- 0.3 tions (more than 10 million inhabitants) reveals a generally similar performance 0.2 profile. For EPHF 3 (health promotion), 0.1 EPHF 5 (policies and management in 0 public health), EPHF 8 (HR develop- EPHF EPHF EPHF EPHF EPHF EPHF EPHF EPHF EPHF EPHF EPHF ment), and EPHF 11 (disaster reduc- 1 2 3 4 5 6 7 8 9 10 11 tion), the smaller countries generally per- formed slightly better than the larger countries. The opposite situation was ob- countries. The previous is confirmed by than the remaining groups, as shown served for the remaining functions, with the fact that a positive correlation exists below (see Figure 41). the exception of EPHF 9 (quality assur- between the performance of this func- ance) and EPHF 7 (equitable access), for tion and the educational level of the In view of the above, it is important to which performance was very similar. population, because the small countries keep in mind that results are more dif- of the Caribbean also have the highest ficult to achieve in countries with larger Upon analyzing the performance of literacy rates. rural populations, and that the drop-off EPHF 87 by population quartiles, an in- point occurs at a rural population of ap- verse relationship is observed between The EPHF and the rural population proximately 25% (the last quartile). population and EPHF performance, al- percentage though this is not the case for the third The EPHF and per capita gross An analysis of performance of the quartile (countries with population be- domestic product EPHF in the countries grouped accord- tween 2 and 10 million inhabitants). ing to rural population percentage indi- The EPHF performance profile of Leaving this fact aside, it may be stated cates that, for all of the functions (ex- groups with greater per capita GDP that potentially better performance of cept EPHF 11), the median score of the (higher than US$8,400) as compared to this function depends upon the size of group with the smaller rural population groups with lower per capita GDP (up the country. In general, the most (less than 25%) is significantly higher to US$3,800) is heterogeneous. EPHF geoFigureically concentrated countries— than that of the group with the highest 7 and, to a lesser extent, EPHF 9 and which, for purposes of this analysis, are rural population (more than 53%), as 11 correlate positively with expendi- the smaller countries of the Caribbean— shown in Figure 40. ture; in other words, the group with the could achieve better performance in highest per capita expenditure level also human resources development, because If the performance of the countries is exhibits better performance of these the necessary investment for achieving analyzed in terms of rural population functions. On the other hand, the op- this end is much smaller than in larger percentage quartiles, it can generally be posite is true for EPHF 4 and, with in- stated that the group of countries with significant differences, for EPHF 1, 5, 7 The EPHF for which the two groups ex- the smallest rural population exhibits a 6, 8 and 10. The two groups exhibit vir- hibit the greatest difference. significantly better performance profile tually no difference for EPHF 2 and 3.

152 poorest quartile clearly stands out from Figure 40 Performance of the EPHF according to Percentage the other groups, which indicates that of Rural Population in the Countries of the Region performance of this function improves 0.8 as per capita gross domestic product Smaller rural population Larger rural population increases. This confirms what was in- 0.7 dicated earlier, since the international 0.6 cooperation organizations focus their interventions on the poorest countries 0.5 of the world. 0.4 On the other hand, the opposite holds 0.3 for equitable access to health services

0.2 (EPHF 7), with regard to which the richest group exhibits the best perfor- 0.1 mance. This partially reflects the popula-

0 tion’s generally higher standard of living. EPHF EPHF EPHF EPHF EPHF EPHF EPHF EPHF EPHF EPHF EPHF As a result, the users are more demand- 1 2 3 4 5 6 7 8 9 10 11 ing, probably require the health author- ity to make a greater commitment to this fundamentally important task, and also The fact that the poorest group of particularly in health, and they were have greater resources for health. countries exhibited better performance often supported by nongovernmental with regard to social participation in organizations and international cooper- The poorest group of countries exhibits health (EPHF 4) is consistent with the ation programs. a slightly higher average than the quar- significant efforts and achievements of tile that follows it, despite the variability the governments of these countries. The following table (Figure 43) shows of the results exhibited by this group. These efforts were aimed at promoting the EPHF profile of the participating This could partially reflect the efforts of generally greater public participation, countries, grouped by quartiles. The multilateral agencies in recent decades, which have invested in projects aimed at improving public access to health ser- vices, particularly for the poor. Figure 41 Performance of the EPHF according to the Quartiles of Rurality of the Countries of the Region The EPHF and Income Distribution Equity 1.0 1.0 The coefficient separating the income .9 .9 of the richest 20% from that of the .8 .8 .7 .7 poorest 20% was used as an indicator .6 .6 for this analysis, both because it is an .5 .5 internationally accepted measure of in- .4 .4 come equity and because this informa- .3 .3 tion was available in the majority of the .2 .2 countries of the Region. .1 .1 EPHF 6 0.0 EPHF 10 0.0 A comparison of the EPHF perfor- I II III IV I II III IV mance of countries with lower income Rurality (quartiles) Rurality (quartiles) distribution equity to the EPHF per- formance of countries with greater in-

153 The EPHF and total health Figure 42 Performance of the EPHF According to GDP expenditure Per Capita An analysis of the relationship between 0.8 Larger per capita GDP Greater per capita GDP performance of the EPHF and total per 0.7 capita health expenditure reveals that the average performance of the group of 0.6 countries with higher health expendi- 0.5 tures is generally better than that of the group of countries with lower expendi- 0.4 tures (see Figure 45). 0.3 The greatest difference between the two 0.2 groups was observed with respect to per- 0.1 formance of EPHF 7 (promotion of eq- uitable access to health services). This is 0 EPHF EPHF EPHF EPHF EPHF EPHF EPHF EPHF EPHF EPHF EPHF reasonable given that countries that in- 1 2 3 4 5 6 7 8 9 10 11 vest more in health invest more in health services that meet public demands. It is therefore to be expected that better per- come distribution equity8 reveals better in the fourth quartile, which comprises formance was observed in countries with performance by the group with lower the countries with the lowest equity in higher health expenditures. The situa- equity (except for EPHF 11). Consider- the Region. tion with respect to EPHF 10 (public ing that the health systems, particularly health research) is similar, probably be- the public health system, should give This finding makes it possible to state cause countries with greater health re- first priority to serving groups at great- (or at least not to discount) that coun- sources are also able to invest in research. est health risk, and that poverty as a re- tries with larger at-risk populations have This does not occur in the countries in sult of income inequity is an important carried out greater efforts in the area of which health expenditures are more re- public health risk factor, it may be con- public health. stricted, where allocation priorities are cluded that the countries’ performance surely oriented primarily toward at- (particularly that of the State) has been tempting to solve basic problems of pub- heading in the right direction with re- Figure 43 Performance of the EPHF 4 According to GDP lic access to health services. gard to the public health functions. Per Capita In particular, an analysis of the average An analysis of various EPHF perfor- 1.0 performance of EPHF 7 by the coun- mance profiles for the countries of the .9 tries grouped in quartiles according to Region grouped according to quartiles .8 health expenditure indicates a positive of income distribution equity always in- .7 correlation between higher expenditure dicates that countries tend to exhibit .6 and better performance in the first three .5 better performance if they have lower quartiles; the correlation is lower for .4 income distribution equity, particularly the group with the most resources for .3 .2 health. These observations coincide .1 with other studies on health variables 8 It is important to note that the comparison 0.0 that have demonstrated that perfor- is of countries within the Region, which I II III IV mance increases significantly up to a means that the description “greater equity” might not apply if the indicator were evalu- GDP per capita (quartiles) certain level of expenditure, but that re- ated with respect to the entire world. sults do not improve beyond this level

154 Figure 44 Performance of the EPHF According to Levels of Figure 46 Performance of Equity in Income Distribution in the Countries of EPHF 7 according to Total Per the Region Capita Expenditure in Health in Participating Countries 0.8 Greater income distribution equity Lower income distribution equity 1.0 0.7 .9

0.6 .8 .7 0.5 .6 .5 0.4 .4 0.3 .3 .2 0.2 .1 0.1 0.0 I II III IV 0 Per capita health expenditures EPHF EPHF EPHF EPHF EPHF EPHF EPHF EPHF EPHF EPHF EPHF (quartiles) 1 2 3 4 5 6 7 8 9 10 11

merely through an increase in expendi- dicates that performance of this func- vations for per capita gross domestic tures (Figure 46). tion is not necessarily associated with product. the availability of resources. As a result, The opposite situation was observed countries with fewer health resources 1.4.2 The EPHF and country with respect to performance of EPHF 4 could obtain better results in this area if organization (social participation in health). This in- desired. The same is true for the obser- The EPHF and type of government organization Figure 45 Performance of the EPHF According to Total Per Capita Expenditure in Health in the Countries of It is interesting to evaluate the differ- the Region ences in the EPHF performance profiles of unitary countries and compare them 0.8 Lower health expenditure Higher health expenditure with those of federal countries, as 0.7 shown in Figure 47.

0.6 In general, the performance profile of 0.5 the federal countries is higher than that of the unitary countries for all of the 0.4 functions. The greatest differences were 0.3 observed with respect to EPHF 1, 2, 3, 4, 5, 6, 7 and 10, the performance of 0.2 which require significant institutional 0.1 capacity, both in terms of infrastructure and organizational development. To 0 EPHF EPHF EPHF EPHF EPHF EPHF EPHF EPHF EPHF EPHF EPHF some extent, these results are in accord 1 2 3 4 5 6 7 8 9 10 11 with the situation concerning other gov- ernmental institutions, which, as a result

155 This assertion is consistent with the re- Figure 47 Performance of EPHF in Unitarian and Federal sults exhibited for overall performance Countries of the public health functions, pre- 0.9 sented previously, which indicated the Unitarian Federal existence of several more traditional 0.8 models of public health management 0.7 that assign a major role to the central 0.6 health authority.

0.5 In light of this evidence, it is necessary 0.4 to review how public health perform-

0.3 ance has been affected in greater depth, particularly in connection with health 0.2 system reforms currently being imple- 0.1 mented in the Region emphasizing

0 mixed systems (public-private) under EPHF EPHF EPHF EPHF EPHF EPHF EPHF EPHF EPHF EPHF EPHF which the State plays a primarily regu- 1 2 3 4 5 6 7 8 9 10 11 latory role.

It is well known that the separation of federal organization into states, re- EPHF 2) in countries with integrated of the health functions, with the health quire greater institutional development public systems than in countries with authority being made responsible for at the decentralized level in view of in- other health systems. The regulated mixed regulating and supervising the good per- sufficient capacities at the central level. system exhibits the poorest performance formance of the other actors in the (with the exception of EPHF 11). health system (insurance and service EPHF 8 and EPHF 9 do not show sig- nificant differences, which may reflect the generally poor development of this function throughout the Region regard- Figure 48 Performance of the EPHF According to Type of less of this variable. Although federal Health System of the Countries countries have greater public health in- stitutional capacities, the areas of public 0.8 health human resources and quality as- Integrated Regulated Segmented 0.7 public system mixed system system surance are still in need of development. 0.6 The EPHF and the type 0.5 of health system 0.4 The health systems of the countries of the Region have been grouped into the 0.3 following categories (defined by PAHO) 0.2 according to their similarity: 1) inte- grated public system, 2) regulated mixed 0.1 system, and 3) segmented system. 0 EPHF EPHF EPHF EPHF EPHF EPHF EPHF EPHF EPHF EPHF EPHF In general, performance of the EPHF 1 2 3 4 5 6 7 8 9 10 11 is better (or very similar in the case of

156 gion. This may be explained by the Figure 49 Performance of EPHF 1, 7 and 8 according to type greater weakness of the health authority of Health System of the Countries under this type of system, since the 1.0 1.0 health authority is responsible for devel- .9 .9 oping standards, accrediting service .8 .8 providers, and evaluating the quality of .7 .7 services provided. If some of the public .6 .6 health functions for this group had to be .5 .5 prioritized, EPHF 9 should probably be .4 .4 a priority. The greater dispersion in the .3 .3 performance of this function in coun- .2 .2 tries with regulated mixed health systems .1 .1 should be studied in greater depth in EPHF 7 EPHF 1 0.0 0.0 123 1 2 3 order to obtain useful data with respect Type of health system Type of health system to the better-performing countries.

1.0 The EPHF and the health and .9 quality-of-life outcome indicators .8 Several health and quality-of-life indi- .7 cators that are frequently available for .6 all of the countries of the Region have .5 been selected. .4 .3 .2 Given that health outcomes (specifically .1 any of the indicators used in this analy-

EPHF 8 0.0 sis) have many causes, it is not our in- 123 Type of health system Figure 50 Performance of Note: 1) integrated public system, 2) regulated mixed system and 3) segmented system EPHF 9 According to the Level of Infant Mortality 1.0 .9 providers), has been a difficult process health institutional capacities. In the .8 that is still very far from achieving opti- case of EPHF 7 (promotion of equitable .7 .6 mal performance, a factor which, in this access to health services), great disper- .5 case, also affects public health perfor- sion is exhibited in the performance of .4 mance. This finding applies to both “tra- the countries with mixed regulated .3 ditional” functions (such as EPHF 1, health systems, indicating the variability .2 monitoring health status) and other of an area that has been an emphasis in .1 functions. The low performance of the reform efforts (see Figure 49). 0.0 regulated mixed group is particularly sig- I II III IV nificant with respect to EPHF 8 (human On the other hand, the performance of Infant mortality (quartiles) resources development), a fact that un- EPHF 9 (quality assurance) is lower in Note: infant mortality is lower in quartile doubtedly affects—or will affect—the the group of countries with segmented 1 and higher in quartile 4. possibility of further developing public health systems than in the rest of the Re-

157 The EPHF and maternal mortality Figure 51 Performance of EPHF 7 and 9 According to Level of Maternal Mortality The relationship between performance of EPHF 7 and 9 and the maternal 1.0 1.0 mortality rate is found to be very simi- .9 .9 lar to the relationship observed for the .8 .8 previous indicator, although with less .7 .7 significant differences (see Figure 52). .6 .6 .5 .5 This same profile is also exhibited with .4 .4 regard to performance of EPHF 11 (dis- .3 .3 aster reduction). .2 .2 .1 .1 The EPHF and mortality due to EPHF 9 EPHF 7 0.0 0.0 infectious diseases I II III IV I II III IV Maternal mortality (quartiles) Maternal mortality (quartiles) An analysis of the EPHF performance profile in relation to mortality due to Note: maternal mortality is lower in quartile 1 and higher in quartile 4. infectious diseases indicates that per- formance of the public health functions is generally better (except for EPHF 3 tention to state here that better or worse tions and this indicator. This underlines and 10) in the group of countries with performance of the essential functions the importance of improving the per- a lower mortality rate (less than 41.8 necessarily causes a health outcome, al- formance of these functions, particu- per 100,000 people) than in the group though it can indeed influence it. Con- larly quality assurance in health services, with a higher mortality rate (greater sequently, this part of the analysis will which is performed at an insufficient than 82), as shown in the following consider the characteristics of particular level throughout the Region. table (Figure 53). functions with respect to these indica- tors, selecting those EPHF for which significant differences are observed. Figure 52 Performance of EPHF According to the Level of Mortality Due to Infectious Diseases The EPHF and infant mortality The average performance of EPHF 7 0.8 Mayor mortalidad Menor mortalidad (promotion of equitable access) and 0.7 EPHF 9 (quality assurance) presents an inverse correlation with the countries 0.6 grouped into quartiles. The countries 0.5 with lower infant mortality rates (less than 12.8 per 1,000 live births) exhibit 0.4 better relative performance of both 0.3 functions than countries with higher in- fant mortality rates (greater than 23.5 0.2 per 1,000 live births), as shown in Fig- 0.1 ure 51. Although infant mortality is af- 0 fected by a number of factors, it is pos- EPHF EPHF EPHF EPHF EPHF EPHF EPHF EPHF EPHF EPHF EPHF sible to state that a relationship exists 1 2 3 4 5 6 7 8 9 10 11 between the performance of these func-

158 pacity to do so (training centers, human Figure 53 Performance of EPHF 8 and 10 According to the and financial resources for research, Level of Life Expectancy at Birth in the Countries etc.). The differences are accentuated in of the Region quartile 4, which comprises the coun- 1.0 1.0 tries with the highest life expectancy .9 .9 rates in the Region. .8 .8 .7 .7 The EPHF and the Human .6 .6 Development Index .5 .5 .4 .4 The Human Development Index (HDI) .3 .3 is another measure of a country’s devel- .2 .2 opment. This indicator is derived from .1 .1 the simple average of three indicators EPHF 10 EPHF 8 0.0 0.0 of the country’s success in securing the I II III IV I II III IV health and longevity of its population Life expectancy at birth Life expectancy at birth (measured by life expectancy and infant (quartiles) (quartiles) mortality rates), education (measured by adult educational level), and standard of living (measured by per capita gross do- Again, the greatest differences are ob- flection of their overall level of develop- mestic product, adjusted for purchasing served in the performance of EPHF 7 ment, because more developed coun- power parity). This indicator shows how and 9. tries generally invest more in these areas far the countries of the Region are from of public health, given that they have achieving the following goals: 1) life ex- The EPHF and life expectancy the infrastructure and institutional ca- pectancy of 85 years, 2) 100% adult lit- at birth An analysis of the EPHF performance profile in relation to life expectancy at Figure 54 Performance of the EPHF in Relation to the Level birth reveals a positive correlation in the of Human Development in the Countries case of EPHF 7 and 9. This confirms of the Region the conclusions already found with re- spect to infant mortality and infectious 0.8 Lower HDI Higher HDI diseases, given that life expectancy in 0.7 the Region is strongly determined by the infant mortality rate, especially for 0.6 children under one year of age. 0.5

A positive correlation is also found with 0.4 respect to other public health functions, 0.3 a fact that is more of an expression of the overall development of the coun- 0.2 tries. Thus, the better performance of 0.1 EPHF 8 (human resources develop- 0 ment) and EPHF 10 (public health re- EPHF EPHF EPHF EPHF EPHF EPHF EPHF EPHF EPHF EPHF EPHF search) associated with countries with 1 2 3 4 5 6 7 8 9 10 11 greater life expectancy rates may be a re-

159 least makes it possible to infer that their Figure 55 Performance EPHF 7 and 9 According to the Level performance is affected by other exter- of Human Development in the Countries of the nal factors. Region

1.0 1.0 However, a positive correlation is ob- .9 .9 served for EPHF 7, 9 and 10; that is, the .8 .8 higher the HDI, the better the perform- .7 .7 ance of these functions. As shown in the .6 .6 following table (Figure 56), in the case .5 .5 of EPHF 7 (promotion of equitable ac- .4 .4 cess to services), the countries in the first .3 .3 tercil, with HDI below 0.72, exhibit the .2 .2 lowest performance; and in the case of .1 .1 EPHF 9 (health quality assurance), each EPHF 7 0.0 EPHF 9 0.0 1 23 123 tercil shows sustained improvement in Human development index Human development index direct proportion to higher HDI. (terciles) (terciles) 1.5 Correlations between functions eracy, and 3) real per capita GDP of way affect the level of development of US$40,000. the health authority and, accordingly, Correlations between the performance the possibility that it will exhibit good scores of the different EPHF in the par- 9 The relationship between the EPHF performance of the EPHF. ticipating countries were also analyzed. and the HDI exhibits two phenomena This analysis revealed a high correlation that are difficult to differentiate: a) on As shown in the table 54, the EPHF between the various functions (Figure the one hand, the inclusion of health performance profile for the majority of 56), with the exception of EPHF 11 outcome indicators (life expectancies) the functions is relatively similar for the (reducing the impact of disasters), could enable one to state that perfor- quartile with the lowest HDI as com- whose performance profile exhibits a mance of the EPHF might contribute pared to the group with the highest very low and insignificant correlation to better results for these indicators, and HDI. For some functions, such as 9 Using the Pearson correlation method, 2) the HDI, as a summary measure of a health promotion and social participa- which is briefly explained at the end of the country’s development, might in some tion, the profile is inverted, which at chapter.

Figure 56 Correlations between performance scores of EPHF

EPHF 1 EPHF 2 EPHF 3 EPHF 4 EPHF 5 EPHF 6 EPHF7 EPHF 8 EPHF 9 EPHF 10 EPHF 11

EPHF 1 0.733 0.502 0.500 0.512 0.609 0.476 0.475 0.496 0.622 0.036 EPHF 2 0.733 0.559 0.608 0.577 0.599 0.360 0.478 0.436 0.350 0.146 EPHF 3 0.502 0.559 0.662 0.670 0.511 0.676 0.668 0.523 0.372 0.049 EPHF4 0.500 0.608 0.662 0.663 0.663 0.640 0.703 0.650 0.367 0.161 EPHF 5 0.512 0.577 0.670 0.663 0.702 0.532 0.611 0.524 0.393 0.169 EPHF 6 0.609 0.599 0.511 0.663 0.702 0.407 0.614 0.637 0.449 0.120 EPHF 7 0.476 0.360 0.676 0.640 0.532 0.407 0.626 0.553 0.430 0.262 EPHF 8 0.475 0.478 0.668 0.703 0.611 0.614 0.626 0.589 0.352 0.194 EPHF 9 0.496 0.436 0.523 0.650 0.524 0.637 0.553 0.589 0.345 0.242 EPHF 10 0.622 0.350 0.372 0.367 0.393 0.449 0.430 0.352 0.345 0.157 EPHF 11 0.036 0.146 0.049 0.161 0.169 0.120 0.262 0.194 0.242 0.157

160 Figure 57 Main Summary and Dispersion Measures of the EPHF in the Countries of the Region

EPHF 1 EPHF 2 EPHF 3 EPHF 4 EPHF 5 EPHF 6 EPHF 7 EPHF 8 EPHF 9 EPHF 10 EPHF 11 Number of countries 41 41 41 41 41 41 41 41 41 41 41 Average 0.58 0.63 0.52 0.48 0.56 0.46 0.55 0.38 0.26 0.42 0.68 Median 0.57 0.63 0.54 0.46 0.53 0.44 0.56 0.36 0.21 0.35 0.71 Standard education 0.17 0.17 0.19 0.20 0.18 0.18 0.25 0.20 0.21 0.23 0.19 25th percentile 0.46 0.52 0.41 0.33 0.49 0.34 0.33 0.21 0.08 0.24 0.54 75th percentile 0.64 0.75 0.64 0.60 0.70 0.56 0.73 0.51 0.39 0.54 0.87

Note: A very high correlation is defined as p < 0.01 (dark blue) and a high correlation as p < 0.05 (light blue)

with the remaining functions. EPHF 10 proving their performance and promot- dor, Guatemala, Haiti, Honduras, Ni- (public health research) only exhibits a ing greater access to health services. caragua, Panama, Puerto Rico, and the significant correlation with EPHF 1 Dominican Republic are presented below. (monitoring of health status). 2. Subregional Analysis The overall performance of the coun- tries of the Region with respect to the The most notable of the observed cor- To compliment to the Regional analysis, EPHF is shown in the following table relations was the strong correlation be- the following presents the results of the summarizing the average performance tween performance of EPHF 5 (policies measurement by subregions: Central of the Region (Figure 1). This average and management in health) and the America, Caribbean, Andean Countries, was chosen as a summary measure in vast majority of the other functions, and Southern Cone and Mexico. The cri- order to eliminate the influence of the particularly EPHF 3 (health promo- teria used in these groupings are based on extreme scores on the small number of tion) and EPHF 6 (strengthening of in- the one hand on facilitating the possibil- observations for the nine countries. stitutional capacity for regulation and ity of future strategies and collaboration enforcement). This confirms the impor- among countries; for example, countries In general, a relatively good perform- tance of concentrating more efforts on that have agreements or previous coop- ance profile was observed for the func- improving the critical areas that pertain eration activities, such as the Health tions of public health surveillance to this function throughout the Region. Services Network of Central America (EPHF 2) and reducing the impact of (RESSCAD), The Andean Pact and One fundamental responsibility of the emergencies and disasters (EPHF 11). MERCOSUR. On the other hand the health authority is ensuring access to the criteria of grouping countries based on health services, particularly for the need- Lower performance was observed for traits or common characteristics as iest sectors of the population. The high the functions of quality assurance in the in the case of putting Mexico with the correlation between performance of this health services (EPHF 9) and human Southern Cone countries, Belize with the function and other so-called “emerging” resources development in public health Caribbean and Cuba with Central Amer- functions (health promotion, social par- (EPHF 8). ica. These criteria were used with the per- ticipation in health, quality assurance in spective of identifying or developing co- health services) leads to the conclusion High-intermediate performance was ex- operation strategies between countries. that, at present, strengthening these new hibited with respect to: monitoring, public health functions is of fundamen- evaluation, and analysis of health status tal importance in promoting equitable 2.1 Central America, Spanish- (EPHF 1); promotion of equitable ac- access to health services. Furthermore, speaking Caribbean and Haiti cess to necessary health services (EPHF the correlation between this function 7); social participation in health (EPHF 2.1.1 General results of the and EPHF 8 (human resources develop- 4); development of policies and institu- measurement ment) obliges the participating coun- tional capacity for planning and man- tries to continue their efforts to develop The results of the measurement in the agement in public health (EPHF 5); these resources as an essential step in im- countries of Costa Rica, Cuba, El Salva- and strengthening of institutional ca- 161 Figure 58 Performance of the EPHF in the subregion of Central America, Spanish-speaking Caribbean and Haiti

1.00

0.90

0.80 0.73 0.70 0.67 0.62 0.60 0.60 0.53 0.51 0.50 0.46 0.49 0.43 0.40 0.36 0.30 0.20 0.20

0.10

0.00 EPHF1 EPHF2 EPHF3 EPHF4 EPHF5 EPHF6 EPHF7 EPHF8 EPHF9 EPHF10 EPHF11

pacity for regulation and enforcement If one studies the variability of the re- all functions—the countries of the sub- in public health (EPHF 6). sults (Figure 58), one can see that EPHF region10 exhibited good performance in 9 (quality assurance)—exhibits the low- some areas and relatively poor perfor- Low-intermediate performance was ex- est performance, as well as EPHF 8 mance in other, more critical areas, hibited with respect to health promo- (human resources development) reflect- which vary from country to country. tion (EPHF 3) and public health re- ing a weakness throughout the coun- search (EPHF 10). tries of the subregion. The results for EPHF 11 (reducing the impact of emergencies and disasters) re- In general, the profile of the EPHF for On the other hand, while EPHF 10 vealed relatively good performance and Central America reveals relatively better (public health research) is a weakness low variability, indicating that this is an performance of functions that may be for the subregion as a whole, its greater area of overall strength for the subregion. considered part of the “tradition” of dispersion indicates that it is a strength public health development (EPHF 2 for several countries. Similarly, some On the other hand, the results for EPHF and 11) and poorer performance of countries exhibited adequate perfor- 8 (human resources development) and emerging functions (EPHF 9). mance with respect to EPHF 5 (policies EPHF 9 (quality assurance in the health and management in public health) and services) revealed relatively poor per- A noteworthy area of concern is the low EPHF 7 (equitable access to health formance and low variability, indicating performance exhibited with respect to services), while the performance of that this is an area of weakness for all of human resources development (EPHF other countries indicates that these the countries. 8). This is very important to take into functions are critical areas that require The results for some functions revealed account, because the future improve- intervention. intermediate performance and low vari- ment of public health in the Region de- ability, such as EPHF 4 (social partici- pends on developing the competencies An analysis of the EPHF performance of human resources, which are the profile for the countries indicates that— 10 Hereafter, ‘the subregion’ refers to Central foundation of the institutional strength with the exception of one country that America and the countries previously men- of the NHA. exhibited generally good performance of tioned.

162 functions related to health system fi- Figure 59 Distribution of the Performance of each nancing and regulation, it is important EPHF in the subregion of Central America, to establish clear guidelines with regard Spanish-speaking Caribbean and Haiti. to collecting and evaluating the quality Central America of information, and to evaluate the true 1.0 usefulness of that information in the decision-making process. In the major- .8 ity of the countries, there are no clear guidelines or criteria requiring that the

.6 quality of information be evaluated at the various levels of health authority ac- tion or at the level of service providers. .4 It is also important to point out that, de- .2 spite the fact that the countries of the Region have indicated that they are deeply concerned about improving equi- 0.0 table access to health services, the great- EPHF_1 EPHF_3 EPHF_5 EPHF_7 EPHF_9 EPHF_11 EPHF_2 EPHF_4 EPHF_6 EPHF_8 EPHF_10 est weakness of the information systems lies precisely in their ability to systemat- ically evaluate the distribution of access to health services, particularly for the pation in the health) and EPHF 6 (reg- of 0.64 for the subregion, is fundamen- most disadvantaged. ulation and enforcement). tal to enabling the health authorities to make decisions related to national Another weakness that should be ad- Finally, the results for EPHF 5 (policies health policy priorities on the basis of dressed is the limited coordination be- and management in public health) and solid information. Although the results tween the management of monitoring EPHF 7 (promotion of equitable access for this function revealed high-inter- systems and the management of na- to health services) revealed the highest mediate performance, the countries of tional statistics systems, which is essen- variability among the countries, sug- the subregion exhibited some common tial to measuring health status from an gesting the possibility that countries weaknesses. intersectoral perspective. which have achieved more progress in these areas might cooperate with coun- First of all, it must be pointed out that In addition, in view of the increasingly tries for which these areas are significant the countries have not established the important role of people in caring for weaknesses. practice of systematically evaluating the their own health and the increasingly quality of the information that is gath- important role of public participation 2.1.2 Analysis of the results ered by the national health authorities. in the health policy decision-making for each EPHF It is very important that this weakness process, it is vital to strengthen the abil- be corrected, given that changing na- ity to adequately communicate the re- The results for each of the essential tional priorities make it necessary to sults of health status monitoring to the public health functions in the subregion continually gather new data on public various actors in society and the general are analyzed in detail below. health threats and risk factors, as well as public. data on how the health services are used EPHF 1: Monitoring, evaluation, and accessed. However, in view of the Generally speaking, significant weak- and analysis of health status fact that reform processes demand an nesses were not observed in the knowl- The relatively good performance exhib- increasingly clear separation between edge and skills of human resources that ited for EPHF 1, with an average score functions related to service delivery and monitor and analyze health status, even

163 As with EPHF 1, deficiencies were noted Figure 60 Performance of the Indicators for EPHF 1 in the in the evaluation of the quality of infor- subregion of Central America, Spanish-speaking mation gathered through surveillance Caribbean and Haiti. programs. This area must be improved in 1.00 order to ensure that the population is 0.94 protected against known threats or 0.90 0.83 emerging diseases. It also is important to 0.80 point out that deficiencies in the in- 0.70 0.62 0.58 tegrity of information sources were ob- 0.60 served in some countries, information 0.50 sources that are still centralized in the 0.40 public health system, despite the increas-

0.30 0.26 ing role of the private sector, both non- profit and for-profit service providers, re- 0.20 sulting in deficiencies in the information 0.10 needed to monitor public health threats. 0.00 12345 The primary deficiencies with regard to Indicators new areas of development were observed in the training of teams responsible for monitoring the collection and analysis of at intermediate levels, which indicates EPHF 2: Public health surveillance, data on mental health threats, threats de- good performance of this indicator (In- research, and control of risks and threats riving from work environments and dis- dicator 3). Although the countries have to public health eases, or risk factors for chronic diseases. been addressing the issue of computer The countries of the subregion exhib- support through various initiatives in With regard to surveillance system ited their best performance with respect recent years (Indicator 4), the greatest management, it should be noted that to EPHF 2, with a score of 0.74. Never- weaknesses were inadequate computer deficiencies were observed in the coor- theless, it is possible to identify some equipment and information technology dination of public health laboratory areas that should be strengthened in at the local level, and deficiencies in networks at the national and interna- order to adapt the good performance of equipment maintenance at all levels. tional levels. Finally, there is a lack of a “traditional” function by the public incentive programs aimed at promoting health systems to the current epidemio- Indicators: the performance of the teams responsi- logical outlook and the future of public 1. Guidelines and processes for moni- ble for public health surveillance and health in general. toring health status protection, particularly in view of the threats likely to be controlled by these 2. Evaluation of the quality of informa- The greatest dispersion of the results for warning systems. tion this EPHF was noted in the indicators designed to evaluate the capacity for Indicators: timely response to control public health 3. Expert support and resources for 1. Surveillance system to identify threats threats. Given the importance of this ca- monitoring health status and harm to public health pacity, without which efforts to gather 4. Technical support for monitoring information and perform research on 2. Capacities and expertise in public and evaluating health status public health risks and threats would be health surveillance meaningless, it must be emphasized that 5. Technical assistance and support to efforts to strengthen surveillance must 3. Capacity of public health laborato- the sub national levels of public health be concentrated in this area. ries

164 Given the importance of the communi- Figure 61 Performance of the Indicators for EPHF 2 in the cations media and public education in subregion of Central America, Spanish-speaking improving public health, it is important Caribbean and Haiti to note that the measurement revealed 1.00 weakness in assessing the impact of 0.90 0.87 these sectors on public health, which is 0.83 0.83 essential to decision-making in this area. 0.80 0.71 0.70 Although all of the countries have ac-

0.60 0.53 cepted the recommendations of world 0.50 conferences with regard to health pro-

0.40 motion, one of the Region’s major weaknesses is related to one of these 0.30 recommendations: the importance of 0.20 orienting personal health services to- 0.10 ward health promotion. Virtually none 0.00 of the countries stated that they have 12345 clear incentives aimed at orienting ser- Indicators vices toward health promotion.

Finally, it is important to note that the countries of the Region have not devel- 4. Capacity for timely and effective re- housing, public works, and transporta- oped plans to encourage health promo- sponse to control public health tion must be strengthened, particularly tion at the subnational levels in which problems with regard to evaluating the health ef- the ministries of health play a central fects of such policies. role. 5. Technical assistance and support for the subnational levels of public health. Figure 62 Performance of the Indicators for EPHF 3 in the subregion of Central America, Spanish-speaking EPHF 3: Health promotion Caribbean and Haiti The results for this EPHF were clearly 1.00 more heterogeneous, with some coun- 0.90 tries exhibiting greater development with regard to health promotion than 0.80 others. In general, weaknesses were ob- 0.70 0.61 served in the following areas. 0.60 0.53 0.50 0.45 0.45 First of all, a limited participation of the 0.42 0.40 health authorities in designing public policies that have an acknowledged im- 0.30 pact on public health. Although inter- 0.20 sectoral commissions aimed at develop- 0.10 ing health promotion programs do 0.00 generally exist, systematic efforts on the 12345 part of the health sector to influence Indicators policy in sectors such as education,

165 Indicators: Figure 63 Performance of the Indicators for EPHF 4 in the 1. Support for health promotion activ- subregion of Central America, Spanish-speaking ities, the development of norms, and Caribbean and Haiti interventions to promote healthy be- 1.00 haviors and environments 0.90 0.80

2. Building of sectoral and extrasectoral 0.70 partnerships for health promotion 0.57 0.60 0.53 0.50 3. National planning and coordination 0.38 of information, education, and social 0.40 communication strategies for health 0.30 promotion 0.20

0.10 4. Reorientation of the health services 0.00 toward health promotion 123 Indicators 5. Technical assistance and support to the subnational levels to strengthen health promotion activities. Finally, NHA support to the decentral- ate these results keeping in mind that at ized levels in the performance of this least two of them are currently involved EPHF 4. Social participation in health function is the lowest performing indi- in health system reform processes mark- The countries of the Region exhibited cator. Given that the best place to es- ing a milestone in the formulation of intermediate performance of this func- tablish contact between the public and new health laws. These reform processes tion as well, but significant variations the health system is at the local level, tend to positively evaluate the capacities may be observed. All of the countries this deficiency indicates that the system of the ministries of health in the area of stated that they have some type of om- is weak. policy development; however, these ca- budsman’s office with the capacity to pacities may be directly influenced by protect the rights of citizens in health- Indicators: the success of these reforms. related matters. However, it should be 1. Empowering citizens for decision- noted that formal channels of social Specific deficiencies were observed in making in public health participation for receiving and respond- the capacity to define national health ing to public concerns and opinions re- objectives in coordination with deci- 2. Strengthening of social participation garding health policies and the organi- sions made about the structure of the in health zation of the health services do not health system. It is particularly impor- exist. In addition, it is difficult to clearly tant to point out that one of the most 3. Technical assistance and support to ascertain the extent to which national significant weaknesses in this area is the the subnational levels to strengthen health authorities are interested in ana- lack of indicators that would make it social participation in health. lyzing and channeling public contribu- possible to evaluate the achievement of tions in the process of defining sectoral national objectives over time. EPHF 5. Development of policies and goals and strategies. institutional capacity for planning and It is important to note that practically management in public health A major deficiency is educating the all political efforts in the area of public public about health law. As with other Although three countries of the subre- health concern the development of the functions, weaknesses were observed in gion exhibit greater development with public sector. Although it is logical to the systematic evaluation of social par- regard to the preparation of public consider this to be the pertinent sector ticipation in health. health policies, it is important to evalu- in evaluating NHA performance of reg- 166 The countries of the subregion exhib- Figure 64 Performance of the Indicators for EPHF 5 in the ited intermediate performance of this subregion of Central America, Spanish-speaking function. In general, better perform- Caribbean and Haiti 1.00 ance was observed with respect to per-

0.90 sonnel expertise in the development of 0.78 regulatory instruments than with re- 0.80 0.75 spect to monitoring compliance with 0.70 existing regulations. Although enforce- 0.60 ment teams are properly trained, it was 0.48 0.50 noted that the primary weakness in en- 0.43 0.41 0.40 forcing the regulatory framework is a lack of human and financial resources. 0.30

0.20 The countries do not regularly review 0.10 their guidelines for regulating the health 0.00 system. These guidelines tend to focus 12345 on establishing laws and regulations, Indicators rather than on providing incentives for ethical compliance with regulations. ulatory functions, it is significant that 5. Technical assistance and support to There appears to be a lack of specific in- the private sector is generally not taken the subnational levels for policy de- terest in establishing policies to prevent into account in national public health velopment, planning, and manage- staff corruption and abuse of authority. decisions. ment in public health. This is as a very important deficiency recognized throughout the subregion, Finally, efforts to base political deci- EPHF 6. Strengthening of institutional given that inspectors are susceptible to sions with regard to public health on capacity for regulation and enforcement these types of administrative and legal data must be significantly strengthened. in public health transgressions. It should also be noted that the coun- tries acknowledged shortcomings in or- ganizational development; standards are Figure 65 Performance of the Indicators for EPHF 6 in the not defined and institutional perfor- subregion of Central America, Spanish-speaking mance with regard to public health is Caribbean and Haiti not evaluated. 1.00

0.90 Indicators: 0.82 0.80

1. Definition of national and subna- 0.70

tional health objectives 0.60

0.50 0.45 2. Development, monitoring, and eval- 0.40 0.36 uation of public health policies 0.30 0.30 3. Development of institutional capac- 0.20 ity for the management of public 0.10 health systems 0.00 1234 4. Management of international coop- Indicators eration in public health 167 Indicators: Figure 66 Performance of the Indicators for EPHF 7 in the 1. Periodic monitoring, evaluation, subregion of Central America, Spanish-speaking and modification of the regulatory Caribbean and Haiti framework 1.00 0.90 0.80 2. Enforcement of laws and regulations 0.80

0.70 0.66 3. Knowledge, skills, and mechanisms 0.60 0.56 for reviewing, improving, and en- forcing the regulations 0.50 0.40 0.40 4. Technical assistance and support to 0.30 the subnational levels of public 0.20

health in developing and enforcing 0.10 laws and regulations. 0.00 1234 EPHF 7: Evaluation and promotion of Indicators equitable access to necessary health services Performance of this function in the sub- improving access to adequate health 3. Advocacy and action to improve ac- region varied considerably. Generally services for underserved populations, cess to necessary health services speaking, better performance was ob- particularly competencies for adapting served in the promotion of equitable ac- health services to the cultural features of 4. Technical assistance and support to cess to health services. It should be noted the population. the subnational levels to promote that evaluations of public access to per- equitable access to health services. sonal health services are under utilized to In addition, the countries stated that correct policies and plans aimed at im- difficulties exist in the promotion of eq- EPHF 8. Human resources development proving access to these services for un- uitable access to health services due to and training in public health derserved populations. other decision-makers with influence in One of the principle problems that this area. Given that access to health The difficulty of the NHA in increasing should be addressed by the countries of services is a major focus of health sector its role in improving access to health the subregion is their low performance reform, it is significant that the coun- services is of particular concern, given with regard to the development of tries—when faced with a subject that that the steering role is being separated human resources in public health. This tends to be central to these reforms; from the role of providing services. It insufficiency endangers all of the accu- namely, establishing guaranteed pack- may be inferred that the NHA is still mulated capital for adequate perfor- ages of health benefits—have difficulty acting as a service provider (primarily mance of the EPHF, and therefore en- evaluating the extent to which these for the poorest) and, in this way, is seek- dangers many years of investment in this packages have been made accessible in ing to solve the problem. Insufficient matter. The countries’ low performance these countries. understanding of the cultural issues in- with regard to human resources develop- volved in improving access to services is ment in public health is a warning sign to Indicators: a weakness that must be addressed, par- the NHA of these countries that they ticularly in countries characterized by 1. Monitoring and evaluation of access could lose their position as leaders in significant cultural diversity. to necessary health services meeting the challenges of sectoral reform.

The countries acknowledged that a 2. Knowledge, skills, and mechanisms Virtually none of the countries have major deficiency is insufficient staff for improving access by the popula- made efforts to establish the characteris- knowledge and technical expertise in tion to necessary health services tics of the workforce—in terms of com- 168 5. Technical assistance and support to Figure 67 Performance of the Indicators for EPHF 8 in the the subnational levels in human re- subregion of Central America, Spanish-speaking sources development. Caribbean and Haiti 1.00 EPHF 9. Quality assurance in personal 0.90 and population-based health services 0.80

0.70 A critical weakness throughout the sub- region is the capacity of the NHA to 0.60 0.56 ensure the quality of personal and pop- 0.50 0.40 ulation-based health services. 0.40 0.32 0.30 0.27 0.24 Deficiencies were observed in the ca- 0.20 pacity to ensure the quality of personal

0.10 and population-based health services, particularly the latter. 0.00 12345 Indicators Fewer than half of the countries re- ported progress in using technological systems as an basic tool in improving the quality of each type of health ser- vice. The capacity of the NHA to per- petencies and professional training— 3. Continuing education and graduate form this function is further weakened needed to fulfill current public health training in public health by difficulties in defining quality stan- responsibilities. dards for the health services. 4. Upgrading human resources to en- Another significant deficiency is the lack sure culturally appropriate delivery One of the subregion’s greatest weak- of cooperation between the health au- of services nesses is the lack of interest at all levels thority and human resources education centers in developing plans and programs Figure 68 Performance of the Indicators for EPHF 9 in the for training and continuing education. subregion of Central America, Spanish-speaking Caribbean and Haiti With regard to retention and develop- ment of human resources, it is clear that 1.00 there are insufficient performance in- 0.90

centives for public health workers. 0.80

0.70 Finally, it should be noted that deficien- cies exist in training health workers to 0.60 interact with populations of various 0.50 cultural groups in each country. 0.40 0.28 0.30 0.28 Indicators: 0.20 0.17

1. Description of the public health 0.10 0.01 workforce 0.00 1234 2. Improving the quality of the work- Indicators force 169 in evaluating and improving user satis- Figure 69 Performance of the Indicators for EPHF 10 in the faction with provided services. subregion of Central America, Spanish-speaking Caribbean and Haiti Indicators: 1. Definition of standards and evalua- 1.00 tion to improve the quality of popu- 0.90 lation-based and personal health 0.80 services 0.70 0.58 0.60 2. Improving user satisfaction with the health services 0.50 0.40 0.33 3. Systems for technological manage- 0.30 ment and health technology assess- 0.20 ment to support decision-making in 0.10 0.05 public health 0.00 123 4. Technical assistance and support to Indicators the subnational levels to ensure quality improvement in the services. 3. Technical assistance and support for The countries of the subregion exhib- EPHF 10. Research in public health research in public health at the sub- ited relatively good performance of this national levels function. Nevertheless, it is important As with EPHF 8 and EPHF 9, the to point out that coordination within countries of the subregion exhibited low the health sector must be improved in performance of this function. Two note- EPHF 11: Reducing the impact of order to effectively address emergencies worthy deficiencies are the absence of a emergencies and disasters on health and their impact on health. priority public health research agenda in each of the countries, and insufficient interaction between the ministries of Figure 70 Performance of the Indicators for EPHF 11 in the health and the public health scientific subregion of Central America, Spanish-speaking community at both at the national and Caribbean and Haiti. international level. 1.00

The countries acknowledged that very 0.90 0.86 0.87 little research has been performed on the 0.80 0.75 impact of public health interventions 0.70 and current risk factors for chronic dis- 0.60 eases. Another area of limited develop- 0.50 ment is research on health systems and 0.41 services. 0.40 0.30

Indicators: 0.20 1. Development of a public health re- 0.10 search agenda 0.00 1234 2. Development of institutional re- Indicators search capacity 170 One particularly sensitive area in need tors for EPHF 8 (human resources de- guidelines aimed at reducing the im- of attention throughout the subregion velopment) revealed low performance, pact of emergencies and disasters; and is the vulnerability of the hospital infra- with the exception of continuing educa- coordination and partnerships with structure and the weakness of policies tion and graduate training, which regis- other agencies or institutions in emer- and plans aimed at improving hospital tered intermediate performance. gency and disaster management. evaluation and correcting deficiencies, making it possible to manage emergen- In addition, it was noted that little • Intervention with regard to develop- cies that may damage the hospital infra- progress has been made in defining na- ing institutional capacities and infra- structure or hinder its ability to reduce tional public health research agendas, structure: capacity and expert assis- the overall harm caused by disasters. and that the capacity of the NHA to di- tance in monitoring and evaluating rectly perform research is insufficient. health status; capacity of public Indicators: health laboratories; and capacity to Although the countries of the Region 1. Reducing the impact of emergencies negotiate international cooperation. exhibited adequate performance with and disasters regard to developing the regulatory • The development of decentralized framework, they exhibited low perfor- 2. Development of standards and guide- competencies: NHA support to the mance with regard to enforcing existing lines that support emergency pre- subnational levels for performance of regulations. paredness and disaster management the functions; monitoring, evaluat- in health ing, and analyzing health status; pub- On the other hand, the subregion ex- lic health surveillance, research, and hibited clear strengths with regard to 3. Coordination and partnerships with control of risk and threats to public emergency and disaster management, other agencies and/or institutions health; evaluating and promoting eq- development of the public health sur- uitable access to necessary health ser- veillance system, and the capacity for 4. Technical assistance and support to vices; and reducing the impact of the timely response to public health threats. the subnational levels to reduce the emergencies and disasters. impact of emergencies and disasters 2.1.3.2 Performance on health. The primary weaknesses of the Region by intervention area (with a score equal to or less than 40% 2.1.3 Identification of priority The primary strengths of the majority of the established standard), and which areas of intervention to prepare of the countries of Central America in should be included in a public health a program for strengthening performing the essential public health strengthening program for Central Amer- the EPHF in Central America functions (with a score equal to or ica, are as follows: greater than 70% of the established 2.1.3.1 Performance of all indicators standard), and which should be main- • Intervention in these key processes: A profile of all of the indicators, classi- tained in the subregional plan, are as evaluating the quality of information fied as strengths or weaknesses for the follows: for monitoring the health status of the subregion, is presented below. In order population; defining national and to facilitate the analysis, the indicators • Intervention in these important pro- subnational public health objectives; for each function have been given a dif- cesses: surveillance systems to identify monitoring compliance with health ferent color. risks and threats to public health; ca- regulations; describing the character- pacity for timely and effective re- istics of the health workforce; contin- The general profile indicates significant sponse to control public health prob- uing education in public health; defi- weaknesses in all of the indicators for lems; developing, monitoring, and nition of standards and evaluation to EPHF 9 (quality assurance of the health evaluating public health policies; re- improve the quality of personal and services); the lack of progress in health viewing, evaluating, and modifying population-based health services; im- technology assessment is particularly the regulatory framework for public proving user satisfaction; and devel- noteworthy. The majority of the indica- health; developing standards and oping a public health research agenda. 171 Figure 71 Performance of the indicators of the EPHF in the subregion of Central America, Spanish-speaking Caribbean and Haiti

9.3 10.1 9.2

8.1 Low 1.2 8.2 9.1 9.4 6.4 8.4 10.2 6.2 4.3 8.3 7.1 5.5 11.1 Fairly Low 3.2 5.1 6.3 3.3 3.4 5.3 3.5 4.1 2.2 7.2 8.5 4.2 10.3 1.1 3.1 Fairly High 1.4 7.3 2.3 5.2 11.2 5.4 7.4 6.1 1.5 2.4 2.1 11.3 High 11.4 2.5 1.3

0.00 0.10 0.20 0.30 0.40 0.50 0.60 0.70 0.80 0.90 1.00

EPHF 1 EPHF 5 EPHF 2 EPHF 6 EPHF 9 EPHF 3 EPHF 7 EPHF 10 EPHF 4 EPHF 8 EPHF 11

172 • Intervention to develop institutional • Disease prevention and control b) Collection and dissemination of capacities and infrastructure: improv- information to guide public health ing the quality of human resources in • Intersectoral action to improve the policies, strategies, and actions public health; upgrading human re- level of health Notable weaknesses include the absence sources to ensure culturally-appropri- of a priority public health research ate delivery of services; developing • Human resources development and agenda in the countries of the subregion systems for technology management creation of institutional competen- and weak interaction between the scien- and health technology assessment to cies for public health tific community and other actors that support decision-making in public could provide information to improve health; and developing institutional a) Development of health policies the decision-making process. capacity for public health research. Specific deficiencies were observed in Strategies and actions for technological • The development of decentralized the capacity to define national health management and health technology as- competencies: NHA support to the objectives in coordination with deci- sessment, which could effectively con- subnational levels for the perform- sions made about the structure of the tribute to the improvement of public ance of the functions: technical assis- health system. It is particularly impor- health policies, are just beginning to be tance and support to the subnational tant to point out that one of the most developed. levels in the policy development, significant weaknesses in this area is the planning, and management in public lack of indicators that would make it It must also be taken into account that health; technical assistance and sup- possible to evaluate the achievement of many countries have not established the port to the subnational levels in en- national objectives over time. practice of systematically evaluating the forcing laws and regulations; and quality of the information that is gath- promoting quality improvement in Although the countries of the subregion ered by the national health authorities. personal and population-based health have the knowledge and institutional It is very important that this weakness services. capacity to monitor and evaluate health policies, they focus on examining pub- be corrected, given that changing na- 2.1.3.3 Performance according lic sector activity, without considering tional priorities make it necessary to to the action priorities of the health policies or what other actors (the continually gather new data on public World Bank private sector, social security institu- health threats and risk factors, as well as tions, etc.) could contribute to these data on how the health services are used The indicators have been regrouped in policies. It was also noted that little ac- and accessed. order to make the results of the mea- tion has been taken in the Region to in- surement operational within the frame- volve other actors in the process of In many countries, the monitoring and work of international financing and defining and designing health policies. evaluation of health status does not in- cooperation strategies. The objective is clude analysis of risk factors, which are to identify action priorities based on: important variables for emerging diseases A critical weakness throughout the sub- a) significant differences in the public and for identifying trends in current pri- region is the capacity of the NHA to health profile of the countries, and ority epidemiological problems. Particu- ensure the quality of personal and pop- b) investment needs. The categories lar weakness was noted in the areas of ulation-based health services, particu- that were considered and the results of mental health, risk factors for chronic larly the capacity to define standards in the analysis are given below. diseases, and occupational health, among order to subsequently evaluate these others. • Development of health policies services. c) Disease prevention and control • Data collection and dissemination to Another challenge is building interest in orient the public policies, the strate- developing strategies that include user It is important to point out that short- gies, and the actions with regard to satisfaction as an essential element of comings were observed in more than public health improving the health system. half of the countries in the integrity of

173 Figure 72 Performance of the indicators of the EPHF in the subregion of Central America, Spanish-speaking Caribbean and Haiti, according to Priorities Areas of Intervention

10.1 9.2 8.1 1.2 9.1 8.4 6.2 8.3 7.1 11.1 3.2 5.1 3.3 3.4 4.1 4.2 Key processes 1.1 3.1 7.3 5.2 11.2 6.1 2.4 2.1 11.3 9.3 8.2 10.2 6.3 5.3 2.2 7.2

1.4 Capacities 2.3 5.4 and infrastructure 1.3 9.4 6.4 4.3 5.5 3.5 8.5 10.3

7.4 Support to

1.5 Decentralization 11.4 2.5

0.000.10 0.200.30 0.40 0.50 0.60 0.70 0.80 0.90 1.00

EPHF 1 EPHF 5 EPHF 2 EPHF 6 EPHF 9 EPHF 3 EPHF 7 EPHF 10 EPHF 4 EPHF 8 EPHF 11

174 the sources of information, which con- performing “emerging” public health health functions and should be priori- tinue to center on the public sector, de- functions, such as quality assurance, de- ties in the effort to strengthen NHA spite the growing role assumed by the veloping strategies designed to improve performance. private sector (nonprofit and for-profit) public access to health services, and pro- in delivering services and the fact that viding support to subnational levels in These critical areas are: this information must therefore be in- order to increase health promotion and • Strengthening the capacity to period- cluded in order to monitor public health social participation in health. ically evaluate implemented actions threats. and strategies (included feedback Most of the countries exhibited low from the pertinent actors: decentral- With regard to new areas of develop- performance with regard to developing ized levels in the performance of ment, the principal deficiencies were human resources in public health, NHA functions, other actors, and the observed in the monitoring of threats to which constitutes a serious obstacle to general public) mental health, threats deriving from the improving the EPHF in the Region. work environment, and diseases or risk • Designing and implementing a sys- factors for chronic disease. 2.1.4 Conclusions tem of stimuli and incentives for With regard to the health services, it The results of this first measurement of achieving results in public health, was observed that evaluations of public the performance of the EPHF in the and access to services are barely used to cor- Region of Central America are primar- rect policies and plans aimed at improv- ily descriptive in nature, although they • Improving public health information ing the ability of poorly-served popula- may serve as a basis for analyzing the systems, particularly those intended to tions to access services. In the majority major trends in the countries’ perfor- support data-based decision-making. of the countries, the NHA addresses mance of the EPHF. priorities through direct actions aimed From the subregional perspective, this at correcting the gaps in the popula- As a result of this measurement, each exercise makes it possible to draw a tions at greatest risk, and less effort is country is provided with a detailed number of conclusions concerning com- made to encourage other pertinent ac- analysis of the current performance of mon areas of weakness and strength that tors to assume their roles and responsi- the EPHF at the level of the national may be very useful in supporting the ef- bilities with regard to this problem. health authority. This profile of the cur- forts of the ministries of health and in rent status of the health infrastructure encouraging the decision-making bodies d) Intersectoral intervention may be very useful in making decisions of each government to provide necessary to improve health with regard to strengthening the NHA’s support for developing health capacities. basic capacity to exercise a steering role This first diagnostic evaluation should In general, the countries of the subre- in relation to the entire health system. also serve as a frame of reference for in- gion exhibited adequate performance in As all of the participating countries stitutions interested in cooperating with this area. However, one area of critical have clearly recognized, the value of the these national efforts. concern continues to be the establish- instrument does not lie in its perfection ment of partnerships to encourage as a diagnostic test, but rather in its ca- In general, it may be concluded that health promotion. The countries may pacity to promote a proactive discussion critical areas in the performance of the be able to learn from the process of es- on the current status of national public EPHF in the subregion are: strengthen- tablishing partnerships for managing health, the reasons for this status, and ing quality assurance in the health ser- emergencies and disasters and their rel- appropriate formulas for overcoming vices (particularly with regard to consid- atively better performance in that area. weaknesses and bolstering strengths. ering user satisfaction as an indicator of quality); human resources development e) Human resources development A transverse analysis of the performance in public health; strengthening the ca- and building institutional capacity of all of the functions reveals several pacity to enforce public health regula- The primary deficiencies in building in- common critical areas. These critical tions; and developing national public stitutional capacity are associated with areas affect a number of essential public health research agendas. All of these 175 Figure 73 Performance of the indicators of the EPHF in the subregion of Central America, Spanish-speaking Caribbean and Haiti, according to priority areas of intervention proposed by the World Bank

9.2 9.1 6.2 Public health 5.1 policy development 3.4 4.1 5.2 11.2 6.1 9.3 10.1 1.2 Collection and dissemination of 10.2 evidence for public health policy 3.3 1.1 7.1 11.1 Disease prevention 7.2 and control 3.1 2.3 2.4 2.1 3.2 4.2 Intersectoral action 7.3 11.3 8.1 8.2 9.4 6.4 8.4 Human resources development 4.3 and institutional capacity-building 8.3 5.5 6.3 5.3 3.5 2.2 8.5 10.3 1.4 5.4 7.4 1.5 11.4 2.5 1.3

0.000.10 0.200.30 0.40 0.50 0.60 0.70 0.80 0.90 1.00

EPHF 1 EPHF 5 EPHF 2 EPHF 6 EPHF 9 EPHF 3 EPHF 7 EPHF 10 EPHF 4 EPHF 8 EPHF 11

176 Figure 74 Performance of the EPHF in the subregion of the English-speaking Caribbean and the Netherlands Antilles

1.00

0.90

0.80 0.71 0.70 0.63 0.63 0.56 0.55 0.60 0.53 0.50 0.46 0.42 0.45 0.38 0.40

0.30 0.26

0.20

0.10

0.00 EPHF1 EPHF2 EPHF3 EPHF4 EPHF5 EPHF6 EPHF7 EPHF8 EPHF9 EPHF10 EPHF11

Essential Function

areas could be improved through ac- gion of the Caribbean are presented in The general performance level exhib- tions undertaken for Central America this report: Anguilla, Antigua, Aruba, ited varied from low to intermediate. In as a whole. One area in need of partic- Barbados, Bahamas, British Virgin Is- the subregion adequate performance ular attention is health technology lands, Cayman Islands, Curaçao, Do- was exhibited only for the function of management and assessment directed minica, Grenada, Guyana, Jamaica, reducing the impact of emergencies and toward providing information to agen- Montserrat, Saint Kitts and Nevis, Saint disasters in health (EPHF 11). cies with decision-making power in im- Lucia, Saint Vincent, Suriname, Turks portant areas such as investments, as and Caicos, and Trinidad and Tobago, The countries exhibited a high-inter- well as providing information to clini- with the addition of Belize.11 mediate performance in the functions cians on clinical protocols for improv- related to evaluation and promotion of ing health practice. 2.2.1 General results of the equitable access to necessary health measurement services (EPHF 7); public health sur- The program’s priorities with regard to veillance, research and control of risks The overall performance of the coun- the remaining functions will depend on and threats to public health (EPHF 2); tries of the subregion with respect to the analysis carried out by each country monitoring, evaluation, and analysis of each of the evaluated EPHF is shown in with regard to its own performance pro- health status (EPHF 1); health promo- Figure 74. Here, the average is used as a file, which will guide each country in tion (EPHF 3); and development of summary measure to eliminate the in- determining its national priorities for policies and institutional capacity for fluence of the extreme scores. the improvement of public health. planning and management in public health (EPHF 5). 2.2 English-speaking Caribbean and Netherlands The functions for which low-interme- 11 Antilles Although geoFigureically part of Central diate performance was exhibited are: America, Belize has been included in this social participation in health (EPHF group because of its political-sanitary charac- The results of the measurement in the teristics, that are closer to the profile for a 4); human resources development and twenty countries that comprise the Re- Caribbean country. training in public health (EPHF 8);

177 eleven essential public health functions Figure 75 Distribution of the Performance of the EPHF in the shows a relatively homogeneous pattern subregion of the English-speaking Caribbean and among all the countries analyzed (Fig- the Netherlands Antilles ure 75). Generally speaking, the coun- Caribbean tries exhibited performances ranging 1.0 between 40 and 80% for functions 1 to 6. From there on, a wider dispersion of .8 scores became evident, with a marked trend toward lower scores for EPHF 9. .6 Although the countries of the Region ex- .4 hibited their highest performance in re- ducing the impact of emergencies and

.2 disasters in health (EPHF 11), a high de- gree of dispersion was observed among the countries, making it a weakness in 0.0 some cases. EPHF_1 EPHF_3 EPHF_5 EPHF_7 EPHF_9 EPHF_11 EPHF_2 EPHF_4 EPHF_6 EPHF_8 EPHF_10 The two functions for which the lowest overall performance (EPHF 9 and 10) also manifested high degrees of disper- sion, and even the highest scores were insufficient to make them a strength for strengthening of institutional capacity There is a clear need for strengthening for regulation and enforcement in pub- the functions related to the steering role some countries of the subregion. lic health (EPHF 6). of the health sector, management of re- sources, and, especially, quality assur- The limited dispersion among coun- The countries of the Region exhibited ance of services offered to the public. tries in performing EPHF 2 (public their lowest performance in public health surveillance, research, and con- trol of risks and threats to public health) health research (EPHF 10) and quality Further exploration of the overall per- and, on the other hand, the high dis- assurance in personal and population- formance requires an analysis of the dis- based health services (EPHF 9). persion in the performance of each persion in the performance of EPHF 7 EPHF by the countries of the subregion. (evaluation and promotion of equitable Generally speaking, this profile indicates To this end, Figure 75 shows the average access to necessary health services) were that the countries of the Caribbean have score, the first standard deviation (repre- noteworthy among the functions in not achieved satisfactory levels of per- senting 66% of the countries), and the which high-intermediate performance formance with respect to the essential maximum and minimum scores12 for was exhibited. In the latter case, this public health functions in the areas con- each function. function represented a strength in some sidered most traditional. However, the countries of the Region. processes of reform have allowed prog- The performance profile of the coun- ress to be made in other areas of more tries of the Caribbean with regard to the 2.2.2 Analysis of the results for each recent impetus, such as evaluation of eq- EPHF uitable access to health services and health promotion, as well as strengthen- The performance of each of the essen- 12 This analysis excludes some results identi- ing of the institutional capacity for fied in the statistical analysis as “outliers” (ex- tial public health functions in the sub- management in public health. ternal elements). region is analyzed in detail below.

178 compiling the relevant information on Figure 76 Performance of the indicators for EPHF 1 in the vital statistics required for monitoring subregion of the English-speaking Caribbean and health status. Despite the foregoing, all the Netherlands Antilles the countries registered good perfor-

1.00 0.94 mance with regard to the medical certi- 0.90 fication of deaths.

0.80 Indicators: 0.70 0.58 1. Guidelines and processes for moni- 0.60 0.55 toring health status 0.50 0.44 0.40 2. Evaluation of the quality of informa- 0.30 0.25 tion 0.20

0.10 3. Expert support and resources for

0.00 monitoring health status 12345 Indicators 4. Technical support for monitoring health status

5. Technical assistance and support to EPHF 1: Monitoring, evaluation, risk factors in their epidemiological the subnational levels of public health and analysis of health status profile, which prevents the use of the health status profile to solve the prob- In the English-speaking Caribbean and EPHF 2: Public health surveillance, lems of inequity and to evaluate the im- Netherlands Antilles subregion, average research, and control of risks and threats pact of the initiatives aimed at control- performance of this function was 56% to public health ling or modifying health risk factors. of the preestablished optimal standard The countries of the subregion exhib- for this measurement. Although adequate material exists, its ited intermediate performance in this function, with an average score of Only the institutional capacity to mon- process of dissemination is deficient. 63% with regard to the defined optimal itor and evaluate health status (Indica- The design of these instruments does standard. tor 3) stood out in the performance of not take into account their target audi- this function, thanks to the high levels ence and there are deficiencies in the The capacity for timely and effective re- of training among the human resources. timeliness with which information is disseminated. sponse to public health problems (Indi- cator 4) and the insufficient expert de- In the preparation of guidelines and velopment of public health surveillance processes for the performance of this The lowest degree of performance was at the level of the NHA (Indicator 3) function, as well as technical assistance exhibited in the evaluation of the qual- stood out in their limited performance. and support to the subnational levels, ity of information. This is due to the the index achieved in the subregion was fact that the majority of the countries of Indicators: only intermediate. the subregion do not have an entity at the level of the health authority respon- 1. Surveillance system to identify No country in the subregion has infor- sible for carrying out this function, nor threats and harm to public health mation available on the obstacles in ac- are audits performed to evaluate the cess to health care, and a limited num- quality of data. Deficiencies in inter- 2. Capacities and expertise in public ber include monitoring of the relevant sectoral coordination also occur in health surveillance

179 gard to surveillance of accidents and oc- Figure 77 Performance of the indicators for EPHF 2 in the cupational health. Finally, despite the subregion of the English-speaking Caribbean and existence of trained staff and action the Netherlands Antilles protocols that would enable the health 1.00 authority to respond effectively to threats and harm to public health, the 0.90 0.83 0.78 capacity for timely response is neither 0.80 0.70 stimulated nor evaluated periodically, 0.70 nor have incentives been defined to im- 0.60 0.53 prove the performance of personnel 0.50 responsible for surveillance in public 0.40 health.

0.30 0.25 EPHF 3: Health promotion 0.20

0.10 The performance of the subregion with respect to this function was from low to 0.00 12345 intermediate, with an average score that Indicators was 55% of the optimal performance.

The English-speaking Caribbean and 3. Capacity of public health laborato- sonnel trained in this area. Its capacity Netherlands Antilles subregion exhib- ries in the area of mental health is parti- ited intermediate and relatively homo- cularly strong, and its principal defi- geneous performance for all the indica- 4. Capacity for timely and effective re- ciencies are associated with the lack tors, although the indicator related to sponse to control public health of regular evaluation of the surveillance technical assistance at the subnational problems systems, as well as weaknesses with re- levels (Figure 78) was slightly higher.

5. Technical assistance and support for the subnational levels of public health Figure 78 Performance of the indicators for EPHF 3 in the subregion of the English-speaking Caribbean and The majority of the countries have an the Netherlands Antilles effective surveillance system to identify 1.00 threats and harm to public health that includes a support laboratory network, 0.90 but its quality generally is not evaluated 0.80 0.69 on a regular basis. 0.70

0.60 0.58 Even though technical assistance is pro- 0.50 0.51 0.52 0.50 vided to the subnational levels in the 0.40 Region is sufficient to support their sur- veillance capacity, the health authority 0.30 generally does not have appropriate and 0.20 timely feedback mechanisms on the in- 0.10 formation produced at these levels. 0.00 12345 With regard to expertise in epidemiol- Indicators ogy, the subregion has experienced per-

180 The subregion has various levels of sup- strengthened, most of the countries of EPHF 4: Social participation in health port for promotion activities, although the subregion are unaware of the needs The countries of the English-speaking the majority of countries manifest the for trained staff. Caribbean and Netherlands Antilles importance of these activities through exhibited low to intermediate perfor- written promotion policies. Indicators: mance in this function, as reflected by 1. Support for health promotion activ- their average score of 46% of the opti- In general, the levels of participation by ities, development of norms, and in- mal score for this measurement. other sectors and actors are low. Prog- terventions to promote healthy be- ress has been achieved in promoting haviors and environments The aspect of this function for which an healthy behaviors and environments, al- improved, although intermediate, per- though mechanisms to evaluate the im- 2. Building of sectoral and extrasec- formance was exhibited relates to the pact of social and economic policies are toral partnerships for health promo- strengthening of social participation in not available. tion health (Figure 79).

The health authorities of the countries of 3. National planning and coordination With regard to empowering citizens the English-speaking Caribbean and of information, education, and so- for decision-making in public health, a Netherlands Antilles subregion are not cial communication strategies for certain degree of progress has been effective in convening or building part- health promotion achieved thanks to the implementation nerships with other sectors, especially of citizen consultation mechanisms, al- due to the low feedback they receive from 4. Reorientation of the health services though these are usually informal in na- joint efforts that have been conducted. toward health promotion ture and their contributions to health policy design are not monitored. Despite the previous, the majority of 5. Technical assistance and support for the countries of the subregion have pre- the subnational levels to strengthen The establishment of ombudsman’s of- pared programs for disseminating infor- health promotion activities fices and the concept of public account- mation and educating the public on subjects related to health promotion. Some have conducted promotion cam- paigns, that have not been evaluated, or Figure 79 Performance of the indicators for EPHF 4 in the established entities for the purpose of subregion of the English-speaking Caribbean and disseminating information on these the Netherlands Antilles subjects among the population. 1.00 Health promotion is a topic of frequent 0.90 discussion in the decision-making bod- 0.80 ies of the subregion. Furthermore, pri- 0.70 mary care is being strengthened and ef- 0.60 0.54 forts are being made to train human 0.50 0.50 resources in this area. In general, the 0.40 countries have still not developed ac- 0.32 tions to reorient health services toward 0.30 health promotion. 0.20

0.10

Although the capacity to provide sup- 0.00 port at the subnational levels is available 123 and the use of tools to improve public Indicators access to health promotion has been

181 ability are recent occurrences in the Figure 80 Performance of the indicators for EPHF 5 in the subregion. subregion of the English-speaking Caribbean and the Netherlands Antilles The strengthening of social participa- tion in health-related matters is an as- 1.00 pect of irregular development across the 0.90 0.80 subregion and, although citizen partici- 0.80 pation is an element of policy in almost 0.68 0.70 all the countries, it is implemented on 0.60 an informal basis. In most cases, proce- 0.53 dures have not been established for con- 0.50 0.46 0.40 sidering public opinion in decision- 0.33 making, and the information provided 0.30 to citizens on their rights with regard to 0.20 health is limited. 0.10

0.00 Nevertheless, most of the countries 12345 have personnel trained to work in these Indicators areas and have allocated specific financ- ing for the development of actions in this regard. The evaluation of these as- tion, with an average score of 53% of The health authority of the countries pects is deficient, however. the optimal score for this measurement. assumes leadership in the process of de- veloping, monitoring, and evaluating Finally, although support is provided to Of particular note was the subregion’s public health policies through a pro- the subnational levels with certain regu- high performance with respect to the gram supported by all State powers, but larity, its scope is limited. management of international coopera- with limited participation by other sec- tion in health public, and, on the other tors. And although the countries have hand, its limited ability to define public implemented policies that have been Indicators: health objectives, both at the national translated into laws and have trained 1. Empowering citizens for decision- and subnational levels (Figure 80). personnel in these areas, not all of them making in public health have evaluated their impact. The low performance exhibited in the 2. Strengthening of social participation subregion with regard to the develop- Most of the countries of the subregion in health ment of plans with goals and objectives have human resources trained in public that relate to sanitary priorities is attrib- health management, but they have lim- 3. Technical assistance and support for utable to the fact that, although this is a ited leadership capacity in this area and process spearheaded by the health au- their supervisory mechanisms are weak. the subnational levels to strengthen thority, it lacks both a well-defined The institutional capacity for informa- social participation in health health system profile to serve as a basis, tion-based decision-making is limited, and financing for the implementation primarily due to insufficient access to EPHF 5: Development of policies and of plans and programs; in addition, nei- information systems to support and institutional capacity for planning and ther the indicators to evaluate perform- manage this information. The majority management in public health ance or achievement of the objectives, of the countries use strategic planning nor the ability to recognize the partner- in management but acknowledge that The countries of the Region exhibited ships necessary for their fulfillment, this methodology is not used systemati- intermediate performance in this func- have been adequately developed. cally. Organizational development and

182 the institutional capacity for human re- The countries of the Region exhibited 4. Technical assistance and support to sources management are limited, espe- low performance in this function, with the subnational levels of public cially with respect to the lack of skilled an average score of 46% of the optimal health in developing and enforcing personnel. score for this measurement. laws and regulations

The majority of the countries of the In the group of countries that comprise To perform this function, most of English-speaking Caribbean and Nether- the subregion, only the capacity to es- the countries of the English-speaking lands Antilles have resources, technology, tablish guidelines for regulating the Caribbean and Netherlands Antilles and capacities with regard to the manage- health system stood out with an inter- have adequate resources and technical ment of international cooperation, and mediate performance level. The other assistance to formulate regulations, but are familiar with the mechanisms and re- areas exhibited limited development timely and periodic studies of the im- quirements of the various international (Figure 8). pact or adverse effects of current regula- organizations for allocating resources. tions are not always performed. Indicators: The countries have trained personnel to Although the majority of the countries provide technical assistance to the sub- 1. Periodic monitoring, evaluation, have personnel assigned to enforcement national levels, but the provision of and modification of the regulatory tasks and systematic processes for en- these services is limited for reasons re- framework forcing regulations, they generally do lating to the policy, planning, and man- not have guidelines for the enforcement agement of public health activities, con- 2. Enforcement of the laws and regula- process. Those who regulate compliance tinuous training, and the availability of tions are trained and educated, but there is a resources, as well as the inability to de- lack of incentives for compliance. On termine technical assistance needs at the 3. Knowledge, skills, and mechanisms the other hand, the implementation of subnational levels. for reviewing, improving, and en- policies and plans aimed at preventing forcing the regulations corruption is not a frequent practice. Indicators: 1. Definition of national and subna- tional health objectives Figure 81 Performance of the indicators for EPHF 6 in the subregion of the English-speaking Caribbean and 2. Development, monitoring, and eval- the Netherlands Antilles uation of public health policies 1.00

3. Development of institutional capac- 0.90 ity for the management of public 0.80 health 0.70 0.70

4. Negotiation of international cooper- 0.60 ation in public health 0.50 0.38 0.40 5. Technical assistance and support for 0.31 0.30 0.30 the subnational levels for policy de- velopment, planning, and manage- 0.20 ment in public health 0.10 0.00 EPHF 6: Strengthening of institutional 1234 capacity for regulation and enforcement Indicators in public health

183 The institutional capacity to perform Figure 82 Performance of the indicators for EPHF 7 in the the regulatory and supervisory function subregion of the English-speaking Caribbean and is irregular in the subregion, mainly due the Netherlands Antilles to limitations in technical capacity and 1.00 resources to perform the function and enforce the regulations established by 0.90 the health authority. Personnel training 0.80 0.71 0.70 is incomplete and mechanisms to evalu- 0.70 0.59 ate training needs generally have not 0.60 been established. 0.50 0.42 0.40 As a result, assistance to the subnational 0.30 levels is limited and usually consists of support with regard to enforcement. 0.20 There is no process available to evaluate 0.10 the quality of technical assistance or its 0.00 1234 impact. Indicators EPHF 7: Evaluation and promotion of equitable access to necessary health services 3. Advocacy and action to improve ac- community and influencing behavior. The countries of the Region exhibited cess to necessary health services In addition, although health personnel intermediate performance in this func- receive training in various areas, they are 4. Technical assistance and support to tion, with an average score of 63% of not subject to periodic evaluation, nor is the subnational levels to promote the impact of their actions measured. the optimal score for this measurement. equitable access to health services The countries of the subregion carry In performing this function, the coun- In the majority of countries, the moni- out activities to promote the improve- tries of the subregion have demonstrated toring and evaluation of access to neces- progress in promoting and taking action sary health services is a process that is ment of public access to health services to improve access to necessary health performed by the respective health au- with varying degrees of success, and ac- services and technical assistance to the thority, in a more or less centralized companied in most cases by concrete subnational levels. Their level of per- manner, which translates into an in- actions that are not always evaluated. Furthermore, the establishment of in- formance in other aspects was lower, es- complete analysis of levels of public ac- centives for service providers to pro- pecially with regard to the monitoring cess, especially due to difficulties in mote access to health services is an area and evaluation of access to health ser- identifying the obstacles involved. Con- of weakness. vices (Figure 82). sequently, the criteria needed to pro- mote equity in access to essential ser- Indicators: vices is not available. Support for the subnational levels is provided unevenly by the different 1. Monitoring and evaluation of access In the majority of countries, the health countries of the subregion, with the to necessary health services authority is familiar with the pattern of greatest success in the coordination and health services used by the population, dissemination of information and 2. Knowledge, skills, and mechanisms but with limitations due to the weak- major deficiencies in the capacity to de- for improving access by the popula- nesses already mentioned and, as a re- tect obstacles to access, as also occurs at tion to necessary health services sult, a low capacity for approaching the the health authority level.

184 The strategies to upgrade the workforce Figure 83 Performance of the indicators for EPHF 8 in the are limited, particularly with regard to subregion of the English-speaking Caribbean and the development of service careers, the Netherlands Antilles ethical issues, and the strengthening of 1.00 leadership.

0.90 The majority of the countries of the 0.80 subregion have service performance 0.70 evaluation systems, but this informa- 0.59 0.60 tion is rarely utilized to improve deci- 0.50 0.50 sion-making. Furthermore, there is a 0.41 0.40 marked shortage of continuing educa- 0.40 tion programs. 0.30 0.20 0.17 The most deficient aspect is the process 0.10 of upgrading the workforce to take into

0.00 account the sociocultural characteristics 12345 of users, at both the health authority Indicators and subnational levels. In this area, however, the majority of the countries support the implementation of decen- tralized human resources development and management plans. EPHF 8: Human resources development The characteristics of the existing pub- and training in public health lic health workforce are not always eval- EPHF 9: Quality assurance in personal uated with sufficient frequency, nor are The countries of the subregion exhib- and population-based health services steps taken to fulfill future needs. Other ited low performance in this function, types of institutions are also excluded The countries of the English-speaking with an average score of 45% of the op- from this process. Caribbean and Netherlands Antilles ex- timal score for this measurement. hibited their lowest performance with Indicators: respect to this function, with an average Performance of each aspect of the func- score of only 26% of the optimal score tion was limited in the English-speak- 1. Description of the public health for this measurement. ing Caribbean and Netherlands Antilles workforce Region, particularly with regard to im- The countries of the subregion exhib- proving the quality of the workforce for 2. Improving of the quality of the ited low performance for all aspects of culturally appropriate delivery of ser- workforce this function, especially with regard to vices (Figure 83). improving the degree of user satisfac- 3. Continuing education and graduate tion (Figure 84). The majority of the countries of the training in public health subregion have undertaken actions Indicators: aimed at determining the characteristics 4. Upgrading human resources to en- 1. Definition of standards and evalua- of the workforce and defining the skills sure culturally appropriate delivery tion to improve the quality of the required for performing the essential of services population-based and personal health functions and population-based public services health services, although difficulties 5. Technical assistance and support to occur in identifying the discrepancies the subnational levels in human re- 2. Improve user satisfaction with the between these factors. sources development health services

185 nology assessment; when technology as- Figure 84 Performance of the indicators for EPHF 9 in the sessment is carried out, it usually has subregion of the English-speaking Caribbean and been limited to aspects of safety and ef- the Netherlands Antilles fectiveness. Accordingly, decisions made 1.00 with regard to technology do not tend to be based on the available data. Fur- 0.90 thermore, the health authority seldom 0.80 assesses its capacity in this area. 0.70

0.60 The subnational levels are provided

0.50 with limited support for technology de- velopment and the evaluation of the 0.40 0.31 quality of both population-based and 0.30 0.24 0.22 personal services. This assistance is usu- 0.19 0.20 ally limited to aspects of organizational 0.10 structure and overall capacity.

0.00 1234 EPHF 10: Public health research Indicators The English-speaking Caribbean and Netherlands Antilles Region exhibited its second-lowest performance in this func- 3. Systems for technological manage- served and on personal rather than pop- tion, with an average score of 38% of the ment and health technology assess- ulation-based services. optimal score for this measurement. ment to support decision-making in public health The health authorities in the countries Of the three aspects, the countries of the subregion seldom promote tech- demonstrated the least progress with re- 4. Technical assistance and support nological management and health tech- gard to the development of a public to the subnational levels to ensure quality improvement in the services Figure 85 Performance of the indicators for EPHF 10 in the In performing the function of the defi- subregion of the English-speaking Caribbean and nition of standards and evaluation to the Netherlands Antilles improve the quality of population-based 1.00 and personal health services, the health authorities of only some countries of the 0.90 subregion apply policies with respect to 0.80 the continuous improvement of health 0.70 0.61 services quality. The preparation of stan- 0.60 dards and the periodic evaluation of 0.50 0.50 their fulfillment have not been suffi- cient, with respect to both population- 0.40 based and personal services, except in 0.30 enforcement-related issues. 0.20 0.10 Efforts to evaluate user satisfaction for 0.00 0.00 services received have been very limited. 123 These evaluations are usually conducted Indicators through surveys of the population 186 health research agenda. Intermediate Figure 86 Performance of the indicators for EPHF 11 in the performance was exhibited in the as- subregion of the English-speaking Caribbean and pects concerning institutional capacity the Netherlands Antilles and technical assistance at the subna- tional levels (Figure 85). 1.00 0.94 0.90 0.85 Indicators: 0.80 0.77

1. Development of a public health re- 0.70 search agenda 0.62 0.60

0.50 2. Development of institutional re- search capacity 0.40 0.30

3. Technical assistance and support for 0.20

research in public health at the sub- 0.10 national levels 0.00 1234 The generalized absence in the subre- Indicators gion of a public health research agenda is the principal weakness in the per- formance of this function.

Nevertheless, the health authorities have developed a certain level of insti- of 71% of the optimal score for this 4. Technical assistance and support to tutional capacity for autonomous re- measurement. the subnational levels to reduce the search, thanks to the availability of impact of emergencies and disasters trained technical teams and computer Of all the aspects of this function, the on health equipment to provide adequate support one in which the highest level of per- for the analysis of information. formance was exhibited is the develop- Management to reduce the impact of ment of standards and guidelines, while emergencies and disasters in the subre- Furthermore, certain technical assis- the lowest performance was exhibited gion is limited, since not all the coun- tance is provided at the subnational lev- with regard to management. In general, tries have an institutionalized national els in operations research methodology intermediate to high performance levels plan to confront these situations, a fact and the interpretation of results. Unfor- were achieved in the remaining aspects that generally is associated with the lack tunately, although the professionals at (Figure 86). of a specific health authority unit that is these levels are encouraged to partici- also funded with a designated budget pate in research of national relevance, Indicators: allocation. the results are rarely disseminated among 1. Reducing the impact of emergencies them or to the rest of the scientific and disasters Health personnel receive a relatively community. high level of training in performing this 2. Development of standards and function, but it is not usually included EPHF 11: Reducing the impact of guidelines that support emergency in professional education programs. emergencies and disasters on health preparedness and disaster manage- The countries of the English-speaking ment in health The establishment of regulations and Caribbean and Netherlands Antilles standards for dealing with the impact exhibited their highest performance 3. Coordination and partnerships with and aftermaths of emergencies and in this function, with an average score other agencies and/or institutions disasters is clearly a strength of the 187 Figure 87 Performance of all the Indicators of the EPHF in the English-speaking Caribbean and Netherlands Antilles

10.1 8.4 9.2 9.4

9.3 Low 2.4 1.2 6.4 6.2 9.1 4.1 5.1 6.3 8.3 8.2 7.1 Fairly Low 1.5 5.5 10.3 8.5 4.3 3.2 3.3 3.4 2.2 5.3 4.2 1.1 1.4 3.1 7.2 8.1

10.2 Fairly High 11.1 5.2 3.5 7.4 2.3 6.1 7.3 11.3 2.5 5.4 2.1

11.4 High 11.2 1.3

0.00 0.10 0.20 0.30 0.40 0.50 0.60 0.70 0.80 0.90 1.00

EPHF 1 EPHF 5 EPHF 2 EPHF 6 EPHF 9 EPHF 3 EPHF 7 EPHF 10 EPHF 4 EPHF 8 EPHF 11

188 English-speaking Caribbean and Nether- to the capacities for orientation and reg- structure: expert support and the re- lands Antilles Region and encompasses ulation, except for the capacity for de- sources for monitoring and evaluating all aspects, except for the impact on velopment of the regulatory framework. health status; and management of mental health. On the other hand, no country showed international cooperation in public progress in preparing a national public health. Coordination between the health au- health research agenda. thority and other agencies or institutions • The development of decentralized With regard to the most traditional to confront this type of situation fre- competencies: technical assistance areas in the performance of public quently occurs in the countries of the and support for the subnational levels health, significant weaknesses were ob- English-speaking Caribbean and Nether- in reducing the impact of emergen- served in the capacity for timely re- lands Antilles, both at the national and cies and disasters on health; and tech- sponse to threats to public health. international levels. This is supported by nical assistance and support for the the existence of protocols for the dissem- subnational levels in public health Evaluating the quality of information ination of relevant information through surveillance. the communications media. for monitoring health status was also a critical area in need of strengthening. On the other hand, the primary weak- Assistance to the subnational levels in On the other hand, the principal nesses of the English-speaking Caribbean this area is widely developed in the sub- strengths of the subregion were found in and Netherlands Antilles Region which region, especially with respect to the aspects related to emergency and disas- should be included in a public health strengthening of technical capacity and ter management, the existence of public strengthening program are as follows: management of resources, thanks to health surveillance systems, and exper- a needs assessment performed at these tise in epidemiology at the NHA level. levels. • Intervention in these important pro- cesses: developing a public health Performance by intervention area 2.2.3 Identification of priority research agenda; upgrading human intervention areas The primary strengths of the majority of resources to ensure culturally appro- the countries of the English-speaking priate delivery of services; improving Performance of all indicators Caribbean and Netherlands Antilles in user satisfaction with health services; In order to identify the priority inter- performing the essential public health evaluating the quality of information; vention areas and consider their levels functions, and which should be main- responding to control public health of development, a profile of all indica- tained in the Regional plan, are as follows: problems in a timely and effective tors of the EPHF in the English-speak- manner; enforcing health regulations; ing Caribbean and Netherlands Antilles • Intervention in these important developing standards and evaluating Region is presented below, classified processes: developing standards and the quality of personal and popula- in increasing order according to low, guidelines to reduce the impact of tion-based health services; empower- low-intermediate, high-intermediate, emergencies and disasters on health; ing citizens for decision-making in and high performance (Figure 87). In surveillance systems to identify risks public health; defining national and order to facilitate the analysis, the indi- and threats to public health; coordi- subnational objectives; and promot- cators for each function have been given nation and partnerships with other ing continuing education and gradu- a different color. agencies or institutions; promotion ate training in public health. and action to improve access to nec- The principal critical areas of the subre- essary health services; and monitor- • Intervention to develop institutional gion were observed in all of the indica- ing, evaluation, and modification of capacities and infrastructure: tech- tors for the function of quality assur- the regulatory framework. nology management and health tech- ance in health services, in most of the nology assessment to support deci- aspects evaluated with regard to human • Intervention with regard to develop- sion-making in public health; and resources development, and with regard ing institutional capacities and infra- knowledge, skills, and mechanisms

189 for reviewing, improving, and enforc- by adequate evaluation of the quality of levels for the execution of most of the ing regulations. information. essential public health functions. How- ever, it is important to note the insuffi- • The development of decentralized Technology management and, in par- ciency of these actions in the areas of competencies: technical assistance ticular, development of a public health regulation and enforcement, especially and support to the subnational levels research agenda, are areas that require with regard to the strengthening of skills to ensure the quality of services; and strengthening on the part of the health and competencies. technical assistance and support to authority. the subnational levels in developing The areas requiring significant efforts and enforcing laws and regulations. c) Disease prevention and control relate to continuing training and edu- cation in public health, development The subregion has developed a high Performance according to the action of the capacity to evaluate the quality capacity for monitoring threats to pub- priorities of the World Bank of services and, especially, adaptation of lic health, based on strong laboratory human resources to the socioeconomic The indicators have been regrouped in support. characteristics of the population. order to make the results of the mea- surement operational within the frame- Nevertheless, in order to fulfill ade- 2.2.4 Conclusions work of international financing and co- quately the functions of disease preven- operation strategies. The objective is to tion and control, the health author- This analysis of the performance of the identify the action priorities based on: ity must be able to respond in a timely EPHF in the English-speaking Carib- a) significant differences in the public and appropriate fashion to the threats bean and Netherlands Antilles Region health profile of the countries and b) in- detected. demonstrates that while the countries vestment needs. The categories that are of the Region display differences, they considered and the results of the analy- d) Intersectoral intervention to share certain areas of weakness, such as sis are given below: improve health regulation and planning, management of resources, and support for the subna- In general, the English-speaking Carib- a) Development of health policies tional levels in performing the essential bean and Netherlands Antilles Region public health functions. In this area, the subregion made pro- has effectively developed intersectoral gress in defining public health objec- action, especially with respect to actions The insufficient capacity to evaluate tives and promoting citizen participa- carried out by the health authority to and prepare the information necessary tion in decision-making. promote adequate access to necessary for decision-making limits the process services and to coordinate actions with of developing policies and plans that are However, the health authorities of other agencies and institutions. adapted to the changes proposed by the the countries of the English-speaking epidemiological pattern and emerging Caribbean and Netherlands Antilles However, significant weaknesses occur sanitary problems. need strengthening in aspects related to in the formation of partnerships for the quality of services, user satisfaction, health promotion and in the efforts to The lack of trained human resources and the ability to enforce regulations. promote citizen participation in health. hinders the performance of the func- tions, and this limitation is reflected b) Collection and dissemination of e) Human resources development particularly in the capacity to enforce information to guide health policy and building institutional capacity the sanitary regulations and, thus, to in public health The countries of the Region have made ensure respect for the rights of the pop- progress in regulating aspects related The health authorities in the English- ulation with regard to health. In this to monitoring and evaluating health speaking Caribbean and Netherlands area, efforts should be made to improve status and institutional research capac- Antilles Region have made progress in the quality of human resources and the ity, but this has not been accompanied providing support to the subnational management infrastructure, as well as

190 Figure 88 Performance of EPHF indicators in the English-speaking Caribbean and the Netherlands Antilles According to Intervention Priorities

10.1 8.4 9.2 2.4 1.2 6.2 9.1 4.1 5.1 8.3 7.1 3.2 3.3 3.4 4.2

1.1 Key processes 3.1 8.1 11.1 5.2 6.1 7.3 11.3 2.1 11.2 9.3 6.3 8.2 2.2 5.3 1.4 7.2

10.2 Capacities 2.3 5.4 and infrastructure 1.3 9.4 6.4 1.5 5.5 10.3 8.5 4.3

3.5 Support to

7.4 Decentralization 2.5 11.4

0.000.10 0.200.30 0.40 0.50 0.60 0.70 0.80 0.90 1.00

EPHF 1 EPHF 5 EPHF 2 EPHF 6 EPHF 9 EPHF 3 EPHF 7 EPHF 10 EPHF 4 EPHF 8 EPHF 11

191 Figure 89 Performance of the EPHF indicators in the English-speaking Caribbean and the Netherlands Antilles Region According to the Intervention Areas Proposed by the World Bank

9.2 6.2 9.1 4.1 Public health 5.1 policy development 3.4 5.2 6.1 11.2 10.1 9.3 1.2 Collection and dissemination of 3.3 evidence for public health policy 1.1 10.2 2.4 7.1 3.1 Disease prevention 7.2 and control 11.1 2.3 2.1 3.2 4.2 7.3 Intersectoral action 11.3 8.4 9.4 6.4 6.3 8.3 8.2 1.5 5.5 10.3 Human resources development 8.5 and institutional capacity-building 4.3 2.2 5.3 1.4 8.1 3.5 7.4 2.5 5.4 11.4 1.3

0.00 0.10 0.20 0.30 0.40 0.50 0.60 0.70 0.80 0.90 1.00

EPHF 1 EPHF 5 EPHF 2 EPHF 6 EPHF 9 EPHF 3 EPHF 7 EPHF 10 EPHF 4 EPHF 8 EPHF 11

192 Figure 90 Performance of the EPHF in the Andean subregion

1.00

0.90

0.80

0.70 0.65 0.60 0.60 0.58

0.50

0.40 0.35 0.32 0.30 0.31 0.30 0.30 0.30 0.27 0.19 0.20

0.10

0.00 EPHF1 EPHF2 EPHF3 EPHF4 EPHF5 EPHF6 EPHF7 EPHF8 EPHF9 EPHF10 EPHF11

Essential Function to strengthen the mechanisms for intra- composed of Venezuela, Colombia, with respect to quality assurance in per- and extrasectoral coordination. Ecuador, Peru, and Bolivia, are pre- sonal and population-based health ser- sented below. vices (EPHF 9). Two elements, in particular, require an increased effort on the part of the health The overall performance of the coun- The remaining EPHF exhibited a dis- authorities of the English-speaking tries of the subregion with respect to creet level of performance with rela- Caribbean and Netherlands Antilles each of the EPHF evaluated is shown in tively similar results. These functions countries: incorporating the measure- Figure 90. Here the average is used as a were: health promotion (EPHF 3), so- ment of user satisfaction as a variable to summary measure in order to eliminate cial participation in health (EPHF 4); evaluate health system results, and adapt- the influence of the extreme scores in a development of policies and institu- ing the health services to the sociocultu- group of only five observations. tional capacity for planning and man- ral characteristics of the user population. agement in public health (EPHF 5); In general, the majority of the functions strengthening of institutional capacity Finally, the lack of progress in defining did not exceed a performance level of for regulation and enforcement in pub- a national public health research agenda 40% of the defined standard for this lic health (EPHF 6); evaluation and makes this a priority area for strength- measurement. promotion of equitable access to neces- ening, so that the available research ca- sary health services (EPHF 7); human pacities are oriented more effectively to- The EPHF that exhibited the best per- resources development and training in ward the sanitary objectives of primary formance were: reducing the impact of public health (EPHF 8), and public concern to these countries. emergencies and disasters on health health research (EPHF 10). (EPHF 11); monitoring, evaluation, and analysis of health status (EPHF 1); and Generally speaking, this profile indicates 2.3 Andean Countries public health surveillance, research, and that the countries of the Andean subre- control of risks and threats to public gion exhibit the most satisfactory per- 2.3.1 General results of the health (EPHF 2). formance with respect to public health measurement functions traditionally carried out by the The results of the measurement in the By contrast, the countries of the subre- public health authority. However, their countries of the Andean subregion, gion exhibited the poorest performance relatively low level of performance with

193 1 (monitoring of health status) and Figure 91 Distribution of the Performance of EPHF in the EPHF 2 (public health surveillance) rep- Andean subregion resent weaknesses for some countries. Andean subregion 1.0 The EPHF exhibiting discreet perfor- mance and high dispersion included

.8 EPHF 3 (health promotion), EPHF 4 (social participation), and EPHF 5 (de- velopment of policies and institutional .6 capacity for planning and manage- ment). In some countries, particularly .4 with respect to social participation, this level of performance may be considered

.2 a strength.

On the other hand, EPHF 9 (quality as- 0.0 surance in health services), EPHF 10 EPHF_1 EPHF_3 EPHF_5 EPHF_7 EPHF_9 EPHF_11 EPHF_2 EPHF_4 EPHF_6 EPHF_8 EPHF_10 (public health research), and EPHF 7 (evaluation and promotion of equitable access to necessary health services), ex- respect to functions related to the steer- EPHF in the five countries of the sub- hibited relatively similar performance, ing role of the health authority, such as region. The results show that two sub- indicating them as weaknesses through- planning and regulation, among others, groups take shape for the first seven out the subregion. places these countries in a weak position EPHF, one with performance generally to respond to the challenges presented above 50%, and another with perfor- 2.3.2 Analysis of the results for each by the sectoral reform process currently mance near or below 40%. Neverthe- EPHF underway throughout the continent. less, this difference is smaller in EPHF 8 to 11. In addition, the performance of The performance of each of the essen- Within the same context, it is troubling each country varies with respect to each tial public health functions in the sub- to note the weakness of the countries in of the EPHF, indicating that although region is analyzed in detail below. performing functions related to health some areas are critical in some coun- promotion and social participation, tries, these same areas are more highly EPHF 1: Monitoring, evaluation, and which are major elements in achieving developed in others. analysis of health status improvements in public health condi- In the Andean subregion, average per- tions. The same applies to the promo- Figure 91 shows the average scores, the formance of the function for monitor- tion of equitable access to necessary first standard deviation (representing ing, analysis, and evaluation of public health services. 66% of the countries), and the maxi- health status was approximately 60%. mum and minimum scores13 for each It is also troubling to note the subre- function in the subregion. The greatest strengths with regard to gion’s poor performance with respect to this function were technical support human resources development, given As the Figure indicates, the most clearly and assistance, assistance to the subna- that this function is vital to strengthen- well-performing function for the group tional levels of public health, and the ing public health. is EPHF 11 (reducing the impact of institutional capacity for expert support emergencies and disasters). While EPHF and resources (Figure 92). All of the The overall performance of the group countries have access to computer exhibits differences upon analysis of the 13 Results identified as aberrant in the statis- equipment for managing current health dispersion in the performance of each tical analysis are excluded here. status information in a timely fashion.

194 disseminate health status information is Figure 92 Performance of the Indicators for EPHF 1 in the limited. Andean subregion

1.00 The area with the lowest overall devel- opment in the subregion is the eval- 0.90 uation of the quality of information, 0.80 primarily because there are no entities 0.69 0.70 0.67 0.61 devoted to this purpose and because 0.60 audits to evaluate the quality of infor- 0.50 mation are not performed periodically. One factor that heightens deficiencies 0.40 0.37 in this area is that information on death 0.30 0.28 certifications is untrustworthy in the 0.20 majority of the countries. 0.10

0.00 EPHF 2: Public health surveillance, 12345 research, and control of risks and threats Indicators to public health Performance of this function, although Indicators: nated to the public, and genuine con- moderate, was among the best for the cern for protecting the confidentiality of 1. Guidelines and processes for moni- Andean subregion, with an average personal information does not exist. toring health status score of 58%. In addition, although all of the coun- The areas of greatest strength in the 2. Evaluation of the quality of informa- tries of the subregion have personnel subregion were due to the existance of tion with experience and training in epi- public health surveillance systems and demiology and statistics, the capacity to technical support and assistance to the 3. Expert support and resources for monitoring health status Figure 93 Performance of the Indicators for EPHF 2 in the 4. Technical support for monitoring Andean subregion and evaluating health status 1.00

5. Technical assistance and support to 0.90 the subnational levels of public 0.80 0.75 0.75 health 0.70 0.63 0.60 0.48 Although progress has been made in the 0.50 development of guidelines and processes 0.40 for monitoring and evaluating health status, this function has not been fully 0.30 0.25 developed in all of the countries of the 0.20 subregion. The main deficiencies are the 0.10 development of guidelines for the local 0.00 level. There are no methodologies for 12345 processing and updating information, Indicators information is not periodically dissemi-

195 subnational levels (Figure 93). The sur- EPHF 3: Health promotion 4. Reorientation of the health services veillance systems are capable of identi- toward health promotion The performance of the Andean subre- fying threats that require a response by gion with respect to this function was the public health authority, are well- 5. Technical assistance and support to generally low but its behavior very het- staffed at all levels, and have adequate the subnational levels to strengthen erogeneous between countries. procedures for disseminating informa- health promotion activities. tion. The strength of technical support In general, the subregion exhibited sig- to the subnational levels is based on ex- In performing this function, the coun- nificant weaknesses in each of the eval- pert knowledge of the network, access tries of the subregion have not made sig- uated areas. However, technical assis- to training, the existence of communi- nificant progress in acknowledging the tance to the subnational levels is more cation standards, and adequate dissemi- importance of health promotion. This highly developed (Figure 94). nation of surveillance results. is evidenced by the fact that most of them exhibit weaknesses in formulating Indicators: Indicators: health promotion policies, in encourag- 1. Support for health promotion activ- ing participation in health promotion 1. Surveillance system to identify ities, the development of norms, and activities, and in promoting healthy be- threats and harm to public health interventions to promote healthy havior and environments. Nevertheless, behaviors and environments they have accepted the guidelines set 2. Capacities and expertise in public forth at international conferences and health surveillance 2. Building of sectoral and extrasec- have started to use tools that will foster 3. Capacity of public health laboratories toral partnerships for health promo- the impact and accessibility of the pub- tion lic to health promotion. 4. Capacity for timely and effective re- sponse to control public health 3. National planning and coordination Intersectoral coordination and coordi- problems of information, education, and so- nation with the civil society is an area of cial communication strategies for weakness. The promotion of social and 5. Technical assistance and technical health promotion economic policies in support of health support for the subnational levels of public health. Figure 94 Performance of the Indicators for EPHF 3 in the By contrast, the area of greatest weak- Andean subregion ness in the Andean subregion was the 1.00 capacity to respond in a timely and ef- 0.90 fective manner to control detected prob- lems. Generally speaking, the capacity 0.80 to analyze threats and harm has not 0.70 been adequately developed, protocols 0.60 0.54 have not been prepared, and the effec- 0.50 tiveness of the emergency response sys- 0.41 0.40 tem is not regularly evaluated. In addi- 0.31 0.30 tion, systems for regularly monitoring 0.22 0.19 security response trends have not been 0.20 adequately developed. 0.10 0.00 Lastly, regulation and certification of 12345 the quality of public health laboratories Indicators is limited throughout the subregion.

196 is an area of incipient development. Planning and coordination of commu- Figure 95 Performance of the Indicators for EPHF 4 in the Andean subregion nication strategies for health promotion is limited, as evidenced by the fact that 1.00 there are no entities devoted to provid- 0.90 ing the general public with information and educational materials (which tend 0.80 to be scarce). 0.70 0.60 0.48 In addition, strategies for the reorienta- 0.50 0.41 tion of the health services toward health 0.40 promotion are slowly beginning to take 0.30 0.25 shape. To this end, most of the coun- tries are preparing clinical protocols 0.20 with respect to health promotion activ- 0.10 ities at the individual level. Measures 0.00 have still not been taken to strengthen 123 primary care and human resources. Indicators

EPHF 4: Social participation in health The countries of the Andean subregion type of autonomous state institution social participation in health. This exhibited low performance of this func- that defends the rights of the public in problem is worsened by the difficulty of tion, as reflected by the average score the area of health. In addition, programs evaluating the health authority’s capac- of 32%. However, this function was a designed to inform and educate the ity both to promote good practices and strength for some countries. public with regard to their health- to provide the subnational levels with related rights have been developed. guidance and assistance in strengthen- The aspects that exhibited limited, but ing social participation activities that better development with respect to the At all levels, the majority of the coun- support decision-making in public performance of this function are related tries have community participation net- health. to strengthening social participation in works and staff trained in promoting health (Figure 95). community participation in individual EPHF 5: Development of policies and and population-based health programs. institutional capacity for planning and Indicators: management in public health 1. Empowering citizens for decision- However, the development of policies The countries of the Andean subregion making in public health aimed giving public participation a cen- exhibited low performance of this func- tral role in the definition and pursuit of tion, with an average score of 35%. The 2. Strengthening of social participation public health goals and objectives con- subregion exhibited a variable perfor- in health tinues to be weak. Indeed, the ability of mance profile, with some countries in- the countries to give account to the dicating significant progress and others 3. Technical assistance and support to public regarding health status and the indicating significant weakness. the subnational levels to strengthen management of personal and popula- social participation in health. tion-based health services is limited, as Of particular note is the subregion’s are mechanisms for using public opin- high performance with respect to the Most of the countries of the subregion ion with respect to these issues. Another management of international coopera- have formal entities for community con- area of limited development is the pro- tion in public health, but limitations in sultation and participation, and some motion of good practices with regard to the ability to define public health ob-

197 limited capacity to exercise leadership in Figure 96 Performance of the Indicators for EPHF 5 in the this area. The institutional capacity for Andean subregion information-based decision-making is

1.00 0.95 limited, primarily due to limited access 0.90 to information systems. The majority of countries use strategic planning in man- 0.80 agement but acknowledge that this 0.70 methodology is not used systematically. 0.60 Human resources management is mod- 0.50 erately well developed; however, most of 0.43 0.40 0.34 the countries do not have the ability to reassign human resources based on pri- 0.30 0.21 orities and necessary changes. 0.20 0.17

0.10 All of the countries of the subregion 0.00 have resources, technology, and capaci- 12345 ties with respect to the negotiation of in- Indicators ternational cooperation and are familiar with the mechanisms and requirements of the various international organiza- jectives, both at the national and subna- and have identified the parties responsi- tions for allocating resources. However, tional levels (Figure 96). ble for implementing these plans at var- all of them exhibit deficiencies in the ious levels. Nevertheless, there is a lack ability to systematically assess outcomes Indicators: of leadership in the health improve- in collaboration with their counterparts. ment process, difficulty in developing 1. Definition of national and subna- financing mechanisms to implement The countries have personnel trained tional health objectives these plans and programs, and limita- in providing technical assistance to the tions in the design and use of indicators subnational levels, but serious limita- 2. Development, monitoring, and eval- to measure achievement of the pro- tions exist in providing assistance related uation of public health policies posed objectives. to policy, planning, and management of public health activities, in addition to 3. Development of institutional capac- the inability to identify technical assis- ity for the management of public All of the countries have implemented tance needs at the subnational levels. health systems policies that have been translated into law, and all of them have trained per- EPHF 6: Strengthening of institutional 4. Negotiation of international cooper- sonnel in these areas. In developing na- capacity for regulation and enforcement ation in public health tional plans of public health policy, al- though the health authorities seek and in public health 5. Technical assistance and support to consider the opinions of other actors The countries of the subregion exhib- the subnational levels for policy de- and recognize the national importance ited low performance of this function, velopment, planning, and manage- of agreements; they usually lack the abil- with the exception of one country for ment in public health. ity to lead this process effectively limit- which it may be considered sufficiently ing the participation of other sectors. developed. Most of the subregion’s national health authorities develop plans with goals and In most of the countries, although The only area with respect to which the objectives for achieving health priori- human resources trained in public health countries exhibited moderate develop- ties, based on the health system profile, management are available, they have ment was the capacity of the NHA to

198 tions, competent and skilled enforce- Figure 97 Performance of the Indicators for EPHF 6 in the ment teams, and institutional resources, Andean subregio significant obstacles exist to obtaining 1.00 sufficient financial resources to enforce

0.90 the regulatory framework. Inspectors are provided with orientations, but on- 0.80 going inspector training programs do 0.70 not exist. 0.60 0.54 0.50 The health authorities of most of the 0.40 countries have developed mechanisms 0.27 for providing support to the subna- 0.30 0.23 0.19 0.20 tional levels in the event of complex en- forcement situations. However, techni- 0.10 cal assistance is usually not provided for 0.00 1234 drafting and enforcing laws and regula- tions, protocols for providing manage- Indicators rial support have not been developed, and technical assistance that has been provided is not periodically evaluated. prepare regulatory frameworks. The lations are not always performed. All of other areas exhibited limited develop- the countries acknowledge as a weak- EPHF 7: Evaluation and promotion ment (Figure 97). ness the fact that the regulatory frame- of equitable access to necessary health work is usually not reviewed or modi- services Indicators: fied in a timely fashion, but rather in The countries of the Andean subregion response to external pressure. 1. Periodic monitoring, evaluation, exhibited limited performance of this and modification of the regulatory function, with an average of score of framework Although the countries of the Andean 37% of the optimal score for this mea- subregion have personnel in charge of surement. 2. Enforcement of laws and regulations enforcement tasks, the health authori- ties do not have systematic processes for In performing this function, the coun- enforcing regulations. This is evidenced 3. Knowledge, skills, and mechanisms tries have achieved moderate progress in by the absence of guidelines for the en- for reviewing, improving, and en- promoting access to necessary health forcement process, the irregular devel- forcing the regulations services and in taking actions to improve opment of bodies devoted to providing it, but they do not exhibit acceptable training and education with regard to 4. Technical assistance and support to levels of development in other areas regulatory compliance, and the lack of the subnational levels of public (Figure 98). health in developing and enforcing incentives for compliance. In general, laws and regulations policies and plans aimed at preventing corruption in the public health system Indicators: In the effort to perform this function, and abuse of authority by inspectors 1. Monitoring and evaluation of access most of the countries of the Region have not been developed. to necessary health services have adequate resources and technical assistance to formulate regulations, but Although most of the countries have 2. Knowledge, skills, and mechanisms timely and periodic studies of the im- sufficient institutional capacity to per- for improving access by the popula- pact or adverse effects of current regu- form regulatory and inspection func- tion to necessary health services

199 addition, the majority of the countries Figure 98 Performance of the Indicators for EPHF 7 in the have national programs aimed at elimi- Andean subregion nating barriers to access.

1.00

0.90 The countries of the Andean subregion have partially defined a basic package of 0.80 personal and population-based services 0.70 that should be available to the entire 0.60 0.58 population, and they have developed 0.50 complementary programs for promot- 0.40 ing equitable access by the population to services; however, the subnational 0.30 0.24 0.22 0.22 levels are provided with little assistance 0.20 in promoting these initiatives. 0.10 0.00 EPHF 8: Human resources development 1234 and training in public health Indicators All of the countries of the Andean sub- region exhibited relatively low perfor- 3. Advocacy and action to improve ac- been formed with other sectors and in- mance of this function. cess to necessary health services stitutions, particularly in the area of human resources, with respect to which Performance of each aspect of the func- 4. Technical assistance and support to weaknesses are generally understood. tion was limited, particularly with re- the subnational levels to promote Some countries have established incen- gard to improving the quality of the equitable access to health services. tives for service providers designed to workforce, which was the greatest weak- increase equitable access to services. In ness of this function (Figure 99). Although information is available in the majority of the countries of the Region, the national authorities exhibit weak- Figure 99 Performance of the Indicators for EPHF 8 in the nesses in evaluating access to personal Andean subregion and population-based health services at 1.00 the national level. Many of them do not have indicators and have a limited ca- 0.90 pacity to identify obstacles to accessing 0.80 health care. 0.70

0.60 Only some countries have personnel 0.50 with training in reaching the commu- 0.40 0.34 0.34 nity and providing guidance in the use 0.32 of health services. 0.30 0.20 0.20

The countries of the subregion carry 0.10 0.05 out activities to promote policies or reg- 0.00 ulations designed to increase access for 12345 the neediest segment of the population. Indicators To this end, strategic partnerships have

200 Indicators: Continuing education programs are not respect to technological management frequently promoted, and their impact and health technology assessment to 1. Description of the public health is not frequently evaluated. support decision-making in public workforce health and with respect to improving Most of the countries have undertaken user satisfaction (Figure 100). 2. Improving the quality of the work- the process of upgrading human re- force sources to take into account the charac- Indicators: teristics of users, particularly the socio- 3. Continuing education and graduate 1. Definition of standards and evalua- cultural characteristics of users. training in public health tion to improve the quality of popu- lation-based and personal health The countries of the Andean subregion services 4. Upgrading human resources to en- provide the subnational levels with par- sure culturally appropriate delivery tial support in developing human re- 2. Improving user satisfaction with the of services sources, particularly through decentral- health services ized management mechanisms. 5. Technical assistance and support to 3. Systems for technological manage- the subnational levels in human re- EPHF 9: Quality assurance in personal ment and health technology assess- sources development. and population-based health services ment to support decision-making in Some of the countries of the subregion The countries of the Andean subregion public health have undertaken actions aimed at deter- exhibited their lowest performance with mining the characteristics of the work- respect to this function, with an average 4. Technical assistance and support to force and defining the required skills for score of 19% of the optimal standard the subnational levels to ensure performing the essential functions and for this measurement. quality improvement in the services. collective public health services. They have also begun to identify differences They exhibited low performance in all Some of the countries have partially de- in the composition and availability of areas of this function, particularly with veloped policies with respect to continu- the workforce that must be overcome.

All of the countries, with greater or Figure 100 Performance of the Indicators for EPHF 9 in the lesser limitations, tend to periodically Andean subregion evaluate the characteristics of the exist- ing public health workforce. However, 1.00 only one has carried out a qualitative 0.90 analysis of these characteristics, and 0.80 none have prepared job profiles. 0.70

0.60 Nearly all of the countries have devel- 0.50 oped strategies for improving the qual- 0.40 ity of the public health workforce, al- 0.32 though these strategies are limited by 0.30 0.25 the lack of accreditation standards and 0.20 guaranteed levels of training. Incentives 0.10 0.07 for professional service careers, pro- 0.02 0.00 grams that include ethical issues, and 1234 performance evaluation systems have Indicators not been established in the subregion.

201 ously improving the quality of health Figure 101 Performance of the Indicators for EPHF 10 in the services. Standards have not been suffi- Andean subregion ciently developed, and national perform- ance goals for population-based services 1.00 have not been established. The quality of 0.90 personal health services is certified and inspected with some regularity. How- 0.80 ever, the use of instruments to measure 0.70 results is limited, and results are usually 0.60 not divulged. None of the countries have 0.50 0.43 0.39 an independent agency devoted to eval- 0.40 uating and certifying quality. 0.30

0.20 With regard to the evaluation of user satisfaction, some countries have devel- 0.10 0.05 oped mechanisms for gauging the gen- 0.00 123 eral response of the public through sur- veys. These evaluations do not refer to Indicators specific personal or population-based services. Unfortunately, the results of these limited efforts have not been used performance with regard to the develop- To some extent, all of the countries of to make decisions with respect to im- ment of institutional research capacity the Region have implemented strategies proving health services or upgrading and providing technical assistance to the for the development of institutional re- health personnel. subnational levels (Figure 101). search capacity, but only three are ready to engage in dialogue with other re- Efforts to develop technological man- Indicators: search organizations. The majority of agement systems or health technology the countries stated that they have au- 1. Development of a public health re- assessment mechanisms are at a very tonomous capacity to do research in search agenda early stage throughout the subregion. public health, a process for which pro- tocols have been partially established in 2. Development of institutional re- two countries and for which they have The subnational levels are provided search capacity equipment and computer programs. with some technical assistance in col- The main limitation is the number of lecting and analyzing information on 3. Technical assistance and support for personnel trained to analyze and update the quality of population-based health research in public health at the sub- the available information. services. Little technical assistance is national levels provided for technology assessment. To a greater or lesser extent, the health With regard to the development of a authorities of the Andean subregion EPHF 10: Public health research public health research agenda, some have the capacity to provide the subna- The Andean subregion exhibited low countries were only able to identify a tional levels with technical assistance performance of this function, with an particular department of the public concerning research methodology, par- average score of 30%, a score shared by health authority with the capacity to ticularly in areas related to epidemic four of the five countries of the Region. oversee this program. With few excep- outbreaks. Only one or two countries tions, national research agendas have provide technical assistance in order to The countries demonstrated the least not been formulated with the full par- study the effectiveness population- progress with regard to developing a re- ticipation of the affected parties, and based interventions, health services, or search agenda. They exhibited moderate they have not been evaluated. community health.

202 The same observations apply to the in- preparedness and disaster manage- All the countries of the subregion have terpretation of results. Limited support ment in health designed strategies and developed health is provided for research at the subna- standards for the national plan of emer- tional levels and for using results to im- 3. Coordination and partnerships with gencies that encompass most of the per- prove public health practices. other agencies and/or institutions tinent aspects, generally excluding those related to the construction and mainte- EPHF 11: Reducing the impact of 4. Technical assistance and support to nance of physical infrastructure. emergencies and disasters on health the subnational levels to reduce the impact of emergencies and disasters The countries of the Region have gener- The countries of the Andean subregion on health. ally not established standards for dealing exhibited their best performance with with the aftermath of disasters, except regard to this function, with some Although all of the countries of the sub- for standards designed to facilitate the achieving very satisfactory scores. region have institutionalized national delivery of services during emergencies, plans to support emergency prepared- which is the most important function of The lowest level of development in this ness and disaster management in the health sector in these situations. function is in the area of management. health, as well as units within the health The remaining areas showed moder- authority in charge of this area, the Coordination between the health au- ately high levels of development. (Fig- quality and coverage of the plans vary. thority and other sectors or agencies ure 102). This is primarily due to deficiencies in does take place throughout the sub- sectoral coordination and in mecha- region, although the level of coverage Indicators: nisms for periodically evaluating the and commitment varies. Coordination 1. Reducing the impact of emergencies plan. is usually handled by the national civil and disasters defense organization or by other bodies Health personnel receive training in with multisectoral responsibility. All of 2. Development of standards and this area, but it is still not part of pro- the countries have established interna- guidelines that support emergency fessional development programs. tional partnerships in order to address emergencies.

The majority of the countries provide Figure 102 Performance of the Indicators for EPHF 11 in the adequate assistance to the subnational Andean subregion levels in reducing the impact of emer- gencies and disasters. To varying de- 1.00 grees, the countries collaborate with the 0.90 0.85 0.83 subnational levels with regard to build- 0.80 0.74 ing response capacity, preparing regu- 0.70 lations, and identifying the parties

0.60 responsible for managing emergency plans. General weakness was observed 0.50 in the ability to evaluate needs at the 0.36 0.40 subnational levels. 0.30 0.20 2.3.3 Identification of priority 0.10 intervention areas 0.00 Performance of all indicators 1234 Indicators In order to identify the priority inter- vention areas and consider their levels

203 Figure 103 Performance of the indicators of the EPHF in the in the Andean subregion

9.3 10.1 8.2 9.2 5.1 3.4 6.2 8.3 Low 5.5 7.2 7.1 3.1 6.4 7.4 9.4 4.3 2.4 6.3 1.2 3.2 9.1 8.5 8.1 8.4

5.3 Fairly Low 11.1 1.1 10.3 3.3 4.1 5.2 10.2 4.2 2.2 3.5 6.1 7.3 1.3

2.3 Fairly High 1.5 1.4 11.3 2.5 2.1

11.4 High 11.2 5.4

0.00 0.10 0.20 0.30 0.40 0.50 0.60 0.70 0.80 0.90 1.00

EPHF 1 EPHF 5 EPHF 2 EPHF 6 EPHF 9 EPHF 3 EPHF 7 EPHF 10 EPHF 4 EPHF 8 EPHF 11

204 of development, a profile of all indica- tus, and developing the capacity to re- should be included in a public health tors of the EPHF in the Andean sub- spond to public health threats in a strengthening program, are as follows: region is presented below, classified in timely and effective manner. increasing order according to low, low- • Intervention in these important intermediate, high-intermediate, and high The subregion’s primary strengths were processes: developing public health performance (Figure 103). In order to noted in the management of interna- research agendas; improving user sat- facilitate the analysis, the indicators for tional cooperation, in the other indica- isfaction with health services; defin- each function have been given a differ- tors related to disaster management, ing national and subnational public ent color. and in the availability of public health health objectives; reorienting health surveillance systems. services toward health promotion; The general profile indicates significant enforcing health regulations; contin- weaknesses in the Region with respect to Performance by area of intervention uing education and graduate training virtually all of the indicators for EPHF 9 The primary strengths of the majority in public health; monitoring and (quality assurance), particularly con- of the countries of the Andean subre- evaluating access to necessary health cerning the improvement of user satis- gion in performing the essential public services; supporting health promo- faction. With regard to human resources health functions, which should be tion activities and developing stan- development, it is especially critical to maintained in the subregional plan, are dards and interventions to encourage improve the quality of human resources as follows: healthy behavior and environments; and to improve continuing education responding to control public health and training activities. In particular, • Intervention in these important pro- problems in a timely and effective weaknesses were noted in levels of cesses: developing standards and manner; evaluating the quality of in- knowledge and expertise for the devel- guidelines to reduce the impact of formation; establishing sectoral and opment of strategies to improve public emergencies and disasters on health; extrasectoral partnerships for health access to health services and activities surveillance systems to identify risks promotion; defining standards for aimed at enforcing the health regulatory and threats to public health; and co- and evaluating the quality of personal framework. ordination and partnerships with and population-based health services; other agencies or institutions to re- describing the public health work- The institutional capacity for public duce the impact of emergencies and force; upgrading human resources to health management and sectoral man- disasters on health. ensure culturally appropriate delivery agement in the event of emergencies of services; managing activities aimed and disasters are also regarded as critical • Intervention with regard to develop- at reducing the impact of emergen- areas. ing institutional capacities and infra- cies and disasters; and maintaining structure: management of interna- guidelines and processes for monitor- In general, efforts to define national tional cooperation in public health. ing and evaluating health status. and subnational health objectives to guide public and sectoral policy are in a • The development of decentralized • Intervention to develop institutional very early stage of development. Weak- competencies: technical assistance capacities and infrastructure: technol- nesses were also noted with respect to and support for the subnational levels ogy management and health technol- developing and enhancing health poli- in reducing the impact of emergen- ogy assessment systems to support cies that are in accord with new health cies and disasters on health; and tech- decision-making in public health; im- challenges. nical assistance and support for the proving the quality of the workforce; subnational levels in public health knowledge, skills, and mechanisms As in other subregions of the Americas, surveillance, research, and the control improving access by the population to limited progress has been made with re- of risks and threats to public health. programs and services; knowledge, spect to developing national health re- skills, and mechanisms for reviewing, search agendas, evaluating the quality of On the other hand, the primary weak- improving, and enforcing regulations; information used to monitor health sta- nesses of the Andean subregion, which and developing institutional capacity

205 Figure 104 Performance of EPHF indicators according to the priority areas of intervention

10.1 9.2 5.1 3.4 6.2 8.3 7.1 3.1 2.4 1.2 3.2 9.1 8.1 8.4 11.1 1.1 Key processes 3.3 4.1 5.2 4.2 6.1 7.3 11.3 2.1 11.2 9.3 8.2 7.2 6.3 5.3 10.2 2.2 1.3 Capacities

2.3 and infrastructure 1.4 5.4 5.5 6.4 7.4 9.4 4.3 8.5 10.3 3.5 Support to 1.5 Decentralization 2.5 11.4

0.000.10 0.200.30 0.40 0.50 0.60 0.70 0.80 0.90 1.00

EPHF 1 EPHF 5 EPHF 2 EPHF 6 EPHF 9 EPHF 3 EPHF 7 EPHF 10 EPHF 4 EPHF 8 EPHF 11

206 Figure 105 Performance of the EPHF Indicators According to priority areas of intervention proposed by the World Bank

9.2 5.1 3.4 6.2 9.1 Public health 4.1 policy development 5.2 6.1 11.2 9.3 10.1 1.2 Collection and dissemination of 1.1 evidence for public health policy 3.3 10.2 7.2 7.1 3.1 Disease prevention 2.4 and control 11.1 2.3 2.1 3.2 4.2 Intersectoral action 7.3 11.3 8.2 8.3 5.5 6.4 7.4 9.4 Human resources development 4.3 and institutional capacity-building 6.3 8.5 8.1 8.4 5.3 10.3 2.2 3.5 1.3 1.5 1.4 2.5 11.4 5.4

0.00 0.10 0.20 0.30 0.40 0.50 0.60 0.70 0.80 0.90 1.00

EPHF 1 EPHF 5 EPHF 2 EPHF 6 EPHF 9 EPHF 3 EPHF 7 EPHF 10 EPHF 4 EPHF 8 EPHF 11

207 for the management of public health faction and reorienting public health In this area, the subregion demon- systems (Indicator 5.3). services toward health promotion. strated good management of interna- tional cooperation, as well as good ca- • The development of decentralized In addition, policies related to the pacity for providing technical assistance competencies: technical assistance enforcement of regulations must be to subnational levels with regard to the and support to the subnational levels strengthened. essential public health functions. in policy development, planning, and management in public health; techni- b) Collection and dissemination However, it is important to note that cal assistance and support to the sub- of information to guide public human resources development needs to national levels in developing and en- health policy be strengthened in several respects. This is because the countries have not yet forcing laws and regulations; technical The countries of the subregion have succeeded in adequately defining and assistance and support to the subna- made progress in providing technical describing the public health workforce, tional levels to promote equitable ac- assistance for monitoring and evaluat- which weakens the already limited ac- cess to health services; technical assis- ing health status, but this has not been cess of the workforce to continuing edu- tance and support to the subnational accompanied by evaluations of the cation and guidance with regard to levels to strengthen social participa- quality of information. tion in health; technical assistance managing the more complex public health functions, such as developing reg- and support to the subnational levels An area of limited development is the na- ulatory policies and mechanisms, guar- to ensure quality improvement in the tional public health research agendas. anteeing equitable access to services, and services; technical assistance and sup- There is also little concern in the area of carrying out health promotion and so- port to the subnational levels in technology management and assessment. human resources development; and cial participation activities. technical assistance and support for c) Disease prevention and control research in public health at the subna- It should be noted that the NHA have tional levels. The subregion has a good surveillance taken little action to adapt human re- system, but there are deficiencies in the sources to the socioeconomic character- Profile according to the action speed and appropriateness of responses istics of the population, or to study the priorities of the World Bank to public health threats. quality of care and service providers.

The indicators have been regrouped in In addition, the NHA have not demon- 2.3.4 Conclusions order to make the results of the meas- strated the ability to improve access to This analysis of the performance of the urement operational within the frame- services or to sponsor promotional ac- EPHF in the Andean subregion demon- work of international financing and co- tivities aimed at improving the popula- strates that while the countries of the operation strategies. The objective is to tion’s quality of life. identify action priorities based on: a) subregion display differences, they share certain areas of weakness, such as regula- significant differences in the public d) Intersectoral intervention to tion and planning, social participation, health profile of the countries, and b) improve health investment needs. The categories that and health promotion. The Andean subregion has good mech- were considered and the results of the anisms for intersectoral coordination, One critical area common to all the func- analysis are given below. but it must strengthen efforts to form tions that should be underlined is the in- partnerships designed to improve the sufficient ability to manage information, a) Development of health policies implementation of health promotion which hinders the policy development In this area, the subregion exhibited activities. and planning process and makes it diffi- weakness in defining public health ob- cult to monitor and evaluate strategies jectives, and exhibited little progress in e) Human resources development aimed at making these policies and plans designing policies to improve user satis- and building institutional capacity more operational. Consequently, this in public health area should be strengthened. In addition,

208 Figure 106 Performance of the EPHF in the Southern Cone and Mexico subregion

1.00

0.90

0.80 0.75 0.70 0.70 0.67 0.70 0.65 0.66

0.60 0.51 0.51 0.50 0.47

0.40 0.35 0.29 0.30

0.20

0.10

0.00 EPHF1 EPHF2 EPHF3 EPHF4 EPHF5 EPHF6 EPHF7 EPHF8 EPHF9 EPHF10 EPHF11

Essential Function

efforts must be made to achieve qualita- used as a global measurement, in order health services (EPHF 7); development tive improvements in the human re- to avoid the influence of extreme values. of policies and institutional capacity for sources and management infrastructure, planning and management in public and to strengthen intra- and extrasectoral This subregion scores over 50% of the health (EPHF 5); health promotion communication mechanisms. pre-established measurement standard (EPHF 3); social participation in health in 8 of the 11 essential functions. (EPHF 4); and strengthening of institu- tional capacity for regulation and en- 2.4 Southern Cone As Figure 106 illustrates, the better-per- forcement in public health (EPHF 6). and Mexico forming EPHF are those related to: public health surveillance, research, and In general, the success achieved in pub- 2.4.1 Overview of EPHF control of risks and threats to public lic health research (EPHF 10) is higher Performance health (EPHF 2); monitoring, evalua- than for other subregions and higher In this chapter, we look at the measure- tion and analysis of health status (EPHF than for the entire Region. ment results for the six countries of 1); and reducing the impact of emergen- the Southern Cone (Argentina, Brazil, cies and disasters on health (EPHF 11). This shows that the countries of the Chile, Paraguay and Uruguay) and Southern Cone and Mexico have Mexico14 subregion. The worst performance by countries in achieved levels of performance in essen- the subregion is found for EPHF 9 (en- tial public health functions not only in Figure 106, above, shows the overall suring the quality of personal and pop- traditional areas, such as epidemiologi- performance achieved by countries in ulation-based health services) and for cal surveillance and the monitoring of the subregion for each evaluated EPHF. EPHF 8 (human resource development health status, but also in other, newer As this subregion comprises only six and training in public health). areas, which have been promoted as part countries, the average value has been of sectoral reform processes. These areas For the remaining EPHF, the perfor- include health promotion and evalua- 14 Mexico is included in this group of coun- mance level is average. In decreasing tion of equitable access of the popula- tries because of its geopolitical similarity with order, they are: evaluation and promo- tion to health services. Significant the countries of the Southern Cone. tion of equitable access to necessary progress has also been made in the plan-

209 source development), where overall de- Figure 107 Distribution of the Performance of each EPHF in velopment levels are regarded as aver- the Southern Cone and Mexico subregion age, and EPHF 9 (ensuring quality of

1.0 services), which scores the worst overall performance in the subregion. In this case, the performance of these functions .8 may be regarded as a strong point in some of the countries analyzed, but a .6 weakness in others. This suggests that there is room for cooperation between

.4 the countries.

2.4.2 Analysis of Results for Each .2 EPHF In this section, the performance of each 0.0 essential public health function is ana- EPHF_1 EPHF_3 EPHF_5 EPHF_7 EPHF_9 EPHF_11 EPHF_2 EPHF_4 EPHF_6 EPHF_8 EPHF_10 lyzed in the context of the subregion, and its constituent elements identified and described.

EPHF 1: Monitoring, Evaluation ning and management functions, as well tries), and maximum and minimum and Analysis of Health Status as in the promotion of equitable access values 15 for each function. to health services. In the Southern Cone and Mexico, the The Figure 107 shows also, EPHF 5 function “monitoring, evaluation and The functions that probably require (planning and management in public analysis of the people’s health status” greater impetus are those related to health), and EPHF 7 (evaluation and achieves 70% of the expected standard, more qualitative aspects of the steering promotion of equitable access to neces- according to the average value. Varia- factors of the of the health sector such sary health services) show the least dis- tion between the countries in the subre- as the regulation and enforcement of persion. We may therefore conclude gion is limited. compliance with health regulations, that these two functions generally repre- human resource development and, in sent strengths for all countries analyzed. Indicators: particular, ensuring the quality of ser- 1. Guidelines and processes for moni- vices offered to the population. EPHF 6 (strengthening of institutional toring and evaluating health status; capacity for regulation and enforcement With regard to the 11 essential public in public health) generally demon- 2. Evaluation of information quality; health functions, all countries of the strates an average to low performance Southern Cone and Mexico show cer- level with less variability. We may there- 3. Expert support and resources for tain weaknesses and strengths in public fore conclude that this is a critical area, monitoring and evaluating health health. This suggests the possibility of which should be strengthened in most status; promoting cooperation between coun- countries in the subregion. tries in the subregion in order to im- 4. Technical support for monitoring prove public health practice. The biggest variations in performance and evaluating health status; levels are found for EPHF 8 (human re- Figure 107 shows the results in terms of 15 For the purposes of this analysis, certain 5. Technical assistance and support to average value, the first standard devia- results identified in the statistical analysis as the subnational levels of public tion (equivalent to 66% of the coun- aberrant values have been excluded. health.

210 Technical assistance provided to the Figure 108 Performance of Indicators for EPHF 1 in the subnational levels for the performance Southern Cone and Mexico subregion of this function is problematical only in 1.00 terms of the timeliness of such actions. 1.00 0.90 0.85 EPHF 2: Public Health Surveillance, 0.80 0.70 Research, and Control of Risks and 0.67 0.69 0.70 Threats to Public Health 0.60 This function demonstrates the best 0.50 performance level in the subregion, 0.40 achieving an average value of 75%. This 0.30 Figure is relatively constant across all 0.20 countries analyzed.

0.10 All areas demonstrate a level of high 0.00 12345 performance, except for the one related Indicators to capacity and expertise in epidemiol- ogy, which achieves only average levels (Figure 109). All areas of this function demonstrate a The strong performance achieved with Indicators: satisfactory performance level (Figure respect to the technological support 108), especially those related to the provided to carry out this function is 1. Surveillance system to identify risks availability of experts and resources for limited by the fact that such support is and threats to public health; monitoring and evaluation. In contrast not widely used locally and by the diffi- to the rest of the Region, this subregion culties involved in having adequate ac- 2. Capacities and expertise in public is especially noteworthy for the good re- cess to maintenance. health surveillance; sult achieved in the evaluation of the quality of information. Figure 109 Performance of Indicators for EPHF 2 in the In the aspects related to guidelines and Southern Cone and Mexico subregion processes for monitoring and evalua- 1.00 tion, the periodic revision and updating 0.89 of its contents is not optimum and there 0.90 0.83 are difficulties in adequately disseminat- 0.80 0.73 ing the information that is produced. 0.70 0.63 0.59 0.60

With regard to the evaluation of the 0.50 quality of information, the countries 0.40 do recognize that the institutions ap- pointed to carry out this function are 0.30 not sufficiently independent of the 0.20 health authority. 0.10

0.00 The subregion has an adequate supply 12345 of expert support and resources to mon- Indicators itor the health status of the population.

211 3. Capacity of public health laborato- els regarding the surveillance situation munication strategies for health promo- ries; in their areas. tion;

4. Capacity for timely and effective re- EPHF 3: Health Promotion 4. Reorientation of health services to- sponse to control public health ward promotion; The performance of the subregion for problems; this function is average. The average 5. Technical assistance and support to value of 65% is relatively constant for 5. Technical assistance and support for the subnational levels to strengthen all countries. subnational levels of public health. health promotion activities. The subregion scores an average per- The surveillance system used by health All countries have formulated promo- formance in all areas. Worthy of note is authorities demonstrates a good per- tion policies that include international the good result achieved in the formula- formance level in countries of the sub- recommendations and incorporate in- tion of standards and interventions to region, but tends not to include quality formation technologies in an effort to encourage healthy behaviors and envi- of life indicators. The system has some encourage promotion. Those policies ronments (Figure 110). difficulties in obtaining information define both short-term and long term feedback and tends not to use the infor- goals. Health authorities are not always Indicators: mation produced by other national successful in eliciting the commitment agencies or institutions that also deal 1. Support for health promotion activ- of all levels and all actors, and applica- with surveillance. ities, development of norms, and in- tion of these policies is not regularly terventions to promote healthy be- evaluated. All countries promote devel- The poorer performance level exhibited haviors and environments; opment of standards and interventions with respect to expertise in epidemiol- aimed at fostering healthy behaviors ogy is linked to the limited use of 2. Building of sectoral and extrasec- and environments. geoFigureic information systems by toral partnerships for health promo- health officials of countries in the sub- tion; All countries in the subregion have set region, and this is compounded by the up a coordinating entity that brings to- lack of training in mental and occupa- 3. National planning and coordination gether other sectors in order to meet tional health. Another limitation is the of information, education and com- targets, but not all have prepared a plan frequency with which data analysis is carried out. Figure 110 Performance of Indicators for EPHF 3 in the Southern Cone and Mexico subregion With regard to public health laborato- 1.00 ries, most countries have a consolidated 0.88 network, but present certain shortcom- 0.90 ings with respect to certification of lab- 0.80 0.69 oratory quality. 0.70 0.58 0.60 0.56 0.53 Health authorities’ response capacity is 0.50 high for all countries in the subregion. 0.40 Difficulties arise only in the implemen- tation of mechanisms that recognize 0.30 good performance by those responsible 0.20 for surveillance and emergency response. 0.10

0.00 Technical assistance at subnational lev- 12345 els is adequate, but health authorities Indicators tend not to receive reports on these lev- 212 of action. Most countries have difficul- EPHF 4: Social Participation in Health sulting with citizens and taking their ties in monitoring joint activities and in opinions into account, both within for- analyzing the impact of social and eco- For this function, the countries of the mal entities and at all levels. Procedures nomic policies. Nevertheless, one of the Southern Cone and Mexico exhibit an for responding to the opinions of civil subregion’s strengths lies in its efforts to average performance, as reflected in the society have not yet been set up. promote the incorporation of these average value (51%). There is little vari- areas in health policies and in policies ation between countries. Most countries have introduced the in- on health promotion, in particular. stitution of the independent public de- The area that exhibits a better (though fense counsel with the legal status to There are community-education pro- average) performance level for this protect the health rights of the citizen. grams that are implemented jointly function is the strengthening of social with other sectors and institutions in an participation in health (Figure 111). All countries, to varying degrees, give effort to improve the people’s health public account of the population’s status. Unfortunately, promotion cam- Indicators: health status and the management of paigns are not often evaluated. The sub- health services. Citizens are not, how- 1. Empowering citizens for decision- region does not have specific entities re- ever, encouraged to offer feedback. making in public health; sponsible for informing the people and providing educational materials. 2. Strengthening of social participation With respect to the strengthening of so- in health; cial participation in health, most coun- One topic of discussion within health tries express the importance of this as a sector decision-making institutions is the 3. Technical assistance and support to key element in defining and imple- refocusing of health services toward pro- the subnational levels to strengthen menting the objectives and goals of motion. This is reflected in the presence social participation in health. public health. Accordingly, they have of project-financing mechanisms created created formal entities, usually at the for that purpose. Application of other With a view to strengthening social de- intermediate and local levels. Unfortu- strategies in the subregion is limited. cision-making power in public health, nately, very few countries offer pro- Such strategies might include payment average progress has been made toward grams for informing citizens about their mechanisms encouraging promotion of implementation of mechanisms for con- rights in health-related matters, which insurance systems, whether public or pri- vate; design of clinical protocols; or strengthening of primary care through Figure 111 Performance of Indicators for EPHF 4 in the the creation of health teams that are Southern Cone and Mexico subregion trained in promotion, are responsible for 1.00 specific population groups and carry out 0.90 specific promotion programs. 0.80 Health authorities do have expert per- 0.70 0.59 sonnel to provide technical assistance at 0.60 0.50 the subnational levels. There is only a 0.50 limited amount of material incorporat- 0.41 0.40 ing cultural diversity and limited evalu- ation of the needs of specialists in health 0.30 education at the subnational level. 0.20 There is coordination with other social 0.10 actors at this level. Moreover, good use 0.00 is made of national tools for strengthen- 123 ing the impact of, and access to health Indicators promotion. 213 is among the fundamental areas of en- Figure 112 Performance of Indicators for EPHF 5 in the abling people to assume responsibility Southern Cone and Mexico subregion for their own health. 1.00 0.90 All countries in the subregion employ 0.90 staff who are trained to promote citizen 0.81 0.80 participation and good practices for so- 0.70 0.66 cial participation in health. Most allo- 0.61 cate resources to organizations involved 0.60 in developing public health programs. 0.50 0.47

0.40 There is broad calling about the need to 0.30 promote participation in health, but this capacity is seldom evaluated. 0.20 0.10 With regard to technical assistance at 0.00 the subnational levels, all countries have 12345 the capacity to promote the develop- Indicators ment of mechanisms for participation in decision-making on public health, but show evidence of difficulties in eval- 2. Development, monitoring and eval- All countries in the subregion have ap- uating the impact of these actions and uation of public health policies; plied policies that are reflected in bodies ensuring a response that is adequate for of law, for which they have trained staff. the needs expressed by the population 3. Development of institutional capac- Development of the national plan for at those levels. ity for the management of public public health policies is a process spear- health systems; headed by the health authority, with the EPHF 5: Development of Policies and participation of other sectors. Moreover, Institutional Capacity for Planning and 4. Negotiation of international cooper- the capacity for monitoring and evaluat- Management in Public Health ation in public health; ing those policies is generally high. Performance for this function in the 5. Technical assistance and support to There is evidence of strong leadership subregion is average. The average value the subnational levels for policy de- in health management. Consequently, of 66% is fairly uniform across the five velopment, planning, and manage- most countries do have technical ex- countries concerned. ment in public health. pertise, while planning, decision-mak- ing and evaluation of activities are usu- With regard to this function, particu- Most countries in the subregion develop ally based on data. Furthermore, there larly noteworthy is the high level plans with goals and objectives related is generally adequate coverage in terms achieved in the monitoring and evalua- to health priorities, based on the health of information-systems (which are defi- tion of public health policies and in the system profile. This process is led by the cient only in terms of quality), person- management of international coopera- health authority and complemented by nel trained to use such systems, and tion in public health. However, the ca- officials appointed to implement those mechanisms for supervision and evalua- pacity of the NHA to assist in these goals and objectives at the different lev- tion. However, this subregion still does matters at the subnational levels is els. The design and use of indicators for not make use of performance indicators somewhat more limited (Figure 112). measuring compliance with the pro- that make it possible to continue im- posed objectives is generally good. Nev- proving management in public health. Indicators: ertheless, problems do arise with fund- 1. Definition of national and subna- ing mechanisms that tie management to Organizational development, which ex- tional health objectives; certain health objectives. hibits shortcomings in all areas, is one 214 of the areas of least progress in the Figure 113 Performance of Indicators for EPHF 6 in the countries under consideration. Southern Cone and Mexico subregion

With respect to resource management, 1.00 most countries in the subregion have 0.90 0.85 adequate capacity as well as experience 0.80 in reallocating resources according to health priorities and observed needs. 0.70 0.60 0.53 Management of international coopera- 0.50 0.38 tion is adequate in all countries in the 0.40 subregion, thanks to the fact that they 0.30 0.27 have the necessary resources, technol- 0.20 ogy, and capacities, and are familiar with the various international organiza- 0.10 tions’ mechanisms and requirements for 0.00 1234 the allocation of resources. Only one of Indicators the countries analyzed exhibits certain shortcomings in this area.

With regard to technical assistance at the Figure 113 illustrates, this is not re- those regulations are not always re- subnational level, the countries under flected in the results, which show a low viewed on a sufficiently timely and reg- consideration do have trained staff, but performance for institutional ability to ular basis to study the impact or adverse demonstrate certain shortcomings in the enforce norms. effects of the regulations established. areas of policy definition, strategic plan- ning and ongoing improvement of Indicators: Although in the subregion those respon- management. The greatest difficulties sible for overseeing compliance of regu- demonstrated by the subregion are 1. Periodic monitoring, evaluation and lations have been identified and guide- linked to the inability to detect technical modification of regulations; lines to support them have been made assistance needs at those levels. 2. Enforcement of laws and regula- available, health authorities do not es- tions; tablish systematic procedures to enforce EPHF 6: Strengthening of Institutional regulations. This is reflected in the lack Capacity for Regulation and 3. Knowledge, skills, and mechanisms of supervision for the enforcement Enforcement in Public Health for reviewing, improving and en- process, the absence of regular activities In this subregion, performance for this forcing regulations; by training and education bodies re- function is among the poorest of the 11 garding compliance with regulations EPHF under consideration. The aver- 4. Technical assistance and support to and the provision of incentives for com- age value is 47%, and there is limited the subnational levels of public pliance. In general, policies and plans to variation among the countries con- health in developing and enforcing prevent corruption in the public health cerned, which confirms its position of laws and regulations. system have not been developed. weakness across the subregion. In order to perform the function of reg- Most countries exhibit sufficient insti- Of particular note for the group of ulation and enforcement in public tutional capacity to perform regulatory countries in the subregion are the high health, most countries of the Southern and enforcement functions, and have level of development of processes for Cone and Mexico have adequate re- competent and skilled teams and insti- monitoring regulations and the strong sources and technical assistance for the tutional resources. However, they ex- capacity for enforcement. However, as formulation of regulations, although hibit marked limitations in terms of ac- 215 cess to the financial resources needed to Figure 114 Performance of Indicators for EPHF 7 in the enforce regulations and in terms of the Southern Cone and Mexico subregion volume of human resources needed to 1.00 perform this function. Orientation ac- 1.00 tivities are provided for enforcement of- 0.90 ficials, but long-term training plans are not provided. 0.80 0.73 0.76 0.70 In their dealings with the subnational 0.60 levels, health authorities in most coun- 0.50 0.40 tries of the subregion have developed 0.40 support mechanisms for complex en- 0.30 forcement situations, but there is gener- ally no technical assistance for the for- 0.20 mulation and enforcement of laws and 0.10 regulations. Protocols that support the 0.00 management at subnational level have 1234 not been developed, and there is no reg- Indicators ular evaluation of the technical assis- tance provided. 3. Advocacy and action to improve ac- services, although there are flaws in the EPHF 7: Evaluation and Promotion cess to necessary health services; methods used to inform society. More- of Equitable Access to Necessary Health over, health authorities do not evaluate Services 4. Technical assistance and support to this capacity often enough. Performance for this function is aver- the subnational levels to promote age. The average value is 67% and there equitable access to health services. Countries in the subregion carry out ac- is little dispersion among countries in tions to promote policies or regulations the subregion. Health authorities in the subregion to increase the access of the neediest manage the evaluation of access to es- population. Strategic partnerships have In the performance of this function, the sential services on an irregular basis, been set up for this purpose with other best-performing areas are the provision with respect both to personal and pop- sectors and institutions, especially in of technical assistance at the subna- ulation-based services. This is mainly the area of human resources. There is tional levels (which achieves very high because the process does not generally generally an awareness of inequalities. levels), followed by promotional efforts involve collaboration with other agen- In this context, three countries have in- and actions to improve access to neces- cies or institutions, and obstacles to ac- troduced incentives for service pro- sary health services. However, there is cess are not fully identified (in general, viders in an effort to reduce inequalities less compliance in the monitoring and variables related to ethnicity, culture, re- in access to services. Most countries do evaluation of access to necessary services ligion, language, or physical or mental have national programs to resolve access (Figure 114). disability are not included). Also, not problems. all countries analyzed use methodolo- gies for the detection of inequalities. Health authorities in the Southern Indicators: Consequently, there is less promotion Cone and Mexico have enough capacity 1. Monitoring and evaluation of access of equity in access to essential health to provide assistance at the subnational to necessary health services; services. levels in all areas, such as in the defini- tion of the basic package of personal 2. Knowledge, skills, and mechanisms There are enough staff who are trained and population-based services that for improving access by the popula- to work with the community and advise should be available to the whole popu- tion to necessary health services; the population on how to use health lation, identification of unmet needs 216 and obstacles to access, and develop- Indicators: tion systems that can show the distribu- ment of complementary programs for tion of the workforce and produce an 1. Description of public health work- working with the community to pro- up-to-date and complete inventory. force; mote equitable access to services. There is little coordination with other institutions to evaluate the quantity and 2. Improving the quality of the work- EPHF 8: Human Resources Develop- quality of public health workers. force; ment and Training in Public Health This is one of the poorer-performing 3. Further education and graduate In the countries of the Southern Cone functions in the subregion, with an av- training in public health; and Mexico, health authorities formu- erage value of 35%. Nevertheless, there late accreditation and certification regu- are major differences between the dif- 4. Upgrading human resources to en- lations to facilitate the hiring of public ferent countries, which means that it is sure culturally appropriate delivery health workers. Compliance with these a satisfactory performance function in of services; regulations is evaluated regularly. There some of them. are also well-defined training policies, 5. Technical assistance and support to which are supported by teaching in- The Southern Cone and Mexico subre- the subnational levels in human re- stitutions, and with which the basic gion exhibits a good overall perfor- sources development. public health education plans have been mance both in the definition of the developed. characteristics of the public health Health authorities in the subregion have workforce and the provision of technical sufficient capacity to define the needs of Unfortunately, the impact of these poli- assistance at the subnational levels. This staff in the public health sector, by de- cies is not evaluated often enough. This is contrasted by countries’ low scores for scribing its profile and identifying the is also the case with plans to improve improving the quality of, and providing skills required. They are successful in the quality of the public health work- continuing education to human re- identifying differences at the national force. sources, as well as training aimed at re- level. However, there are problems with sponding to users’ changing needs (Fig- the evaluation of the existing workforce, Although health authorities provide ure 115). notably the limited access to informa- opportunities to develop leadership in public health and have the ability to identify potential leaders, no effort is Figure 115 Performance of Indicators for EPHF 8 in the made to encourage leaders to remain Southern Cone and Mexico subregion over the long-term, and there are no in- centives to improve the capacities of 1.00 their public health workers. 0.90

0.80 The area that exhibits the least develop-

0.70 ment on the part of health authorities 0.58 in the countries under consideration is 0.60 0.50 the availability of systems to evaluate 0.50 the performance of public health work- 0.40 0.32 ers. This evaluation is carried out only 0.30 on a partial basis in two of the five 0.21 0.20 0.20 countries in the subregion.

0.10

0.00 In order to promote continuing educa- 12345 tion and graduate training in public Indicators health, a certain degree of coordination has been developed with educational 217 entities, but trained staff are not moni- Figure 116 Performance of Indicators for EPHF 9 in the tored, and no strategies have been im- Southern Cone and Mexico subregion plemented to ensure that they remain in their jobs over the long term. 1.00

0.90 In this subregion, adaptation of human resources to provide services that corre- 0.80 spond to users’ characteristics is poor. 0.70 This is mainly due to ignorance of the 0.60 0.52 existing obstacles and the lack of poli- 0.50 cies for hiring a culturally appropriate 0.40 0.34 workforce. 0.30 0.23 0.17 Nevertheless, technical assistance pro- 0.20 vided for human resources development 0.10 at the subnational level is generally 0.00 good. Strategies are applied to ensure 1234 access to continuous training programs Indicators that take into account local sociocultu- ral characteristics and to ensure devel- sonal and population-based health nately, there are problems with dissemi- opment of the capacity for decentral- services; nating evaluation results to providers ized planning and management of these and users. Four of the five countries resources, as well as the implementation 2. Improving user satisfaction with have an autonomous and independent of measures to support them. health services; agency for the accreditation and evalua- tion of individual service quality. EPHF 9: Ensuring the Quality 3. Systems for technological manage- of Personal and Population-based ment and health technology assess- Only in two countries in the subregion Health Services ment to support decision-making in have health authorities succeeded in en- public health; couraging the community to evaluate This is the function with the lowest per- user satisfaction with the health services formance level in the countries of the 4. Technical assistance and support provided. This evaluation, both of per- Southern Cone and Mexico, with an for the subnational levels to ensure sonal and population-based services, is average value of 29%. However, there is quality of services. carried out with limited frequency and a significant amount of performance does not involve all pertinent actors. dispersion, and two countries achieve All countries, to varying degrees, imple- The results, which generally make it average performance levels. ment policies for the continuous im- possible to orient strategies toward im- provement of health services, which take proving access, are not disseminated to The performance of countries in this into account standards and performance the community or to providers. subregion is low in all the relevant areas, goals at the national level, and whose except in the definition of standards implementation is evaluated on a more Technical management and assessment and in the evaluation to improve the or less regular basis. This process incor- of technologies is an area of limited de- quality of personal and population- porates the use of new methodologies velopment in the Region. Although based health services (Figure 116). for quality assessment and includes eval- health authorities have tried to promote uation of user satisfaction. National au- them and have identified the responsible Indicators: thorities have achieved good progress entities, their opinions are not generally 1. Definition of standards and evalua- with such strategies, both for personal taken into account in decision-making tion to improve the quality of per- and population-based services. Unfortu- or in the formulation of health policies.

218 Furthermore, strategies are not imple- Institutional capacity and technical as- research, thanks to the availability of mented to ensure that the existing sys- sistance at the subnational levels, on the technical teams capable of conducting tem of technology management oper- other hand, demonstrate an adequate autonomous research, as well as instru- ates adequately. Only in three countries performance level (Figure 117). ments for qualitative and quantitative is there a certain degree of assessment of analysis for research into public health available technologies and advocacy of Indicators: problems and for support of appropri- their use by decision-making bodies. ate information systems. 1. Development of a public health re- search agenda; Support to the subnational levels to en- The health authorities of the countries in sure quality of services is limited. Al- 2. Development of institutional re- the subregion do provide adequate tech- though technical assistance in method- search capacity; nical assistance to the subnational levels ologies of data collection and analysis regarding methodologies for operational is good, only one of the countries 3. Technical assistance and support for research in public health and the in- analyzed promote the use of tools for research in public health at the sub- terpretation of results. Furthermore, ef- the management and evaluation of national levels. forts are made to promote participa- technologies. tion of professionals at those levels in na- All countries in the subregion have de- tional research. What has still not been EPHF 10: Research in Public Health veloped a public health research agenda, achieved, however, is the creation of a The public health research function ex- but its content is generally limited to an network of institutions that might bene- hibits an average performance in the awareness of the existing potential fund- fit from the results of pertinent research. subregion, with an average value of ing sources and cooperation agencies. 51% and limited variation among the Implementation is evaluated in only one EPHF 11: Reducing the Impact of different countries. of the five countries analyzed. Emergencies and Disasters on Health This is one of the functions with a good Of the three areas, the one that exhibits In the Southern Cone and Mexico ex- performance in the countries in the the least progress relates to the develop- ists there is good development of the subregion, with an average value of ment of a public health research agenda. institutional capacity for public health 70% and limited dispersion.

Figure 117 Performance of Indicators for EPHF 10 in the In the performance of this function, Southern Cone and Mexico subregion countries have achieved high perform- ance levels in technical assistance at the 1.00 subnational levels and the development 0.90 of standards and guidelines. It is note- 0.77 0.80 worthy is the low level achieved in re- 0.70 0.63 ducing the impact of emergencies and 0.60 disasters (Figure 118).

0.50 Indicators: 0.40

0.30 1. Reducing the impact of emergencies 0.20 and disasters; 0.13 0.10 2. Development of standards and 0.00 123 guidelines that support emergency Indicators preparedness and disaster manage- ment in health;

219 disasters is carried out adequately, both Figure 118 Performance of Indicators for EPHF 11 in the with respect to collaboration with those Southern Cone and Mexico subregion levels in order to establish a response 1.00 capacity, and with respect to support for the drafting of regulations and the iden- 0.90 0.88 tification of staff to manage emergency 0.76 0.80 0.72 plans. Unfortunately, even though health 0.70 authorities do have the ability to detect 0.60 needs at the subnational levels, the re- 0.50 sources needed to respond to those needs 0.40 0.40 are not forthcoming.

0.30 2.4.3 Identifying Priority 0.20 Intervention Areas 0.10 2.4.3.1 Performance of All EPHF 0.00 1234 Indicators Indicators In order to identify the priority inter- vention areas and consider their devel- opment level, a profile of all EPHF in- 3. Coordination and partnerships with of health standards for a national emer- dicators for the subregion is presented other agencies and/or institutions; gency preparedness plan. The areas that below, classified in ascending order ac- exhibit less progress in this area are those cording to whether their performance 4. Technical assistance and support to related to mental health, standards for level is low, low-intermediate, high- the subnational levels to reduce the donation of drugs and medical supplies, intermediate or high (Figure 119). In impact of emergencies and disasters and the construction and maintenance order to facilitate the analysis, the indi- on health. of the health infrastructure. cators for each function have been given a different color. All countries in the subregion have an Especially noteworthy is the good level institutional national plan for reducing achieved by three of the five countries As this overview shows, the main criti- the impact of emergencies and disasters in the development of standards for cal areas are human resource develop- on health, a unit responsible for this the delivery of health services during ment (especially quality improvement area at the health authority level, and an emergencies. allocated budget. Nevertheless, health and efforts to improve continuing edu- authorities lack the capacity to coordi- Coordination between the health au- cation and graduate training); the ab- nate the whole sector, even though they thority and other sectors or agencies is sence of a national public health re- have communication and transporta- present in all countries in the subre- search agenda to help direct research tion networks, whose operation tends gion, with a good level of coverage and toward health priorities; the low level of not to be evaluated. The responsible commitment, primarily at the national concern about user satisfaction; the in- staff is trained appropriately, but these level. There is generally coordination cipient progress in assessment of health contents are still not integrated into vo- with the respective national civil de- technologies; shortcomings in the en- cational training. fense organization or other multisec- forcement of existing health regula- toral agencies and the creation of inter- tions, and the capacity for management Health authorities in the Southern Cone national partnerships for dealing with to deal with emergencies and disasters. and Mexico have achieved an adequate emergencies. development level of strategies for re- On the other hand, there is a very good ducing the impact of emergencies and Assistance at the subnational levels for subregional performance in the provi- disasters, which includes the preparation reducing the impact of emergencies and sion of support to decentralized entities

220 Figure 119 Performance of all EPHF Indicators in the Southern Cone and Mexico subregion

10.1 9.2 8.3

8.2 Low 9.3 6.2 8.4 9.4 6.4 7.1 11.1 4.1 5.5 8.5 4.3 9.1 Fairly Low 6.3 3.5 3.3 3.4 8.1 2.2 4.2 5.3 10.3 2.4 5.1 1.1 1.4 3.2 1.2

11.3 Fairly High 2.5 7.2 7.3 11.2 10.2 5.2 2.1 6.1 1.5 11.4 3.1 2.3 5.4 High 7.4 1.3

0.00 0.10 0.20 0.30 0.40 0.50 0.60 0.70 0.80 0.90 1.00

EPHF 1 EPHF 5 EPHF 2 EPHF 6 EPHF 9 EPHF 3 EPHF 7 EPHF 10 EPHF 4 EPHF 8 EPHF 11

221 Figure 120 Performance of EPHF Indicators According to priority Areas of Intervention in the Southern Cone and Mexico subregion

10.1 9.2 8.3 6.2 8.4 7.1 11.1 4.1 9.1 3.3 3.4 8.1 4.2 2.4

5.1 Key processes 1.1 3.2 1.2 11.3 7.3 11.2 5.2 2.1 6.1 3.1 8.2 9.3 6.3 2.2 5.3 1.4 7.2 10.2 Capacities

2.3 and infrastructure 5.4 1.3 9.4 6.4 5.5 8.5 4.3 3.5 10.3

2.5 Support to

1.5 Decentralization 11.4 7.4

0.000.10 0.200.30 0.40 0.50 0.60 0.70 0.80 0.90 1.00

EPHF 1 EPHF 5 EPHF 2 EPHF 6 EPHF 9 EPHF 3 EPHF 7 EPHF 10 EPHF 4 EPHF 8 EPHF 11

222 in order to ensure access to health ser- international cooperation with regard and enforcement of regulations; and vices, the capacity and expertise to to public health. technical assistance and support to monitor health status and public health the subnational levels to ensure qual- surveillance, the capacity to manage in- • Development of decentralized compe- ity improvement in health services. ternational cooperation, and the devel- tencies: technical assistance and sup- opment of national and subnational port at the subnational levels of public 2.4.3.3 EPHF Performance by health promotion plans. health with regard to the promotion of World Bank Action Priorities equitable access to health services; technical assistance and support at the These indicators have been regrouped in 2.4.3.2 Performance by subnational levels for reducing the im- order to make the results of the meas- Intervention Area pact of emergencies and disasters on urement operational within the frame- The primary strengths of most countries health; technical assistance and sup- work of international financing and co- of the Southern Cone and Mexico in per- port at the subnational levels with re- operation strategies. The objective is to forming the essential public health func- gard to public health surveillance; and identify action priorities based on: a) sig- tions, which should be maintained in the technical assistance and support at the nificant differences in countries’ public subregional plan, are the following: subnational levels of public health. health profile, and b) investment needs. The categories considered and the results of the analysis are given below: • Intervention in the following impor- On the other hand, the primary weak- tant processes: support for health nesses exhibited by the subregion, which a) Development of Health Policies promotion activities; preparation of should be part of a program for improv- ing public health in the Southern Cone standards and interventions designed In this area, the subregion exhibits a and Mexico, are the following: to encourage healthy behaviors and good general performance level, but environments; development of stan- • Intervention in the following impor- there is a need to apply strategies to dards and guidelines to help reduce tant processes: development of a pub- strengthen the power of the health au- the impact of emergencies and disas- lic health research agenda; continuing thority to enforce health regulations. ters on health; coordination and part- education and graduate training in Furthermore, one area that needs to be nership with other sectors and actors public health; improving user satis- strengthened is the implementation of to reduce disasters; evaluation of faction with health services; enforc- policies to improve user satisfaction with quality of information; follow-up, ing health regulations; monitoring the services provided. evaluation, and modification of regu- and evaluating access to necessary lations; promotion and action to im- health services, and sectoral manage- b) Collection and Dissemination prove access to necessary health ser- ment to reduce disasters. of Information to Guide Public vices; surveillance system to identify Health Policy risks and threats to public health; and • Intervention to develop institutional In order to develop this area adequately, development, monitoring, and evalu- capacities and infrastructure: improv- health authorities of countries in the ation of public health policies. ing the quality of the work force; im- subregion should advance in the formu- proving human resources for the de- lation of a comprehensive research • Intervention to develop institutional livery of culturally appropriate health agenda and promote technological man- capacities and infrastructure: expert services; technology management agement and technology assessment, in support and resources for the moni- and health technology assessment order to take advantage of their existing toring and evaluation of health sta- systems to support decision-making technical capacity and infrastructure. tus; development of the institutional in public health. capacity for research; capacity of the c) Disease Prevention and Control public health laboratories; knowl- • Development of decentralized com- edge, aptitudes, and mechanisms to petencies: technical assistance and Overall, this area represents a strength bring programs and services closer to support to the subnational levels of in the subregion. However, there are the population; and management of public health for the drafting of laws some areas that can be improved, espe-

223 Figure 121 Performance of EPHF Indicators according to priority Areas of Intervention proposed by the World Bank in the Southern Cone and Mexico subregion

9.2 6.2 4.1 Public health 9.1 policy development 3.4 5.1 11.2 5.2 6.1 10.1 Collection and dissemination of 9.3 3.3 evidence for public health policy 1.1 1.2 10.2 7.1 11.1 Disease prevention 2.4 and control 7.2 2.1 3.1 2.3 4.2 3.2 11.3 Intersectoral action 7.3 8.3 8.2 8.4 9.4 Human resources development 6.4 and institutional capacity-building 5.5 8.5 4.3 6.3 3.5 8.1 2.2 5.3 10.3 1.4 2.5 1.5 11.4 5.4 7.4 1.3

0.00 0.10 0.20 0.30 0.40 0.50 0.60 0.70 0.80 0.90 1.00

EPHF 1 EPHF 5 EPHF 2 EPHF 6 EPHF 9 EPHF 3 EPHF 7 EPHF 10 EPHF 4 EPHF 8 EPHF 11

224 cially in monitoring access to necessary in technological management, limits de- strengthening the leadership of the services and managing the impact of cision-making in the delivery of services health authorities in relation to the en- emergencies and disasters. that are able to meet people’s needs and tire health system. that are based on data that can improve d) Intersectoral Action to the population’s level of health. Sectoral reforms face the challenge of Improve Health strengthening the steering role of the The opportunity to advance in the health authority, and an important part This is a good area of development preparation of national research pro- of that role consists of exercising the overall, but more progress still needs to grams in public health will direct insti- EPHF that are the responsibility of the be made in creating partnerships and tutions’ efforts according to countries’ State at its central, intermediate, and strengthening social participation in health needs and priorities and to im- local levels. health. prove public health practice. The objective of identifying the e) Human Resources Development Cooperation can be initiated between strengths and weaknesses of public and Building Institutional Capacity countries in the subregion, in most health practice in the Americas is to in Public Health EPHF. In that way, those that exhibit offer the countries an operational diag- Although the development of human greater strengths in certain areas can help nosis of areas that require greater sup- resources exhibits a level of high-inter- address the weaknesses of the others. port in order to strengthen public mediate progress in most countries in health infrastructure, understood in its the subregion, health authorities must 3. Major conclusions broadest sense to include human com- strengthen decentralized institutional from the first performance petencies and the facilities and equip- ment necessary for good performance. competencies regarding regulation and measurement of the EPHF enforcement, and policy planning and in the Region The measurement exercise does not at- design, which are the two weakest areas. tempt to establish a classification of With regard to the public health work- The purpose of the first evaluation of the countries but rather offer both a Re- force, quality-improvement policies “Public Health in the Americas” (PHA) gional and subregional overview, of the must be strengthened, notably through Initiative was to provide Member States principal areas of greatest weakness, in adequate monitoring, the promotion of with a profile of the current state of pub- order to provide data to support policies continuing education institutions, and lic health practice. Using a common in- and plans for the development of pub- further efforts to adapt to the sociocul- strument, a self-evaluation was carried lic health in national, subregional, and tural characteristics of the population. out in each country of the Americas on Regional contexts. performance of the essential public 2.4.4 Conclusions health functions, based on pre-estab- The decision was made to not prepare a Analysis of EPHF performance in the lished optimum standards. The objective composite indicator comprising all the subregion indicates a good performance of this measurement exercise was to EPHF, given that each function has its level in most functions, with certain identify the fundamental areas that re- own value and includes pertinent compe- variations that are not very pronounced. quire priority actions and the elements tencies for the development of public that hinder or facilitate the development health in the countries. It would therefore However, there are common areas of of public health in the Americas. not be appropriate to construct an aver- weakness, such as the ability to enforce age using the scores on all the EPHF to regulations, the strengthening of human This comprehensive review, based on reflect the broad reality of public health resources (especially with regard to qual- the consensus of a group of expert rep- in each country or in the entire Region. ity), assessment of the population’s satis- resentatives in each country, is intended faction with the services offered, and the to provide an overview of the current Notwithstanding these considerations, decision-making power of citizens with state of public health in the Americas in the presentation of an overall picture regard to health. The latter area, which order to spur advances toward improv- allows decision makers to compare their is linked to the limited progress achieved ing public health in the future, thus reality with that of other countries and

225 to define areas of collaboration toward • An analysis of the performance pro- to improve the fundamental areas of common objectives of improving pub- file of the essential public health this function throughout the Region. lic health in their respective areas of functions shows that all the countries responsibility. have areas of better performance and • An aspect of public health that con- other areas that are more critical; stitutes a fundamental function of The instrument is not intended to have these areas differ from one country to the health authority is that of ensur- validity in the strict scientific sense of the another. With a few exceptions, one ing access to necessary health services term, given the possibility of error in the cannot point to countries with con- (EPHF 7), especially for the neediest positive or negative response to each sistently better or worse performance groups. The high correlation of per- specific question, if that response is con- on all the functions evaluated. formance levels of this function with trasted with the reality as depicted by an- performance levels of other functions other observer or by independent arbitra- considered to be “emerging” (health tion. The responses reflect the opinions • In general, the profile shows interme- promotion, social participation in of the participants in the measurement diate to low performance on the over- health, ensuring the quality of serv- exercise, which means that readers of the all set of EPHF. Two functions had ices) suggests that, in the current con- results who believe they know the na- relatively better performance: reduc- text, strengthening these new public tional situation could disagree with these ing the impact of emergencies and health functions has a key role in judgments. But despite these limitations disasters on health (EPHF 11) and guaranteeing access to health. with regard to validity, the instrument public health surveillance (EPHF 2). presents a reasonably accurate overview Nevertheless, no function exceeded • The evaluation points to priority areas of the fundamental areas for the develop- 70% fulfillment in relation to the that should be promoted within the ment of public health in the Region. standard used for the evaluation. framework of health policy develop- Special attention was given to con- ment. These include the definition of structing a common picture based on • The following functions showed national health objectives, together the consensus of a broad and represen- lower performance levels: ensuring with relevant actors including the pri- tative group of national experts regard- the quality of personal and popula- vate sector and social security, as well ing the status of the EPHF in each tion-based health services (EPHF 9) as ensuring compatibility of these ob- country, and preparing a profile of the and human resource development jectives with decisions on how to status of public health in the Region, and training in public health (EPHF structure the health system. It should through an analysis of those practices 8). These two functions also showed be noted that one of the greatest that are most clearly defined and repre- less variability of results among coun- weaknesses is the failure to define in- sentative for the entire group of coun- tries, which underscores the need to dicators that can be used to evaluate tries. This also allows each country to strengthen these areas in the great achievement of the national objectives review internally other characteristics majority of countries of the Region. over time. that show greater variability in results. • Efforts to collect and disseminate data The reports of each country reflect this • Although EPHF 5 (health policies for decision-making need to advance. important emphasis and allow national and management) shows an interme- There should be a shift from an ap- authorities to make decisions based on diate level of performance, it is im- proach centered on delivery and use more precise data concerning their re- portant to note that there is a high of health services—usually only those spective situations. correlation between this and the per- of the public sector—to a compre- formance level of almost all the other hensive view of health systems, con- 3.1 Profile of the Region functions, especially health promo- tion (EPHF 3) and strengthening of 16 Health technologies are understood here capacity for regulation and enforce- in the broadest sense, as including not only The principal conclusions, derived equipment and medicines but also health from all 41 countries taking part in the ment (EPHF 6). This highlights the care processes, clinical practice, etc., as de- self-evaluation exercise, were as follows: importance of making focused efforts fined by PAHO/WHO. 226 centrating on the areas of technologi- improvement of strategies designed fered by countries of the Region in re- cal management and evaluation of on the basis of accomplishments. cent decades, have revealed the serious health technologies16 to provide data limitations of health institutions in on safety, risk, effectiveness, effi- • Performance incentives: Where the managing their resources, it is inter- ciency, and the economic and quality existence of incentives is measured esting to note that the countries with impact of using such data to guide de- as part of the performance of the greater inequity in income distribu- cisions (by health personnel, patients, EPHF, this appears as a critical area tion (and thus more poverty) show a funding entities, insurers, planners, in all the countries of the Region. relatively better performance of the service administrators, and political This weakness is important because EPHF. This conclusion suggests that decision-makers, among others). lack of incentives undermines ef- it is possible (or at least cannot be forts to promote and reward good ruled out) that in those countries with • With respect to disease control and performance and thereby reinforce a larger at-risk population, govern- prevention, the principal shortcom- improvements in public health ments have made stronger efforts in ings are found in the adaptation of work. the field of public health. surveillance systems to new epidemi- ological challenges: mental health, • Information management: In order 4. In general, performance of the risk factors for chronic diseases, occu- to raise performance on several of EPHF in the countries with inte- pational health, and the environ- the essential public health func- grated public health systems is better ment. Although there is concern tions, it is necessary to improve the than in countries with other health about access to health services, mech- conditions of collection, analysis, systems (or very similar, in the case anisms are not available to identify and dissemination of information, of EPHF 2). The regulated mixed obstacles to access or, in particular, especially quality control of data system shows the lowest level of per- problems of inequitable access. The used to prepare public health indi- formance of public health functions absence of intersectoral coordination cators that, ultimately, guide the (except for EPHF 11). among public and private subsectors, authorities in making decisions on as well as limited progress in the over- health priorities. 5. In this regard, it is necessary to review all development of the primary health more thoroughly how health system care strategy, are areas that need to be 1. There are certain general characteris- reforms implemented in the Region, strengthened in the Region. tics of countries, such as a small oriented to regulated mixed (public- rural population, higher levels of private) systems, have affected public • When levels of performance across all school enrollment, and higher total health performance. It is known that functions are compared, several com- health expenditure, that are broadly the separation of functions in health, mon fundamental areas are seen that associated with better performance strengthening the health authority affect a set of essential public health of the EPHF. and giving it a role in regulating and functions and that should be estab- supervising the performance of other lished as priorities for strengthening 2. Although indicators of harm to health actors in the health system (insurance performance of the NHA in the ma- depend on a broad set of health and companies and providers), has been a jority of the countries. These com- quality of life factors, those countries difficult process. It is still very far mon fundamental areas that need that show better performance of the from achieving optimal performance, strengthening are as follows: functions linked to ensuring access to which, in this case, also affects per- and quality of health services also formance in public health. • Evaluation and monitoring: In gen- have better indicators of infant and eral, the countries do not periodi- maternal mortality and mortality 6. There is a set of factors, consistent cally and systematically carry out from infectious diseases. with those identified in the evalua- actions to evaluate and monitor ini- tion of the countries of the Region tiatives they have planned and im- 3. Although financial restrictions, stem- carried out under the Health for All plemented, a weakness that hinders ming from the economic crises suf- strategy, that stand in the way of bet- 227 ter public health performance. They The Southern Cone and Mexico subre- health policy and institutional capacity include the following: gion, in general, shows good perform- for regulation. ance on the majority of the EPHF, with – Limited institutional capacity for relatively minor variations. The princi- ensuring adequate interaction on pal areas of weakness that should be ad- 3.3 Bases for the preparation health matters among the State, dressed are: increasing the decision- of a public health civil society, and the general pop- making power of citizens with respect strengthening plan ulation, to support the develop- to health, increasing user satisfaction, ment of public health. monitoring access of the population to This diagnosis suggests several priority services, and advancing the preparation areas for strengthening public health: – Excessive centralization of decision- of a national program of public health making and available resources that research, provided the institutional ca- 1) For the definition of new functions has considerably limited develop- pacity is available to do so. of the national health authority and ment of the decentralized subna- strengthening the State’s steering tional levels, impeding creation of In the Caribbean, identified areas of role in health, the following, at min- innovative strategies that are close weakness include the capacity for imum, should be considered: to the population. timely and effective response to public health problems and support to the • Definition of national health ob- – Weakness of mechanisms for in- subnational levels in the performance of jectives tersectoral coordination, under- the EPHF. No country in the subregion mining the integration needed to shows progress in development of a na- • Sectoral management in accor- define and set priorities and carry tional research program. On the other dance with equitable access to out action strategies focused on hand, the countries of the Caribbean health the neediest groups, thereby hin- show notably good performance on the dering the synergy of efforts that function of guaranteeing access to nec- • Strengthening the capacity for public health requires. essary health services, especially in regulation of the health system terms of encouraging provider institu- tions to ensure access to health care. – Insufficient development of • Financing of priority health in- mechanisms for monitoring and terventions to achieve national evaluating the impact of public The Central America subregion has a health objectives and structural policies that affect profile that is very similar to that for the health, resulting in reactive re- entire Region of the Americas, with ef- • Harmonization of service delivery, sponses by the health authorities forts to promote social participation in with particular attention to strate- rather than proactive public health health and empower citizens in public gies having greatest impact on per- measures to improve the well- health standing out as areas of achieve- sonal and population health being of the population. ment. None of the countries show progress in assessment of health tech- • The modulation of insurance nologies to guide decision-making. regimes, with emphasis on the 3.2 Specificities of each universal guarantee of necessary subregion Finally, the countries of the Andean individual and collective health Area show low levels of performance services. Since the Regional profile is also valid in all the functions, except for EPHF 1, for the subregions, the section below 2, and 11. The principal areas that In short, all this involves challenges fo- summarizes only those elements most should be strengthened are probably cused on the inclusion of public health characteristic of each subregion. those related to the development of areas in health sector reform plans.

228 2) Development of information sys- and material capacities needed for 5) Reorientation of health services to- tems, including efforts in: the exercise of authority in health ward health care and maintenance, including: • Improvement of data quality and • Increasing competencies for the standardization of information on design and evaluation of public • Development of individual and public health, essential for deci- policies that promise greater im- collective health services consis- sion-making pact on population health tent with defined health objectives

• Orientation of information sys- • Strengthening the leadership ca- • Creation of real incentives for tems to reduce equity gaps and pacity of the health ministries promotion and protection of the promote equal opportunities for through strategies such as defini- health of population groups, fam- the entire population with respect tion of national health plans and ilies, and individuals to health promotion of a reorientation of health sector reforms based on the • Development of capacity for in- principles of equity, quality, effec- • Priority assignment of resources formation analysis, with special tiveness, and sustainability. to primary care attention to public health moni- toring that integrates epidemio- 4) Human resources development and • Incentives to strengthen the com- logical surveillance and perfor- training in public health that in- mitment of citizens to their health mance evaluation of the health cludes: and promote their involvement in services decision-making on local and • Formation of partnerships with general health policies. • Strengthening of essential areas of human resources training centers information for higher-level man- to strengthen continuing educa- agement of the health system, 6) Quality assurance for personal and tion and advanced and graduate such as systems of national health population-based health services that studies in public health accounts that provide information strengthens development of: on how the economic resources of the health system are used. • Improvement of human resources • Assessment of health technologies management by promoting the and technological management in 3) Development of institutional com- decentralization of competencies, health petencies for management of public the capacity for promotion and articulation of policies, research health policies, with a view to: • Methodologies for development and production of technologies, of data-based actions in public technical cooperation, leadership, • Strengthening data-based deci- health sions and improving management and conflict resolution control systems • Definition of professional profiles • Accreditation of providers and in- stitutions • Strengthening public accountabil- necessary for performance of the ity mechanisms in health EPHF and development of strate- gies to retain trained staff • Strategies to guide health services • Promoting institutional develop- toward greater user satisfaction. ment of the health ministries, es- • Development of incentive systems pecially the definition of roles, for improving the performance of 7) Innovation in public health should structure, functions, and human public health personnel. include:

229 • Creation of national research pro- • Promote technical cooperation through • Reinforce the leadership of the health grams that respond to the coun- an exchange of successful experiences authorities in all spheres of develop- try’s health priorities from other countries, the Region, ment related to health, especially the and the world, making it possible to essential common areas of perform- • Strengthening of essential research establish networks for strengthening ance of the EPHF in the countries of public health. the Region, as outlined previously. • Promotion and development of public policies favoring health • Support the process of health sector and based on the health objectives reform, thereby strengthening public health programs. With respect to international coopera- tion, steps can be taken to:

230 A Case Study in Performance 12 Measurement at the Subnational Level: United States of America

1. Public Health in the assembled to characterize the role of nicable disease control, community out- United States of America public health in the United States. The reach and education, epidemiology and Steering Committee and a complemen- surveillance, food safety, restaurant in- 1.1 Essential Public Health tary workgroup were assembled: 1) to spections, and tuberculosis testing. Gen- Functions develop a taxonomy of the essential erally, public health agencies at the state services of public health; and 2) to de- and local level prevent epidemics and the In 1988, the Institute of Medicine iden- velop methods to address the deficien- spread of disease; protect against envi- tified the functions of public health in its cies identified in the 1988 Institute of ronmental hazards; prevent injuries; pro- landmark report, The Future of Public Medicine report. A consensus statement mote and encourage healthy behaviors; Health, (1988). The Institute identified describing the mission, vision, activities, respond to disasters and assist communi- assessment, policy development, and as- and services of public health in the ties in recovery; and assure the quality surance as the “core functions of public United States resulted from the collabo- and accessibility of health services. health.” These core functions, although ration of the Core Functions Steering meaningful to public health leaders in Committee, its workgroup, representa- 1.2 Public Health the United States, did not resonate with tives of public health service agencies Administration legislators and the general public. The and major public health organizations. inability to universally interpret the core The consensus document is commonly The Department of Health and Human functions and health care reform in the known as the “Public Health in America Services is the principal government 1990’s prompted public health leaders to Statement”. The public health functions agency responsible for protecting the describe the core functions with more outlined in this statement are trans- health of all Americans. The Depart- precision. formed into health outcomes through ment, state, local, and tribal govern- implementation of the ten essential ments and various agencies administer In 1994, the United States Surgeon public health services. health services. There are eleven operat- General (Dr. Jocelyn Elders) and the As- ing divisions in the Department, includ- sociate Secretary for Health (Dr. Phillip In 2001, 70% of local public health ing the National Institutes of Health, Lee) co-chaired a Core Functions Steer- agencies reported the provision of adult Food and Drug Administration, the ing Committee. This Committee was and childhood immunizations, commu- Centers for Disease Control and Preven- 231 tion (CDC), the Indian Health Service, CHO) database contained 2,912 en- The existence of multiple state and local the Health Resources and Services Ad- tries for local public health agencies. operational frameworks adds complexity ministration, the Substance Abuse and According to NACCHO, a local public to the task of evaluating public health Mental Health Services Administration, health agency is “an administrative or systems. the Agency for Healthcare Research and service unit of local or state government Quality, the Centers for Medicare & concerned with health and carrying The National Public Health Perfor- Medicaid Services (formerly the Health some responsibility for the health of a mance Standards Program (NPHPSP) Care Financing Administration), the jurisdiction smaller than a state.” The was created in 1997 to establish ex- Administration for Children and Fami- relationship of a local public agency to cellence in public health practice. State lies, and the Administration on Aging. the state-level public health agency and local public health agencies are not varies from state to state. Generally, independently evaluated in the National The Centers for Disease Control and state public health systems are organ- Public Health Performance Standards Prevention (CDC), in collaboration ized in either a centralized, decentral- Program. Rather, public health system with states, provides a system of health ized, shared or mixed framework as effectiveness is evaluated to determine if surveillance to monitor and prevent dis- shown below: essential public health services are ade- ease outbreaks, implements strategies to quately provided. A “public health sys- prevent disease, and maintains national • Centralized (15 states)—Local public tem is a complex network of people, sys- statistics. In addition, CDC provides health agencies are operated by the tems, and organizations working at the for the prevention of international dis- state or the state provides local health national, state and local levels. The pub- ease transmission, national immuniza- services directly without local health lic health system is distinct from other tion services, workplace safety, and en- agencies. parts of the health care system in two key vironmental disease prevention. respects: its primary emphasis on pre- • Decentralized (2 states)—Local health venting disease and disability, and its The United States health care system has agencies are managed by local govern- focus on the health of entire popula- unique characteristics that distinguish ments. tions.” Local public health systems are it from all others in the world. “U.S. subunits of state health systems. State healthcare is not delivered through a • Shared (2 states)—The state exercises public health systems are subunits of the network of interrelated components de- some control over the local health national health system. Collectively, na- signed to work together coherently, agencies. This could include the ap- tional, state, and local health systems en- which one would expect to find in a ver- pointment of a health officer or re- sure the provision of the essential public itable system. To the contrary, it is a quiring the submission of an annual health services and living conditions that kaleidoscope of financing, insurance, de- budget or health improvement plan. are conducive to health. livery, and payment mechanisms that remain un-standardized and loosely co- • Mixed (9 states)—Both centralized Partners in the National Public Health ordinated.” Because public and private and decentralized frameworks. The Performance Standards Program in- health systems are not logically inte- state serves as the local health agency clude: the American Public Health As- grated, a national framework for evalua- if none exist. A mixed framework is sociation, the Association of State and tion is essential to ensure equitable ser- commonly found where a local gov- Territorial Health Officials, the Na- vice provision. National Public Health ernment chooses not to form a local tional Association of County and City Performance Standards provide a logical health agency and the state must pro- Health Officials, the National Associa- evaluation framework to improve collab- vide services. tion of Local Boards of Health, the Pub- oration and service integration among lic Health Foundation, and the Centers health care organizations. At the local level, public health jurisdic- for Disease Control and Prevention. tions are established in accordance with Academic partners representing the As- 1.3 Public Health Systems governmental units. Local jurisdictions sociation of Schools of Public Health may correspond with counties, cities, also made considerable contributions. In 2001, a National Association of City towns, townships, special districts or any CDC and national public health organ- and County Health Officials (NAC- combination of these categorizations. izations presented the first set of drafts 232 for the performance standards to the ceptable. Minimum standards poten- The National Public Health Perfor- public in June 1999. tially create a ceiling for performance mance Standards Program is a forum for with few incentives to advance be- public health agencies to serve as cata- The overall goal of the NPHPSP is to yond this threshold. lysts and facilitators for public health improve the practice of public health by improvement. State and local agencies providing leadership in research, develop- • Public health standards apply to all take a lead role in organizing data col- ment, and implementation of optimal, communities. lection. A liaison is designated within science-based performance standards. the state health department to facilitate The specific goals of the NPHPSP are: • Performance standards should be used the data collection process. CDC and 1) to improve quality and performance not only to measure public health ca- national public health organizations co- of public health systems, 2) to increase pacity but also as a tool for achieving ordinate with state liaisons to arrange re- accountability, and 3) to further develop consensus on the role and function of gional orientation conferences and de- the scientific foundation for public health public health. velop a time line for data collection, practice. These goals are achieved, in part, analysis, and reporting. through the systematic implementation • Performance standards reflect the roles of nationwide surveys of public health of public health agencies as essential, Survey data is collected at the state and systems and intervention to address ser- but inadequate to address comprehen- local levels. Local level public health vice delivery gaps. The Public Health sive public health needs. The local agencies are categorized as county, city, Practice Program Office of the CDC ad- public health system is a term that de- city-county, township or multi-county/ ministers the NPHPSP in collaboration scribes the constellation of organiza- district/r. The most common type of with national public health organizations. tions and individuals that help achieve local public agency is county-level. Sepa- public health goals within communi- rate surveys are administered to state 2. Public Health ties. A similar concept is used to de- public health systems, local public health Assessment scribe the state public health system systems and local boards of health. Ide- where the primary distinction is the ally, representatives of the state or local 2.1 Theoretical Framework locus of action. The goal is not to min- public health system convene to com- imize the role of official government plete the NPHPSP surveys. A public health system includes public, public health organizations but rather private, and voluntary entities, as well to promote the inclusion of other or- During the data collection process, the as individuals and informal associations ganizations that contribute to public CDC, Public Health Practice Program that contribute to the delivery of essen- health practice. Office, provides technical assistance to tial services of public health. Perfor- answer questions about the surveys and mance measurement for public health 2.2 Assessment Methodology to resolve issues that emerge with data systems is guided by principles estab- entry and submission. NPHPSP web- lished for the National Public Health National Public Health Performance based surveys cannot be submitted for Performance Standards Program to fa- Standards surveys are voluntary self- analysis unless every question is an- cilitate comparable data collection from assessments for state and local public swered. Data is not registered in the discrete state and local public health health systems and local boards of CDC database until data is fully submit- systems. The guiding principles of the health. Data collection during the early ted for each of the ten essential services. National Public Health Performance phase of the NPHPSP was accomplished Web-based data entry is the method of Standards Program are: using hardcopy surveys. After the con- choice; however, hardcopy surveys are tent and format were refined, a web- available if technology prohibits elec- • Performance standards include pro- based local public health system survey tronic data submission. cess and outcome measures. was developed in April 1999. When re- spondents contact the CDC to complete Data analysis generates quantitative • Public health system improvement is a NPHPSP survey, a user identification scores for each essential public health the primary goal and as such, a mini- number is assigned to allow access to service, relevant indicators and meas- mum standards approach is not ac- web-based instruments. ures. Data extraction, analysis and re- 233 port generation is accomplished using 3. The local public health governance of the scope of the service. At the next Statistical Analysis Software. Summary performance assessment instrument level, a maximum of four indicators de- reports include quantitative scores and (governance instrument) scribe the attributes of each essential a descriptive analysis that describes service. Each indicator has a correspon- strengths, weakness, opportunities and The survey instruments are designed for ding model performance standard. threats. Numerical scores are calculated public health systems to conduct volun- to provide a mechanism to compare tary self-analysis. State public health sys- Performance standards represent expert similar public health systems across the tems administer the state instrument to opinion concerning actions and capaci- nation. Scores less than 0.80 indicate obtain an analysis of strengths, weak- ties that are necessary to optimize pub- opportunities for improvement or gaps nesses, opportunities, and threats. The lic health system effectiveness. Each in service delivery. Hardcopy reports local instrument is similarly designed for model standard is followed by a series of depicting data in histograms, tables, local public health system assessment. In questions that serve as measures of per- and narrative summaries are sent to both instances, the state or local public formance. An example of an essential respondents. health agency convenes other members service with a corresponding indicator, of the public health system to conduct a model standard, and measures is shown The National Public Health Perfor- comprehensive, collaborative assessment. in Table 2. mance Standards Program is a develop- Public health governing bodies, such as mental activity that will continue to local boards of health, are components 2.4 Data Collection evolve over time. Ultimately data analy- of local public health systems. A separate sis and reporting will be fully auto- survey, the governance instrument, is Three strategies exist for data collection mated. CDC personnel and staff from specifically designed to assess organiza- in the National Public Health Perfor- national public health organizations tional effectiveness of public health gov- mance Program: conduct site visits at the conclusion of erning bodies. each data collection to review results • National Data Collection: CDC may and answer questions. With full imple- Each assessment instrument is divided systematically collect data to assess mentation of the NPHPSP in 2002, into ten sections each corresponding and monitor the development of site visits will be conducted as federal with an essential public health service. public health infrastructure through- resources permit. Results from National Table 1 provides an outline of the survey out the nation. In this instance, par- Public Health Performance Standards format. Essential public health service ticipation is prescribed by research surveys characterize the status of public titles are followed by a brief description protocols. health in the United States. • Mobilizing for Action Through Plan- 2.3 Survey Instruments ning and Partnership (MAPP): MAPP Table 1 Design Inquiry is a strategic planning tool principally of National Public Health The CDC and national public health developed through a cooperative Performance Standards organizations developed three comple- Program agreement between the National As- mentary assessment instruments for the sociation of City and County Health NPHPSP: Level I: Essential Public Health Officials and the CDC. The local in- Service strument is one of four assessments in 1. The local public health system per- Level II: Indicator the MAPP strategic planning process Level III: Model Performance formance assessment instrument Standard for communities. (local instrument) Level IV: Stem Question (Measure) Level V: First tier sub-measure • Public Health System Self-Assessment: 2. The state public health system per- Level VI: Second tier sub-measure Public health systems and local formance assessment instrument Level VII: Third tier sub-measure boards of health may voluntarily col- (state instrument) lect data using surveys developed for

234 After the regional conference, the state Table 2 Sample Essential Public Health Service with an liaison and CDC establish a time line Indicator, Model Standard, and Measures for data collection and analysis. CDC EPHF 10: Research for New Insights and Innovative Solutions to Health Problems provides technical assistance to facilitate For the Local Public Health System (LPHS), this service includes: survey completion during the empirical • A continuum of innovative solutions to health problems ranging from practical field- phase of the process. based efforts to foster change in public health practice, to more academic efforts to encourage new directions in scientific research. To generate reliable data that represent • Linkages with institutions of higher learning and research. the status of public health systems, state • Capacity to mount timely epidemiological and health policy analyses and conduct health systems research. and local agencies convene staff and rep- resentatives of other public health or- Indicator 10.1: Fostering Innovation ganizations. In this forum, public health Local Public health System Model Standard: system representatives develop consen- Organizations within the local public health system foster innovation to strengthen pub- sus responses to survey questions. Sur- lic health practice. Innovation includes practical field-based efforts to foster change in public health practice as well as academic efforts to encourage new directions in scien- vey completion at the state or local level tific research. may encompass several meetings. The • Enable staff to identify new solutions to health problems in the community by pro- time allowed for data collection varies viding the time and resources for staff to pilot test or conduct experiments to deter- mine the feasibility of implementing new ideas. since public health systems across the • Propose to research organizations one or more public health issues for inclusion in nation are diverse. Generally, the local their research agenda. instrument requires 24 hours for orien- • Research and monitor best practice information from other agencies and organiza- tation, consensus meetings, data collec- tions at the local, state, and national level. • Encourage community participation in research development and implementation tion and submission. State instrument (e.g., identifying research priorities, designing studies, preparing related communica- completion requires 15 hours and the tions for the general public). governance instrument requires 6 hours. Please answer the following questions related to Indicator 10.1: Web-based data entry and scoring facil- Sample Measures itate data analysis and dissemination 10.1.1 Do LPHS organizations encourage staff to develop new solutions to health of results. A quantitative performance problems in the community? score is assigned for overall performance If so, and scores are also calculated for each 10.1.1.1 Do LPHS organizations provide time and/or resources for staff to subdivision of the instrument. Qualita- pilot test or conduct experiments to determine new solutions? tive comments are provided in summary 10.1.1.2 Have LPHS organizations identified barriers to implementing innova- reports to highlight opportunities for tive solutions to health problems within the community? public health system improvement. 10.1.1.3 Do LPHS organizations implement innovations determined to be most likely to lead to improved public health practice? 2.5 Field Testing

The first draft of the local instrument was introduced to the public health the National Public health Perfor- public health systems. Regional confer- community in June 1999. Since that mance Standards Program. ences are planned to include participa- time, primarily as a result of validity tion according to the Department of studies and field tests, the state, local and To initiate the data collection process, a Health and Human Services Regions, governance instruments have been sub- state liaison is designated by the state (see figure 1). Conference attendees are stantially revised. The local instrument health officer. The state liaison and oriented to the NPHPSP, key concepts, has undergone the most rigorous testing. CDC organize a 1-day regional confer- such as the public health system frame- Figure 2 depicts state and local public ence for members of state and local work, and the data collection process. health systems that have participated in

235 Figure 1 Department of Health and Human Services Regional Map

I

BOSTON SEATTLE II X NEW YORK V VIII PHILA. CHICAGO IX VII III D.C. DENVER SAN KANSAS CITY FRANCISCO

ATLANTA IV VI DALLAS

the National Public Health Performance in New York, Minnesota, Mississippi, monitor and promote public health sys- Standards Program. Data from these Hawaii and San Diego, California par- tem improvement over time. Evaluation state and local public health systems are ticipated in the local instrument field questions were developed to assess the not readily comparable since multiple test using version 5b of the local instru- utility of results generated by the NPH- versions of the instruments were used ment. The governance instrument was PSP survey instruments. A series of rec- over time and public health systems dif- piloted in Massachusetts. ommendations emerged from the field fer by jurisdiction types, governing bod- test experience. ies, population served, workforce com- Field tests were designed to evaluate the position and funding sources and levels. adequacy of preparation for data collec- Several state and local public health tion, the efficiency of the data collec- agencies self-nominated to evaluate the As a part of the National Public Health tion process, survey format, and con- usefulness of draft performance stan- Performance Standards Program field tent validity. Of special interest to CDC dards. In the pre-testing phase of survey test in 2000, Hawaii, Minnesota and and national public health partners, was development, health officials represent- Mississippi completed the state instru- the feasibility of convening representa- ing state and local agencies completed ment. Subsequently, the Indian Health tives of state and local public health the surveys and provided recommenda- Service in New Mexico also completed systems to collaborate and complete tions to improve the surveys and the data the state instrument to assess public survey instruments. The goal of data collection process. To assess the validity health service provision. Local agencies analysis was to develop methodology to of responses, the University of Kentucky

236 Figure 2 National Public Health Performance Standards Program State and Local Public Health System Participation

Legend State & Local Instrument Completed State Instrument Completed State & Local Instrument Development PHPPO/Division of Public Health Systems Development & Research Local Instrument Completed Prepared by: A. Gardner Local Instrument Completed via Mobilizing for Action through Partnership and Planning June 2002

deployed a team of researchers to con- surveys in the National Public Health strated that literacy, language barriers, duct a retrospective study of selected Performance Standards Program extends and clarity of questions influenced re- performance indicators. The researchers the capacity of CDC and its partner or- sults. Response options are limited to concluded that evidence was available to ganizations to generate a national dataset “Yes”, “high partially”, “low partially” support data generated by self-assess- to describe the capacity and limitations or “No”. A high degree of subjectivity ment using the local instrument. of existing public health systems. is introduced with responses limited to these four options without explanatory 2.6 Data Limitations The disadvantage of voluntary assess- remarks or quantitative data to support ment is that, collectively, self-nominated answers. The most frequently used methodol- respondents may form a non-representa- ogy for data collection in research is tive convenience samples for the nation. All survey results are subject to non- self-administered questionnaires. Data The field test survey frame was limited sampling errors, random and non- collection is accomplished in the Na- to a convenience sample of field test random. Random non-sampling errors tional Public Health Performance Stan- states. This sample may not be represen- result from various interpretations of the dards Program through self-administered tative of the nation; therefore results survey questions. Some randomness is surveys. cannot be generalized. also introduced when respondents esti- mate capacity based on program experi- Although widely employed, advantages Response rates are also less predictable ence, current documentation and the and disadvantages are inherent in this with self-administered surveys. Field collective expertise of public health sys- approach to data gathering. Cost effec- test experience with survey instruments tem representatives. Non-random sam- tiveness and simplified administration in the National Public Health Perfor- pling errors can also arise from difficulty are obvious benefits. Using web-based mance Standards Program demon- interpreting questions, non-response,

237 partial responses, or incorrect informa- each indicator to assess the respondents’ Public health agencies convened public tion. Survey instruments in the National perception of the contributions of the health system representatives to com- Public Health Performance Standards public health system and the direct con- plete state and local instruments. In Program are completed on-site and sub- tribution of public health agencies. many instances, participants reported mitted electronically. Survey data is not processed unless every question is an- swered. This quality measure limits non- Figure 3 Distribution of EPHS Scores for Local Level random sampling errors. The allowance Agencies of partial answers conversely contributes State A: (n = 81) to non-sampling error. 1.0 Nominal survey data was analyzed using descriptive statistics. Mean scores 0.8 were calculated for each essential ser- vice. The data presented in figures 3, 4, 0.6 and 5 was obtained by tabulating an av- erage score for indicators that support 0.4 each essential service.

0.2 Measurement error may be generated by the survey format (self assessment) and the inconsistent administration of 0.0 the survey at the local level. Some field ESS1 ESS2 ESS3 ESS4 ESS5 ESS6 ESS7 ESS8 ESS9 ESS10 test respondents reported completion of the instruments without involvement Essential Public Health Services (EPHS) by other public health system represen- tatives. Additional reliability and valid- ity testing is warranted to ensure that performance scores represent the true Figure 4 Distribution of EPHS Scores for Local Level capacity of public health systems to de- Agencies liver the essential public health services. State B: (n = 8)

2.7 Format and Process 1.0 Revisions 0.8 Self-assessment of the “public health system” has proved to be a new concept 0.6 for many local agencies. Consistently, respondents commented that addi- tional information on the components 0.4 of the system would facilitate the data collection process. Respondents also ex- 0.2 pressed an interest in a separate section within the tools that would generate 0.0 and assessment of the agency in addi- tion to the system analysis. Current in- ESS1 ESS2 ESS3 ESS4 ESS5 ESS6 ESS7 ESS8 ESS9 ESS10 struments retain the system focus, how- Essential Public Health Services (EPHS) ever, two Likert questions now follow 238 sive glossary and reference section was Figure 5 Distribution of EPHS Scores for Local Level developed for the instruments to im- Agencies prove face validity. The state, local and State C: (n = 42) governance instruments were re-tooled after field-testing to reduce subjectivity 1.0 and improve face validity. Additionally, model standards were simplified and 0.8 summarized in bulleted statements that correspond with stem questions. 0.6 Reports were retooled to “retain the in- 0.4 formation in the data” by providing guideposts to improve performance.

0.2 Initially there were three response op- tions for NPHPSP survey questions: 0.0 “Yes”, “Partial” or “No”. Evaluation

ESS1 ESS2 ESS3 ESS4 ESS5 ESS6 ESS7 ESS8 ESS9 ESS10 feedback indicated that the partial cate- gory was too broad. Respondents were Essential Public Health Services (EPHS) confused by an intermediate “partial” category offered as one response option. To clarify the response options, the as- that they did not have an adequate strument for various divisions within sessment instruments were revised to amount of time to engage system part- the agency to complete, and others en- include 4 response options with numer- ners. Feedback on evaluation forms gaged a few key organizations. More ical quartiles assigned to each category clearly indicated that respondents also work is needed to assist state and local as shown in table 3. needed more time for orientation activ- agencies with stakeholder analysis and ities. As a result of these findings, the the use of effective techniques to engage Regarding the efficiency of the data col- time required to review, complete, and public health system partners. Although lection process, field test participants submit the local instrument was ad- participants believed the assessment in- who completed the web-based survey justed from 8 to 24 hours. Time al- struments were time and labor inten- encouraged its continued use. Partici- lowances for the completion of the state sive, the consensus among respondents pants were satisfied with the availability and governance instruments were also was that the results of the process would of technical assistance on a customer increased as a result of consistent feed- be beneficial for overall evaluation and care hotline established for field test back from field test state and local par- strategic planning activities. Most re- support. ticipants. Many of these comments are spondents agreed that the instruments similar to those received during the should be completed in collaboration 3. Data Utilization evaluation of the Latin America and with other public health system repre- Caribbean exercise. sentatives, not independently by public 3.1 State Experiences health agencies. The feasibility of convening representa- The State of Texas has been actively in- tives of state and local public health sys- While field test respondents agreed that volved with the development of the Na- tems to collaborate and complete survey the survey instruments have value, par- tional Public Health Performance Stan- instruments proved to be a challenge in ticipants recommended reducing the dards Program. Texas used the National almost every instance. Various methods subjective nature of questions. Field test Public Health Performance Standards as were employed to generate responses. participants also consistently identified a a template to dissect assessment ques- Some local agencies completed the en- need to explain terminology used in the tions that were most relevant to its state tire instrument, others divided the in- assessment instruments. A comprehen- and local public health systems. Texas 239 data is used to familiarize new health offi- Table 3 Possible answers on the evaluation tool cers with opportunities for public health 1 Response Description infrastructure improvement. “Yes” Greater than 75 percent of the activity described within the ques- tion is met within the local public health system. 3.2 Local Level Gap Analysis “High Partially” Greater than 50 percent, but no more than 75 percent of the activity described within the question is met within the local public health Assessment results and respondent eval- system. “Low Partially” Greater than 25 percent, but no more than 50 percent of the activity uation forms from several states were re- described within the question is met within the local public health viewed and summarized at the CDC in system. the summer of 2000. Figures 3, 4, and “Low” No more than 25 percent of the activity or resource described within the question is met within the local public health system. 5 illustrate the distribution of perfor- mance scores for three field test states, 131 local public health systems. Overall scores ranged from 0.40 to 0.62 with has created a state-specific version of the standards provided a framework for 1.00 representing optimal performance. local instrument to enhance the pre- statewide discussion of public health im- Figures 3, 4 and 5 are box plots with the paredness of local public health agencies provement and for strengthening the range of possible scores on the vertical to respond to public health threats and partnership between state and local axis and the factors of interest, the es- emergencies. In addition, the 76th Texas agencies. Minnesota participants be- sential public health services, on the Legislature passed House Bill 1444. The lieved that patterns in the data could also horizontal axis. Each figure contains ten essential public health services are now potentially be used to identify state and box plots, each representing an essential incorporated into the Texas Health and regional strengths and needs for capacity service. The box plot identifies the me- Safety Code with House Bill 1444. building. Minnesota noted that per- dian, a lower quartile (the 25th per- formance scores were consistently low centile) and an upper quartile, (the State and local agencies that participated throughout the state for essential service 75th percentile). Additionally an inter- in the field test planned to use the re- 1, 8 and 9. The Minnesota State Com- quartile range, (the difference between sults for strategic planning, in grant ap- munity Health Services Advisory Com- the upper and lower quartile-IQ) was plications to illustrate needs, to justify mittee planned to use performance stan- calculated as shown below: increased funding to expand the work- dards information to further analyze force, and to justify funds to develop policy strategies to address gaps, focus (L1) Lower quartile 1 = lower quartile – community health improvement plans. on staff development and direct strategic 1.5 IQ Respondents completing the local tool planning. strongly recommended sharing results (L2) Lower quartile 2 = lower quartile – with elected officials, local boards of The State of Mississippi used perfor- 3.0 IQ health and other organizations within mance standards to educate their Legis- the public health system. lative Sunset Review Body on public (U1) Upper quartile 1 = upper quartile health and its role. Mississippi also used + 1.5 IQ In Minnesota, considering data limita- assessment data to support development tions, National Public Health Perfor- of a bond bill for capital facilities im- (U2) Upper quartile 2 = upper quartile mance Standards results were shared provement. The bill was presented to the + 3.0 IQ with the State Department of Health State legislature to improve information and local public health partners to initi- systems and public health laboratory sys- In figures 3, 4 and 5, a line is drawn from ate discussion on potential opportunities tems. Performance standards data was the lower quartile to the smallest point to develop the workforce, improve tech- also used to develop grant applications for that is greater than L1. Likewise, the line nology and evaluation methods. Min- bio-terrorism and environmental health. from the upper quartile to the maximum nesota used the model standards to sup- Mississippi found the performance stan- 1 Personal Communication. Kage W. Ben- port and improve the State system for dards data useful in strategic planning at der, RN, PhD, FAAN, Deputy State Health community health services. The model the State level. Performance standards Officer. 240 was drawn to the largest point smaller Figure 6 State A Profile of Essential Public Health Service than U1. Points between L1 and L2 or Scores for Local Level Agencies U1 and U2 are drawn as small circles. Points less than L2 or greater than U2 1.0 are drawn as large circles. 0.9 0.8 0.77 0.7 0.64 0.60 Field test results demonstrated wide 0.6 variation among states and within es- 0.5 0.44 0.39 sential service categories. State A repre- 0.4 0.35 0.37 0.28 sents a centralized state-local public 0.3 0.24 0.22 health system framework and State C is 0.2 organized in a shared framework. In 0.1 0.0 State B, the state health department ESS1 ESS2 ESS3 ESS4 ESS5 ESS6 ESS7 ESS8 ESS9 ESS10 serves at the local level in a manner sim- ESS1 Monitor health status to identify community health problems. ilar to but not synonymous with a cen- ESS2 Diagnose and investigate health problems and health hazards in the community. tralized system. Average scores by essen- ESS3 Inform, educate, and empower people about health issues. tial service at the local level for 131 ESS4 Mobilize community partnerships to identify and solve health problems. ESS5 Develop policies and plans that support individual and community health efforts. local public health systems are provided ESS6 Enforce laws and regulations that protect health and ensure safety. ESS7 Link people to needed personal health services and assure the provision of health care when otherwise in figures 6, 7, and 8. unavailable. ESS8 Assure a competent public and personal health care workforce. ESS9 Evaluate effectiveness, accessibility and quality of personal and population-based health services. With the exception of essential service 6 ESS10 Research for new insights and innovative solutions to health problems. (State B), essential service scores for these field test states consistently fell below the standard of 0.80. A range of 65 exists between the highest and low- est essential service score, (0.22-State A, essential service 9; 0.87-State B, essen- Figure 7 State B Profile of Essential Public Health Service tial service 6). Opportunities for im- Scores for Local Level Agencies provement are more readily apparent in 1.0 some areas; however, this wide variation 0.9 0.87 0.79 0.8 in scores indicates potential risks to 0.69 0.70 0.7 0.65 public health in every category of ser- 0.61 0.6 vice delivery. 0.52 0.5 0.45 0.42 0.4 0.37 Abbreviated state profiles are provided 0.3 in table 4. Factors that impact public 0.2 health, such as population density, met- 0.1 ropolitan/non-metropolitan population 0.0 ESS1 ESS2 ESS3 ESS4 ESS5 ESS6 ESS7 ESS8 ESS9 ESS10 distribution, gross state product, health care expenditures and the percent of ESS1 Monitor health status to identify community health problems. ESS2 Diagnose and investigate health problems and health hazards in the community. persons below the poverty level are pro- ESS3 Inform, educate, and empower people about health issues. vided to characterize each state. ESS4 Mobilize community partnerships to identify and solve health problems. ESS5 Develop policies and plans that support individual and community health efforts. ESS6 Enforce laws and regulations that protect health and ensure safety. Without calculating correlation coeffi- ESS7 Link people to needed personal health services and assure the provision of health care when otherwise unavailable. cients, one can observe an apparent re- ESS8 Assure a competent public and personal health care workforce. lationship between performance scores, ESS9 Evaluate effectiveness, accessibility and quality of personal and population-based health services. ESS10 Research for new insights and innovative solutions to health problems. predominantly metropolitan popula- tion, gross state product and health 241 performance capacity and ultimately Figure 8 State C Profile of Essential Public Health Service health outcomes such as infant mortal- Scores for Local Level Agencies ity. Infant mortality in State A in 1998 1.0 was 10.1 and in State C 5.9 deaths per 0.9 1,000 live births. 0.8 0.72 0.67 0.7 0.61 0.61 0.59 Scores were in close approximation on 0.6 0.54 0.51 0.51 essential service 1 (Figures 6, 7, and 8), 0.5 0.42 0.4 0.36 with a range of 10. For essential service 0.3 1, the three states received similar 0.2 scores: 0.35, 0.45, and 0.42. The first 0.1 filter in the NPHSPS, the essential ser- 0.0 vice, points these states in the direction ESS1 ESS2 ESS3 ESS4 ESS5 ESS6 ESS7 ESS8 ESS9 ESS10 of improved methodology for commu- ESS1 Monitor health status to identify community health problems. ESS2 Diagnose and investigate health problems and health hazards in the community. nity assessment and health monitor- ESS3 Inform, educate, and empower people about health issues. ing. The three indicators for essential ESS4 Mobilize community partnerships to identify and solve health problems. service 1, (population-based commu- ESS5 Develop policies and plans that support individual and community health efforts. ESS6 Enforce laws and regulations that protect health and ensure safety. nity health profile, access and use of ESS7 Link people to needed personal health services and assure the provision of health care when otherwise unavailable. current technology, maintenance of ESS8 Assure a competent public and personal health care workforce. population health registries), provide ESS9 Evaluate effectiveness, accessibility and quality of personal and population-based health services. ESS10 Research for new insights and innovative solutions to health problems. additional details for gap analysis re- lated to health status monitoring.

Since surveillance is an old tenet of care expenditures. Population density is expenditures for personal health care public health practice, one expects to nearly constant at 60.3 for State A and are twice as much as State A. State C see high scores for essential service 2. 61.8 persons per square mile for State also has a gross state product that is Each of the three states scored better C. The overall performance score for more than double that of State A and than .60 on essential service 2 with a State A (0.44) is barely more than half poverty rates are twice as low in State C. range of 12. Mean scores were 0.77, the standard 0.80. State A is predomi- State A scores consistently fell below 0.79, 0.67 respectively for State A, B nately non-metropolitan with a lower 0.50 for seven out of ten essential pub- and C. State A performed best overall gross state product and lower personal lic health services. State C scores were on essential service 2. health care expenditures, but higher consistently higher than 0.50 for 8 out poverty rates than State C, (see table 5). of ten services. This data suggests that Survey questions for essential service 3 State C has a substantially higher over- health care expenditures and gross state are designed to assess public health sys- all performance score (0.60). State C product may influence public health tem capacity to inform, educate and

Table 4 Abbreviated State Profiles

Personal Population NPHPSP Non- Gross Health Below Poverty Overall Population Metropolitan metropolitan State Care Level Average Density % % Product* Expenditure** % State A .44 60.3 34.0 64.0 62.2 8,882 16.1 State B .56 188.6 72.3 27.7 39.7 4,658 10.9 State C .60 61.8 70.4 29.6 161.4 20,313 7.2 Source: U.S. Census Bureau, 2001 Statistical Abstract of the United States. * In billions **In millions

242 Table 5 Comparison of state profiles

Personal Population NPHPSP Non- Gross Health Below Poverty Overall Population Metropolitan metropolitan State Care Level Average Density % % Product* Expenditure** % State A .44 60.3 34.0 64.0 62.2 8,882 16.1 State C .60 61.8 70.4 29.6 161.4 20,313 7.2 Source: U.S. Census Bureau, 2001 Statistical Abstract of the United States. * In billions **In millions

empower communities. Wider varia- on essential service 3, while states B & 4, mobilizing community partnerships. tion among the states on this essential C scored 0.61 and 0.65 respectively. With a range of 33, scores fell between service may correlate with the percent Poverty levels for State B & C levels 0.28 and 0.61. Developing partnerships of persons below the poverty level or in- were substantially lower, 10.9 and 7.2, is a recent addition to the gestalt of adequate resource availability for health respectively. Infant mortality was also public health concerns that can be education. State A had the largest per- lower in States B (5.9) and C (6.9). traced back to ancient Greece. Public cent of persons below the poverty level health has the most experience linking 16.1% and the highest infant mortality. The widest variation among the three environmental conditions to diseases, State A also had the lowest score (0.44) states was observed for essential service and inconsistent experience developing partnerships to accomplish essential services.

Table 6 Essential Public Health Services Essential Service 5 is focused on the de-

Essential Service # 1: Monitor Health Status to Identify Community Health velopment of policies and plans that Problems support individual and community health efforts. Scores on essential ser- Essential Service # 2: Diagnose and Investigate Health Problems and Health Hazards in the Community vice 5 also varied widely from 0.24 for State A to 0.54 for State C. Extremely Essential Service # 3: Inform, Educate, and Empower People about Health Issues low scores for this essential service sig- nal opportunities to improve strategic Essential Service # 4: Mobilize Community Partnerships to Identify and Solve planning for community health im- Health Problems provement. The gap analysis provided Essential Service # 5: Develop Policies and Plans that Support Individual and by the NPHPSP is intended to comple- Community Health Efforts ment, not replace local efforts to con- Essential Service # 6: Enforce Laws and Regulations that Protect Health and duct community health assessments Ensure Safety and develop community health im- Essential Service # 7: Link People to Needed Personal Health Services and provement plans. Both are critical to Assurethe Provision of Health Care when Otherwise establish effective system-wide partner- Unavailable ships to address issues that result in Essential Service # 8: Assure a Competent Public and Personal Health Care poor health outcomes. Gross state prod- Workforce uct and personal health care expendi- Essential Service # 9: Evaluate Effectiveness, Accessibility, and Quality of tures may limit resource availability for Personal and Population-Based Health Services individual and community health ef-

Essential Service # 10: Research for New Insights and Innovative Solutions to forts. Data provided in table 4 illus- Health Problems trates the budget climate for these states in terms of gross state product and per-

243 sonal health care expenditures. Further essential service 9. Strategies that are systems to share data, develop the public investigation in this area with a larger agency specific may not succeed in iso- health workforce and enhance organiza- data set may confirm the hypothesis lation to combat public health threats, tional capacity. These are the essential el- that a direct correlation exists between emerging infections or bio-terrorism. ements of public health infrastructure. these expenditures and organizational Public health systems must collaborate capacity to deliver the essential public to evaluate the combined influence on 4. Lessons Learned health services. community health. Effective program evaluation is a systematic way to im- The NPHPSP field test experience Most public health systems have honed prove public health actions by involving taught many lessons. Priorities that their skills in compliance enforcement procedures that are useful, feasible, eth- emerged from the experience included and the delivery of direct services, essen- ical and accurate. the need for: tial service 6. State B (0.87) and State C 1. Case examples of successful state (0.72) scored highest on essential service Research is not a traditional function for and local public health systems 6. The performance score for State A local public health systems. In addition was slightly lower at 0.64. Since areas to environmental health, preventive 2. Detailed gap analyses of peak performance are not mirrored medicine, epidemiology, and disease con- state-to-state at the local level, public trol, local public health systems have pri- 3. Improved evaluation mechanisms health may not be sustaining the bene- mary responsibility for direct medical fits of past success. Continuous quality care, advocacy, school health, crisis re- Participants encountered difficulty with improvement focused on delivering the sponse, family planning, care of the poor, the notion of meeting with health part- essential public health services at the dental care, licensure and certification, ners from the community to assess their local level remains a national priority to mental and home health care. Often the combined capacity to deliver the Essen- ensure effective public health action. workforce is stretched to provide these tial Services. As a result, the NPHPSP services on a limited budget. Local pub- will incorporate case examples from Essential service 7 scores varied within a lic health systems in close proximity to around the nation in the orientation range of 0.08. Scores for State A, B, and academic institutions are more likely to package for program implementation. C were 0.60, 0.69 and 0.61 respectively. engage in research activities. Gap analysis for field test sites needed Serving as a “safety net” provider of di- fortification with specific recommenda- rect health care, for individuals without State A, with 64% of the population liv- tions to improve performance in each Es- access to care, is an established function ing in non-metropolitan areas, scored sential Service. Hardcopy and electronic of public health systems. Essential ser- lowest on essential service 10 (0.36). resources have been identified to provide vice 7, scores are demonstrative of con- The majority of residents in State B specific recommendations to address sistent capacity in these three states. (72.3%) and State C (70.4%) live in gaps that may emerge in Essential Service metropolitan areas. State B and C scored delivery. A stronger evaluation compo- Workforce development is an emerging .70 and 0.59 on essential service 10 re- nent for all phases of implementation competency for public health systems. spectively. The correlation between ru- (orientation, survey administration and State scores varied from 0.37 to 0.53 rality and the capacity to participate in data analysis) also emerged as a priority. with a range of 15 on essential service 8. research warrants future analysis. A formal evaluation process with regular Workforce assessment is a process that intervals of data analysis has been imple- many local public health systems need to The NPHPSP is a nation-wide program mented to identify barriers to excellence add to the credentialing and licensure to identify elements of public health in- in public health system assessment. process to ensure workforce competency. frastructure that lack adequate capacity and resources. The information gener- 5. Conclusion Evaluation was a weaker component of ated by the assessment process is in- service provision for this sample of tended for use by decision makers to The intent of the National Public states. Each state scored below 0.40 on create robust information technology Health Performance Standards Program

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245 PART IV From Measurement to Action 13 Institutional Strengthening for the Performance of the EPHF

1. Introduction 3. to strengthen the steering role of the This diagnosis is a starting point—that national health authority. is, the baseline or point of departure Based on the results obtained in the representing the current level of public EPHF measurement exercise in the Re- The design and implementation of health performance in the countries— gion of the Americas, the challenge of strategies and actions aimed at achiev- and its realization is what will make it encouraging member countries to de- ing these objectives and, consequently, possible to make solid progress with a velop national plans for the institu- bridging the existing gaps between the clear vision toward the preparation of tional strengthening of their national optimal standard and the degree of plans for strengthening public health health authorities is addressed in an ef- performance obtained in the measure- institutions. fort to improve public health practice in ments of EPHF are fundamental for this each country. purpose. 2. Guidance in Moving From Diagnosis to Action In preparing those national plans, it is Measuring the degree to which the essential that the actors involved under- EPHF are carried out in each country A preliminary finding of the diagnosis is stand the relationship between EPHF utilizing a common instrument has that some countries are stronger in some performance measurement and the in- made it possible to identify critical areas areas, while others are weaker. Thus, stitutional work of the NHA, so that shared by two or more EPHF and oth- there are situations that call for comple- progress may be made toward achieving ers that are specific to each function. mentary synergistic exercises between the strategic objectives proposed by the Accordingly, it should be recognized neighboring countries, or even countries Initiative: that these weaknesses may require both with similar political, demographic, and immediate action for improvement and socioeconomic features. 1. to improve public health practice the identification of the principal ele- ments that favor or hinder the develop- This reveals the great potential for es- 2. to develop the infrastructure to im- ment of public health in the countries tablishing partnerships in the Region prove the performance of EPHF, and of the Region. and underscores the potential for stim-

249 ulating cooperation among countries to cluded for economic, social, geographi- to use consensus or collective decision- improve performance in public health. cal, or cultural reasons. making among the key national actors The opportunity to establish or consol- who have assumed responsibility for idate opportunities for sharing experi- Notwithstanding the different profiles evaluating the performance of the ences, as well as to intensify efforts for deriving from the regional and subre- EPHF, since this will encourage repre- the socialization of satisfactory practices gional analyses discussed in detail in the sentativeness and objectivity in priori- in the field of public health, emerges previous chapter, it must be ensured tizing problems and thus increase the immediately as a primary recommenda- that critical aspects of the performance viability of the approach and the feasi- tion for initiating the move from diag- of EPHF revealed by the diagnosis will bility of executing the strategies and nosis to action. be given national priority in each coun- lines of action selected. try, so that programs appropriate to Notwithstanding the initiatives pro- each national reality can be formulated Once the principal critical areas have grammed or undertaken by each coun- to orient public health action in a par- been identified, prior to determining try according to its capacities, problems, ticular manner specific to the country. the strategies for the national plans, the and priorities, the fact is that an analysis In this regard, a number of questions future vision and desirable scenarios of the average obtained for the Region that can guide this discussion should be should be defined in order to direct ef- following application of the measure- considered, namely: forts toward the expected results. To ment instrument indicates three essen- this end, the performance optimums tial functions that require a redoubling • What are the main findings of the di- of the different measurement indicators of efforts for improvement at the na- agnosis and what is their relevance to of EPHF should be analyzed and tional, subregional, and regional levels, the country? adapted to the national reality, under since they are highly relevant to the the definition of a possible optimum preparation of plans for strengthening • How do the results of the perfor- that leads, within well-defined and rea- the EPHF. They are, in order of im- mance evaluation affect the national sonable terms, to the institutional vi- portance: Quality Assurance Personal health authority? sion crafted by each country. and Population-based Health Services (EPHF 9); Human Resources Develop- • What decisions should be made to After specifying the most positive and ment and Training in Public Health correct the deficiencies encountered least satisfactory aspects in the perfor- (EPHF 8); and Development for Poli- and to reinforce favorable processes? mance of EPHF based on the national cies and Institutional Capacity for Plan- analysis, it is also advisable to identify ning and Management in Public Health Decisionmakers should establish param- opportunities and threats—that is, (EPHF 5). eters and have criteria at their disposal the external factors that can positively that enable them to use the results to or negatively affect the viability of the In addition, an aspect of public health identify the critical problems and deter- interventions to overcome weaknesses that is a primary function of the health mine their priority. This presupposes or reinforce strengths in the perfor- authority is ensuring access to necessary that each country define the threshold mance of EPHF. A criteria to define a health services (EPHF 7), especially for of differentiation between strengths and factor as external is the impossibility to the most disadvantaged populations. Its weaknesses; this will permit an objective affect it directly in order to modify it, high correlation with the performance distinction between the scores consid- making it a condition, rather than an of other functions considered to be “in- ered problematic—that is, those corre- object of management. cipient”, including health promotion sponding to weaknesses—and those that (EPHF 3) and social participation are relatively satisfactory—that is, the 3. Design of Systemic (EPHF 4), leads to the conclusion that strengths of the public health system. Actions strengthening these public health func- tions is fundamental to guarantee access In selecting the method to define the For each country that initiates the plan- to health services and expand social pro- threshold and determine the correspon- ning process to develop institutional ca- tection in health to the population ex- ding reference values, it is preferable pacities for the performance of EPHF,

250 Figure 1 Relationship between diagnosis of the EPHF, planning, and intervention for the development of institutional capacity

EPHF EPHF exercise diagnostic

EPHF 1 EPHF 1

EPHF 2 EPHF 2 Planning Areas of Objectives Activity EPHF 3 EPHF 3 Improve the Achievement of practice of results and EPHF 4 EPHF 4 Public Health key processes Planning EPHF 5 EPHF 5 for the Develop the development infrastructure Capacity EPHF 6 EPHF 6 of in-house to support the development and capability to practice of EPHF Infrastructure EPHF 7 EPHF 7 perform EPHF building Strengthen EPHF 8 EPHF 8 the steering of the EPHF 9 EPHF 9 National Health Decentralization Authority of capacities EPHF 10 EPHF 10 (NHA)

EPHF 11 EPHF 11

Factors that systematically define the practice of EPHF

the results of their diagnosis will be the proach of the intervention, making it ized in a manner consistent with those starting point or primary input. Subse- possible to group the results into three categories. Thus, the principal strengths quently, a logic with a synthetic ap- strategic intervention areas: and weaknesses that should become the proach should be utilized to incorporate basic input in preparing the plans to these results into the planning process 1. adequate performance of key pro- improve public health are inferred from aimed at generating interventions, rec- cesses and the securing of results; the diagnosis, based on the strategic ob- ognizing that the level of performance of jectives defined by each country, each the various EPHF responds to some ele- 2. development of institutional capaci- subregion, or the Region of the Ameri- ments that are common to other func- ties and strengthening of infrastruc- cas as a whole. (see Figure 1). tions or even to the EPHF as a whole ture, and and may be affected by them. As observed in this figure, systemic fac- 3. support for the development of de- tors affect the area of several EPHF or The methodology followed in measur- centralized competencies. all of them; that is, represented graphi- ing the performance of the EPHF and cally, they affect the EPHF horizontally the diagnostic instrument facilitate the This logic was used in the design of the or cross through them because they have progression from the analytical-diag- measurement indicators and, accord- a significant influence in promoting or nostic approach to the synthetic ap- ingly, the indicators have been organ- impeding the EPHF. This graphic repre-

251 sentation makes it possible to observe quires special mention as a specific area whose improvement is technically how the planning of interventions or ac- of action whose improvement simulta- and financially feasible; they can be tions for improvement uses planning neously results in the overall strength- addressed effectively within the limits objectives as referents and establishes a ening of action in public health, as of the resources available immedi- link with the areas of intervention that stated in Chapter 15. ately or in the short term; may be considered. The results of the diagnosis indicate • Multidimensional and highly complex. 4. Specific Areas of that within the context of each nation These are problems in which the spe- Intervention to Improve and the regional scenario, it is urgent cific area to be addressed is difficult the Performance of EPHF that countries implement strategies to to pinpoint; they require the efforts correct the weaknesses encountered. of numerous actors and entail finan- In addition to identifying the systemic cial and technical difficulties. interventions that affect the perfor- 5. Setting Priorities mance of various EPHF and that impact Once the priorities of the national plan on institutional capacities in general, In setting priorities, it is useful to ensure have been set, an analysis of the in- such as the training of human resources that the formulation of strategic objec- stitutions, agencies, and actors involved or the upgrading of infrastructure, it is tives for the national plan corresponds should be performed, through the also essential to identify the weaknesses to the interests, objectives, and expertise preparation of a political map of par- and strengths specific to each function of the key actors in the national, subna- ticipants that enables the strategies and that are relevant to addressing the par- tional, and local contexts who will be in mechanisms that guarantee its viability ticular elements necessary for each case. charge of this effort or affected by it. Ac- to be incorporated into the plan. cordingly, it is particularly important to Some examples of this type of interven- convene a full meeting with the repre- To perform that analysis, a list of stake- tion may include the strengthening of sentation of these actors. holders, or people affected by the im- the public health laboratory network, plementation of the plan, should be the design of timely mechanisms for re- In order to achieve practical validation of prepared. As part of this process, the sponding to public health hazards, and the priorities set in the strategies and position and specific weight of each the improvement of health sector man- lines of action, an analysis of causal rela- stakeholder in the public health system agement in emergencies and disasters. tionships among the problems identified should first be identified. Finally, the The special features of these areas are or critical areas requiring intervention political map resulting from the stake- both the resources and specific interven- should be performed. To establish an ob- holder analysis should reflect the signif- tions in public health stemming from jective order of priority, the following icance and function of each actor and the diagnosis, as well as the specializa- taxonomy, which allows problems to be entity in fulfilling the contents of the tion of the actors involved and the classified for subsequent analysis and plan and contain information that per- sphere of action that will be affected. prioritization, can be used: mits an analysis of the situation and outlook. These areas are highly significant and • Urgent. These are cases that, due to thus should not be overlooked when de- their exigency, magnitude, and im- Finally, since setting priorities for the signing the plans, although they could portance, cannot be postponed. national plan to improve public health produce strategies that are more isolated goes beyond the health sector’s sphere of and, in some cases, very restricted in • Systemic and serious. These respond to action to include the entire set of stake- their sphere of action or more limited in systemic factors involving several holders that comprise the different lev- terms of their capacity to bring together EPHF and demand significant actions els of government and social actors in- the actors involved. over time. volved, it must employ an intersectoral approach with broad social participa- Human resource development and • Of high vulnerability. These are prob- tion to allow the plan to be incorporated training in public health (EPHF 8) re- lems of a specific or systemic nature into national development strategies.

252 It is therefore essential to forge concrete How will the people and institutions 1. worker competence; ties between these priorities and the po- make a commitment to carrying out litical, social, and economic develop- each EPHF? 2. information and data systems, and ment strategies of each country, main- taining the plan within the national Based on this analysis, a practical, ob- 3. organizational capacity. public policy framework to promote jective relationship can be established joint responsibility with the entire realm with the principal elements and dimen- These components are closely linked; of actors and entities, governmental and sions of the development of the NHA’s deficiencies in each have an impact on nongovernmental alike, that participate institutional capacity. the others and, thus on the entire sys- in the national effort and are relevant to tem. Therefore, the strategic interven- the success of this initiative. 7. Institutional tions aimed at strengthening institu- Development for the tional capacity should be directed at the 6. From Diagnosis of the Exercise of EPHF components as a whole. Institutional Performance of EPHF to capacity should respond in a timely and the Development of the The meaning and scope of the concept adequate manner and operate systemi- Institutional Capacity of of institutional development imply a cally, articulating information, material, the Health Authority focus on the continuous improvement human, and financial resources. of the capacities, competences, and ap- The starting point for articulating the titudes of the work force and of the Information resources include data diagnosis and plan for improving public means and instruments that support collection systems and communication health in the countries is the recogni- public health systems in their task of ex- technologies utilized as a result of this tion that exercising the EPHF is one of ercising the essential functions properly, institutional capacity. Human resources the basic missions of the national health effectively, efficiently, and in a sustained contribute the talent and skills needed authority. manner. to carry out the work of public health.

The nature of the EPHF has been Institutional capacity cannot be devel- There are two distinctive features that widely discussed in earlier chapters and oped without appropriation of the con- should be considered in analyzing and the level of importance and significance cept of EPHF by national and subna- dealing with organizational capacity for of this effort has been confirmed. In tional institutions, recognizing also that institutional development of the public order to move toward action based on the performance of an individual, team, health system. On the one hand, we have the measurement of EPHF performance, or organization is a systemic function the fact that in many countries, the na- the health sector and relevant institu- that includes both internal and external tional ministry of health is responsible tions in the country should raise at least factors and, naturally, affects the actors for the delivery of health services to both the following questions: directly involved. individuals and the population at large.

What is the operative definition of each It is important to establish a link be- On the other hand, a precedent has EPHF in the country? tween the institutional capacity and been set in linking public health almost infrastructure of the public health sys- exclusively to certain specific or pro- What value does each EPHF have or tem and ensure their adaptation to one grammatic activities—for example, the what does each represent for the another. Although on certain occasions eradication of malaria, the prevention practice of the sector? these two basic components are managed and control of cholera, and the preven- What does each EPHF represent for separately, we know that they represent tion and control of HIV/AIDS. the practice of each participating complementary notions that overlap. institution? Thus, it is important to carefully exam- The area of institutional capacity or de- ine the relationship between these pro- Who are the primary and most signifi- velopment encompasses three broad grammatic activities and the system’s in- cant actors in each EPHF? components: stitutional capacity and infrastructure,

253 in order to determine the connections cuit board,” which handles differenti- coping with change and increasingly between institutional development, the ated, constant, and specific demands to complex needs and requires that work- adequacy of infrastructure, and effec- which it responds in a timely and effec- ers be provided with the technology, in- tiveness in the execution of EPHF. tive manner, appropriate to the moment struments, and training necessary to meet and type of need presented. these growing needs. Institutional capacity based on a strong and functional public health infrastruc- For example, in the case of chronic dis- In this regard, it is necessary to creatively ture is considered an essential element in ease surveillance, a developed insti- articulate: 1) the use of public health the effectiveness of programs and ser- tutional capacity based on a solid infra- competencies to develop educational vices. The goal of that infrastructure is to structure will allow the public health and in-service training programs based deliver complete and quality services. system to acquire more reliable data on practice; 2) a framework for certifica- That goal can be attained more easily if with a superior power of analytical in- tion and accreditation; and 3) the use of the construction and development of the ference. Using the essential public telematic media and appropriate tech- system’s infrastructure follows an explicit health functions as a frame of reference nology to provide public health educa- conceptual definition of the essential pub- also facilitates and gives greater empha- tion and foster health promotion. lic health functions and services. sis to the development of strategic inter- ventions to solve problems completely, 9. Information Unfortunately, this network of people, and not just with isolated responses that and Data Systems organizations, resources, and systems meet the needs of only certain specific suffers from different weaknesses in dif- programs: this promotes the implemen- Strengthening institutional capacity im- ferent countries and has been under tation of more integrated methods with plies systematically formalizing and re- stress for many decades. Thus, a frame of a greater response capacity to address inforcing the ties among the different reference that is sufficiently documented public health issues and needs. areas and institutional responsibilities in terms of the evolution of public health of public health practice. It is therefore in each context becomes a particularly 8. Worker Capacity essential that all components of the sys- valuable input for an adequate and ob- and Competence tem be able to share information among jective evaluation of the existing infra- themselves and have access to multiple structure: this can yield greater dividends The linchpin of institutional capacity data sources. A number of studies have or clarifications regarding the strategic development is a trained public health reported serious deficiencies in the facil- planning exercise to be carried out. workforce—that is, as proposed in ity with which public health informa- Chapter 15, health workers whose com- tion can circulate rapidly through the This analysis becomes even more impor- petencies and aptitudes are those re- system. Other studies have revealed the tant if we consider that these actions to quired by the tasks they will perform. existence of gaps in the utilization of strengthen the national health authority Lack of a formally trained work force the technology infrastructure. represent varying degrees of evolution, poses obstacles to the development of budgetary sufficiency, and cumulative the system and public health in general. Deficiencies in the basic information in- experience among the different coun- frastructure are an obstacle, not only be- tries of the Hemisphere. A 1997 study in the United States indi- cause they prevent public health agencies cated that 78% of the local Department from communicating among themselves Programmatic activities cannot be car- of Health directors did not hold gradu- in a timely manner, but also because ried out in a vacuum, but must have a ate degrees in public health. That same they hinder communication among system to support them in their differ- study revealed that these professionals public health workers, private physi- ent processes if they are to function also lacked opportunities for continu- cians, and other sources of information properly. An appropriate infrastructure ous education in their fields. This re- about emerging health problems. These that supports the institutional ability veals the existence of a gap, which de- basic gaps in communication also frag- to provide services can act like a “cir- mands more from the workforce in ment surveillance systems because of the

254 great differences in the countries’ com- rently available for performing this type building human and institutional ca- munications infrastructure. of public health system evaluation. For pacities should be different. example, the National Public Health Health institutions need to address Performance Standards Program (NPH- Capacities for planning and execution aspects related to strengthening the PSP) of the United Kingdom has de- differ in nature, but are interdependent. capacity of the information and data in- signed three tools for measuring the re- The close link between policies, plans, frastructure in their public health sys- sults of state and local systems, and their execution is fundamental. tems. Much more is required for this including measurement of the effective- Both capacities must be cultivated with- purpose than the acquisition of equip- ness of local health institution Governing out sacrificing one for the other. ment. One of the major decisions to be Councils. These tools and the methods made involves obtaining the human re- for utilizing them will be discussed in Micro and macro dimensions reveal the sources necessary to operate the equip- greater detail in the following chapters. need for diagnosing capacity in terms of ment and properly maintain it. the appropriate level. Different capaci- International and local organizations ties are required at the micro level (for 10. Organizational have become aware that, while technical example, within a program) than at the Capacity and financial inputs are fundamental to highest level, where policy and plan- help improve the operation of systems, ning capacities should be emphasized. Capacity may be defined in many ways, they do not by themselves ensure that but as it pertains to the field of health, the system is sufficiently flexible to In the cognitive and practical dimensions, it could be defined as follows: adapt to a changing and significantly the need to increase capacities beyond dynamic environment. This strengthen- the level that can be achieved through The capacity of a health professional, ing of capacities implies that the organi- formal or informal training must be un- team, organization, or system is its abil- zation or system is capable of perform- derscored. Learning by trial-and-error or ity to effectively, efficiently, and sustain- ing the basic functions and of including on-the-job, conceiving new practices and ably exercise the functions established and meeting its own development needs systems, and assimilating work modes are for it to contribute to the institutional in a broad context and a sustainable some of the methods for applying and mission and vision and to the policies manner in four dimensions. This con- adapting knowledge and are part of the and strategic objectives of the health cept is based on identifying the capaci- strengthening of capacities. This learning team, organization, and system. The ties that are indispensable to strengthen- takes a long time, which explains the public health system has numerous com- ing the capacity of any organization. need for a long-term perspective. ponents that should work in unison to The four dimensions referred to above achieve the common goal of implement- are described as follows: As the above classification makes clear, ing quality public health functions and the capacities related to some of these activities. Strengthening capacity and or- Human and institutional capacities are dimensions can be strengthened more ganization in these circumstances can indispensable for competent staff per- rapidly than others. Thus, while the pose a challenge, because in the process, formance. If the organization where order of priority for these dimensions the system must not become the result of people work has serious deficiencies— may vary, it should not be overlooked piecemeal solutions with many variants such as the lack of a precise mission and that strengthening capacity requires a in its ability to function. vision, inadequate structures, anom- solution for each of these dimensions at alous practices, management, and sys- some point in the process. This is par- The first step in strengthening organiza- tems, a lack of incentives, and an envi- ticularly important for smaller coun- tional capacity consists of evaluating the ronment that does not facilitate high tries that lack enough technical special- strengths and weaknesses of the organi- levels of performance—the performance ists to strengthen their capacities. zations or systems, in addition to ana- of its staff is probably inadequate, at the lyzing the threats and opportunties that margin of its knowledge and aptitudes. In cases where external technical assis- they face. Many instruments are cur- The methods and steps required for tance is required, it would be advisable

255 to include these dimensions in a plan of general capacity. This expansion in the • development and technological ex- action to define the critical needs for community can be achieved through the pansion of information, manage- which this level of expertise is required. formation of long-term associations and ment, and operating systems, and de- A useful resource for obtaining exter- plays an inestimable role in the sustain- velopment of the regulatory and nal help is the network of WHO Col- ability of the capacity-strengthening political framework; laborating Centers, which offer a wide process. variety of technical assistance. These • strengthening of the institutional Centers are the national institutions des- The organizations have described strate- organization of the NHA; ignated by the Director-General of gies to strengthen organizational capac- WHO to be part of an international ity. Outside of those strategies, it is always • strengthening of management capac- collaboration network charged with important to have a mechanism in place ity; carrying out activities that support the for supervising and evaluating the sys- WHO mandate to work in interna- tem, with the purpose of obtaining feed- • development of human resources in tional health, as well as its programmatic back to improve system performance and public health; priorities. The directory of these centers make adequate use of operations. This • organization of the budget relative to can be found on at following website: surveillance and evaluation function is the performance of EPHF; http//whqlily.who.int-search.asp. particularly important in health sector re- form, since changes in institutional re- • strengthening of institutional infra- The strengthening of true capacities sponsibilities and the duties of personnel structure capacity; throughout the system can be a chal- may be introduced as a consequence of lenge, given the structural inequalities health system restructuring (figure 2). It • development and technological ex- that tend to exist among its compo- would be very easy for essential processes pansion of information, management, nents. Hence, there is a need to establish to disappear during restructuring and, and operating systems, and a process to measure system perfor- instead of strengthening system capaci- mance and evaluate its total capacities. ties, for the opposite to occur. • expansion of social participation in Deficiencies at any point in the system sectoral decision-making and over- thus become evident and can be system- It is therefore recommended that the sight. atically detected and corrected. planning process for the institutional strengthening required for the exercise In the process of identifying the most Any plan for strengthening organiza- of the EPHF include the active partici- relevant intervention options to be in- tional capacity should include improve- pation of sectoral actors as the agents cluded in the national plans for improv- ments in the entire organization. This responsible for the financial support ing public health, it should be deter- implies developing the leadership skills of the process, with a vision that goes mined whether the proposal envisions of managers, strengthening effective sys- beyond the traditional organizational some of the elements that, based on tems for financial and human resources boundaries of the NHA. institutional development experiences planning, and developing processes that around the world, have been the most ef- promote institutional, programming, Although the objectives, strategies, and fective in achieving satisfactory develop- and financial sustainability. Depending actions are aimed at developing the ca- ment of institutional capacity, including: on these improvements, NGOs, commu- pacity for performance of EPHF, the in- nity organizations, and public sector terventions required for their achieve- • Development of skills to manage the health programs make good manage- ment ultimately depend on developing process of institutional change, based ment decisions and provide high-quality, concrete areas for the institutional work on the organizational culture. sustainable health services. This approach of the NHA. Some practical examples fosters the strengthening of capacities in of potential areas of intervention for the • Recognition and consideration of in- the community and promotes the most performance of EPHF, based on the di- centives and limitations external to satisfactory expansion and integration of agnosis performed, are the following: the change.

256 • Definition of the phases of the process In order to facilitate the entire process portance of making public health a pri- of change, taking into account con- of planning and preparing the national ority area of action. textual limitations, existing strengths, plans, PAHO/WHO has put together a and cultural or functional rigidities. practical guide containing a set of tools From these national health objectives, available to the countries. strategies are derived to achieve the ex- • A guarantee that the national interest pected results, which are directly related translates into sustained investment, 11. Development of Lines to ensuring the fulfillment of EPHF, the meaning that international cooperation of Action execution of population-based interven- will have to be complementary, while tions to prevent and reduce specific risks promoting the creation of broad partic- The framework for preparing the na- in priority areas (tuberculosis, etc.), and ipatory networks and partnerships. tional plan to strengthen the essential the maintenance of satisfactory strategies public health functions should include to control disease in each country and • Confirmation that all participants un- two simultaneous and synergistic lines address new threats to public health. derstand the purposes of the initia- of action: a) the development of na- tives, thus ensuring their commitment. tional health objectives, and b) the de- Considering all of the above, the insti- velopment of the institutional objec- tutional objectives to improve the practice • Promotion of an environment open tives of the NHA to improve public of the NHA should be geared toward, to experimentation in the develop- health practice in the countries. and incorporated in, health objectives. ment of processes at different levels, This implies the challenge of designing with clear objectives and priorities There are interesting examples of the new institutional arrangements for the that can be translated into concrete definition of national health objectives NHA consistent with these national plans. in the Region (the United States, health challenges. Canada, the United Kingdom, Chile, At the conclusion of this process, it Uruguay), all of which concur in the Without detriment to the priorities es- should be clear which interventions formulation of two major general objec- tablished by each country for strengthen- could be undertaken to secure the ex- tives: to prolong healthy life and reduce ing the institutional capacity of the pected results, defining the horizon inequities in health. The major prob- NHA, based on the identification of crit- that will characterize the country once lematic areas tend to be related to ical areas in the performance of EPHF, the limitations detected and prioritized chronic diseases, injuries, environmental the regional diagnosis and the subre- have been overcome. and mental health, and other illnesses gional analyses suggest certain courses of related to lifestyle. Furthermore, the action that can contribute to the reposi- Subsequently, progress should be made need to coordinate activities with other tioning of the NHA. toward definition of the work aimed at social sectors is emphasized, since many developing the EPHF, justifying the rea- of the determinants of health are not the Strengthening the steering role of the son for the institutional strengthening, responsibility of the health sector. NHA requires, in large measure, resolu- specifying the necessary strategies and tion and improvement of the perfor- courses of action, and indicating who This framework of health challenges, mance of EPHF at both the central and benefits, what services and actions will which by and large are common to the subnational (intermediate and local) lev- be carried out, and who will be responsi- countries of the Region, should be the els. Reorienting health care to reduce in- ble for them. This type of design should basis for reorienting the sectoral reform equities and barriers to access, designing be consistent with the framework of the processes currently under way, making strategies that provide social protection three basic goals of the Initiative: 1) to the population’s health problems the in health for ever-growing groups of improve public health practice; 2) to de- central element in the orientation of people who remain unprotected today, velop the infrastructure for performance health policies. Without neglecting the ensuring greater effectiveness and qual- of EPHF; and 3) to strengthen the steer- timely care of disease, the emphasis on ity in health interventions to promote ing role of the national health authority. health protection underscores the im- the efficient use of always-limited avail-

257 able resources, reorienting health care ulatory capacity, in the area of care (pub- mentation of strategic plans that articu- models toward health promotion to pre- lic and private health care providers) as late the efforts of the sector’s public and vent growing harm, and promoting pub- well as the environment and occupa- private institutions, as well as other so- lic policies that protect and improve the tional health, to increase the health im- cial actors, the establishment of partici- health of the population are some of the pact and attempt to place the well-being patory mechanisms, and the building of areas that need improvement and whose of the population ahead of the pressures partnerships and consensus to make the fulfillment is not only fundamental to that may be exerted by the various inter- proposals viable and facilitate the mobi- improve the levels of health and quality est groups. lization of the necessary resources to car- of life of the population, but is also part rying out the proposed actions require of the State’s regulatory responsibility in Improving the evaluation of access to stronger NHA leadership in health. health. health services; promoting knowledge, skills, and the development of mecha- Finally, the importance of including a In addition, ensuring the supply of public nisms to bring health programs and framework for monitoring and evalua- goods with positive externalities for services closer to the population; and tion in the national plan should be em- health—including semiprivate or private increasing access to services, within a phasized. To this end, indicators must goods whose impact on public health is framework characterized by multiple be established to describe institutional a significant factor—and ensuring that public and private actors responsible for performance, define responsibilities for they are consistent with national epi- access to health, become fundamental monitoring and evaluation, and allocate demiological priorities should also be part to reduce the vulnerability of the most specific resources that make it possible of any plan to strengthen the NHA to susceptible populations at the greatest to verify fulfillment of the programmed improve national public health practice. risk of disease. In this regard, efforts to actions, establish accountability, intro- establish explicit rights in health duce the necessary corrections, and take Developing greater competencies and through mechanisms that guarantee away lessons in this regard. skills to improve public health prac- benefits; the creation of regulatory sys- tice also requires the development of tems to ensure their faithful fulfillment; Bibliography strategies to upgrade the workforce in and the facilitation of necessary infor- public health, adopting new educa- mation for users are other areas for Bryson JM. Strategic Planning for Public and tional approaches, new practices and strengthening the institutional capacity Nonprofit Organizations. San Francisco: forms of training, and upgrading public of the NHA that should be among the Jossey-Bass; 1995. health personnel, as well as other human priorities in the national plan. Centre for Development and Population Ac- resources who may contribute to pub- tivities. Planificación estratégica, un en- foque de indagación. Serie de Manuales lic health practice in general (see Chap- The challenge of adequately integrating de Capacitación de CEDPA; 2000. ter 15). public health actions to ensure the antic- ipated health impact of these health pro- Fundación Acceso. Metodología de ACCESO de Planificación Institucional. San José. Pointing the compass that separates sec- motion and disease prevention measures, tor functions toward the strengthening in an environment marked by the grow- Ganeva I, Marín JM, Segovia M. Capacidad de negociación en el sector salud. Guate- of regulatory and supervisory functions, ing differentiation of functions and actors mala: Proyecto Subregional de Consoli- while improving management in health within the health systems, also implies dación e Incremento de la Capacidad services delivery, emerges as a priority the need for the organizational and func- Gerencial de los Servicios de Salud, Orga- for better performance of the EPHF. tional redesign of public health programs nización Panamericana de la Salud; 1993 All this, together with public account- to achieve the successes envisioned. Milén A. What do we know about capacity ability, helps to strengthen the image of building? An overview of existing knowl- the health authority in the eyes of the The management of sectoral action to edge and good practice. Geneva: World Health Organization, Department of citizenry. strengthen the NHA’s capacity to formu- Health Service Provision; 2001. late, organize, and direct the execution Another action that helps to promote the of the national health policy through Organización Panamericana de la Salud/ Organización Mundial de la Salud, Cen- role of the NHA is to move forward with processes that include the definition of ters for Disease Control, Centro Lati- the harmonious development of the reg- objectives, the preparation and imple- noamericano de Investigaciones en Sis- 258 temas de Salud. Guía para la aplicación ricano de Investigaciones en Sistemas de Reich MR and Cooper DM. PolicyMaker: del instrumento de medición del desem- Salud. Instrumento para la medición del Computer-Aided Political Analysis. (Ver- peño de las Funciones Esenciales de Salud desempeño de las Funciones Esenciales sion 2.3.1). Brookline Massachussetts; Pública. Iniciativa “La salud pública en de Salud Pública. Iniciativa “La salud 2000. las Américas”, Medición del Desempeño pública en las Américas”. Washington, USAID Center for Development Information de las Funciones Esenciales de Salud D.C: OPS; 2001. and Evaluation. Selecting Performance In- Pública. Washington, D.C.: OPS; 2001. Organización Panamericana de la Salud/ dicators. Performance Monitoring and Organización Panamericana de la Salud/Or- Organización Mundial de la Salud. For- Evaluation TIPS, #6. Washington, D.C.: ganización Mundial de la Salud. Desa- talecimiento del desempeño institucional PN-ABY-214; 1996. rrollo institucional de la capacidad de rec- de las FESP. Guía metodológica para el Valladares R and Forrtín A. Sistema de Moni- toría en salud. Washington, D.C.: OPS, diseño de planes nacionales. Washington, toreo del Proyecto de Acceso a la Edu- División de Desarrollo de Sistemas y Ser- D.C.: OPS. (In press.) cación Bilingüe Intercultural (PAEBI): vicios de Salud. (In press.) Reich MR. Applied Political Analysis for Descripción del Modelo Global. Guate- Organización Panamericana de la Salud/Or- Health Policy Reform. Current Issues in mala World Learning/USAID, GSD Con- ganización Mundial de la Salud, Centers Public Health 2:186–191;1996. sultores Asociados. (In preparation.) for Disease Control, Centro Latinoame-

259 Estimate of Expenditures and Financing for EPHF and 14 Mechanisms for Determining Cost and Budgeting

1. Estimate of the importance of reviewing and spending was concentrated at the terti- expenditures and strengthening its obligation to guarantee ary level in urban areas. Due to a lack of financing citizens’ rights to have access to a series information that would permit the of benefits and services, for which the analysis of financing sources, the con- 1.1 Introduction market has proven to be a poor admin- clusion was perhaps reached that urban istrator of resources in terms of equity populations with a certain amount of Among other factors, the performance and social well-being. resources, as opposed to populations of the essential public health functions with limited resources, made the most (EPHF) in each country is determined One explanation may lie in the fact that intensive use of hospital facilities fi- by the management of the institutions until now, no instrument was available nanced with public funds. and organizations that implement them, to measure the “output” of health sys- the capacity of the human resources in- tems with respect to EPHF. That defi- In recent year, with a view to analyzing volved in the process, and the availabil- ciency hinders the ability to allocate the sector’s financial flows, the countries ity and distribution of economic re- resources based on the criteria of ration- of the Region have joined in the world sources allocated to their financing. ality or, ideally, profitability. initiatives aimed at developing a useful methodology for designing health poli- In the process of State and, particularly, In terms of the analysis of expenditure cies. Along this line, most countries health sector reform in the Americas, and financing, EPHF have not received have prepared national health accounts. the level of resources allocated to EPHF adequate attention. With regards to The national health accounts are ma- has been affected by the introduction of health care, for many years the sector trixes that make it possible to present, in modalities—both organizational and fi- studies in the different countries main- an organized way, the tracking of finan- nancial—that result in differentiated tained a tradition of concentrating on cial resources from their integration in care. The introduction of those modali- problems related to expenditure. As a the sector to their final destination. ties was attributable to an economic result, the information was usually model that initially advocated “reducing guided by how much was spent on the Although the development of the na- State intervention.” The effort made to different levels of care, and the conclu- tional health accounts has been an im- diminish the role of the State neglected sions took into consideration that portant contribution to the analyses of 261 some areas—such as equity in financ- the level of resources allocated by the • To contribute to the improvement of ing—the systems of national health ac- countries for that purpose and their the public health infrastructure and counts should concentrate on the guar- sources of financing. Knowing the cur- performance of the EPHF. antee of care. Consequently, some rent level of expenditure and comparing elements of EPHF are in a category de- it with the estimated cost required for • To improve the quality of health sys- nominated “healthcare-related expendi- adequate performance will make it pos- tems as a whole by increasing the reg- tures”, described in the jargon of the sible to quantify the additional re- ulatory capacity and performance of United Nations System of National Ac- sources needed. At the same time, the the health authorities. counts with the specification “below the data on financing sources will facilitate line”, in order to indicate that the cate- the determination of the additional • To record the allocation of resources gory of expenditures is related to, but sources required. to the EPHF in the budgetary statis- not an inherent part of, those accounts. tics and, accordingly, in the national In cases where expenditure on EPHF During the development and testing of health accounts. has been taken into account, it has been the methodology provided in this chap- blurred as an administrative category. ter, the difficulties of the task were evi- The evolution of the concepts related to dent. Although there are several reasons EPHF and attempts to quantify soci- The performance evaluation of EPHF in for this with respect to setting limits on ety’s efforts to produce them can be the Region—discussed in another chap- the analysis, the most important is the classified into three major initiatives: ter of this book—demonstrated that the form and breadth of the information countries generally reached a high level on budgets and expenditures presented. • The PAHO “Public Health in the of performance in the most traditional Another challenge arises because multi- Americas” initiative dealing basically functions, that is, those of public health. ple institutions participate in the exer- with the methodology for estimating This conclusion underscores the need cise of some EPHF. the performance of EPHF in the for restructuring the way in which pub- countries of the region and their sub- lic health is administered, so that health This chapter outlines a preliminary sequent execution. systems are adequately prepared to ad- methodological proposal for estimating dress health problems that arise world the expenditure and financing of the • The World Bank strategy, in which wide and to respond to the so-called EPHF.1 The application of a methodol- the institution proposes to utilize the “diseases of poverty” that affect a signifi- ogy with these characteristics will pro- tools of public health to improve the cant part of the population. vide data that have an inestimable po- health of the population and help tential usefulness in policy-making and reduce poverty, expanding the con- As previously stated in other chapters of public health practice. Some benefits of tent and quality of its health projects the book, EPHF are primarily the re- the proposal are indicated below: portfolio. sponsibility of the health authorities in the sector. The fundamental task is to • To improve the capacity for resource • The studies conducted in some states establish the operating rules of the allocation—both in the immediate and counties of the United States to health system and safeguard compliance and in the long-term—for EPHF estimate the expenditure and financ- to the rules. This role of the State is es- and, consequently, fro the increased ing of the essential functions defined sential to guarantee equity in access and the effectiveness of public spending. by them. to ensure financing of care as well as the promotion of quality health services • To improve knowledge of the manner Although this chapter presents some that ultimately lead to high levels of in which the EPHF are executed and proposals on how to incorporate EPHF health in the general population and in how the countries can move closer to into the studies of financing by means of each subgroup identified by either eth- the standard. the national health accounts, the greater nicity, sex, age, and level of income. challenge remains to move beyond 1 In another chapter, a proposal is presented health services delivery to a broader The performance evaluation of EPHF for estimating the cost of implementing the study area that encompasses all the com- confirmed the need to estimate both EPHF at a given level of performance. ponents of expenditure and financing 262 sources for public health programs and, In the mid-1990s, the Office of Plan- was conducted in three local jurisdic- where possible, each of the EPHF in ning and Evaluation of the Department tions and concluded in March 1998. particular or, at least, all of them as a of Health and Human Services recom- The third and most recent study was whole. mended conducting a study on the pos- performed by the Maryland state health sibility of collecting periodic informa- agency and included all its local juris- 2. Estimates of Public tion with regard to health services dictions. The following table summa- Health Expenditure in the infrastructure, including expenditure rizes the three studies. United States and financing. Although the criteria were still provisional and therefore did With respect to the results obtained, For the last decade, the United States not allow systematic and comparable there is a clear disparity in the funds al- has shown interest in EPHF and how to information systems on the subject to located to public health, ranging from estimate the quantity of resources as- be established, the work demonstrated US$ 30 to US$ 394. These disparities signed to them. As early as 1993, they the great potential for that area of study are attributable to the different institu- recommended the need for structural to respond to and to determine the im- tional organizations and different polit- health sector reforms to modify the al- portant political issues concerning the ical priorities, but also to incoherence in location of resources in order to im- effect of the public health services infra- the definitions. prove the health system and prevent structure on the operation and results of diseases. For this, it was necessary to the health system. All the studies presented their results by know the amount devoted to financing grouping the functions into personal public health. An initial estimate of the state expendi- public health services—regarded as ture devoted to disease prevention indi- clinical services for individuals—and Naturally, the first step was to define cated that only 1% of the national population-based public health services, the essential public health functions or budget was allocated to public health considered measures to promote health services. The lack of a common lan- programs. Although the study recog- and prevent disease in large population guage confused the political debate dur- nized the impossibility of establishing groups. As expected, the bulk of the ex- ing the process of discussion of health the appropriate amount, the results penditure is concentrated in the former, sector reform in the United States. The demonstrated the need for strengthening as demonstrated in table 2. task of structuring that common lan- the public health services infrastructure guage was commissioned to the Public so that it can react adequately in the fu- The results of the three studies indicate Health Association. We have already ture to possible outbreaks of epidemics. the need to delve even further into the mentioned that these functions or serv- Three pilot studies of state and local ex- definition of the functions, so that it ices were defined through a participa- penditure were carried out, utilizing the becomes very clear “what is included tory process, in which numerous agen- Public Health Association’s frame of ref- and what is excluded”, in order to make cies2 contributed and which resulted in erence on the ten essential services. it possible to compare across different the definition of ten essential services, jurisdictions. Large differences were ev- with their respective programmatic The first study, conducted by the Pub- ident in the various types of institu- lines of action included and not in- lic Health Foundation in 1996, pre- tional organization, with the conse- cluded, that would facilitate the process sented results from nine states. The sec- quent variations with respect to public of resource estimation. ond study, based on the previous one, responsibility.

It is recommended that these studies 2 Some of the agencies participating in the Public Health Functions Steering Committee are: American Public Health Association, Association of Schools of Public Health, Association of continue to be conducted repeatedly, State and Territorial Health Officials, National Association of County and City Health Offi- both in the same location as the pilot cials, National Association of State Alcohol and Drug Abuse Directors, National Association of studies and in new localities. In this State Mental Health Program Directors, Public Health Foundation, Partnership for Prevention, way, the methodology can continue to Agency for Healthcare Research and Quality, Center for Disease Control and Prevention, Food and Drug Administration, Health Resources and Services Administration, Indian Health Servi- be evaluated and improved in order to ces, National Institutes of Health, Mental Health Services Administration, and Office of the As- achieve valid, reliable, and comparable sistant Secretary for Health Substance Abuse. results. 263 Table 1 Characteristics of U.S. studies on public health expenditure

Study year(s) and associations Study objectives Responses Conclusions 1995–1996 • To create instruments that facilitate the esti- 9 States–AZ, IA, IL, LA, 1. Public spending in health can be PHF mation of expenditure allocated to the NY, OR, RI, TX, WA measured and tracked through EPHF, in order to make comparisons among the EPHF the various regions 2. The local health institutions • To transfer the results to the national area should be directly involved in • To evaluate the strengths and weaknesses the process of measuring the of the instruments expenditure

1997–1998 • To enhance and adapt the local measure- 3 local health inst. 1. The process is safe and the NACCHO ment instruments Onondaga, NY results are very valuable NALBOH • To conduct studies on experiences of the TriCounty, WA 2. Despite differences in methodo- PHF institutions involved in the project Columbus, OH logy and preparation, the results • To make recommendations for developing were acceptable a standard methodology and enhancing the 3. The guidelines and rules with instruments regard to decision-making should be strengthened in order to obtain better parameters for comparison 4. The improved instruments should be tested at the national level

1998–1999 • To check the measurement instruments (to Health Department of 1. The process can produce relia- ASTHO improve definitions and rules for decision- Maryland, and the ble estimates, usable as a guide NACCHO making; to provide examples) 24 local health for establishing policies NALBOH • To compile the expenditures of all health in- departments of MD 2. There should be more emphasis PHF stitutions at the regional level, utilizing the on awareness of the benefits improved instruments derived from the entire project • To evaluate the safety, reliability, and com- 3. The process can fit into the cate- parability of the information gories established by the health • To evaluate the essential service paradigms, budgets such as education and communication instruments

Other recommendations include the uct and income, in that they are not in- the area corresponding to public health need for educating public agencies, tended to measure the value added but is still not very developed. health institutions, and students of pub- rather the financial resources transferred lic health with regard to the essential among the different institutions within Many countries have not yet prepared functions. It is also necessary to coordi- the sector. The methodology utilized is national health accounts, but most are nate the work of institutions that de- entirely compatible with the United Na- in process of doing so. The current velop instruments for performance tions System of National Accounts. methodological framework for estimat- measurement of public health functions. ing the expenditure and financing of The national health accounts report on the EPHF does not require that the na- 3. The EPHF in the the origin of funds, their distribution tional health accounts already exist in National Health Accounts among the different institutions in- countries to which it will be applied. volved, and the use of resources pertain- However, because it utilizes the princi- The national health accounts are a con- ing to areas of interest for establishing ples and classifications of the national sistent set of matrixes that describe the public health policies. The national heath accounts, the results of this re- financial flows within the health sector health accounts are the most appropri- search can be applied to the national in a given year. They differ from the ac- ate instrument for analyzing the health health accounts that are prepared in the counts that measure the national prod- expenditure of any country, although future. 264 Table 2 Expenditure on health services per inhabitant, according to studies conducted on the EPHF

Expenditure per inhabitant

Personal Population-based health services health services Total essential Study (date) Site (total in%) (total in%) health services

Study in some states of the Arizona US$ 73 (66%) US$ 38 (34%) US$ 111 United States Iowa US$ 29 (57%) US$ 22 (43%) US$ 51 (1995–1996) Louisiana US$ 52 (61%) US$ 34 (39%) US$ 68 New York US$ 168 (77%) US$ 51 (23%) US$ 219 Oregon US$ 91 (63%) US$ 53 (37%) US$ 144 Rhode Island US$ 78 (55%) US$ 65 (45%) US$ 143 Texas US$ 56 (64%) US$ 32 (36%) US$ 88 Washington US$ 72 (53%) US$ 64 (47%) US$ 136

Study in LHD Columbus US$ 24 (49%) US$ 25 (51%) US$ 49 Local Health Depts. Onondaga US$ 9 (19%) US$ 42 (81%) US$ 51 (1997–1998) TriCounty US$ 2 (4%) US$ 35 (96%) US$ 37

Study in Maryland Maryland (Total) US$ 170 (73%) US$ 62 (27%) US$ 232 (1998–1999) Local US$ 54 (53%) US$ 48 (47%) US$ 102 State US$ 116 (89%) US$ 14 (11%) US$ 130

To analyze the national health accounts as other international classifications Current health expenditure refers to the as a basic instrument for estimating ex- (those of private industry, for example). set of economic contributions devoted penditure on EPHF, the classifications Hence, it is compatible with the systems to functions HC.1 to HC.7. Total in the document A system of health ac- of national accounts throughout the health expenditure is obtained by adding counts were reviewed. This document, world. to this the health-related function the basic manual for classifying alloca- HC.R.1, representing the capital invest- tions corresponding to the health sec- The area of fundamental interest in the ment in the sector. The other related tor, was prepared by the Organization health accounts is “health care.” It is functions may or may not be added— for Economic Cooperation and Devel- limited to what is referred to as “disease according to the policy of each coun- opment (OECD), published originally prevention, improvement of sanitary try—but are presented separately in in 2000 and revised in 2002. Further- programs, treatment, rehabilitation, order to allow them to be compared on more, the latest version of the Produc- and long-term care.” Health care refers an international level. ers’ Guide—still in draft form—was to the personal services provided di- studied; this Guide is being developed rectly whereas the population-based The public health functions are con- through a joint initiative by the PAHO, services are commonly called “public tained basically in category HC.6. Some the WHO, the World Bank, and the health.” These services are the improve- of them fit into HC.7, referring to gov- U.S. Agency for International Develop- ment of sanitary programs, regulatory ernment administration. Others are in- ment (USAID), through the project standards, the tasks aimed at disease cluded in some of the health-related Partnerships for Health Reform (PHR). prevention, and the administration of functions, that is, HC.R. As shown in the system. Chapter 6, the WHO made an initial at- The 1993 United Nations Manual on the tempt to individualize the nine essential System of National Accounts and the IMF 3.1 Functional Classification functions identified. Its conclusions ap- Manual on Government Finance Statistics pear in the table of the OECD manual were also reviewed. It should be noted The functional classification of the on health accounts. However, the func- that the OECD manual on health ac- OECD manual on health accounts tions are not the same as those analyzed counts was written based on the United specifies the functions within the health in this document because as we have Nations and IMF classifications, as well sector listed in table 3. stated, these are the result of a process of 265 ducted—and the activities that the Table 3 Functional classification of the health accounts system health authorities should undertake in ICHA Code Functional classification order to carry out these functions are optimally defined—the classification HC.1 Curative care HC.1.1 Inpatient curative care should be reviewed. HC.1.2 Day cases of curative care HC.1.3 Outpatient curative care HC.1.4 Services of curative home care It should be pointed out that the classifi- cation in the OECD manual does not HC.2 Rehabilitative care coincide with the description of the HC.2.1 Inpatient rehabilitative care HC.2.2 Day cases of rehabilitative care EPHF. For example, the manual specifi- HC.2.3 Outpatient rehabilitative care cally mentions environmental health HC.2.4 Services of rehabilitative home care and occupational health as public health HC.3 Long-term nursing care functions, neither of which are among HC.3.1 Inpatient long-term nursing care EPHF, while it explicitly excludes reduc- HC.3.2 Day cases of long-term nursing care HC.3.3 Long-term nursing care: home care ing the impact of emergencies and disas- ters as part of health expenditures. It also HC.4 Auxiliary health care HC.4.1 Clinical laboratory mixes population-based measures with HC.4.2 Diagnostic imaging personal measures and with normative HC.4.3 Patient transport and emergency rescue and regulatory tasks. For example, one HC.4.9 All other miscellaneous ancillary services of the public health functions in the HC.5 Medical goods dispensed to ambulatory care patients manual is “prevention of communicable HC.5.1 Pharmaceuticals and other medical non-durables HC.5.2 Therapeutic appliances and other medical durables diseases”, HC.6.3. Epidemiological sur- veillance and the population-based im- HC.6 Prevention and public health provement of health programs would HC.6.1 Maternal and child health; family planning and counseling HC.6.2 School health services have to be included within this category, HC.6.3 Prevention of communicable diseases even though they are typical functions of HC.6.4 Prevention of noncommunicable diseases HC.6.5 Occupational health care the health authorities and therefore part HC.6.9 All other miscellaneous public health services of the steering role tasks. But numerous personal measures, such as advice at the HC.7 Health administration and health insurance HC.7.1 General government administration of health primary level on the need to boil water HC.7.2 Health administration and health insurance: private in order to prevent diarrhea, immuniza-

HC.R Health-related functions tion, or tuberculosis surveillance, are also HC.R.1 Capital formation of health care provider institutions the responsibility of the health authori- HC.R.2 Education and training of health personnel ties, although not an essential responsi- HC.R.3 Research and development in health HC.R.4 Food, hygiene, and drinking water control bility within the steering role. HC.R.5 Environmental health HC.R.6 Administration and provision of social services in kind to assist the ill or disabled Profound reflection is clearly indispen- HC.R.7 Administration and provision of health-related cash-benefits sable at the international level on what information is of interest in the field of public health, which are the basic activ- debate and consensus in the region over idea of the allotments under which most ities that permit the health authority to the last three years. of the actions of each EPHF will proba- perform fully its steering role function, bly evolve. Without detailing the most how those activities can be measured, 3.2 Preliminary Functional important activities of each EPHF, this and how they can be monitored over Classification of the EPHF classification can only be provisional. the course of time. The consensus Nevertheless, when the field investi- reached in this area will orient the fu- A preliminary attempt to classify EPHF gation that clarifies which tasks are ture modification of public health- is outlined below, solely to provide an performed for each function is con- related categories, within the system of 266 3.3 Classification of Sources Table 4 Preliminary classification of the EPHF according to of Financing and Financing the OECD manual on health accounts Agents ICHA Code Essential public health functions (EPHF) (preliminary) A different focus on the classification of 1. Monitoring, evaluation, and analysis of health status HC6.9/ HC7.1 sources of financing and financing 2. Public health surveillance, research, and control of agents exists between the systems in the risks and threats in public health HC6.3/ HC6.4/ HC7.1 3. Health promotion HC7.1/ HC6.3/ HC6.4 OECD manual on health accounts and 4. Social participation in health HC7.1/ HC6.9 the Producers’ Guide. The former calls 5. Development of policies and institutional capacity for “sources of financing” what the latter planning and management in public health HC7.1 6. Strengthening of institutional capacity for regulation calls “financing agents.” The Producers’ and enforcement in public health HC7.1 Guide indicates that the national health 7. Evaluation and promotion of equitable access to necessary health services HC7.1 accounts should be broken down into 8. Human resources development and training in public three categories: the flow of financing health HC.R.2 among sources, the financing agents, 9. Quality assurance and improvement in personal and population-based health services HC.R.3 and how financing is to be utilized. The 10. Research in public health HC.R.3 “sources” are the same as in the national 11. Reducing the impact of emergencies and disasters on health — product and income account system, namely:

• the government, at its various levels (central government, local govern- ments, decentralized institutions, health accounts. Meanwhile, it will be It is important to consider that the ma- public corporations, social security necessary to adapt to the existing classi- jority of countries are only now begin- funds) fication, prepare the necessary explana- ning to develop national health ac- tions, and, if possible, slightly expand counts. Only very few of them consider • households the classification criteria. this an institutionalized and ongoing ac- tivity. The reality is that national health • corporations We should point out that the OECD accounts are generally done at various manual on health accounts is a “work in intervals as a sporadic study. Application • the rest of the world progress;” the first version has just been of the OECD manual classification— published. In light of its implementation that serves as the international model— As a last resort, the sources would be at the international level and the infor- is still an incipient initiative. For this households and the rest of the world, mation needs of the different countries, reason, it is unlikely that the currently- since the government takes money from it will be modified and adapted to match existing national health accounts can be households in the form of taxes and reality. The classification has been carried used to study the expenditure and fi- other contributions. With regard to cor- out mainly using two digits. In most nancing of EPHF, although it is advis- porations, they could well consider their cases, a more accurate way of breaking able that the studies dealing with the health expenditures part of the cost of down the classification is still being re- subject follow their methodology. The labor and, ultimately, this would also searched. In this regard, the results of classifications of the system of health ac- benefit households. However, by con- this work and the studies that are con- counts and the matrix of the structure vention and given the importance of ducted in several countries to estimate proposed—both by the national health what they represent, a distinction is the expenditure and financing of EPHF, accounts and the aforementioned Pro- made among the four sources. The rest will contribute valuable information that ducers’ Guide—will be very useful in of the world refers to the resources that will stimulate thought about how to ad- understanding the movement of finan- enter a country to finance health by var- dress the classification of public health cial flows earmarked for the implemen- ious means, such as donations, loans, tasks in the national health accounts. tation of the EPHF. and the net balance of expenditures by 267 people who travel for health reasons, 4. Challenges for This instrument will make it possible to both inside and outside the country. Estimating Expenditure know the total government spending and Financing on all public health works, although the In the case of EPHF, the bulk of fi- for the EPHF expenditure is not differentiated by type. nancing will come from the govern- For example, the Dominican Republic’s ment, although in some countries inter- As seen in the previous section, it is rec- national health accounts show the fol- national cooperation plays an important ommended that the methodology of lowing categories in which EPHF could role in public health measures. Elements the national health accounts proposed be found in table 6. of personal health such as immunization by the OECD manual on health ac- can also receive financing from house- counts and the Producers’ Guide be fol- This table reveals surprising informa- holds in the form of recovery rates or lowed for the matrix approach and tion that should motivate the health au- fees. adapted to the needs of the essential thorities to conduct more in-depth re- public health functions. The following search and even rethink their priorities. In short, the resources assigned to health paragraphs present the expected format It should be noted that spending on the are mobilized through these sources. with the basic tables resulting from the improvement of sanitary programs and The “financing agents”, in turn, are field investigations executed in each preventive care receives only 1.3% of those that allocate the funds, in other country. the total assigned by the health author- words, that purchase and pay for the ities to the health of the public sector. services. These are the entities that nor- 4.1 Review of the national The private sector allocates a consider- mally operate in the health sector: min- health accounts Figures ably higher amount for those activities. istries, social security institutes, non- How can that difference be explained? governmental organizations, and others. The first task imposed is the review of A true explanation is that Dominican The international classification for fi- the national health accounts. We have families pay an important portion of nancing agents is presented in the fol- already noted that many countries still the cost of preventive services out-of- lowing table. do not have them, and even those that pocket, either due to mistrust of public do, have not always been able to break services or for other reasons. In accordance with the purpose of this down their expenditures as they should, study, we will utilize the Producers’ or else they lack a frame of reference to Guide approach, which separates the help them indicate the importance of Another explanation could be that pub- sources from the financing agents. identifying one allotment or another. lic hospitals dispense certain primary- level services. This does actually occur and the problem stems from the fact Table 5 Classification of financing agents that the accounting system does not dif- ferentiate the expenditure by level of ICHA Code Financing agents care within public hospitals. As a result, HF.1 General government the practice can lead to classification er- HF.1.1 Public administration, excluding social security rors in the national health accounts, be- HF.1.1.1 Central government HF.1.1.2 State/provincial government cause—based on the statistics for bud- HF.1.1.3 Local/municipal government getary spending—it is not possible to HF.1.2 Social security administrations discern the expenditures corresponding HF.2 Private sector to preventive services dispensed in the HF.2.1 Private social insurance public hospitals. The anomaly requires HF.2.2 Private insurance companies HF.2.3 Private household out-of-pocket expenditure specific research that has not yet been HF.2.4 Nonprofit institutions carried out in the country. HF.2.5 Corporations (other than medical insurance)

HF.3 Rest of the world The allocations that would most likely include EPHF are the following:

268 Table 6 The Dominican Republic: health expenditure by function, 1996

Public Private Rest of Functions sector % sector the world Total % Total 3,154.2 100.0 8,643.4 121.0 11,918.7 100.0 Improvement of preventive care programs 39.9 1.3 695.5 735.1 6.2 Curative care 1,520.3 48.2 4,009.6 121.0 5,650.9 47.4 Research and human resources development 4.5 0.1 5.4 9.8 0.1 Regulation 386.6 12.3 0.2 386.8 3.2 Production and purchase of inputs 885.7 28.1 220.3 1,106.0 9.3 Administration 301.8 9.6 2,989.4 3,291.2 27.6 Facilities 15.5 0.4 723.3 738.8 6.2

Source: Banco Central, Cuentas Nacionales de Salud del Sector Público, 1996 (cited in: Rathe, M. Salud y equidad).

• Improvement of health and preven- In the Dominican case, these figures are health authorities, a first step toward a tive care programs approximate. We could have more com- detailed analysis of this aspect. Although plete and detailed information in the the activities to which they are allocated • Research and human resources devel- countries that have already applied the are not clearly specified, the identifica- opment new methodology, albeit with the limi- tion of the financing sources is the first tations previously indicated regarding step toward a more thorough study. • Regulation to the functional classification in which public health activities are included. After performing an initial analysis of • Administration the overall figures, it will be necessary to A more recent example is that of the address the work of estimating the ex- These allocations total RD $ 1,215.2 national health accounts of Nicaragua, penditure and financing of each one of million for 1996, equivalent to 38.5% where preventive services constituted the EPHF. The task requires knowledge of the public sector health expenditure. 7% of the total health expenditure of the institutional organization for the That would be the “ceiling” for EPHF during the period 1977–1999. This implementation of each EPHF. that year. amount, however, reflects only the spending on health care services at the 4.2 Government Budget It should be pointed out that 1996 was primary level—the so-called SILAIS— Statistics the only year in which the Dominican and does not include the tasks related to Republic—with PAHO’s support and EPHF. These cannot be identified in the Since the figures of the national health the support of the PHR project—pre- national health accounts of Nicaragua accounts are not broken down as they pared complete national health accounts since they are included within the Min- should be, it is also necessary to review following the methodology developed istry of Health’s administrative expendi- the budgetary spending statistics. The by Harvard University. At that time, tures. Something similar would occur majority of the countries in Latin Amer- neither the OECD manual on health if we reviewed the national health ac- ica budget by program without a uni- accounts nor the Producers’ Guide ex- counts of any other country. The lack of form classification of these programs. In isted. Accordingly, the functional classi- specificity regarding EPHF, or the diffi- all cases, it is necessary to thoroughly fication utilized does not follow the in- culty in separating the regulatory tasks analyze the systems of budgetary spend- ternational model used today. from services are dependent on the ing and to talk with the technicians who methodology used in the functional classify the expenditures. Accordingly, In subsequent years, the Central Bank classification of the health accounts. the work will necessarily deal with the continued to repeat the national health area of each institution or department accounts of the public sector using the As we will see further on, the national linked with the EPHF in question in same methodology as in 1996. Research health accounts also show—in general order to obtain the required informa- on the private sector was never repeated. terms—the financing sources of the tion first-hand.

269 Table 7 Identification of programs, subprograms, and activities related to EPHF 2 in the Dominican Republic

Public Health Function 2 Program Subprogram Activity Public health surveillance, research, and Program 1: High-level control of risks and threats to public administration health

Principal institutions or departments involved:

General Bureau of Epidemiology Program 2: Coordination, Subprogram 1: Activity 4: Control of standards, and control of Health services communicable and health programs noncommunicable diseases

Provincial Health Bureaus Program 3: Operational Subprograms 1 to 8 Activity 1 in each sub- services (services to the program (intermediate regions) coordination, super- vision, and control services)

Dr. Defilló Laboratory Program 2: Coordination, Subprogram 1: Activity 2: Laboratory and standards, and control of Health services blood bank department health programs

Laboratory department and provincial Program 2: Coordination, Subprogram 1: Activity 2: Laboratory and public health laboratory network standards, and control of Health services blood bank department health programs

Bureau of the Environment Program 2: Coordination, Subprogram 3: Activity 1: Bureau of standards, and control of Environmental services for protection health programs services of the environment Activity 2: Sanitation and environmental control

Expanded Program on Immunization–EPI (SESPAS)

Maternal and child department (SESPAS) Program 2: Coordination, Subprogram 1: Activity 3: Health services standards, and control of Health services for the mother and child, health programs nutrition

General Bureau for Control of AIDS and STI (DIGECIT)

National Institute of Drinking Water and Program 5: Financing to Activity 1 Sewerage (INAPA) institutions

Center for Control of Tropical Diseases Program 5: Financing to Activity 3 (CENCET) institutions

Other

By way of example, table 7 shows some separation between the planning and the same as those that record its execu- of the programs identified in the case of preparation of the budget, and its sub- tion. The guidelines for budgetary exe- the Dominican Republic. But an addi- sequent execution. The departments cution follow the national methodology tional problem exists, concerning the that prepare the budget are usually not for preparing reports on this subject

270 and in the process, a great deal of the workshop and a plan of visits to the in- ria will be utilized subsequently in the information related to the health pro- stitutions or departments, in order to pilot study to be conducted in the Do- grams is lost. It is a problem that affects estimate the effort required by both the minican Republic. Once completed, we the entire government, not just the PAHO staff and the technicians from will have a set of more consistent and health sector. local institutions and departments. complete guidelines, which will serve as a basis for the studies that case are con- As can be observed, in the case of the 4.3 Example of Institutional ducted in various countries of the region. Dominican Republic, information pro- Organization to Execute vided by the budgets at the level of the the EPHF We begin the section by offering re- central government or even by the Min- search findings, that is, the basic tables istry of Public Health itself, is still not We have already indicated that one of obtained for EPHF, with the aim of es- broken down precisely. To estimate the the first tasks in studying EPHF should timating their expenditure and financ- expenditure and financing of the EPHF, be to decipher which institutional or- ing. These tables are based on those pro- primary information must be collected. ganization in the country is devoted to posed by the OECD manual on health In summary: the EPHF in question. By way of illus- accounts and the Producers’ Guide, but tration, in the case of EPHF 2—public have been adapted to the need for un- • Identify the institutional organiza- health surveillance—the entities in- derstanding the financial flows of EPHF. tion for executing the EPHF in ques- volved are detailed in the next table. It After presenting the tables, we will offer tion. should be clarified that the column some guidelines on how to analyze the headed “activities related to EPHF 2” work and analyze the results. • Analyze the budget of each institu- refers exclusively to those cited by the tion or department. Annual Report of SESPAS for the year The scope of the exercise is limited to the 2000. A more thorough field investiga- expenditure made by the health authori- • Separate the entity’s EPHF-related tion needs to be performed in order to ties, that is, to research the expenditure tasks from other activities. discern the basic programmatic lines re- of public funds. In turn, financing can lated to the corresponding EPHF. come from both the public treasury • Estimate the level of effort made in (through various means or types of taxes) performing the EPHF. The table 8 shows the complexity of the and the private sector (corporations and work involved in estimating the expen- households) and the rest of the world • Identify the sources of financing. diture and financing of the EPHF, since (loans and donations). it requires the investigation of the dif- • Add the values and present the results ferent participating entities from a new Below we provide an initial approxima- in a coherent manner. perspective. The work is worthwhile as tion of the data collection design tools it helps coordinate the activities of all of and some of the intermediate results of The realization of this work obviously the entities under the steering role of the process. We will then offer some requires the unconditional support of the health authorities. ideas on how to address the field work the health authorities. It is essential to in practice. Subsequently, we will pro- visit the authorities of the ministry, ex- vide some guidelines for data collection plain the work to be conducted, and 5. Methodological and results analysis. gain their cooperation. We also suggest guidelines for estimating using the advisory services of an expert expenditure and financing 5.1 Results Pursued in the selected EPHF who is very famil- iar with its execution and the institu- This section presents the preliminary As we have already indicated, the pro- tions and key people involved. In order methodological criteria for estimating posed format for the final tables is pre- to facilitate the fieldwork, we also rec- the expenditure and financing of essen- liminary. It will improve as it is com- ommend organizing an introductory tial public health functions. These crite- pared against reality once the specific

271 Table 8 Example of entities that participate in the exercise of EPHF 2 in the Dominican Republic

Entities Type of entity Activities related to EPHF 2

General Bureau of Epidemiology General bureau of the • Investigation of outbreaks (patients with fever, (SESPAS) central government, vaccine-preventable diseases, meningococcemia, within the framework vital statistics, maternal and child mortality, etc.) of SESPAS • Investigation of isolated cases and patterns of outbreaks • Workshops and training • Participation in congresses and international meetings • Participation in national and international courses • Support for epidemiological surveillance at the international level • Support for vaccination campaigns • Evaluation of the epidemiological surveillance systems • Regulations

National Center for Control of Tropical Decentralized agency of • Entomological surveillance and control of Diseases (CENCET) SESPAS bilharziasis, malaria, dengue, and filariasis, and diagnosis of parasites.

Dr. Defilló National Laboratory Decentralized agency of • Epidemiological surveillance: SESPAS • Microbiology (bacilloscopy and parasitology) • Virology • National reference laboratory

General Bureau of the Environment General bureau of the • Environmental surveillance (SESPAS) central government, within the framework of SESPAS

Expanded Program on Immunization • Surveillance of eruptive febrile outbreaks and flaccid (SESPAS) paralysis

Tuberculosis Program (SESPAS) • Tuberculosis surveillance

Nutrition Program (SESPAS) • Nutrition monitoring

Rabies Control Center (SESPAS) • Rabies surveillance

Maternal and Child Bureau (SESPAS) • Vital statistics

Provincial Health Bureaus (SESPAS) Provincial Bureaus • There are eight public health regions and 29 provinces, each with its own area of epidemiology. The provincial health bureaus play a key role in the detection, alert, and control of diseases. The type of surveillance performed in the country is basically of infectious diseases and syndromes.

Laboratory department of SESPAS Department of SESPAS • Coordinates the regional public health laboratory network

General Bureau for Control of AIDS and General bureau of the • Surveillance of sexually transmitted diseases STI (DIGECIT) central government, within the framework of SESPAS

272 Table 8 (continued)

Entities Type of entity Activities related to EPHF 2

Department of Infectious Diseases of the Department in a hospital • Surveillance of infectious diseases Robert Reid Cabral Hospital

Dermatological Institute NGO with public funding • Leprosy surveillance and control in conjunction with CENCET

National Institute of Drinking Water Autonomous State Entity • Monitoring of water quality (INAPA)

Source: SESPAS, Annual Report 2000.

data for the different countries is com- process of performance measurement ing source, as they are normally desig- piled. In addition, the table formats will and are therefore unfamiliar with it. nated in the preparation of institutional be improved by incorporating expert budgets. We hope to obtain this infor- opinion on both public health and on Tool 2 : Questionnaire to Estimate mation directly from the various de- national health accounts. We refer to the Expenditure and Financing partmental budgets. We will incorpo- these tables (5 and 6). of the EPHF rate the information obtained relating to EPHF within the programs, based on The purpose of this tool is to identify the use of the tools mentioned above. In certain countries, it is customary to the tasks carried out by the institu- finance some public health activities tion—whether related or unrelated to Tool 5: Budget Prepared according with taxes or special contributions. It EPHF—in order to separate those that to Expenditure Allocation would be of interest to know this infor- are not. At the same time, we intend to mation in detail. In these cases, an aux- define as best as possible the program- Here we will indicate the expenditure iliary table, such as 5 and 6, could break matic activities that the entity considers made as it is normally calculated in down the origin of the public funds. part of the EPHF in question, in order preparing the budget, but without to link them to performance indicators. distinguishing the EPHF to which it 5.2 Design of Instruments corresponds. Tool 3: Estimate of the Required With the purpose of obtaining budget- Labor Allocation All these instruments will be field- tested. In the implementation phase of ary information related to EPHF, we With this tool, we intend to estimate the pilot plan for the Dominican Re- have designed a set of instruments using the time devoted by the entity’s person- public, it will be necessary to speak with the basic data described below. nel to each of the EPHF. We begin with the technicians who participate in the the list of personnel, annual wages, and execution of EPHF 2 and 9. The strong Tool 1: General Information on EPHF the estimated time devoted to each and weak points of the plan will be de- EPHF, administrative tasks, and other The purpose of this tool is to define tected as well as its usefulness and abil- tasks outside EPHF. each EPHF, the performance evaluation ity to adapt to real needs arising during indicators, and the standards for each. the process. The information obtained Tool 4: Budget Executed for Each Many of the technicians who will be in- for each institution or department Program by Financing Source volved in the work of financial data col- should then be added to the function lection in the entities of the ministry of This spreadsheet will detail the pro- requirements to allow structuring of the health have not been involved with the grams and activities classified by financ- final tables.

273 5.3 Data Collection should be focused on obtaining the co- Once all the information is gathered, it operation of each entity’s technicians should be processed to generate the final Since EPHF are carried out by various and an estimate of the effort required. tables. The next stage is the analysis of institutions, and since their content is This means ascertaining how many peo- the figures and presentation of results. still not very clear with regard to pro- ple work in the corresponding function, grammatic activities, the research re- the type of personnel involved, their We suggest that the final study report be quires the participation of the techni- wages, and the amount of time they de- structured according to the following cians involved in them. vote to it. It also means determining chapters and sections: I. Status of public whether the collaboration of each insti- health in the country; II. General insti- The first task therefore is to determine tution, technical assistance visits, and tutional organization and organization the institutional agency involved in ac- the organization of discussion work- of each of the particular EPHF; III. Ex- complishing each of the EPHF, in order shops (general or for each EPHF) will be penditure and financing of the EPHF: to later organize a workshop in which necessary. 1. Difference between expenditure on the basic activities that define each EPHF and expenditure on public health EPHF are decided by consensus. The The next task, which is the responsibil- programs; 2. Quantity of resources mo- task could be completed in a single day ity of the researchers, is to break down bilized; 3. Proportion relative to the with working groups on EPHF or in sev- the activities of the EPHF and other total public health expenditure; 4. Pro- eral separate workshops, one for each of functions and then attribute the admin- portion relative to public expenditure in the EPHF. This first workshop is also in- istrative expenditures, gather figures, health; 5. Other indicators of interest tended to describe the research, the im- code by health account classification, (proportion relative to the total expendi- portance of the results, and the most ad- and present the results. ture, GDP, expenditure per capita, etc.); visable instruments for data collection. 6. Analysis of financing sources; IV. 5.4 Addition of Data Analysis of expenditure and financing A simultaneous review of the public for each function: EPHF 1 to 11; and V. budgets should be performed, prefer- In order to be able to complete the final Conclusions and recommendations. ably using the budget preparation re- tables that will represent the findings, it port for the most recent year. In general will be necessary to create a group of ta- 6. Essential public health or at least, in the Dominican Republic, bles devoted to each of the EPHF indi- functions: costs and the published report does not clearly cating the institutional agency that budget separate programs and activities, nor deals with them. The information re- does it offer information on certain de- flected in those tables will be provided 6.1 Objective and Basis for the partments individually. Consequently, by the data collection instruments. Proposed Approach it will be necessary to obtain the tables detailing allocations or request a special As such, each institution or department The objective of this section is to at- printout from the budget department should prepare a table similar to the tempt to contribute to the current of the Ministry of Health. final tables. Subsequently, all the data methodology for costing and budgeting will be aggregated to provide the infor- of EPHF and the measurement pro- These data will make it possible to meet mation corresponding to each of the cesses carried out in more than 41 coun- the preliminary requirements of instru- EPHF. tries of the Region of the Americas with ments 2 and 3. We will thus know what the aim of identifying their outcomes the activities and programs are as they 5.5 Presentation of Results and providing the conceptual tools for are currently described by the Ministry, determining their cost.3 the corresponding sources of financing The explanation in the previous para- and the classification for each expendi- graph indicates that this research re- ture allocation. The next step will be to quires intensive fieldwork and should 3 PAHO/WHO, CDC, CLAISS. (2001). identify EPHF within the classification be performed in close collaboration Instrument for Performance Measurement of of programs and activities. During that with the agencies responsible for carry- Essential Public Health Functions. Public phase, the attention of the researchers ing out the EPHF. Health in the Americas Initiative. 274 To this end, an Input-Output approach those who recognize the strategic value The definition of products, subprod- was adopted, with a view to developing of the knowledge of costs and budget ucts, and activities elaborated below the analysis and definition of products, preparation as management tools. Pro- makes it possible to perform quantifica- as well as their disaggregation into sub- gress in this regard is of the utmost value tions and physical measurements that products, activities, sub-activities, and to our countries, even more when con- provide the basis of information neces- inputs. sidering that many discussions inex- sary for determining the cost of per- orably refer to the efficient allocation of forming EPHF. In addition to differen- Unlike the contents related to the Ex- the limited economic resources available. tiating products and subproducts, it has penditure and Financing of EPHF4 that been deemed necessary to extend the quantify current expenditure, this sec- 6.2 Definition of Products, breakdown in order to determine the tion on Costs and Budget seeks to deter- Subproducts, and Activities. operational elements involved in the ex- mine the cost of the products required to Methodological Framework ercise of EPHF. achieve the optimal performance of each of the functions so that they can sub- In order to begin looking at measuring It is worth noting that the activities de- sequently be integrated into a Budget the costs of carrying out EPHF, they scribed for each of the EPHF are in Process. should be analyzed in detail to de- some cases specific for achieving the termine their outcomes as measurable product desired for a particular func- It is important to note that we will con- consequences that make possible the tion, and in other instances are common centrate on the concept of operating ex- recognition of their effectiveness and to more than one or all of the functions. penditures of the EPHF and the process performance. Based on the analysis con- of determining the cost of the activities ducted and as previously indicated, the The following is an example of the dif- financed by the operating budget, need to identify the products, subprod- ferentiation between different types of while, broadly speaking, the infrastruc- ucts, activities, and inputs that enable activity: ture required (capacity building) relates the performance of each of the EPHF to the Investment budget, which will be should be determined. discussed in the corresponding chapter • The activity entitled “establishing of Institutional Strengthening of the In this regard, we will define subproducts and coordinating a laboratory net- EPHF.5 as those goods or services required for work” is specific to achieving sub- the performance of EPHF. These are product 1 of Product 2 of EPHF 2. Finally, it is appropriate to clarify that partial or detailed in nature and differ in the costs of EPHF have not yet been de- their limited scope or in their specificity. • The activity entitled “advising and termined. This is probably due to the Products, on the other hand, are those giving technical support at the subna- lack of regional consensus on the basic goods or services that in many cases are tional levels” is common to all of the activities that should be included in each comprised of a set of subproducts. EPHF. function in order for the objectives of the function to be completely achieved. Activities are those occurrences neces- This differentiation between common sary for the effective performance of the and specific activities will permit a more This represents an important stumbling EPHF, that result in the specific and accurate estimation of costs. block but also an exciting challenge for general effects characteristic of each of them. Finally, the resources applied in The following are some examples of the exercising EPHF are called inputs. 4 Rathe, Magdalena. OPS. (2002) Estima- separation of functions into products, ción del gasto y financiamiento de las Fun- subproducts, and activities: ciones Esenciales de Salud Publica (FESP): It is important to note that these re- Un marco de referencia. sources can be grouped or defined in 5 Example 1 Alvarado, Félix, OPS/OMS (2002). Forta- various ways, depending on the execut- lecimiento Institucional para el Desempeño de las Funciones Esenciales de Salud Pública. ing organization or the characteristics of EPHF 2: Public health surveillance, Lineamientos para Planes Nacionales de the input-output ratio utilized in each research, and control of risks and threats Acción. case. to public health. 275 With regard to the purpose of this func- • Implement an adequate epidemiolog- able to guarantee this quality improve- tion, that is, the continuous monitoring ical surveillance network. ment to the population. A product of health to ensure that if events should linked to this function could be the de- occur (epidemics, outbreaks of disease), • Systematize and standardize the velopment of a program for evaluating the adequate information is available process of decision-making. and improving the quality of Health immediately to facilitate the process Services. One of the subproducts that of decision-making, the predominant • Evaluate and monitor the quality of contributes to the achievement of this product should be the formation and the system for its improvement and product could be the production of reg- development of an Active System for adaptation. ulations on the structure and processes Epidemiological Surveillance and Con- of the Health Services. Another could trol of Communicable and Noncom- Example 2 be the preparation and use of indicators municable Diseases. EPHF 5: Development of policies and to evaluate the quality of services. institutional capacity for planning and The subproducts necessary to achieve this management in public health. The following are among the activities product could be defined as follows: that could be carried out: The major product of this function is • The existence of surveillance systems the establishment of a health policy. For • Implement the production of regula- at the subnational levels that are ac- its creation, we would first need essen- tions on the structure and processes tially two subproducts: tive and coordinated with the na- of the Health Services. tional level. The first would be the definition of the • Promote the development of quality sanitary objectives pursued and the • Creation of a warning system to in the Health Services. other, the monitoring and evaluation monitor the communicable diseases of the degree of achievement of these prevalent in the country. • Monitor and evaluate quality through objectives. the use of indicators. • The same monitoring system for To this end, we should define the fol- non-communicable diseases. • Continuously train personnel. lowing activities, among others:

• Structures and processes that detect 7. Analysis of the • Update the legal instruments that fa- and monitor the environmental fac- Input-Output Ratio cilitate the development of policies. tors that affect communicable and for EPHF with regard noncommunicable pathologies. • Establish participatory forums that to the Optimal Regional make it possible to achieve consensus Standard Among other activities that should be on the policies. carried out in order to arrive at the In previous works associated with the product through the various subprod- • Establish indicators and utilize them definition and improvement of the ucts could be: in evaluating and implementing the EPHF in the Americas, the level or policies. standard of optimal performance has • Prepare instruments (standardized been defined as that which can be guidelines) to permit the gathering Example 3 achieved under the most favorable con- of information for epidemiological ditions and in a reasonable amount of EPHF 9: Quality assurance and surveillance. time by all countries of the region. improvement in personal and population-based health services. • Develop a training process for all per- This definition and its utilization to sonnel involved in the collection and The purpose in this case is to improve measure the levels of performance in analysis of information. the quality of Health Services and to be each country require a complete knowl-

276 edge of the resources and institutional ture to enable the performance of This study has dealt only with determin- processes of the countries involved. Fur- EPHF). ing the cost of recurrent activities with thermore, the exact definition of “most the aim of constructing the operational favorable conditions” and “reasonable 3. Financing necessary for the func- costs of EPHF. On the other hand, the time frames” cannot be formulated with tioning and operation of EPHF. determination of investment costs re- absolute objectivity in view of the fact lated to institutional capacity (Infra- that the elements for consideration in- We will focus on the analysis of the last structure, Resource Supply, etc.) is in- clude subjective or debatable aspects. of the aspects cited. In this regard, it is cluded in the development plans of the important to distinguish between: project “Institutional Strengthening for Based on the above, the optimal level of Performance of EPHF.” In the first case, performance is an amount that, while it • the expenditures aimed at developing the costs would be assimilated into should be adapted to the current and and/or strengthening the capacity for Short-Term Costs, while the second potential status of the countries of the performance of a given EPHF, that is, would introduce elements of Long-Term region, should be conceived as a fair in- the investment budget necessary for Costs. centive for continuous improvement. If the design, installation, and testing of the level defined as optimal were very new competencies within the sector, 7.2 Analysis of the EPHF, easy to attain, it would be ineffective as and their Products and Costs an incentive, but if it were excessively demanding, it would discourage efforts • the expenditures associated with those To identify the recurrent expenditures at improvement. actions that should be carried out on associated with the performance of an ongoing basis if the sustainability EPHF, that is, the primary responsibility 7.1 Bases of the capacity to perform EPHF is to to which the institutions involved in be ensured. their performance should dedicate them- As mentioned earlier, in order to move selves, they should be analyzed as partic- ahead with the projects of health sector Thus, the first set of expenditures corre- ipants in an input-output ratio. Table 96 reform in which most countries of the sponds to actions that are carried out presents a schematic representation of region are involved, PAHO has imple- once and the second refers to activities the problem areas associated with deter- mented the “Public Health in the Amer- that are performed repeatedly over time. mining the cost of EPHF. In it, the na- icas” initiative. Within this framework, tional level has been differentiated from PAHO has defined EPHF through a This distinction should also be recog- the subnational level, although their par- participatory process at the continental nized in the financing modality in- ticipation is similar with regard to the level. At a later stage and based on the cluded in the budget for the execution input-output ratios characteristic of each development of an appropriate instru- of these activities; in the first case, the EPHF, and therefore, we will concern ment, the performance of countries in investment budget can come from an ourselves mainly with the analysis of the the achievement of EPHF was measured. external source. On the other hand, in national level in this study. the second case, financing from an in- It is now necessary to move ahead in de- ternal source should be ensured so as to The table describes the relationships and termining three fundamental aspects: guarantee recurrent expenditure and actions that must first be dealt with when sustainability. The national interest in determining the expenditures associated 1. Financing currently allocated to the achieving optimal performance of with the performance of EPHF, and sec- execution of EPHF by countries. EPHF should result in the support for ond, it describes expenditures needed for the recurrent expenditure required. their sustainability. Therefore, the time 2. Financing necessary for developing 6 EPHF that are operating deficiently In sum, this section will concentrate on Prepared based on the work: Ginestar, Angel y colaboradores. (1990). Costos Edu- or are nonexistent (an investment the analysis of operational costs related cacionales para la gerencia universitaria. necessary for the development of in- to the products and activities defined INAP – UN de Cuyo – CICAP – OEA. stitutional capacity and infrastruc- for each EPHF. EDIUNC. Mendoza, Argentina.

277 period for which the analysis will be con- Table 9 Problem areas associated with determining the cost ducted must be specified. of the EPHF

As previously noted, at this stage of the Performance of the EPHF at the national level analysis we will concern ourselves only with developing a methodology aimed at determining the production function The objective of the NHA is to im- and its associated costs at the national prove public health practice at the national and subnational levels level, leaving the subnational level aside for the moment. Performance of the EPHF at the subnational level The agencies responsible for the By disaggregating each of the EPHF into benefits or actions involved in each function and the needs or demands products, subproducts, activities, and that must be met should be identi- sub-activities, it will be possible to iden- fied, along with quantifiable indica- tify the inputs necessary for the perform- tors of the actions specified ance of each activity, to allocate costs, Identification of the products and subproducts necessary and to qualify them as fixed and variable, to satisfy needs in a given period direct and indirect, as pertains to the analysis. Table 10, presented below, re- Identify for whom and why each At the different levels and identify- function will be performed in a ing responsibilities, propose what 7 ports the sequence described thus far. given time human and material resources will be used to perform the function in a given time 7.3 Identification of the Principal Cost Categories Identify and characterize the benefi- Identify the production functions ciaries of the products and subprod- associated with the products and of EPHF ucts that comprise the EPHF subproducts that comprise the EPHF (expenditures, costs, supply In order to determine both the cate- relationships) gories of costs that make up the differ- Agree on criteria among the differ- ent input-output ratios characteristic ent levels to compare objectives of each EPHF, and the proportion of with requirements and decide what and how much to do, based on the their participation in it, an institutional availability of resources analysis of the performance and expen- ditures associated with them must be Determine the product and subproduct amounts for each EPHF and carried out. This analysis will enable us the resources required to define goals for a certain period (utilizing agreed-upon quantifiable indicators–optimization) to know: Each responsible entity executes • the institutional organization linked the specified actions as planned (projected and budgeted) to the products that comprise each of the EPHF at the relevant level Compare objectives and goals with the results obtained to determine the degree of fulfillment • the activities and sub-activities car- ried out by each area within the framework of the particular input- • the specific allocation of resources this determination will be to establish output ratio of a given subproduct (human and material) in each area the allocation of human resources nec- within the framework of the input- essary for their adequate performance. 7 Prepared based on the work: Ginestar, output ratio of a given subproduct Angel y colaboradores. (1990). Costos Edu- cacionales para la gerencia universitaria. Nevertheless, there are functions that INAP – UN de Cuyo – CICAP – OEA. Given the work-intensive nature of can require a wide variety of inputs, and EDIUNC. Mendoza, Argentina. most of the EPHF, a central aspect of this study therefore adopts a broad clas- 278 appropriate for further study in the next Table 10 Determination of function cost stages of development of the methodol- ogy. The first are capital expenditures, Direct expenditures considered primarily “one-time expen- National Subnational level level ditures” that can be carried out within Year J the framework of the project “Institu- tional Strengthening for Performance of the EPHF.” The total expenditure on the activity is deter- Secondly, we have also not included mined by its duration and frequency and the Activity the expenditures corresponding to the levels at which it will “Charge for depreciation of the produc- be carried out. tive capacity assignable to the activity”, since the current development of bud-

The total expenditure on getary accounts generally hinders their a subproduct is deter- determination (the countries of the re- mined by the expendi- Subproduct gion in which progress has been made ture on the activities. It is made up of in this area are limited).

The total expenditure on a 8. Cost Analysis for product is determined by the expenditure on the Product EPHF in order to achieve subproduct. It is made up of Optimal Regional Performance Level

The total expenditure of The different input-output ratios char- a function is based on the acteristic of each of the EPHF are af- expenditures for the sub- products and products that Function fected by a set of factors, among which comprise it. are the characteristics of political organ- ization at the national level (unitary or federal), the different levels of decen- tralization with regard to the NHA, the assignment of the EPHF to the various sification of the possible inputs that Table 12 presented below shows the ex- agencies (ministries, decentralized bod- would comprise the various input-out- pected sequence for determining the ies, etc.), and the modalities of produc- put ratios and the budgetary imputa- cost of EPHF and explains the develop- tion adopted by each of them for the tion of the expenditures associated with ment of the methodology used thus far.8 performance of EPHF (labor-intensive them. Table 11 presents the categoriza- or capital-intensive technologies). tion adopted for the expenditures. There are two types of expenditures that are key to the determination of The inputs that make up each of these 7.4 Cost analysis costs but have not been included in the input-output ratios have been previ- table and whose treatment is considered ously characterized and can be summa- In accordance with the above, this pro- rized as Human Resources, Goods, and posal for determining the cost of EPHF Services. Computer equipment (hard- 8 is based on the attempt to specify the Prepared based on the work: Ginestar, ware) and applications (software) will Angel y colaboradores. (1990). Costos Edu- different input-output ratios character- cacionales para la gerencia universitaria. play a prominent role as part of the istic of each EPHF in terms of their INAP – UN de Cuyo – CICAP – OEA. technology associated with the perfor- products, subproducts, and activities. EDIUNC. Mendoza, Argentina. mance of each EPHF. On this basis, the 279 mon activities, distributed among the Table 11 Budgetary categorization of expenditures products they affect. The determination of the cost of the different input-output EXPENDITURES ITEMS CATEGORIES SUBCATEGORIES Top-level ratios is made possible as a result of High-level the relationship between products/sub- Administrative products and the indicator/standard for Personnel Permanent Professional the optimal regional achievement of the Teaching performance measurement instrument. Technical Worker Contracted 9. Conclusions and Temporary Monthly Recommendations CURRENT Daily EXPENDITURE Medical and pharmaceutical The methodological framework for esti- products mating the expenditure and financing of Goods Materials and supplies EPHF presented in this chapter is a first Non-personnel Medical and sanitary goods and equipment broaching of the subject. It is based on services Publicity and advertising the literature related to EPHF, the na- Services Communications tional health accounts methodology, and Other the experience of the United States in its Hospital equipment attempt at this type of exercise. In the Technical and scientific instruments design of the methodology, the principal Capital goods Computer equipment reference points are taken from the Do- Vehicles and vessels minican Republic, where a preliminary Real property CAPITAL Other acquisitions collection of data was carried out. It is EXPENDITURE Construction public buildings highly probable that there are funda- Construction Infrastructure works mental differences in both the scope and Other works methods of estimation in other coun- Maintenance of Rehabilitation and repair of public buildings tries, particularly larger countries that are preexisting goods organized according to a federal model.

It should be noted that consensus has different input-output ratios character- require adjustments for the characteris- never been reached among the countries istic of each EPHF will present different tics of each country in terms of the to determine the cost of and break down alternative combinations of these inputs aforementioned considerations. of the basic activities that each of the to produce the activities, subproducts, EPHF should perform for the complete and products, according to the technol- With regard to the performance indica- achievement of all its components. The ogy adopted in each country. tors as described in the Guide, it should instrument currently utilized to measure be noted that some of these indicators the performance of EPHF focuses only On the other hand, it should be consid- are for results, others for processes, and on results and assumes a given institu- ered when carrying out the work that still others for institutional capacity. The tional organization and some given the composition of the activities, sub- determination of the cost of EPHF and methods of performing EPHF that, products and products that comprise of these indicators as a part of them is until now, have not been specified. each EPHF can vary among countries, based on associating the indicators with depending on their degree of institu- products and activities. To the extent Accordingly, the work to estimate the tional development and the availability that these indicators affect more than expenditure for EPHF and their sources of resources. Thus, the application of one product of the EPHF, the activities of financing requires the reconstructing the cost methodology of the EPHF will go from being specific to being com- of the way in which each of them is

280 Table 12 Sequence to be followed to finance the EPHF’s

Function Data structure: Products, Primary subproducts and activities

Estimation of the Cost for: Activity Data National Direct current S Expenditures in Level Primary personal goods Subnational U and services Level P B R F P O U Activity R N Data Direct current National D expenditures in Level O non-personal Primary U C goods and Subnational D services Level C T U T I C S O Activity T N Data Indirect current National expenditures Level S assigned to the Primary activity Subnational Level

achieved, in those countries which of each country, as well as the budgetary sources education, and the tasks related apply the methodology. The lessons and statistical systems are considered. to emergencies and disasters. Some of learned from their practical application This way, the instrument will be trans- these functions could also be executed by will lead to the necessary changes, both formed as it progresses through a pro- the for-profit private sector, as in the case in scope and in the procedure as well as cess of successive applications. of private universities or the pharmaceu- in the presentation of results. For that tical industry. In this case, it would be of reason, this methodological framework In almost all countries, the health au- interest to determine which of these tasks will not be completed until it has been thorities are responsible for implement- corresponding to the steering role func- applied in several countries. It will be ing most of the activities included within tion of the health authorities are never- verified by way of a pilot plan so that the EPHF. Nevertheless, there exists a theless delegated to private institutions. the practical viability of the method- growing sector of nonprofit institutions ological proposals and the differences dealing particularly with the improve- In carrying out the work, it is impor- with regard to the internal organization ment of health, research, human re- tant to consider that the content of the

281 competencies included in each of the Achieving that possibility is fundamen- mance levels. This framework was ad- EPHF can vary a great deal from one tal to the development of the health sys- dressed from an Input-Output approach country to another given the different tem. The current trend in reform pro- in order to subsequently develop a levels of development and characteris- posals is to separate the functions of the budgeting and management-by-results tics specific to each. There can be a steering role, financing, and services de- process. The purpose of this methodol- significant factor of subjectivity that livery. The lack of foresight in defining ogy is to move toward the determina- hinders the adoption of a uniform the sources of funds that make the steer- tion of the cost of EPHF and integrate methodology involving the calculation ing role of the health system, within management-by-results into the budget of expenditures whether they are realis- which the public health activities and processes through identification of the tic or ideal. functions are framed, operate, can lead products in their current state and the the countries to a crisis in this area with setting of goals to achieve their optimal The subject addressed in this chapter is consequent danger to the population. performance (analysis of gaps). completely new. For the first time, an at- tempt is being made to adapt the na- Furthermore, it is well known that the To this end, it is suggested that each tional health accounts to EPHF. The market does not allocate health sector country implement the Methodological analysis performed shows that the func- resources as it should, and that State in- Framework for determining the Cost tional classification of the national tervention is necessary to correct mar- and Budget, adapting it to the national health accounts does not take into ac- ket failures. Hence, the function of the reality and to the health sector. The ap- count public health functions, although State is described as the production of plication of this Framework in each it may be very exhaustive with respect to public goods and goods of social inter- country should consider the general po- the care of disease. If we want health sys- est, that are part of the public health litical characteristics (unitary or federal tems to be oriented further toward the function. These include the capacity countries), the conditions of Health Sys- promotion of health and the prevention needed for the regulation of the entire tem organization (different degrees of of disease, it is indispensable that we be health system—including the essential decentralization), the staffing of public able to monitor changes in the alloca- functions—and the decisive capacity agency personnel and others (labor- tion of resources to the tasks of public for the performance of the steering role intensive production relationship), with health, with respect to programs, essen- function. The health systems require regard to the man-hours required for the tial functions, and services. It is neces- that these activities be reflected in the products of each of the EPHF. On the sary to be able to determine the lines of public accounts and that it be possible other hand, the price vectors to establish action; first, with regard to the budget, to identify them clearly in the budgets the cost of inputs and products will be and second, with respect to the national to subsequently transfer them to the readjusted on the basis of the conditions health accounts. health accounts. and variability for each country.

The task implies reviewing the defini- This issue leads us to the need for ad- It should be noted that the Method- tion of health in the national accounts dressing an additional problem: the sep- ological Framework for determining the and, accordingly, the classification of aration between the planning and Cost and Budget offers the possibility functions. In order to do so, it is neces- preparation of budgets, on the one of its joint application with the respec- sary to perform an in-depth and broad hand, and their subsequent application, tive frameworks for Expenditure and analysis of the function of public health on the other. It is a generalized problem Financing and Institutional Strengthen- and its importance in achieving the ul- in the financial administration of the ing of EPHF, which will make it possi- timate objective of every health system: State, but it is important that it be ble to connect aspects of the operating to improve the health of the popula- pointed out here. budget with those of the budgets for In- tion. One of the principal advantages of vestments and National Accounts, con- the system of health accounts is the pos- This chapter also presented the elements tributing to an integral implementation sibility of setting priorities in the alloca- of the Methodological Framework for of EPHF and completing the progress tion of resources devoted to those tasks determining the Cost and Budget of in measurement and characterization and their monitoring over time. EPHF based on their optimal perfor- achieved thus far.

282 Finally, the development of the Molina R, Pinto M, et al. Gasto y finan- Rathe M. La reforma de salud y la seguridad Methodological Framework for deter- ciamiento de salud: situación y tendencias. social. Santo Domingo, RD: Pontificia Organización Panamericana de la Salud. Universidad Católica Madre y Maestra; mining the Cost and Budget by country Revista Panamericana de Salud Pública, 2002. will facilitate an application of tools for Vol.8, Nos. 1/2, July–August 2000. management-by-results that are more Rathe M. Salud y equidad: una mirada al fi- Muñoz F, López Acuña D, et al. Las fun- nanciamiento a la salud en la República advanced than in the case of the Analy- ciones esenciales de la salud pública: un Dominicana. Santo Domingo, RD: ses of Cost Effectiveness (for example: tema emergente en las reformas del sector Macro Internacional; 2000. study of the cost effectiveness of Epi- de la salud. 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283 Evaluación del servicio hospitalario”. las Funciones Esenciales de Salud Pu- OPS/OMS. Dr. Pedro E. Brito. (2002). Li- Capítulo 13. Ed. Trillas. blica. Washington, D.C. neamientos Metodológicos: Desarrollo de la Fuerza de Trabajo para el Desempeño Lic. Salvo Horveilleur, Lucía. Republica Do- OPS/OMS, CDC, CLAISS. (2001). In- de las Funciones esenciales de Salud Pu- minicana. (2002) Reunión Subregional forme Ejecutivo de la Medición de las blica. Reunión Subregional sobre Fun- de Seguimiento a las Funciones Esen- Desempeño de las Funciones Esenciales ciones Esenciales de Salud Publica, Santo ciales de Salud Publica. de Salud Publica ejercidas por la Autori- Domingo. dad Sanitaria en los países de Centro- OPS/HSD, CDC, CLAISS. (2001). La Prac- américa y Republica Dominicana. Inicia- Berrueta Colombo, Oscar. (1995). La efica- tica de la Salud Publica en Centroamérica tiva “La Salud Publica en las Américas”. cia del proceso presupuestario. Revista y Republica Dominicana. Medición del Nicaragua. ASIP N° 29. desempeño de las Funciones Esenciales de Salud Publica. Informe a la XVII Reu- OPS/OMS, Ministerio de Salud de la Re- García Balderrama, Teresa; Calzado Cejas, nión del Sector Salud de Centroamérica y publica Argentina. (2001) Medición del Yolanda. (1997). Metodología de eva- la republica Dominicana. Desempeño de las Funciones Esenciales luación de la eficiencia en las entidades de Salud Publica Ejercidas por la Autori- publicas. Revista Internacional de Pre- OPS/OMS (Organización Panamericana de dad Sanitaria en la Republica Argentina. supuesto Publico N° 35. ASIP. la Salud / Organización Mundial de la Resultados del Taller de Aplicación del Salud), CDC (Centers for Disease Con- U.S. Department of Health and Human Ser- instrumento llevado a cabo en Buenos trol), CLAISS (Centro Latinoamericano vices (HHS). (1991). Healthy People Aires, Argentina, November 2001. de Investigaciones en Sistemas de Salud). 2000: National Health Promotion and (2001). Guía para la Aplicación del Ins- OPS/OMS. (2002) Fortalecimiento Institu- Disease Prevention Objectives. Washing- trumento de Medición del Desempeño cional para el Desempeño de las Fun- ton, DC: HHS, Public Health Service de las Funciones Esenciales de Salud Pu- ciones Esenciales de Salud Publica. Li- (PHS). blica. Iniciativa “Salud Publica en las neamientos para Planes Nacionales de Américas”, Medición del desempeño de Acción.

284 15 Development of the Public Health Workforce

1. Introduction Pan American Conference on Educa- and essential public health functions tion in Public Health held in Mexico were analyzed and debated with regard In addition to being a concerted action City, on “Sector Reform and Essential to education in public health; the influ- to renew the concept of public health Public Health Functions: challenges for ence of academic institutions in these re- (that will allow the adoption of new ap- human resources development”. This proj- forms; the proposal of future strategies proaches, practices and training modal- ect is a joint effort with the Latin Amer- for the development of public health ed- ities) and an effort to empirically ap- ican and Caribbean Association for ucation. To overcome specific deficien- proach public health practice in Latin Public Health Education (ALAESP) as cies in public health education, a pro- America—according to existing condi- well as with other institutions in the Re- posal was made, within a programmatic tions—The “Public Health in the gion. During this meeting, the academic framework, for academic institutions Americas” initiative is also an opportu- institutions explicitly acknowledged to develop five training areas that will nity to redefine education in public their meager prominence in the pro- contribute to the improvement and health and in its practice contribute to cesses of transformation of developing strengthening of the essential public the development of institutional capac- health systems in almost all of the coun- health functions: political articulation; ity and workforce competence for those tries in the Region. In addition, two sig- pedagogic and educational training; re- working in the field, who in Latin nificant gaps in the political agenda of search and technology development; America are known as “sanitaristas”. health sector reforms were highlighted: technical cooperation; and management the little attention given to the func- capacity of academic institutions. Reorienting education in public health, tions and participation of public health using as a frame of reference the essen- institutions during these processes (re- The “Public Health in the Americas” ini- tial public health functions is a project sulting in serious consequences for col- tiative, sponsored by the Pan-American that was begun in 1998 by the Human lective health) and the absence of topics Health Organization (PAHO)/World Resources Development Program in the related to human resources. Health Organization (WHO), was an Division of Health Systems and Services important step in keeping with the ef- Development of the Pan American During the conference, aspects related forts begun in 1998 for changing edu- Health Organization, during the 2nd to the demands of health sector reform cation in public health. In the XIX

285 ALAESP Conference held in Cuba in Figura 1 Programatic proposal for the development of the July 2000, agreements were formalized public health workforce and strategies and procedures were more precisely outlined. Schools committed more firmly to their essential functions NATIONAL PLANS FOR THE as a principal political and program- DEVELOPMENT OF THE PUBLIC HEALTH matic reference in educational participa- tion. From then on, various joint work plans have been carried out by PAHO and ALAESP. Today, ALAESP represents PERFORMANCE DEVELOPMENT OF EPHF 8 THE PUBLIC HEALTH more than fifty teaching institutions MEASUREMENT OF THE FUNCTIONS WORKFORCE dedicated primarily to graduate educa- tion in public health.

Nonetheless, there is still work to be done at the undergraduate level in DESCRIPTION OF terms of public health education in the THE PUBLIC HEALTH WORKFORCE health fields, as well as in continuing INSTITUTIONAL education of the public health work- DEVELOPMENT FOR force. In order to meet the professional THE PERFORMANCE development needs of public health OF THE ESSENTIAL PUBLIC HEALTH staff in charge of everyday activities, FUNCTIONS programs and tasks, PAHO has formed a consortium with eleven academic and technical cooperation institutions in the Americas and Europe to develop the Virtual Campus in Public Health Ini- Development and Training in Public This paper provides the conceptual, tiative which was launched in July this Health) irrefutably show a low level of methodological and programmatic ele- year. This Initiative will be further ad- performance, albeit with national and ments for preparing plans for the devel- dressed later in the chapter. sub-regional differences. The formula- opment of the public health workforce tion and implementation of plans to de- (highlighting PAHO/WHO’s program- Progress in the development of a con- velop and boost public health practice in matic responsibility in educational and ceptual framework, evidence derived the member state countries requires an professional development), with the from the performance measurement of important pillar: education of the work- goal of contributing to the improve- the essential functions in the countries of force which will allow the consolidation ment of institutional capacity at the na- the Region, and results from a number of the institutional capacity of the public tional level in the performance of the of diagnostic studies on the state of grad- health infrastructure. essential public health functions. uate education in public health (done in Central and South America) show trou- The figure above shows the logic behind With this in mind, some general lines blesome results urging us to double our the programmatic proposal for the “De- of action for the formulation of human efforts in taking concrete measures in the velopment of the Public health work- resources development measures will be field of education in public health. As force”. It is based on discussions and proposed (one of the key components expected, the results of performance conclusions drawn from various national of national and sub regional plans) and measurement of the essential public meetings and the sub-regional confer- with time, design a feasible regional health functions—one of them being es- ence for Central America, Haiti, Cuba project that will allow for the develop- sential function 8—(Human Resource and Puerto Rico, held in April 2002. ment of public health based on the

286 measurement of the essential public cruitment strategies nor retention of sure continuing staff development, and health functions. these workers is evaluated. In general, without suitable systems for assessing there is a lack of an incentives system to the results or impact that these pro- 2. Essential Function 8 promote professional development and grams may have on the effect of educa- the retention of the best performing tional plans. There are no criteria or As previously mentioned, EPHF 8 (De- employees. As is the case with the work- norms for staff retention. It is evident velopment of Human Resources and force, there are serious problems with the already mentioned lack of systems Training in Public Health) shows a low the performance evaluation of staff and for assessing the performance of person- performance level with a mean of 0.40 the availability of appropriate systems nel and of incentives for public health for the Region. Despite the fact that all of remuneration and recognition. workers. five indicators performed poorly, some point out deficiencies that deserve fur- In many countries that have imple- These conditions have to do with the ther comment given their importance mented institutional development proj- lack of coordination that has traditionally for the development of plans that will ects or investment projects in support of existed and continues to exist between improve the national capacity to offer health sector reform, with external fi- academic institutions in the field of pub- public health services. nancing, it is necessary to highlight the lic health and the employing institutions anomaly in the structure of the execut- of the public health workforce. This can 2.1 Description of the public ing or coordinating units. These units be better exemplified by data in the health workforce profile are usually created by outsourcing con- U.S.A. where only 20% of the workforce sultants hired for a limited time whose has had the opportunity to receive some Although the countries report that the remuneration is significantly higher than kind of formal education in public basic characteristics of the workforce are that of the staff in the ministries of health. Although this case is not determi- evaluated, only half define staff needs health. In many cases, the personnel of nant, it draws attention to the limited for performing public health activities such units do not belong to the perma- communication between such institu- that include an estimate of necessary nent units of the ministry, enter into col- tions reflected—among other factors— personnel or the required profile. This lusion with the established programs, or in the almost non-existent offer of con- situation makes it difficult for the health duplicate efforts. This situation has gen- tinuing education and public health authorities to intervene in an effective erated much conflict and problems with programs by the schools, and their lim- manner should they decide to enhance regards to maximizing the performance ited presence in most countries on de- the performance of the workforce or of the hired consultants. In addition, this bates held regarding the need for reforms. guide the development of personnel arrangement threatens the efforts of the whether they be within or outside the national institutional capacity. health authorities’ realm of action. The 2.4 Improving workforce to weakest areas are the lack of availability 2.3 Continuing education ensure culturally-appropriate of information as well as lack of criteria and graduate training delivery of services to determine needs for future growth. in public health Only a small proportion of the coun- 2.2 Improving the quality Most countries of the Region promote tries in the Region provide different of the workforce and create incentives for the participa- communities with technical support tion of staff in continuing education and incentives to select and promote Most of the countries of the Region are (usually in accordance with the institu- the incorporation of human resources weak in the area of workforce manage- tional needs of the moment) favoring according to their socio-cultural needs. ment in the field of public health. De- formal agreements with academic insti- And only half of these countries en- spite the existence of criteria to evaluate tutions to facilitate training. This is courage the development of strategies staff credentials, these criteria are not done however, without adhering to the to encourage the decentralized manage- met at the time of hiring. Neither re- established policies and norms that en- ment of such human resources.

287 In this regard, it is essential to deal with are workers who interpret and apply bility in public health practice: govern- and overcome these conditions in order both knowledge and information to mental public health organizations, to achieve efficiency in human resources provide solutions with an added value other public sector organizations, health development plans. From the previous regarding the problems of public care organizations, volunteer organi- considerations, it can be inferred that health, and as part of their daily tasks, zations, community-based groups, aca- any measure to improve workforce per- make recommendations in a continu- demic institutions, etc. formance should consider strategies for ally changing environment. Thus, they educational development and integrated require access to organizational condi- Figure 2 attempts to show the various management, generated and developed tions that will allow them to acquire organizational groups where the PHWF based on reliable information and the theoretical and analytical concepts in is employed in the Region. characteristics of the workforce. addition to developing the practice of continuous education and to continue As can be noted in the performance As was mentioned in the meeting of to be competent and productive through- measurement and according to the Central America and the Caribbean re- out their lives. These conditions in- available reports, little is known in gion, there is a special condition of dicate a clear orientation of the edu- other countries about the public health EPHF8 which must be taken into con- cational proposals and management workforce. This is a critical deficit since sideration: EPHF8 is not only one more criteria that should be used for the pub- it determines an essential task yet to function among the eleven defined lic health workforce. be done in planning workforce develop- functions, but rather, the one without ment. Nonetheless, it is important to which the other ten functions can be The definition of workforce that is used mention that until recently even devel- performed; that is, it is polyvalent with is similar to the one utilized in econom- oped countries lacked such data. regard to the other ten essential func- ics. In these cases, the definition of tions. EPHF8 is strategic for the per- workforce in any economic activity is es- For a number of years now, the United formance of the other essential func- sentially based on socio-demographic States has been conducting censuses of tions which public health authorities and economic criteria. That is to say, it the public health workforce. These cen- must provide. is about quantifying how many people suses have demonstrated, among other are employed in a certain activity at things, that public health nursing pro- 3. Public Health a given moment, according to age, sex, fessionals are by far the largest group in Workforce (PHWF) educational level and established qualifi- this workforce (10.9%), estimated at cations. This definition is thus limited, 450,000 workers. Public health doctors In the initiative “Public Health in the according to what they do rather than represent a mere 1.3%. There is also a Americas”, public health workforce what they are or where they work. serious problem with supply and de- consists of all those health workers re- mand, and only a 20% of nurses have sponsible for contributing—either di- As for public health which includes a received formal education or training to rectly or indirectly—to the perfor- wide field of practice and participation perform their functions. mance of the essential public health which goes beyond the limits of the functions, regardless of their profession health sector, the definition of the work- In most countries of the Region, the and institution where they actually force cannot be limited to the people public health workforce had never been work. Given this wide definition, it is working in the public sector; it must subject of analysis and least of all plan- important, though challenging, to iden- also include all the State and civil organ- ning. It is necessary to acknowledge that tify the various institutions which have izations with responsibilities in public there are serious problems with avail- responsibility in and contribute to the health. Therefore, the public health ability, quality and handling of informa- essential public health functions. workforce is multi-professional, multi- tion on human resources in health in the sectoral, diverse and dispersed through- majority of the countries of the Region. Recently, the condition of the public out a country. In the U.S., the PHWF is However, these problems, little by little, health workers has been emphasized as employed by a wide range of organiza- are being overcome by the Human Re- “knowledgeable workers”. That is, they tions with differing degrees of responsi- sources Observatory initiative, already

288 terms, it is not quantitatively nor func- Figure 2 Where does PHWF work? tionally the main factor. It would also seem that, as is the case in the U.S., that most of the workforce has actually never SOCIAL UNIVERSITIES, SECURITY PUBLIC HEALTH taken a formal course in public health. INSTITUTIONS EDUCATION INSTITUTIONS The PAHO-WHO Human Resources • MINISTRY OF Observatory has developed a proposal HEALTH to characterize the public health work- • PUBLIC force. In this proposal, the Observatory SERVICES regards the creation of a set of basic data Other state to characterize the public health work- organizations Private Sector force as an essential element. To date INDUSTRY REL. TO (for profit and non profit). NGOs, HEALTH, ECONOMIC this initiative has been working in 16 community based countries of the Region providing qual- GOODS INDUSTRY, health OTHER ECONOMIC organizations ity information to narrow the gap of ex- ACTIVITIES isting information on human resources in most countries, as well as to provide information for decision making and to develop the bases for or to rebuild the working in 16 countries in the Ameri- Within the public health workforce, deficient information systems. cas. The need to know the characteris- there are those that are specifically pub- tics of the public health workforce lic health workers but, there are also The proposal of collecting basic data can within the initiative framework has to sanitary personnel that perform func- be very useful for characterizing the pub- do with the objectives of human re- tions of health care and management in lic health workforce. Such data are col- sources management, the improvement health services programs. Therefore, the lected by doing an exhaustive search of of distribution and accessibility, eco- description of the public health work- existing information not only regard- nomic and gender equity, quality assur- force should include this group of per- ing human resources in public health, ance, and the development of policies sonnel that are not specifically identi- but by also looking at other sources that for the PHWF, among others. As previ- fied as public health workers. generate or contain information such ously mentioned, in order to quantita- as various types of surveys. Whenever tively and qualitatively develop the pub- In order to define and set development necessary, information from secondary lic health workforce, it is necessary to fill strategies for the workforce, it is partic- sources can be complimented with ad the gaps in information and knowledge ularly important to take into account hoc research of some of the variables that about that workforce. this situation, especially at the primary are not found in the primary sources. service level and basic levels of assis- There can never be too much emphasis tance, where the same individuals per- placed on the diversity of the public form such public health services. Table 1 shows the proposal of basic data health workforce. The essential func- of the Observatory, adapted to meet the tions are a responsibility of many oc- Possibly, due to a lack of an integral per- needs of the “Public Health in the Amer- cupational and professional categories spective, there is the mistaken idea that icas” Initiative, taken into consideration throughout the structure of the health this workforce essentially consists of for the study of the main variables of the system: general and family doctors, pub- people who have attended school and definition of the PHWF. lic and primary health care nurses, nurs- who have completed graduate courses in ing auxiliaries, sanitary engineers, health public health or related disciplines. It Further details about the selection of educators, promoters of sanitary mea- would seem that no matter how impor- variables, indicators, availability and sures, administrators, etc. tant this negative factor is in qualitative characteristics of sources can be found

289 nical function but at the same time an termine the level of intervention and Table 1 Group important social function for the health configure the bases of a development of basic data for the of the population, which implies politi- plan for the public health workforce. In characterization of PHWF cal decisions that should be examined. the intersection of interventions and limits of the workforce, main areas and • Availability, structure and composition The field in which these agents’ work is criteria are identified for the integral de- of PHWF • Work links mainly determined by the interactions of velopment of the public health work- • Education/Training of the PHWF two key processes: education (acquired force. These areas and criteria map out • Productivity in social institutions created to educate • Remuneration and incentives important topics which will differ in • Work location such individuals) and work (or technical nature, magnitude and priority accord- • Regulation of the education and prac- and social performance of the health ing to each country. tice of the PHWF agents) which takes place at the different levels of the health services systems. This The main idea is that this matrix be ap- complex interaction results in other im- plicable to any country, allowing the in the PAHO-WHO Human Resources portant processes such as the function- identification in the national institu- Observatory website. ing of the labor market, on the one tional context, the main issues or prob- hand, and professionalization processes lems to be faced, considering the charac- 4. Development of the on the other hand. In this latter process, teristics of the health system, the results Public health workforce the occupational groups—since they of the performance measurement, the have and control certain knowledge— priorities of the population, the institu- 4.1 A New Integrated are structured as groups of autonomous tional responsibilities and the availabil- Approach to Workforce power which, together with the society, ity of resources. Development are in conditions to impose regulations in the behavior of its members as well as The main objective is to prepare and im- Unlike the usual approach which con- to obtain special negotiation situations. plement a workforce development plan siders that the development of the work- based on the competencies derived force consists of only specific training The proposed concept is that the devel- from the essential public health func- activities, the approach used by the Pan- opment of the public health workforce tions. Such a plan must be supported by American Health Organization in its implies political decisions and institu- a clear resolve in development policies technical cooperation implies an inte- tional interventions at various levels of for the public health workforce and in grated and complex approach (see figure the field. Table 2 matrix intends to pro- guiding the improvement of public 3) for workforce development in public vide a modus operandi of analysis to de- health practice, based on the following: health. Figure 3 Development field of the public health workforce The concept of field is based on the idea that the workforce (in any area and also in public health) consists of people, UNIONS agents who have developed a series of HEALTH SERVICES skills (based on knowledge, technolo- LABOR MARKETS REG gies, qualifications, values and specific REG attitudes of social service), which allows EDUCATION WORK them to contribute to solving health REG REG problems (both collective and individ- PROFESSIONALIZATION ual) of the population in a given institu- UNIVERSITIES tional context. This contribution, spe- SCHOOLS cific to the development of health is an PROFESSIONAL essential element that determines its so- CORPORATIONS cial function. That is, it not a mere tech- 290 Table 2 Map of Issues for the Preparation of a Workforce Development Plan

Education— Work or Area Training performance Labor Intervention of the PHWF of the PHWF market Professionalization Public health It is a set of ideas and definitions that generate and shape efforts, considering the State and society, in order workforce to create plans and institutional conditions to improve the contribution of the PHWF in the performance of development policy essential public health functions (EPHF)

Planning Systematic prevision of the political conditions, institutional capacities and resources to meet the quantitative and qualitative needs of the workforce at a given time. Basically, it is the preparation of PHWF Development Plan. Efficiency in the placement of staff to improve its distribution Regulation Accreditation of Regimens of work, Regimens of Recertification? schools and programs. modalities of hiring, remuneration and Organization and Quality strategies. labor protection incentives representation of the Regulatory efficiency in public health the management and practitioners development of the workforce

Professional and Development of Orientation of training Structural and dynamic Participation of technical competency based in according to analysis of the labor professional agents in education the EPHF in performance markets for educational the definition of plans professional and requirements planning of curricula technical careers

Professional and Participation of the Development of PHWF Continuing education Participation of technical Training public health academic competencies based on and development of organizations of public and development institutions in the EPHF employability health practitioners in continuing education continuing professional Continuing education of the PHWF development based on competencies.

Management of the Use of continuing Management of Design and Participation in the workforce education as a strategy individual and implementation of definition of criteria for for the development of collective work incentives systems the professional career PHWF relations Distributive efficiency Assurance of good Access to continuing Criteria and normative to revert the environment and education as a frameworks for concentration of staff working conditions condition of and selection, recruitment, in urban areas definition of career induction, and development assignment Non monetary Management of the incentives system quality of productivity and performance

• Educational development of the • Reorientation and improvement of 4.2 Strategic Conditions workforce based on competencies the quality of both undergraduate for the Development and graduate education in public of the Workforce health based on the essential pubic • Management of the public health health functions The national authorities which have ap- workforce proved the regional mandates to pro- Figure 4 illustrates what could be called mote the “Public Health in the Ameri- • Regulation of educational and labor the development cycle of the public cas” Initiative, have completed the processes of PHWF health workforce. performance measurement of the essen- 291 and consolidating collaboration. One of Figure 4 Development cycle of the public health workforce the goals of this initiative and specifi- cally of the proposal outlined here is Description of the that it should contribute to the progres- public health workforce sive development of the integrated edu- cation systems in the countries of the subregions. REORIENTATION AND EDUCATIONAL IMPROVEMENT OF THE DEVELOPMENT Special attention should be given to the QUALITY OF TRAINING OF THE OF THE WORKFORCE PUBLIC HEALTH WORKFORCE components of training that are part of almost all of the investment or institu- tional development projects in many AGENTS countries in the Region to support RESOURCES processes of health sector reform. It is important to evaluate these experiences since a considerable amount of money REGULATION OF has been invested. Thousands of work- WORKFORCE MANAGEMENT OF ers have been trained in various areas of DEVELOPMENT THE WORKFORCE public health management. Such train- ing has followed the logic of the respec- tive projects and goals frequently with- tial public health functions and have vide public health education and train- out any previous agreement or general committed to preparing plans for the ing is extremely important. Without orientation of the institution or health development of the public health work- their involvement it is not possible to system. In general, there has been little force. Moreover, they have shown in- develop and implement plans for im- coordination between projects that creasing concern in the face of the dete- proving the competencies of the public share the same target population, objec- rioration of public health practice in health workforce. tives and areas of work. When properly most of the countries as well as political coordinated, these projects have been will to change such conditions. Such As leaders of the Initiative, health au- and may continue to be an important political resolve should be highlighted thorities need to take measures to end source of institutional and financial re- since it is one of the basic conditions to the lack of communication and “di- sources which can be mobilized to de- bring about change. vorce” that exists between the academic velop the public health workforce. institutions, health service and state in- Political resolve should be reflected not stitutions, responsible for public health, 5. Educational only in the mobilization of will and re- in order to join efforts and resources for Development based sources of the public sector, but it should the development of the national sani- on Competence also be reflected in the various institu- tary capacity. Gradually the foundation tions which, together with the State and will be set and conditions met for the 5.1 Continuing Education society—are responsible for providing development of an integrated educa- for Performance based public health services and employees. tional system for public health. This on Competence Communication with institutions that system will be the primary infrastruc- provide public health education is essen- ture for workforce development, central The objective of this measure is to im- tial. The improvement of public health to strengthening the national capacity prove the performance of the workforce depends on sensitization, awareness of in public health. As mentioned in the currently working in the health system the issues and commitment to finding Santo Domingo Conference, the Cen- and related areas, through educational solutions. The participation and involve- tral America experience shows that strategies and plans. The educational ment of academic institutions that pro- there are conditions for joining efforts plans will be developed with the goal

292 since it implies the coming together of strengthening thus the professional and Figure 5 Function of various occupations and professions. social commitment of the worker.” work performance

A second consideration in favor of the Cognitive Constructivism focus on competence approach is the changing and complex nature of the Cognitive constructivism states that the M . C health systems, which continuously gen- subject—the health worker—actively P. organizes the knowledge, integrating and O erates new challenges for continuing ed- ucation and training of staff. Such chal- reinterpreting the information and expe- lenges go beyond the fundamentally riences received during the learning biomedical contents and focus by which process. In order to achieve this, he/she the majority of health technicians and uses previous experiences, comprehen- professionals are trained. sion skills, exchange of information and of forming competent staff. The plans opinions that take place in various con- must also be useful and valuable for un- Dealing with these challenges requires a texts. When learning, the immediate dergraduate and graduate education in different approach, both theoretical and context (both work and social) plays an health, and in particular public health. methodological, for the education of important role since the learning process the workforce, both in training and the has a meaning, thus, an impact and effect This approach is based on the concept development and maintenance of the when it takes place in a context in which that the performance of individuals as performance of quality functions, and aptitudes and newly acquired knowledge part of the workforce is a complex func- maintenance and improvement of com- can be used effectively. At this point a tion whose main factors are self-motiva- petence. The educational focus based on link with a motivation to learn is pro- tion and professional competence, as well competence is part of a new approach of duced, stemming from a desire to under- as institutional and organizational factors education in health called Continuing stand and structure meanings to what is reflected in management, availability of Education in Health by the Pan Amer- learned. All knowledge has to be “some- resources and working conditions. ican Health Organization and a good where” in the learner’s mind to have sig- part of the Region. It is characterized by nificance (that is, it should “make Where: the following components: sense”). Otherwise, learning will be me- P is workforce performance chanical and an exercise of memoriza- tion. Moreover, it will lack the basic con- 5.1.1 Learning at work place M is motivation ditions of constructivist learning. Such Continuing education has emphasized C is the workforce competence and conditions are: reflection, decision-mak- “work” as the space where educational ing skills during the learning process and O are the obstacles (regulatory, mana- demands and needs are defined. The ed- the ability to solve practical problems. gerial, organizational, etc.) ucational potential of the work situa- tion, the analysis of daily problems at Adult learning The focus of competence allows the de- work and the orientation of the educa- velopment of educational plans and tional process towards the transforma- The technical basis of continuing edu- measure for workforce management tion of the social and technical practices cation includes principles of adult edu- from the point of view of requirements, of the worker make the work place a cation such as: problems and challenges of work, that is, special place to develop learning. “Needs from the point of view of performance and problems are evaluated and contin- • Linking acquired knowledge with ac- that, for the “Public health in the Amer- uing education strategies and processes tual problems, thus generating a prob- icas” Initiative means within the practice are proposed so that they can integrate lem pedagogy of the essential public health functions. individual, institutional and social is- One of the main features of this strategy sues, besides taking into consideration • A close relationship between learn- is that this practice be interdisciplinary the affective and intellectual aspects, ing, life and work

293 • Responsibility in learning and man- aging personal educational develop- Figure 6 Concept of work competence ment

• Active participation in the process

APTITUDE • Cooperation in the design of learning processes KNOWLEDGE

• Assessment of the usefulness of knowledge according to parameters of efficacy, based on personal experi- ence and the ability to use the knowl- edge to solve practical problems ATTITUDES AND VALUES COMPETENCY In other words, the health agent (the IN A DETERMINED adult in the learning situation) is consid- LABOR CONTEXT ered the architect of his/her practice. Learning is based on work and other vital experiences. This means that in the case of adult education, learning based on experience is essential. Experience is type of relationships are established, teraction of knowledge, aptitudes, atti- the foundation and starting point for the what reasoning process is used (induc- tudes, and work values put into action development of concepts and for seeking tion, deduction, comparison, etc), what to achieve meaningful results in a given out the comprehension of concepts and is his/her ability to recognize difficult work context. The above figure shows a theories. With this focus, the learning learning aspects, where and how to way to represent the meaning of the cycle begins thus with experience, con- begin to overcome them, how long it word “competence”. tinues with reflection and leads to action will take to achieve, etc. Reflection on based on experience or practice, which these processes will lead the learner to In complex adaptation systems (charac- gives way for a new experience and a search for help when he/she needs it and terized by low levels of agreement and new cycle of reflection-action. will allow him/her opportunities for high degrees of uncertainty) such as learning increasingly more complex cog- health services organizations and health 5.1.2 Meta-cognitive strategies: nitive processes. This is what is com- sector institutions, it is well known that learning to learn monly called “learning to learn”. a basic condition for good workforce In continuing constructivist education, performance is a clear definition of the organizing knowledge based on previous organization’s mission and organiza- Focus on what is understood as experience and knowledge is as impor- tional results. But, the achievement of “work competence” tant as the development of meta-cogni- such results requires a precise definition tive strategies of each person. Meta-cog- “Work competence” can be simply de- of the competence of the staff and an nition is the process of thinking how fined as: a person is competent in the assurance of certain subjective condi- to think. That is, it is a self analysis of work environment if he/she is able to tions (intellectual strategies such as one’s personal cognitive process which use his/her knowledge practically. In “learning to learn”, a essential condi- allows one to regulate one’s own learn- other words, competence is evaluated tion) and objective conditions (institu- ing process. It implies awareness of men- by what a person knows, if he/she can tional), that allow the worker to adapt tal processes that the learner develops put it into practice and why he/she does to change, acquire new knowledge and when learning a certain concept: what it in an given work context, with the in- continuously improve performance. In

294 specialized English literature, this con- is based on mastering the three cate- Table 3 Fields of cept is known as capability. gories of competence. competence in public health practice The identification of competence re- When essential functions are analyzed quires a frame of reference determined in regard to educational requirements by a taxonomy of competence that con- to assess competence (knowledge, apti- • Values and professional ethics • Analysis and evaluation verts “essential functions” into orientat- tude, attitudes, and values), the fields of • Adaptability and maintenance of ing elements of educational program- competence are classified in the follow- competence • Management of relations with the ming. With regards to the Initiative, ing manner in order to determine spe- external environment PAHO’s Human Resources Develop- cific performance measures for public • Technical command specific to an ment Program consulted with experts health workers (table 3). essential function • Communication and conducted a bibliographical review • Management skills in order to reach a taxonomy which Planning the development of institu- • Formulation, analysis and assessment of policies would functionally allow the step to tional and personal capacities, like the • Management of the development of be taken from “essential functions” to ones proposed for the appropriate per- institutional capacities “competence.” That is how the follow- formance of the essential public health ing taxonomic approach arose: functions, is based on, in addition to the foresight of the quantitative needs of the various workforce categories, on a Basic competence provide the elements of work and per- clear definition of work competence of formance that currently exist. Therefore, Competence which provides the funda- the staff and the organizational condi- a basic premise is that the development mental understanding of what is public tions for their performance. health and what is its purpose. All pub- of educational programs—from the phase of the identification of educa- lic health workers must master it. As previously stated, one of the basic tional needs to the management of such components of the plan will be the ed- practices—is a participatory experience Transversal competence ucational development of the workforce between educators and workers, who based on competence. The implemen- It provides the staff with both general will be the learning agents and at the tation of this plan implies a complex and specific knowledge, aptitudes and same time the objective of the program. skills in areas which allow the perform- process stretching from the conversion of the essential functions into compe- ance of one or more essential functions. a) Analysis of performance tence, according to a given taxonomy, It must be mastered by various cate- problems of the essential public to the definition of the necessary gories of public health professionals and health functions technicians according to their corre- knowledge, aptitudes and attitudes for sponding responsibilities. effective performance, passing through It is the identification phase of learning the identification of elements of com- needs. It aims to identify the perform- ance problems of the essential public Technical Competence petence and the definition of perfor- mance criteria. Figure 7 reflects this health functions in the specific contexts It is the technical knowledge, aptitudes process. where they are applied by systematically and necessary skills to fulfill an essential desegregating the functions by the de- function, program, or specific area of A necessary condition of the educational cisions and actions necessary to fulfill application. It is based on the previous focus based on competence is that no them. two categories. Work teams in charge of objectives, strategies nor educational ac- a specific essential function, must mas- tivities can be programmed without the As previously stated, it requires the par- ter it. participation of those who perform the ticipation of those responsible in prac- function and demonstrate their compe- tice for the performance of a function. That is to say, the satisfactory perform- tence. That is, without the participation The definition of participants will de- ance of one or more essential functions of the workers. They are the ones who pend of the each function and on the

295 gard to competence; it determines ex- Figure 7 Process of educational programming based on pected performance and whenever nec- competence essary, the performance level considered as most desirable. From this expected Analysis of the performance problems performance, a level of competence can of the essential public health functions be set. In other words, competence is

the expected performance in a specific work context of the staff. In some cases, the ideal requirements are complex and it is necessary to divide them into com-

Identification of Definition of priorities petence units if they are to be useful to competencies (where to begin?) determine the learning content.

d) Definition of criteria for Identification of Definition of performance evaluation competency units performance criteria

Once the expected performance is de- fined, it is necessary to define the crite- ria by which the performance will be Definition of knowledge, aptitudes, and attitudes Evaluation evaluated, by assessing competence. model Those responsible for designing learn- ing programs must approximate as much as possible a realistic work situa-

tion in order to define variables and

Programming of indicators which will eventually com- experiences and pare actual performance with expected activities (management performance. In other words, whether of education) competence has been reached and if this acquired competence is exercised appropriately. importance of the decisions that will be jectives of the change of the health sys- Conclusions in this regard are quite im- implied (executives at strategic political tem and the ability to insist on a certain portant since learning assessment crite- level, managers of programs and units, public health function. The result is a ria depend on such conclusions. Con- staff at the managerial or operational critical path indicating a sequence to siderable effort is required to define the level). The result is a set of performance be followed which identifies the target learning assessment model. problems that will be considered in the workforce group that will be prioritized future in a list of learning needs. in the educational process. e) Definition of knowledge, aptitudes and attitudes b) Definition of Priorities c) Identification of competence This is the most familiar stage since it is It is a political decision that must be It is a process by which with the partic- performed daily. It involves choosing undertaken by those who direct the ipation of educators and public health between various methodologies for con- process of workforce development. This workers, problems with the perform- tinuing education which is most suit- means that the function or problem ance of essential public health functions able to the process in progress and the that will begin the process will be deter- are identified as well as the learning programming of the learning content. mined according to the characteristics needs according the previously estab- This educational plan must systemati- of the political process of the sector, the lished competence criteria. That means, cally establish the necessary knowledge, health needs of the population, the ob- it points out the learning needs in re- aptitudes and attitudes to proceed to 296 Traditionally there has been a division Figure 8 Identification of the work competence between academic institutions of public health and institutions that employ the public health workforce. The same oc- AREA OF LEARNING NEED COMPETENCY curs in other areas of human resources development in public health. The asso- ciations of public health workers, which are not very developed in the Region, have been absent, with few exceptions, from the national debates on health sec- EXPECTED PERFORMANCE tor reform.

Nonetheless, ever since PAHO and WHO began technical cooperation to stimulate the understanding and use of COMPETENCIES essential public health functions, as a response to the challenges of health sec- tor reform, academic institutions and Competency Competency Competency employing bodies have demonstrated a unit unit unit common interest and concern. As pre- viously mentioned, the Latin America and Caribbean Association of the Pub- the stage of educational activities and lems of the essential public health func- lic Health Education (ALAESP) has experiences. It is during this stage that tions, and on the other hand, in the supported the essential public health the taxonomy of basic, transversal and definition of performance criteria. In functions proposal, regarding them as technical competence becomes quite the current educational framework the general guidelines for curricula devel- useful, since it the most opportune mo- Human Resources Development Pro- opment of public health graduate pro- ment to define the composition of the gram has created set of evaluation tools grams as well as for institutional de- learning groups. The fundamental prin- to provide technical support to ongo- velopment. Cuba is organizing an cipal is that the learning groups be anal- ing training programs and projects in integrated public health education sys- ogous to the working groups, which in the Region. tem utilizing the essential public health education during actual service form functions as a frame of reference for ed- part of the same team. ucational development that is based on competence. Through the family health 5.2 An Education System for f) Educational evaluation strategy, Brazil is testing new and prom- Public Health It is a permanent process in the educa- ising forms of integration between uni- tional cycle that from the perspective of The massive requests from various versities and municipalities, responsible the Human Resources Development countries in the Region for workforce for local health systems, within the Program should be follow the Kirk- training to guarantee adequate per- framework for improving basic health patrick principles and take into account formance standards, forces us to think care services. It will be necessary to eval- the four levels of evaluation, in particu- of an educational infrastructure of na- uate and disseminate these experiences lar level III (performance) and IV (im- tional reach. It is necessary to develop a as good and correct practice. pact). public health education system articu- lating with academic, employer, service 5.3 Distance learning On the one hand, it is based on a frame and professional institutions, to jointly of reference that defines learning needs contribute to the development of the The enormous need for education for identified by the performance prob- public health workforce. the development of the public health 297 workforce coupled with the increasing ment plans. The main objectives of the management show an accumulation of access to information technology in the Virtual Campus are: management models, with some traces countries of the Region, encourages the of flexibility which make up a complex development of strategies for distance • Contribute to the development of framework that can be characterized as learning as one of the most important professional and institutional compe- follows. development plans. tence for the performance of essential public health functions. In transferring responsibilities and re- The emergence of a world connected by sources for workforce management, the computers, satellites and telecommuni- • Promote access to knowledge and in- processes of decentralization of health cation technology represented by the In- formation for the public health staff in systems have been a determinant force the Region, for better decision making. ternet, the world wide web and the con- for the transformation of management figuration of corporative nets (intranet) into a strategic and complex function • Promote exchanges between profes- have changed the working and learning that to be operative urgently requires sionals and public health institutions conditions of many workers, among qualified personnel, quality informa- (education and health) for institu- them those in the field of public health. tion and special tools. tional learning purposes. The increasing use of modern informa- tion and communication technology in Figure 9 shows the general services and Although there is a lack of specific and distance learning allows not only the de- educational and informational pro- reliable information regarding the pub- velopment of programs based on educa- grams offered by the Virtual Campus. lic health workforce, there is no reason tional theories but also the improvement to indicate that it may differ from the of education outcomes, the transforma- general health workforce in terms of tion of practice and accessibility for 6. Management of the salaries, professional career, etc. This is workers, who until recently did not have public health workforce particularly true if one considers the de- this access due precisely to work. Current terioration of the infrastructure and in- circumstances make this modality be- The development of the public health stitutional capacity of public health as come a fundamental strategy in the edu- workforce also requires the conscience reflected in the results of the perform- cational development of the workforce. and sustained efforts of the health au- ance measurement of the essential pub- thorities as well as each of the employing lic health functions. The Pan American Health Organization entities to improve institutional, admin- with the Cataluña Open University and istrative and material conditions of the As established in the base document of ten leading academic institutions in pub- workforce where the work is carried out the CS43.R6 resolution of the PAHO/ lic health education and international daily in exchange for a fee. Workforce WHO 43rd Directing Council (2001), cooperation, are currently developing management has been a grey area in both regional and national concerted the “Virtual Campus in Public Health”, health systems and services, limited to efforts are required to strengthen the in- whose goal is to stimulate the develop- the administrative and formalist treat- stitutional capacity for the management ment of competencies demanded by the ment of the tasks of personnel. of human resources, including processes essential public health functions. At and measures affecting the public present, there are very few academic in- The means of work regulation (which health workforce. The following meas- stitutions that are not attempting to decide, among other things, contracts ures can be highlighted: make the leap to education based on in- and salaries) have changed very quickly formation networks. It is a strategic ne- in countries of the Region as a conse- Short, medium and long term cessity to get these academic institutions quence of the changes in the economy, planning of the public health to commit to offering distance learning the State and in public administration. workforce to the public health workforce. This far-reaching process has generated changes in the management of the gen- This function implies not only the The Virtual Campus offers an effective eral health workforce and in particular quantitative estimate of needs (as has wide reaching means to incorporate dis- the public health workforce. The situa- been done traditionally) but rather in tance learning in workforce develop- tion analysis and trends of workforce the determination of competencies and 298 Figure 9 Services offered by the Virtual Campus in Public health

Virtual Campus for Public Health

Courses, Clearinghouse Nucleus of Data Base programs of educational public health Lists servers on distance resources to information Directories education support health Publications professionals Virtual forum 1 2 3

Virtual Health Sector Related Library Reform "Links" BIREME Clearinghouse (PAHO/USAID) 4

1 Continuing education for in-service personnel, responsible for management of services and programs, and leaders of the sector, in the various decision-making levels 2 Methodologies, technologies and educational instruments to strengthen public health education institutions. 3 Resources of information: newsletters, information, news, summaries, links to other web sites. 4 Example: Public Health Foundation, ALAESP, ASPHER, APHA, ASPH, etc.

workforce profiles. There is an essential where the greatest effort should be made updating of retribution and acknowl- interaction with the educational devel- in terms of modernization, changes in edgment systems. opment programming based on profes- focus, procedures and tools. sional competence. It is therefore a Management of work relations function of quantitative and qualitative Performance management foresight of management based on pro- This function—which has generally fessionalism. Management based on competence re- dealt with the regulations regarding defines criteria for programming, or- work life without taking into consider- ganizing and evaluating the work of the ation the improvement of the develop- Qualitative improvement in staff. It entails that, new forms of work ment of staff administration—is strate- selection, recruitment and retention organization to obtain higher levels of gic in the current context of reforms of the workforce (staff supply) productivity and quality should be re- and deregulations. It entails participa- This has been one of the weakest func- defined based on the expected perfor- tory management, negotiated and con- tions in the area of staff administration mance of the essential functions. In this certed with union agents with regard to and has become an essential condition regard, it is necessary to include the individual work relations (principally in the current context of increasing promotion of work teams, the applica- contract and salary) and collective work complexity and flexibility in work rela- tion of adequate incentives, new modal- relations (representation, union, strike, tions. It is probably in this function ities of performance evaluation and the negotiation, career). Likely changes and 299 training and continuing education), Table 4 Problems with human resources management in management, workforce regulation and health its processes.

Former problems New problems resulting from reforms • Lack of balance in the availability of • Demands of productivity and Figure 10 shows the main regulating staff performance quality mechanisms of the workforce develop- • Inadequate geographical distribution • Descentralization and disgregation of of resources (inequity) functions ment processes and can be used to char- • Imbalance in the composition of • Flexibilization-precarización of the acterize certain normative aspects in the health staff work field of public health. • Weak information systems • Demands from new modes of • Low integration of training and regulation services • Generation of production-related Without further analysis of each one of • Low salaries and few incentives incentives the mechanisms, perhaps the most im- • Changes in the educational offer • Challenges of training for reform portant ones with regards to the current changes in the Region are:

Accreditation of educational chances to achieve better system per- educational development—serves as a programs and institutions formances are based on effective man- guide to point out some of the demands The main objective is the development agement of work relations, and conse- that those teams responsible for essen- and application of quality criteria of ed- quently on a better performance of the tial function 8 must take into account. ucational processes and infrastructure essential public health functions. which will guarantee a quality standard The strategic approach of adopting the (predetermined and accepted) for the competence focus is to attain an inte- Management of the continuing benefit of the students, the employing grated management of educational de- education of the workforce institutions, and the population bene- velopment and workforce performance. In regular conditions, continuing staff fiting from these services. Moreover, it is important to emphasize education—the professional develop- that when speaking of work force devel- ment by educational means—is one Incentives for staff performance opment we are not talking about only more function, although strategic, of training, but also the interaction and They are instruments for regulation and workforce management. Given the ur- the integrated effect of education (both management. They encourage the in- gent needs arising from the perform- ance of essential function 8, certain conditions to meet the requirements of Figure 10 Main Regulatory Mechanisms workforce development planning must be taken into account. salaries incentives, and methods of Safety conditions and work accreditation payment environment TRAINING WORK It is another of the less developed func- tions which needs to be promoted due to certification labor contract the particular conditions and risks that professional public health workers are exposed to. carrier

PROFESSIONS This functional framework for the de- self regulation velopment of the institutional capacity recertification for workforce management—in regards to regulation of work processes and

300 corporation of people into the public and the ALAESP are promoting a strat- • Increasing regulation of specializa- health workforce, their commitment to egy of institutional and associate al- tions: recertification. the function performed, and improve- liances in the area of quality manage- ment of daily performance. ment, taking into account the needs of • Competence requirements regarding both students and teachers. These lines health promotion. In this case, it is not only improving of action are mainly geared towards: salaries (which are usually low) nor es- • Performance requirements using a tablishing a monetary policy of incen- medical focus based on reality. tives (widely spread and encouraged in Invert the old pedagogic model by adopt- many reform processes, which many ing new ideas and promoting debates • Increasing practice based on con- times results in questionable outcomes), in both undergraduate and graduate trolled care to improve performance and commit- studies. ment to the employer. It mainly entails • Clinical decisions based on criteria of of offering adequate conditions for per- Promote and support the education sec- cost and efficacy sonal and professional development. In tor to define or redefine a quality focus this case, since it is dealing with a special in public health, centered on objectives worker, requiring ongoing acquisition Along with these trends, most of the of changes in the health systems and health professions maintain an unsus- of knowledge, the opportunities for ed- based on agreements with various sec- ucational development are important. tainable concept in the current profes- tors that participate in public health sional education: segregation between education. clinical and public health. The van- 7. Reorientation and guard experiences in medical education improvement of the Table 5 summarizes these lines of action. propose that the 21st Century health quality of undergraduate professional have the appropriate com- and graduate education in As for undergraduate health studies, it petence, clearly demonstrating a break public health from the traditional profiles. In the case is necessary to acknowledge that public of medical doctors, it is considered that health has not been a topic of discus- Defining the profile, evaluating and de- he/she must be competent as a profes- sion in the past years, despite being re- veloping a competent worker for the sional providing integral care, responsi- performance of the essential public garded a priority area during the 70’s ble for adopting decisions, sharing in- health functions is a task that has been and 80’s. The progressive decrease of formation, community leader, health defined as a frame of reference for grad- public health content and similar disci- promoter, service manager, gatekeeper uate education in numerous academic plines in schools of medicine around and manager of resources. It is also re- institutions that are part of the ALAESP. the region is well known. garded that he/she must be able to work This association develops joint activities in a team, be a good clinician, take into with PAHO with the aim of increasing Over the past six years, both the PAHO consideration human relations, etc. All the quality of graduate education by and WHO have evaluated the impact of these conditions require a profound re- promoting the use of suitable quality health sector reforms in medical prac- definition of the educational model and criteria in the processes of program and tice and nursing to identify new trends the incorporation of experiences in the institution accreditation. This frame of learning environment. and reorient undergraduate education reference also considered valid for the accordingly. Below is a summary of reorientation and strengthening of un- In most cases, schools of health sciences these trends: dergraduate education in various health require, among others, a substantial professions, especially in medicine and change in the disciplinary models of pro- nursing. • Demand of generalized profiles: uni- fessional programs that allow an integral versal expansion of proposals and focus to the human being. This objective In regard to graduate studies in public models of practice in general and fam- requires a new definition of health which health and related programs, PAHO ily medicine. goes beyond the biomedical definition, 301 Table 5 Lines of action to improve the quality of graduate public health education (PAHO-ALAESP)

Interventions Educational programs Teaching environment Student environment Improvement and • Continuing education and • Review of selection criteria strengthening of public selective sharing of (profiles and requirements health graduate degrees information for educators according to the quality Definition of areas of approach and the research and creation of institutional mission) conditions to permit the • Application of an research. androgenic model: • Strengthening the tutoring learning contracts, group capacity learning, flexible curricula, • Promotion of learning and integration of information problem resolution among and disciplines for learning interdisciplinary groups based on problem solving Invert the tendency of simple • Take advantage of the information transmission potential for the intellectual • Early definition of thesis and the weakness in production of the student and graduate papers, permanent tutoring knowledge production • Development of spaces for (research) debate and discussion on • Educational experience in Sanitary policies services and institutions: New service-education links • Services

Proposal of initiatives for Promotion of the integration Wide spread debates on essential public health functions, the promotion of quality in of disciplines and sector reforms, quality of education, quality management public health education knowledge: Reorganization • Promotion of the participation of public health graduates in based on usefulness in the creation of a quality focus resolving priority problems • Organization of forums for the exchange of educational in the social and health theoretical advances, sanitary changes, quality focuses, systems. Incorporation of quality management models, etc. epistemological approaches and debates favoring this • Organization of work groups on priority topics of sanitary integration debate • Development of a critical mass of educational agents in quality managment

Source: PAHO-ALESP. Quality of Public Health Education: an Imminent Challenge. from the Special Consultative Meeting in. Santiago de Chile, November 2001. proposes the training of proto-clinical Among these redefinitions a new bal- stance taken in regard to those func- specialists with training that supports ance and a new relationship between tions. As a general guide, in organizing general practice and stimulates a new re- clinical and public health is proposed. the health care system, the improve- lation with services (beyond the formali- This change can be functional by means ment of the analysis capacity of health ties of the traditional articulation of of a deep analysis of the essential public conditions, the community’s health de- service-education) health functions and the educational mands and ways of applying con-

302 development and implementation of na- Figure 11 Necessary change in Public Health Education tional plans for workforce development.

Clinical education 8.1.1 Active collaboration among Current countries situation Clinical practice Public health education This strategy is fundamental for putting into practice the Pan-American principle of public health. It is imperative that the Essential countries complement efforts to develop Health of the public health New situation the workforce in each country. Comple- functions community mentation is very evident and has great potential. This has been demonstrated in the experience with Central America, the work of ALESP and the multina- Integrated Integrated tional participation of the Region in na- clinical and public practice directed health training at community tional and international public health health events.

8.1.2 Strengthening of human clusions must be taken into account. gestions for the preparation of national resources policies in general and Figure 11 illustrates these necessary plans for the development of the public particularly those of the public changes. health workforce have been presented. health workforce As a tool for development a plan, it is If the increasing trends of work flexibil- 8. An integral look at not necessary to develop a special ity and deregulation of higher educa- technical cooperation for model. One can adopt the proposal de- tion are taken into account, it is neces- workforce development veloped in Chapter 13 on “Public Health sary, now more than ever, to have Infrastructure”, in a way that will be co- definitions of human resources policies In the present chapter approaches and herent with proposals of other plans. in general and in particular for human proposals by the PAHO-WHO have resources development. Policies indicate been systematically presented to con- Nevertheless, it would be pertinent to change and set frameworks for educa- tribute to defining policies and public propose the formulation of the purpose tional development, planning and health workforce development plans as of the workforce development compo- changes in regulation and workforce an important component in the im- nent of the plan that should make ref- management. provement of national institutional ca- erence to the accomplishment within a pacities in the performance of the essen- certain time frame of : tial public health functions. This section 9. Strengthening provides a synthesized, but complete ma- workforce management ...a competent and self motivated trix of PAHO and WHO’s possible areas workforce to perform essential pub- of cooperation in the field of human re- Human resources management has al- lic health functions with quality sources development. See table 6. ways been a politically weak and under- and efficiency. developed function. If education based 8.1 Perspective of regional on work competence is proposed, it is collaboration Since the Human Resources Develop- impossible to develop the public health ment Program’s technical cooperation is workforce in the different countries Throughout this chapter, various ap- of regional reach, it is desirable to pro- without transforming management in a proaches, orientations and useful sug- pose strategies of regional support in the strategic function of public health.

303 Table 6 PAHO-WHO Contribution to the development of public health workforce

Contribution to the development of the public health Programmatic proposals workforce for the performance of essential functions Human Resources Observatory • Production of information and knowledge in order to define and execute policies of in Health workforce development International network for the production • Production of basic data to characterize the workforce of evidence in support to the • Strengthening of human resources information systems development of policies in human • Production of information for workforce planning resources

Continuing education • Methodologies and tools for educational programming based on work competence New educational model based on adult • Tools for the management of education based on competencies education for ongoing education and • Development of institutional capacities for ongoing education professional development

Virtual Campus of Public Health • Production of distance educational services and materials for continuing education of the public health workforce and development of institutional capacities Virtual educational environment for distance education in public health, • On-line courses and materials defined by competencies and according to the needs guided by essential public health for the performance of essential functions functions. • Coordinating center of educational and informational resources for public health practice • Access to education and information in English, Portuguese and Spanish

Development of management of quality • Development of frames of reference, tools and techniques for the educational and in public health education programmatic renovation and transformation of graduate studies in public health and health sciences careers Program to support academic public health institutions in the development • Development of a quality focus in public health education and appropriate of a quality focus as well as the regulating (accrediting) tools strengthening of institutional capacities • Through an alliance of institutions, guarantee the spread of information and in the management of quality of public management of up to date pertinent knowledge for public health education health education • Promotion of the frame of reference of essential public health functions

Human resources management • Service training in human resources management to improve the management of the public health workforce Support plan for the development of institutional capacities in the countries • Tools for short and medium term programming of the public health workforce for the development of a new focus • Adequate tools for the change and improvement of the functions and procedures for and practice in the management of recruitment, selection, assignment and performance evaluation human resource in health • Tools for the management of productivity and quality of workforce performance • Guarantee of workforce educational opportunities based on a competencies • Technical support for the improvement of the quality of the work life and work conditions

10. Intensive use of the and training management in almost all essary to coordinate initiatives and join existing capacity; the countries. This transformation al- efforts. coordination and lows the shaping of reforms according complementation to advances consolidated in many na- 11. Promotion, spreading of resources tional institutions (The Observatory and incorporation of Series 3, 2002). On the other hand, in correct practices and One of the most important lessons of many countries, there was a duplication successful educational cooperation—that accompanies educa- of efforts, lack of coordination, waste of modalities tional projects in health sector re- resources and excessive measures taken forms—has been to establish the trans- for similar objectives of the population. The past years have been very rich in formation of the educational practices In these conditions, it is even more nec- both national and international educa- 304 16 International Cooperation for Improving Public Health Practice

1. Cooperation for imply improving the health of the peo- multilateral cooperation agencies, along Development and ple, promoting healthy environments with the principal international financ- Strengthening of Steering and social practices, reaching out to the ing institutions, to sponsor a hemi- Capacity in the Health poorest, most excluded members of so- spheric meeting to discuss the status of Authority ciety, and eliminating the current in- health sector reforms. equities in the health situation, access to services, and sectoral financing. The heads of State and government also PAHO has made a commitment to its issued a mandate to PAHO in Miami in member countries to support the pro- On that occasion in December 1994, 1994 to launch a process for monitoring cesses aimed at transforming their health the leaders of our member countries rec- and evaluating health sector reform in sectors, commonly known as health re- ommended that a hemispheric forum the countries of the Region. Today, form. This means working intensely with be convened to discuss progress and the backed by the member countries, this the countries to devise options for the challenges confronting health sector re- framework is an ongoing process that is health sector that represent real progress form processes in the Region. It was making it possible to study the course toward equitable access to health services held in September 1995, in Washing- that the reforms have taken and lay the by the peoples of our Hemisphere. ton, D.C., within the framework of foundation for the adjustments and PAHO’s Directing Council, comprised changes in direction required—changes At the first hemispheric summit in of all the ministers of health of the that will ensure that the transformations Miami, the heads of State and govern- Americas. Also participating were repre- in the sector have a truly positive impact ment of the countries of the Americas sentatives of the social security health on the delivery of health services, mak- were very clear about the need to forge institutions and other government sec- ing them accessible to the people who ahead with health sector reform pro- tors responsible for economic decision- need them the most. cesses that would ensure equitable ac- making and development planning re- cess to basic health services. Not to re- lated to the sector. As requested by the The deliberations held and the man- form for reform’s sake, but to reform heads of State and government, PAHO dates subsequently signed by the minis- with an awareness and a direction that joined forces with several bilateral and ters of health of the Americas at the

307 meetings of PAHO’s Governing Bodies idating the institutional develop- to economically sustainable and so- in 1997 and 2001 underscore the high ment of the health authority in the cially irreversible achievements; priority given to strengthening the countries of the Region, to enable steering function of the health authori- them to fully discharge their re- • promoting policies that foster contin- ties at all levels of the State and to im- sponsibilities in management, regu- uous quality improvement in the ser- proving the performance of the essential lation, exercise of the essential pub- vices to ensure the satisfaction of the public health functions pertaining to lic health functions, coordination population; them. They also stress the need to in- of health service delivery, oversight tensify cooperation in this area, given of insurance, and the compensatory • utilizing research for decision-making the multiplicity of actions that these redistribution of sectoral financing; and technological upgrading of the tasks require. health system; d) circulating information and sharing Within the framework of PAHO’s national experiences on the exercise • utilizing health situation analysis to set strategic and programmatic orientations of the steering role by the ministries policies that promote greater equity; for the quadrenniums 1995–1998 and of health and on institutional devel- 1999–2002, the proposed Strategic opment for that purpose. • promoting research in public health Plan 2003–2007, and the technical co- and health services to steer health operation activities to support the sec- These activities were designed to help policies in the direction of greater toral reform processes, an effort has the health authorities in the Region to equity; been made to pay special attention to strengthen their steering capacity and strengthening the health authority, de- intersectoral leadership through prog- • evaluating popular satisfaction to veloping its steering capacity, and im- ress in the following areas: monitor the impact of the policies on proving the exercise of the EPHF as the users of the services. basic lines of action for the institutional • heightening their regulatory role, giv- development of the sector. ing them the necessary flexibility to • developing the capacity to analyze the identify national and local problems demands and conflicts arising from To this end, regional and country pro- and solve them, within the frame- civil society and the responses pro- gramming efforts have centered on ac- work of decentralization; vided, together with their impact on tivities geared to: public health policy. • ensuring that social participation a) preparing, disseminating, and pro- plays a key role in public health prac- These tasks call for new professional ca- moting a conceptual and opera- tice in our societies; pacity, extensive development of the cor- tional framework for the steering responding legislative instruments, and role of the ministries of health, • ensuring effective promotion and use a reorganization of the structure and op- within the new context of state of mass communication for health erations of the ministries of health to modernization and sectoral reform; purposes; enable them to perform their duties. In many cases, it is not just a matter of b) providing technical guidance and • strengthening public health practice; administrative reorganization, but of a support for the reorganization and profound reengineering that demands institutional strengthening of the • formulating and executing policies institutional strengthening, workforce ministries of health of the member that promote greater equity in access, development, and well-targeted invest- countries to enable them to serve use, and financing of the health ser- ment. As part of its efforts to support as steering entities to confront the vices, fostering social solidarity in the health systems and services development new sectoral realities; solution of health problems; and the sectoral reform processes in the countries of the Region, PAHO must c) preparing, disseminating, and pro- • preparing forecasts that will make it give high priority in the coming years to moting guidelines, methodologies, possible to formulate policies whose cooperation activities that improve the and specific instruments for consol- implementation and actions will lead health authority’s exercise of the sectoral 308 steering role by strengthening the insti- advance more rapidly and staunchly in formance of the EPHF and thereby ob- tutional capacity for that purpose. this effort. tain substantial improvements in public health practice. 2. The Need for Hence, the importance of gradually crafting a multifaceted international co- 3. Toward the Definition International Cooperation operation program or “agenda” in this to Improve Public Health field in terms of content and the neces- of Priority Areas and Practice sary implementation processes. This is Critical Processes to Guide central for the future work of PAHO, International Cooperation PAHO’s Centennial, which commemo- both regional and in each member rates a century of collaboration in country. Notwithstanding, this pro- The wealth of experience garnered in health in the Americas, offers an unpar- gram cannot be limited to the efforts of the three years since the design and im- alleled opportunity for international co- the Organization, since it transcends its plementation of the Public Health in operation and joint action by all the sphere of action. Naturally, a program the Americas Initiative, the information countries of the Region to improve the of this type must bring together other yielded by the hemisphere-wide evalua- health of our peoples. To this end, it is international actors in the field of tion of the performance of the EPHF essential to intensify collaboration to health (bilateral, multilateral, interna- pertaining to the health authority in 41 strengthen the health authorities’ steer- tional financing institutions, and pri- countries and territories, and the com- ing role as the key to good performance vate foundations). It must also involve mitment made and internalized by the of the EPHF and, thus, to the improve- subregional health groups and major supreme health authorities of the mem- ment of public health practice. actors within the countries—especially ber countries to overcome the weak- the health authorities and public health nesses and reinforce the strengths iden- The EPHF performance measurement education and research institutes— tified after the EPHF performance exercise in 41 countries and territories whose assistance is required. measurement have made it possible to of the Americas, grounded in a renewed determine a number of priority areas framework for action in public health International cooperation, both techni- of action for international cooperation and in the pressing need to strengthen cal and financial, must be characterized and certain critical processes that make the steering role of the health authori- by a spirit of collaboration among coun- them viable, create synergies among them, ties (as discussed in the first three parts tries and agencies to support the devel- and establish economies of scale. of the book), has yielded results whose opment and strengthening of public immediate follow-up must be a major health in our countries and, ultimately, Very briefly, as a preliminary sketch, the effort to promote institutional develop- improve the health of our peoples. priority areas for cooperation in this ment and strengthen the infrastructure Thus, it is essential for the countries of field in the coming years can be sum- to improve public health practice in the the Hemisphere to maintain a dialogue marized as follows: Region. and close collaboration with bilateral, multilateral, and private agencies, on the 1) The EPHF performance measurement As seen in the earlier chapters of this one hand, and with the development instruments should continue to be re- fourth and final part, the magnitude banks, on the other, to ensure the great- fined and adapted to changing con- and complexity of the task at hand still est possible convergence between tech- cepts, realities, and technologies and demand conceptual, methodological, nical and financial cooperation. This is to the institutional and organiza- and instrumental action that transcends especially important for the health sec- tional structure of public health in national borders and can benefit from tor reforms, which must define how our the Region. The progress to date joint efforts by countries and interna- societies will meet the needs of individ- should serve as the basis for further tional cooperation agencies in health. uals; for development of the health au- review and validation of the vari- This will make it possible to join forces, thorities’ institutional capacity to exer- ables, indicators, and forms of mea- share information on successes and fail- cise their steering role in the health surement that will increasing the ures, identify opportunities for joint ac- system; and for strengthening the infra- objectivity of the instrument and di- tion, and create economies of scale to structure needed to improve the per- rectly link it with decision-making 309 and resource allocation to develop ensure that it does not end up as the magnitude of the resources neces- the public health services infrastruc- a parallel, and to certain extent, ver- sary to sustain operations and make ture. The goal is for it to become a tical exercise that represents an op- the necessary investments to enable common tool for self-evaluation, the portunity cost for the rest of the or- the health authority to exercise its es- determination of investment needs, ganized development efforts of the sential functions. The current levels of and the promotion of improvements sector. Chapter 13 outlines some of expenditure have a historic inertial di- in practice. the key guidelines that must be con- mension but are not based on a sound sidered to advance successfully in this cost-analysis that would allow for ad- 2) There is a growing need to move for- endeavor, analyzing some of the ob- equate evaluation of the interventions ward with the development of subna- stacles and opportunities that arise from an economic and health stand- tional EPHF performance measure- along the way. The national EPHF point and permit optimization of the ment instruments for unitary and performance measurement exercises types of institutional organization federal States alike. The instrument serve as a reference point for defining needed to exercise the EPHF. currently employed to measure the intervention areas and resource needs performance of the EPHF by the na- for institutional strengthening. Nev- 5) Very little progress can be made in tional health authority can be used at ertheless, as noted in points 1 and 2 improving public health practice if the intermediate (provinces, states, above, as the effectiveness of the in- adequate priority is not given to in- regions, etc.) and local levels (munic- strument improves and progress is stitutional strengthening activities and ipalities, counties, parishes) to in- made in EPHF performance mea- building national, subregional, and crease the effectiveness of the process surement at the subnational level, regional capacities to develop the pub- and the instruments, bringing the ex- the planning exercises and efforts to lic health workforce. Chapter 15 ex- ercise closer to the particular opera- improve practice will become more plores in detail the conceptual and tional realities and permit swifter cor- relevant and draw ever closer to op- instrumental aspects associated with rective action. This should involve a erational realities. this key element in infrastructure certain degree of regional or subre- strengthening. It outlines a range of gional harmony, in order to identify 4) An area that is just beginning to be possibilities that should be discussed common lines of action and generate explored and uncovered, and whose in each country to identify how economies of scale. It will be equally methodologies, concepts, and appli- much emphasis should be given to important to adapt the design of the cations require a much more detailed developing and upgrading the com- instruments and the definition of the analysis, is the development of analyti- petencies of public health workers. weighted variables in the subnational cal frameworks for financing, expendi- Action in this area should be geared, exercise to competencies by each ture, cost-analysis, and budgeting of the on the one hand, to the staff cur- country to the health authority at the EPHF. Chapter 14 offers a very pre- rently working in the services who different levels of the State (national, liminary examination of the topic, perform tasks related to the exercise intermediate, and local). suggests some initial approaches, of the EPHF, and on the other, to ac- identifies a series of relevant issues, ademic institutions devoted to train- 3) Particularly important are the devel- and indicates the long road that must ing and public health research to opment and refinement of methodolo- be traveled in this direction. Much of give them greater relevance in the gies and instruments for planning and the work consists of improving the processes for improving public strengthening the infrastructure, for capacity to identify more precisely the health practice. In this regard, inno- promoting the institutional develop- sources of resources and items of ex- vative multi-institutional collabora- ment of the health authority, and for penditure related to the EPHF. Even tive efforts, such as the Virtual Pub- procuring general improvements in more important, however, is defining lic Health and Health Management public health practice. This line of ac- the production functions of the vari- Campus, are critical for reaching tion must be consistent with other ous components of the EPHF to pro- large numbers of public health pro- national processes for planning and vide a solid foundation for cost-analy- fessionals through distance learning the design of sectoral investment to sis. This will paint a clearer picture of via the Internet and information re-

310 sources for professional development ation as a periodic national exercise. alyst for efforts to improve public in public health. The challenge is to shift from self- health practice in the Hemisphere. evaluation sponsored by interna- 6) Development of the concepts of so- tional cooperation to a permanent 3) The experience acquired in the field cial practices and essential health periodic activity, in which the exer- of EPHF performance measurement public functions, the progress made cise becomes an integral part of in- and the actions to improve public in EPHF performance measurement, frastructure development and the health practice must be documented and the growing interest in develop- ongoing improvement of public and circulated among stakeholders, ing and implementing processes to health practice. This presupposes both in the countries and interna- improve public health practice—all that EPHF performance measure- tionally. Here, it would be very useful stemming from the Public Health in ment is viewed, with the adaptations to create an observatory or clearing- the Americas Initiative—open the that each country deems pertinent, house for the collection and dissemina- door and at the same time demand as a component of the instrument tion of information and the lessons new opportunities for conceptual de- panel that must be switched on to learned. This center would record, bate, methodological development, and evaluate and improve health system analyze, compare, and lend added instrumental design for articulating the performance; as an indicator and a value to the available information, EPHF with the rest of the health system. spur to action that enable the health thus serving as an information and Areas that must be addressed include authority to keep its guard up to un- intelligence resource to support the the link between the EPHF and pri- dertake a critical part of the activities countries’ efforts in this field. mary health care, the impact of the that constitute its raison d’être. EPHF on the reorientation of services 4) Closely allied with the previous using health promotion criteria, the 2) Of similar importance will be the de- point is the issue of promoting and link between the definition of health velopment of conceptual and instru- consolidating institutional networks objectives and EPH performance mental aspects to guarantee linkage for information exchange, as well as measurement, the impact of the between EPHF performance measure- interagency coalitions that support EPHF on policy-making, strategy de- ment, the formulation of national EPHF performance evaluation and sign, and health planning, and, last plans to improve practices and develop the improvement of public health prac- but not least, the rethinking of tradi- the public health workforce, and the tice. To accomplish this, it will be tional public health programs defined establishment of national, subregional, essential to encourage the participa- by category that imply substantive and regional health objectives. In- tion of national institutions that population-based interventions and creasingly, the countries of the adopt the concepts and methodolo- personal care (immunization, vector Hemisphere are developing strategic gies consolidated during the imple- control, prevention and control of plans for the sector and establishing mentation of the Public Health in communicable and noncommunica- medium- and long-term objectives the Americas Initiative, disseminate ble diseases, occupational health, etc.) in terms of health outcomes (reduc- them, and replicate them in their from the standpoint of the EPHF tions in mortality and morbidity, im- spheres of action, perfecting and de- and the institutional development provements in the quality of life, and veloping them as far as possible and and infrastructure strengthening im- elimination of threats to health), and adapting them to the specific cir- plicit in them. of the intermediate processes neces- cumstances of the countries. Build- sary to meet the targets set for results ing this critical mass in the Region With regard to the critical processes that (organization of health care, evalua- will promote a more intensive hori- can make the priority actions indicated tion of system performance, intersec- zontal exchange and increase cooper- above viable, the following should be toral interventions, adequate execu- ation among countries in this field. noted: tion of the EPHF). This is almost However, for this type of effort to virgin territory in many countries in pay off, it will be necessary to maxi- 1) It is important to make progress in the Americas, but it is also fertile mize the collaboration of technical instituting EPHF performance evalu- ground and can be turned into a cat- and financial cooperation agencies—

311 bilateral, multilateral, and private— health and access to health care, to convergent processes—within the coun- so that their actions converge and advance toward meeting the millen- tries and beyond national borders—to heighten the countries’ institutional nium development goals set by the strengthen the infrastructure and con- capacity to take up the challenges United Nations system, affirm a cul- tribute to institutional development outlined in this book. ture of health and life, create healthy leading to improvements in public spaces, ensure universal access to health practice. If this occurs, we will 5) The complement to the four critical health care and, ultimately, improve have learned how to rethink our future processes mentioned above is sus- the quality of life and human security. and contribute to integral human devel- tained advocacy and promotion in the opment, which, as Amartya Sen would countries and the international com- It is becoming increasingly clear in say, expands human freedom and dig- munity to meet the challenges, explore today’s world that the work of public nity and permits full expression of the the possibilities, and recognize the im- health and its material translation as the potentialities of individuals and soci- portance of public health. The goal EPHF are a global public good. Thus, eties. The Public Health in the Americas here is to improve the health of the international cooperation in this field Initiative has sought to make a modest population, contribute to a reduction has become a priority. It demands spe- contribution to that effort, and this in poverty, and reduce inequities in cial efforts to foster the development of book, to place it on record.

312 APPENDICES APPENDIX A EPHF Performance Measurement Instrument

Introduction • Identification of the population’s health needs including an assessment of health risks and the demand for health Due to the fact that chapters 8, 9, and 10 of the book give a services. detailed description of the EPHF measurement instrument, • Management of vital statistics and the status of special the present annex has omitted that information to avoid du- groups or groups at greater risk. plications. The reader may refer to the chapters in section III • Assessment of the performance of health services. to complement the contents of Appendix A. • Identification of those nonsectoral resources that support health promotion and improvements in the quality of life. • Development of technology, expertise and methodologies for The measurement exercise begins with the EPHF, explicitly management, analysis and communication of information to defining each EPHF. Indicators are created, standards are de- those responsible for public health (including key players termined, and a group of measures and sub-measures are ap- from other sectors, health care providers and civil society). plied that are described below. • Identifying and establishing agencies that evaluate and ac- curately analyze the quality of collected data.

EPHF 1: Monitoring, Evaluation Indicators and Analysis of Health Status 1.1 Guidelines and Processes for Monitoring Health Status Definition Standard This function includes: The NHA: • Up-to-date evaluation of the country’s health situation and • Has guidelines for measuring health status at all levels of the trends including their determinants with special emphasis health system. on identifying inequities in risks, threats, and access to • Has a comprehensive and integrated national system for services. monitoring health status, focusing on identifying inequities.

315 • Has specific protocols that protect the confidentiality of 1.1.1.8 Described procedures for communicating personal data. information to the mass media and general • Uses health status profiles to allocate resources and priori- public? tize community health problems based on criteria of equity. 1.1.1.9 Protected the confidentiality of informa- • Uses trending in health status parameters, correlations with tion through the use of specific protocols risk factors, gender analysis and other relevant variables to for accessing data? monitor health status. 1.1.1.10 Described the procedures to organize a health status profile that contains informa- 1.1.1 The NHA has developed guidelines for measuring and tion on national health objectives? evaluating the health status of the population. 1.1.2 The NHA identifies and annually updates the data Have the guidelines or other instruments for monitor- collected in a country health status profile. ing health status: 1.1.1.1 Been developed for use by the health system Does this profile include: at the national level? 1.1.2.1 Social and demographic variables? 1.1.1.2 Been developed for use by the health system 1.1.2.2 Mortality data? at intermediate levels? 1.1.2.3 Morbidity data? 1.1.1.3 Been developed for use by the health system 1.1.2.4 Data on risk factors? at local levels? 1.1.2.5 Information on lifestyles? 1.1.1.4 Described suitable methods for collecting 1.1.2.6 Data on environmental risks? data and selecting appropriate sources of in- 1.1.2.7 Data on access to personal health services? formation which provide that data? 1.1.2.8 Data on contact with population-based health 1.1.1.5 Described the roles of the national and sub- services? national levels in collecting data? 1.1.2.9 Data on utilization of population-based and 1.1.1.6 Given citizens and organized community personal health services? groups access to information while at the 1.1.2.10 Data on cultural barriers in accessing health same time protecting the right to privacy? care? 1.1.1.7 Included a process that continuously im- proves information systems to better meet 1.1.3 The NHA uses the health status profile. user needs at both national and subnational Is the health profile used: levels (decisionmakers, program directors, 1.1.3.1 To monitor the health needs of the popula- etc.)? tion? If so, does the process: 1.1.3.2 To evaluate inequities in health conditions? 1.1.1.7.1 Include uniform standards at all 1.1.3.3 To monitor trends in health status? levels (national and subna- 1.1.3.4 To monitor changes in the prevalence of tional) of the information sys- risk factors? tem? 1.1.3.5 To monitor changes in utilization of health 1.1.1.7.2 Include procedures that provide services? information to national and in- 1.1.3.6 To determine the adequacy and significance ternational agencies that form of reported data? part of the health system? 1.1.3.7 To identify the population’s priorities and 1.1.1.7.3 Include a periodic review of needs in terms of access to services, partic- standards and procedures that ipation in health promotion activities, re- evaluate their relevance in view source allocation, focusing on the elimina- of the technological advances tion of inequities in access and improving and changes in health policy? health services?

316 1.1.3.8 To define national health objectives and ble throughout the country and allow international com- goals? parisons as accepted by the country. 1.1.3.9 To evaluate compliance with national health • Continuously updates these instruments, protocols and objectives and goals? standards in concordance with advances in technology and 1.1.3.10 To improve the efficiency and quality of the knowledge, as well as with local information needs. health system in discharging the essential • Collaborates with other national institutions in producing public health functions by the NHA? relevant data for monitoring health status so as to ensure the 1.1.3.11 Can you cite an example where this profile quality of the data. has been used?

1.1.4 The NHA disseminates information on the health sta- 1.2.1 The NHA has a unit that evaluates the quality of the tus of the population. information generated by the health system. 1.2.1.1 Is the unit outside the direct control of the Does the NHA: NHA? 1.1.4.1 Produce an annual report? 1.2.1.2 Does the unit conduct periodic audits of 1.1.4.2 Disseminate this report and its information the information system that assesses the to interested parties? country’s health status? 1.1.4.3 Present this report to groups of key deci- 1.2.1.3 Does the unit suggest modifications to the sionmakers in the country? system in areas recognized as being weak or 1.1.4.4 Regularly organize seminars or other activi- ties that explain and raise awareness of key in need of improvement? decisionmakers about the implications of 1.2.1.4 Does the NHA take into consideration the the information on the health status of the suggestions made by the evaluation unit for population contained in the annual report? improving the measurement of health status? 1.1.4.5 Provide data on trends in health outcomes, comparing them with standards and goals 1.2.2 The NHA is part of an national coordinating agency specifically mentioned in the profile? for statistics. 1.1.4.6 Provide communities with a common set of measures that help them make compar- Do the NHA and the national coordinating agency for isons, prioritize community health prob- statistics: lems and determine allocation of resources? 1.2.2.1 Meet at least once a year to propose modi- 1.1.4.7 Periodically solicit and evaluate suggestions fications to the information systems to that improve the content, presentation and make these systems more compatible? dissemination of the health profile? 1.2.2.2 Take the proposed modifications into ac- 1.1.4.8 Regularly evaluate how the recipients of the count to improve the NHK’s information health profile report use the information? systems? 1.2.2.3 Propose specific measures to improve the 1.2 Evaluation of the Quality of Information quality and usefulness of information from the NHA? Standard 1.2.2.4 Know the percentage of medically certified The NHA: deaths known? • Has objective instruments to evaluate the quality of the information generated by the different levels of the health If so, system. 1.2.2.4.1 Does the NHA consider that • Has protocols and standards for producing, analyzing and this percentage makes the mor- interpreting data so that the instruments used are compara- tality data reliable?

317 1.3 Expert Support and Resources 1.3.2 The intermediate levels of the NHA use or have access for Monitoring Health Status to personnel with training and expertise in epidemiol- ogy and statistics. Standard Does this personnel have training and expertise in the The NHA: following areas: • Has personnel skilled in the collection, evaluation, manage- 1.3.2.1 Sampling schemes for data collection? ment, translation, interpretation, dissemination, and com- 1.3.2.2 Consolidating data from various sources? munication of health status data. 1.3.2.3 Data analysis? • Has developed specialized monitoring and evaluation ca- 1.3.2.4 Interpreting results and formulating scien- pacities based on the characteristics of the country’s health tifically valid conclusions based on data profile. analyzed? • Has access to expertise and resources necessary to convert 1.3.2.5 Translating data into clear and useful infor- data into useful information for individuals who influence mation? 1.3.2.6 Design and maintenance of disease reg- health policy and also for community leaders and represen- istries (e.g., cancer registries)? tatives involved in the planning of health activities. 1.3.2.7 Communicating health information to the • Has the above capacities at the different levels of the public population? health system within which the national level should have 1.3.2.8 Communicating health information to de- (or have access to) at least one professional with a doctorate cisionmakers? in epidemiology. 1.3.2.9 Was this personnel trained in public health at the Master’s degree level? 1.3.1 The NHA uses or has access to personnel with train- ing and expertise in epidemiology and statistics. 1.4 Technical Support for Monitoring Does this personnel have expertise in the following and Evaluating Health Status areas: 1.3.1.1 Was this personnel trained in epidemiology Standard at the Doctoral level? The NHA: 1.3.1.2 Sampling methodologies for collecting • Has computer resources for monitoring and evaluating health status at all levels qualitative and quantitative data? • Is capable of sharing data from various sources and convert- 1.3.1.3 Consolidating data from various sources? ing them to standard formats. 1.3.1.4 Data analysis? • Uses a high-speed computer network to link with other 1.3.1.5 Interpreting results and formulating scien- agencies and individuals in the national and international tifically valid conclusions based on the data arena. analyzed? • Ensures that those at all levels of the public health system 1.3.1.6 Translating data into clear and useful infor- who access these computerized data systems and registries mation to produce comprehensible and are trained in the proper use of these resources. well-designed documents for different audi- ences? 1.3.1.7 Design and maintenance of disease reg- 1.4.1 The NHA utilizes computer resources to monitor the istries (e.g. cancer registries)? health status of the country’s population. 1.3.1.8 Communicating health information to de- Does the NHA: cision makers and members of community 1.4.1.1 Utilize computer resources to monitor the organizations? health status of the country’s population at 1.3.1.9 Research and quantitative analysis? the intermediate levels?

318 1.4.1.2 Utilize computer resources to monitor the 1.5.1 During the past 12 months, the NHA has provided health status of the population at the local technical assistance to one or more subnational levels level? in data collection and analysis. 1.4.1.3 Have personnel trained in the use and basic 1.5.1.1 Has the NHA advised the subnational lev- maintenance of these computer resources? els on the design of instruments for collect- 1.4.1.4 Use a system that includes one or more ing relevant health data? computers with high-speed processors? 1.5.1.2 Have all subnational levels been informed 1.4.1.5 Have programs with commonly used utili- of the NHK’s availability to advise them on ties (word processors, spreadsheets, graphic data collection methodology? design and presentation software)? 1.5.1.3 Have the subnational levels been informed 1.4.1.6 Have the capacity to convert data from var- of the NHK’s availability to advise them on ious sources to standard formats? methodology for the analysis of data col- 1.4.1.7 Have a dedicated line and high-speed access lected locally? to the Internet? 1.5.1.4 During the past 12 months, has the NHA 1.4.1.8 Have electronic communication with the actually advised one or more subnational subnational levels that generate and utilize levels on the methodology to analyze data information? collected locally? 1.4.1.9 Have sufficient storage capacity to maintain the databases on the country’s health pro- 1.5.2 During the past 12 months, the NHA has constantly file? disseminated information periodically to users at the 1.4.1.10 Meet the design requirements for compil- subnational levels. ing vital statistics? 1.4.1.11 Have rapid access to specialized mainte- 1.5.2.1 Has feedback been sought from these users nance of the computer system? of this information? 1.4.1.12 Annually assess its need for upgrading its computer resources? 1.5.2.2 Have these users been advised on how to 1.4.1.13 Can you give an example in which com- interpret these analyses? puter resources were used to monitor health 1.5.2.3 During the past 12 months, has the NHA status? advised those responsible for producing the community health profile at the subna- tional levels? 1.5 Technical Assistance and Support to the 1.5.2.3.1 Have those responsible for pub- Subnational Levels of Public Health in lishing the community health Monitoring, Evaluating and Analysis profile been informed that pro- of Health Status visions exist to advise them on this? Standard The NHA: EPHF 2: Public Health Surveillance, • Collaborates with the subnational levels to ensure the Research, and Control of Risks and timely collection, analysis and dissemination of data that Threats to Public Health support the development and evaluation of health policies. • Offers mechanisms for training and practice to professional Definition at the subnational levels in interpreting and using data. • Supports the preparation and publication of community This function includes: health profile and informs the entire jurisdiction of the • The capacity to conduct research and surveillance of epi- availability of this support. demic outbreaks, patterns of communicable and noncom-

319 municable disease, injury and exposure to toxic substances 2.1.1.2. Is the surveillance system capable of moni- or environmental agents harmful to health. toring threats and health hazards over time? • A public health services infrastructure designed to conduct 2.1.1.3. Is the surveillance system capable of moni- population screenings, case-finding and general epidemio- toring changes in living conditions that call logical research. for a public health response? • Public health laboratories capable of conducting rapid 2.1.1.4. Can the surveillance system identify those screening and processing of a high volume of tests neces- threats that call for a public health re- sary for identifying and controlling emerging threats to sponse? health. 2.1.1.5. Is the system integrated with surveillance • The development of active programs for epidemiological systems at the subnational levels? surveillance and control of infectious diseases. 2.1.1.6. Does the surveillance system provide infor- • The capacity to link with international networks to allow mation for the production and dissemina- better management of health problems. tion of periodic bulletins? • Preparedness of the NHA to initiate a rapid response for the 2.1.1.7. Does the surveillance system process sys- control of health problems or specific risks. tematic feedback on its publications? 2.1.1.8. Have the threat response roles of key indi- Indicators viduals in the surveillance system been de- fined at subnational levels (especially the 2.1 Surveillance System to Identify Threats local levels)? to Public Health 2.1.1.9. Does the surveillance system regularly ana- lyze trends in disease, threats and risk fac- tors? Standard 2.1.1.10. Does the surveillance system include infor- The NHA: mation from other health surveillance sys- • Operates one or more, ideally integrated, public health sur- tems (e.g. private insurers or service veillance systems1 in collaboration with local and interme- providers, NGOs, etc.)? diate levels capable of identifying and analyzing threats to 2.1.1.11. Is the surveillance system part of an inter- public health. national surveillance system? • Assumes leadership in defining the roles and responsibilities 2.1.1.12. Does the surveillance system include activi- of the system’s key personnel and in developing communi- ties that describe the nature and implica- cation and epidemiological response networks that provide tions of the information generated? feedback to the subnational levels. • Identifies public health threats and risk factors in the country. 2.2 Capacities and Expertise in Public • Is prepared to respond rapidly at all levels of the surveillance Health Surveillance system to control the problems detected. Standard 2.1.1. The NHA has a surveillance system in place with the The NHA: capacity to detect risks and threats to health in a • Has sufficient epidemiological expertise2 at the national and timely manner. subnational levels to develop and disseminate written pro- 2.1.1.1. Is the surveillance system capable of analyz- tocols that help identify and analyze priority problems and ing the nature and magnitude of the threats? health risks.

1Having an integrated epidemiological surveillance system for var- ious problems is the ideal, provided that the effectiveness of the sur- veillance systems already in place is not compromised by the integra- 2 In the case of small countries, this expertise can be concentrated at tion process. the international level.

320 • Has access to clinical and environmental services capable of 2.2.1.14 Designing new surveillance systems for conducting rapid population screening and environmental emerging health problems? sampling. • Conducts timely analyses of threats to health and health 2.2.2 The NHA regularly evaluates information generated risks, using inputs from the above services, as well as other by the public health surveillance system. epidemiological surveillance systems at subnational levels 2.2.2.1 Does the NHA annually evaluate the qual- (e.g. private insurance or private clinic data). ity of the information generated by the • Directly conducts or solicits research from other institutions public health surveillance system? on leading public health threats. 2.2.2.2 Does the NHA annually evaluate the use of this information? 2.2.1. The NHA has sufficient expertise in public health sur- 2.2.2.3 Has the NHA conducted or requested re- veillance to analyze threats and risks to public health. search that provides a greater understand- Does this include expertise in: ing of problems representing threats to 2.2.1.1 The capacity to develop written protocols public health? for identifying threats to public health? If so, 2.2.1.2 Forensic medical services? (e.g. pathology, 2.2.2.3.1 Can you give an example of medico-legal, police laboratories, etc). such research conducted during 2.2.1.3 Management and use of geographic infor- the past 12 months? mation systems? 2.2.2.4 Has the NHA used the results of this re- search to improve its epidemiological sur- If so, veillance system? 2.2.1.3.1 Does the NHA have in use an active geographic information system? 2.3 Capacity of Public Health Laboratories 2.2.1.4 Basic sanitation? Standard 2.2.1.5 Environmental health and toxicology? The NHA: 2.2.1.6 Analyzing and conducting demographic • Has a national public health laboratory network of growing (population-based) research on infectious complexity with the capacity to support epidemiological diseases? surveillance and research. 2.2.1.7 Analyzing and conducting demographic • Complies strictly with the norms and standards for accred- (population-based) research on chronic itation and evaluation with respect to the public health lab- diseases? oratories’ personnel, equipment, physical structure and se- 2.2.1.8 Analyzing and conducting demographic curity, exercising quality control over their procedures. (population-based) research on injury? • Has the capacity to carry out all procedures for diagnosing 2.2.1.9 Mental health? diseases subject to compulsory notification and that require 2.2.1.10 Occupational health epidemiological surveillance. 2.2.1.11 Rapid epidemiological evaluation methods • Ensures that network laboratories have the capacity to ex- (aggregate sampling, detection of risk fac- change information with other participating laboratories, tors, rapid survey methods, etc.)? standardizing their procedures with those of a national ref- 2.2.1.12 Conducting rapid screening of at-risk pop- erence laboratory. ulations or populations for which specific • Ensures that the national reference laboratory effectively co- health problems have been reported? ordinates with international reference laboratories. 2.2.1.13 Conducting rapid environmental sampling • Ensures that the public health laboratory network has in response to reports of environmental mechanisms in place to utilize information received from health risks? public and private laboratories to monitor diseases.

321 • Oversees strict compliance with the norms, accreditation ance with regulations for certifying the standards, and protocols for handling, storing and trans- quality of laboratories within the network? porting samples collected by public and private laboratories. If so, have these public health laboratories: • Ensures a timely response by which laboratories are capable 2.3.1.8.1 Complied strictly with the regu- of analyzing clinical or environmental samples in epidemic lations governing certification outbreaks or changes in disease behavior. of the quality of these laborato- 2.3.1. The NHA has a laboratory network capable of sup- ries within the network? porting epidemiological surveillance and research. 2.4 Capacity for Timely3 and Effective Response 2.3.1.1 Does the laboratory network have the ca- to Control Public Health Problems pacity to identify the causative agents of all reportable diseases in the country? Standard 2.3.1.2 Does the laboratory network maintain an The NHA: up-to-date list of laboratories capable of • Is capable of responding promptly and effectively at all its performing specialized analyses that meet levels to control public health problems. needs indicated by surveillance? • Evaluates the capacity of its system to respond in a timely 2.3.1.3 Does the laboratory network have strict and effective manner. protocols for the handling, transportation, • Ensures that the subnational levels have the human re- and storage of samples collected by public sources and infrastructure necessary for this response. or private laboratories? • Promotes ongoing evaluation of the intersectoral links nec- 2.3.1.4 Does the laboratory network have formal essary to respond at all levels. mechanisms for coordination and reference • Ensures that organized action in response to public health between the national public health labora- threats is systematically evaluated, indicating deficiencies tory network and one or more international for subsequent correction. laboratories of recognized excellence? • Ensures that constantly active mechanisms for communica- 2.3.1.5 Does the laboratory network periodically tion between the various levels are in place. evaluate the quality of the results from the • Ensures that appropriate, timely and educational public in- network’s reference laboratory by compar- ing them with results from an international formation for the control of public health problems is made reference laboratory? available and disseminated. 2.3.1.6 Does the laboratory network have stan- • Ensures that the response of levels closest to the problem is dardized procedures for obtaining informa- automatic and does not require waiting on a national re- tion from private and public laboratories to sponse or directives. monitor specific diseases? 2.4.1. The NHA has the capacity to respond in a timely and If so, effective manner to public health problems. 2.3.1.6.1 Have some of these procedures been evaluated to determine Does the NHA: their effectiveness in specific 2.4.1.1 Have protocols and procedure manuals in situations? line with surveillance information to pro- vide a rapid response to health and envi- 2.3.1.7 Is the laboratory network capable of meet- ronmental threats? ing routine epidemiological surveillance needs? 2.3.1.8 Does the laboratory network have a mecha- 3 “Timely” refers to acting within a time frame that permits effective nism that determines the degree of compli- public health intervention for each specific problem.

322 2.4.1.2 Define the responsibilities for personnel • Provides information on best practices in public health, in- who maintain active communication be- cluding current research findings on the most effective tween the different components of the sur- methods of disease prevention and control. veillance system? • Ensures that communication systems between all levels are 2.4.1.3 Promote in its procedural manuals and simple, expeditious and based on widely used software. standards the importance of a rapid, au- tonomous response by the levels closest to 2.5.1 The NHA provides technical assistance and support the health problem? to the subnational levels to develop their surveillance 2.4.1.4 Have formal mechanisms in place to recog- capacity. nize good performance by surveillance teams? Does the NHA: 2.4.1.5 Have formal mechanisms in place to recog- nize good performance by teams respond- 2.5.1.1 Conduct an assessment of its needs for spe- ing to emergencies? cialized personnel, training, equipment, 2.4.1.6 Has the NHA detected public health threats maintenance of equipment and other needs in a timely manner in the past 24 months? for surveillance at the subnational levels? If so, If so, 2.4.1.6.1 Can you give an example of 2.5.1.1.1. Does it utilize this assessment to such a detection? prioritize the contracting, train- ing and investment in the epi- 2.4.2 The NHA evaluates the response capacity of its sur- demiological surveillance system? veillance system to each health emergency that it has 2.5.1.2 Inform all subnational levels how to access had to confront. the public health laboratory network? Does the NHA: 2.5.1.3 Provide information and training to the 2.4.2.1 Communicate the results of the system subnational levels in critical areas to ensure evaluation to all those who contribute in- the quality of the work of the subnational formation to the system in order to correct levels? any deficiencies identified? 2.5.1.4 Advise the subnational levels how to re- 2.4.2.2 Oversee implementation of these correc- spond to queries on what to do when faced tive actions in order to improve response with an emergency? capacity? 2.5.1.5 Define the responsibilities for personnel at subnational levels on how to communicate with those responsible for the central man- 2.5 Technical Assistance and Support for agement of the surveillance system? the Subnational Levels in Public Health 2.5.1.6 Inform the subnational levels of the avail- Surveillance, Research, and Control of Risks ability of experts from the national level for and Threats to Public Health collaboration in dealing with public health emergencies? Standard 2.5.1.7 Have simple and effective standards for The NHA: communication between the different levels • Guides and supports the subnational public health systems of the surveillance system? in identifying and analyzing public health threats. 2.5.1.8 Disseminate information to the subna- • Informs subnational levels how to access the public health tional levels on the current status of the dis- laboratory network. eases under constant surveillance? • Provides guidelines, protocols, standards, consultations and 2.5.1.9 Disseminate information to the subna- training in the epidemiological methods to the subnational tional levels on “best practices” in disease levels. control?

323 2.5.1.10 Disseminate guidelines to the subnational • Assists local communities in creating incentives for the de- levels for developing plans to deal with velopment of effective health promotion initiatives that are public health emergencies? integrated with personal health care and other related extra- 2.5.1.11 Receive periodic and regular reports from sectoral programs. the subnational levels on trends and disease • Promotes interventions and regulations that encourage behavior under constant surveillance? healthy behaviors and environments. • Creates incentives for the subnational levels to develop and EPHF 3: Health Promotion4 implement health promotion and education activities acces- sible to the population. Definition 3.1.1 The NHA has a written statement of its health pro- This function includes: motion policy. 5 • The promotion of changes in lifestyle and environmental 3.1.1.1 Does the NHA take into account the rec- conditions to facilitate the development of a “culture of ommendations of international conferences health.” in this area?6 • The strengthening of intersectoral partnerships for more ef- 3.1.1.2 Does the NHA take advantage of infor- fective health promotion activities. mation technology to facilitate health • Assessment of the impact of public policies on health. promotion? • Educational and social communication activities aimed at 3.1.1.3 Has the NHA clearly defined its short- and promoting healthy conditions, lifestyles, behaviors and long-term goals in health promotion? environments. • Reorientation of the health services to develop models of If so, have these goals been established for: care that encourage health promotion. 3.1.1.3.1 The national level? 3.1.1.3.2 The intermediate levels? Indicators 3.1.1.3.3 The local level—for exam- ple, Healthy Cities or similar 3.1 Support for Health Promotion Activities, strategies? Development of Norms, and Interventions to Promote Healthy Behaviors and Environments 3.1.2 The NHA has established an incentive system that en- courages the participation of the subnational levels, Standard private institutions, other public-sector institutions, The NHA: and community organizations in health promotion • Has a health promotion policy that is in accordance with activities. relevant sectoral and extrasectoral actors. Has the NHA: • Implements health promotion strategies at all levels, both 3.1.2.1 Conducted an annual evaluation of this in- intra- and extra-sectoral, that respond to the health needs of centives system? the population. If so, 3.1.2.1.1 Are modifications to this system 4 This function encompasses the definition of the capacities specifi- cally required to implement, from the perspective of the NHA, the based on the results of the components of health promotion defined in the Ottawa Charter and evaluation? reaffirmed in the recent Global Conference on Health Promotion in Does the NHA: Mexico. Since it has been considered necessary to define another es- 3.1.2.2 Have national recognitions for excellence in sential function to cover social participation, this latter has concen- trated on defining capacities that largely facilitate health promotion. health promotion? 5 In this context, the term environment encompasses a wider scope than just physical environment, but also includes social and cultural 6 That is, the global conferences in Ottawa, Jakarta, and Mexico, environment. among other meetings on this topic.

324 3.1.2.3 Finance trainings, attendance at health pro- • Ensures that activities carried out reinforce the actions of motion events, etc. State institutions and are consistent with defined health pri- 3.1.2.4 Provide funding for health promotion proj- orities at subnational levels. ects on a competitive basis? • Has the support of a broad-based action and advisory group 3.1.2.5 Can you mention an example of an incen- that guides the process to improve health. tive provided in the past 12 months to a • Enters into partnerships with governmental and non- private institution? governmental organizations that contribute to or benefit 3.1.2.6 Can you mention an example of an in- from the essential public health functions, creating incen- centive provided in the past 12 months tives to promote the development of linkages at the subna- to a nonprofit, nongovernmental organi- tional levels. zation? • Periodically reports on health priorities, actions to 3.1.2.7 Can you mention an example of an incen- strengthen health promotion, public health policies and en- tive provided in the past 12 months to a gages in advocacy for the establishment of those policies. community organization? • Monitors and evaluates the health impact of extrasectoral public policies, taking corrective action based on the results 3.1.3 The NHA encourages the development of standards of the evaluation. and interventions that promote healthy behaviors and 7 environments. 3.2.1 The NHA has access to a coordinating unit that brings together representatives from community or- 3.1.3.1 Has the NHA identified a set of standards ganizations, the private sector, and other government that promote healthy behaviors and envi- sectors to plan initiatives for meeting health promo- ronments? tion targets. 3.1.3.2 Does the NHA annually plan the course to follow in preparing standards that promote 3.2.1.1 Is there a plan of action with explicit re- healthy behaviors and environments? sponsibilities for individuals who belong to 3.1.3.3 Does the NHA have a policy designed that this coordinating unit? encourages the development of interven- If so, tions promoting healthy behaviors and 3.2.1.1.1 Does the plan of action take environments? into account the health status profile as well as the country’s If so, health needs? 3.1.3.3.1 Can you mention an example of 3.2.1.1.2 Is health promotion evaluated the above interventions that periodically and are results of have implemented in the past this evaluation communicated 12 months? to members of the coordinating 3.1.3.3.2 Are the results of the interven- unit? tions evaluated at least once a 3.2.1.1.3 Does the plan of action describe year? corrective measures based on 3.1.3.3.3 Has the course of action ever the results of the evaluation? been modified as a result of the 3.2.1.1.4 Is a report issued each year to evaluation? key decisionmakers about the activities of the health promo- 3.2 Building Sectoral and Extrasectoral tion coordinating unit? Partnerships for Health Promotion 3.2.1.2 During the past 12 months, has the NHA carried out some national promotional ac- Standard The NHA: 7 This coordinating unit may be located outside of the NHA.

325 tivity in conjunction with another organi- 3.3 National Planning and Coordination zation or sector? of Information, Education, and Social Communication Strategies for Health Promotion If so, has the NHA: 3.2.1.2.1 Evaluated the results of this in- tersectoral partnership? Standard 3.2.1.2.2 Has it reported the results of this The NHA: evaluation to its collaborators? 3.2.1.2.3 Taken corrective action to im- • Engages in a systematic effort to inform and educate the prove the results based on this public to play on their role in improving health conditions. evaluation? • Collaborates with public and private, sectoral and extrasec- toral agencies at various levels to carry out health promotion 3.2.2 The NHA has the capacity to measure the health initiatives that ensure healthy lifestyles and behavior. impact of the public policies generated by other • Coordinates health promotion initiatives to ensure an in- sectors. tegrated approach consistent with healthy lifestyles and behaviors. 3.2.2.1 Does it have access to personnel proficient • Supports the development of culturally and linguistically in the use of multifactoral epidemiological appropriate educational programs that target specific analysis? groups. 3.2.2.2 Are resources allocated to measure the • Conducts health education campaigns through mass media, health impact of public policies? such as television, radio, and the press. • Uses a variety of methods to disseminate health information 3.2.3 The NHA works to promote the development of to the entire population. healthy social and economic policies. • Uses feedback from the population to annually evaluate the Does the NHA: effectiveness and relevance of health promotion and educa- 3.2.3.1 Identify and promote the definition and tion activities. implementation of those policies having a greater probable impact on the health of in- 3.3.1 In the past 12 months, the NHA has developed and dividuals and the environment? implemented a community education agenda that 3.2.3.2 Monitor and assess the health impact of so- promotes initiatives to improve the health status of the cial and economic policies? population. If so, can you cite an example of a health 3.3.1.1 Was this agenda developed in collaboration impact assessment conducted by the NHA with other public institutions? with respect to: 3.3.1.2 Does this agenda include private institutions? 3.2.3.2.1 Environmental policies? 3.3.1.3 Does this agenda include input from the 3.2.3.2.2 Economic policies? community? 3.2.3.2.3 Social policies? 3.3.1.4 Does this agenda include current scientific perspectives on communication in health? 3.2.3.3 Advocate the strengthening of public poli- 3.3.1.5 Does this agenda include the most signifi- cies in order to improve the population’s cant international recommendations on health and environment? health promotion? If so, can you cite an example of advocacy 3.3.1.6 Does this agenda ensure nationwide consis- conducted by the NHA with respect to: tency of health promotion activities? 3.2.3.3.1 Environmental policies? 3.3.1.7 Does this agenda include activities that 3.2.3.3.2 Economic policies? make health promotion accessible to cul- 3.2.3.3.3 Social policies? turally diverse groups?

326 3.3.2 During the past 12 months, the NHA has conducted 3.3.3.6 Does the NHA evaluate the usefulness of health promotion campaigns through the mass media. other alternative media in use? Did the campaigns include: 3.3.2.1 The press? 3.4 Reorientation of the Health Services toward 3.3.2.2 Radio? Health Promotion 3.3.2.3 Television? 3.3.2.4 Internet? Standard 3.3.2.5 Were campaign results evaluated through The NHA: population surveys or focus groups? • Promotes and facilitates dialogue and consensus among de- If so, did this evaluation include: cisionmakers in order to maximize health promotion re- 3.3.2.5.1 Understanding of the messages? sources in providing health services. 3.3.2.5.2 Ability to access to the mes- • Has mechanisms in place that allocate resources to service sages? providers, motivating them to adopt a health promotion 3.3.2.5.3 Results based on changes in knowledge of the population? approach. 3.3.2.5.4 Results based on changes in be- • Reorients public health infrastructure to improve the per- havior of the population? formance of services from health promotion perspective. 3.3.2.5.5 Incorporation of the results in • Includes health promotion criteria in the regulatory mech- planning subsequent mass media anisms governing certification and/or accreditation of campaigns? health facilities, service provider networks, health profes- sionals and health insurance plans. 3.3.3 The NHA has special systems in place for delivering • Emphasizes primary health care (PHC) and establishes pro- information and educational materials to the popula- grams through which providers assume responsibility for tion to promote health (e.g. information offices, web- comprehensive community care. sites, telephone hotlines, and other alternative media). • Strengthens the concept of health promotion in human re- source development programs at all levels of the health 3.3.3.1 Does the NHA have a Web page for con- system. veying useful health information? • Promotes consensus among experts on clinical guidelines If so, that incorporate disease prevention and health promotion, 3.3.3.1.1 Is utilization of this Web page as well as oversees their application. evaluated periodically (at least • Encourages communication between service providers, every six months) by taking into communities and patients to make health care more effec- account the number of hits and tive and establishing joint responsibility for health care users’ opinions? through specific commitments. 3.3.3.2 Have the educational materials distributed in these media been updated in the past 12 months as a result of the evaluation? 3.4.1. The NHA has discussed the importance of encourag- 3.3.3.3. Has the management of the information of- ing health promotion in the health services with other fice (clearinghouse) and its usefulness been organizations and decisionmakers. evaluated in the past 12 months? 3.4.1.1 Has it provided evidence with respect to in- 3.3.3.4. Are the results periodically evaluated? vesting in promotion versus curative activi- 3.3.3.5. Does the NHA have a telephone hotline for ties and the outcomes of such of activities? conveying health promotion messages? 3.4.1.2 Has it obtained a commitment from other If so, organizations to support investments in 3.3.3.5.1 Is the use of the hotline evalu- health promotion activities in the delivery ated at least every six months? health services?

327 3.4.2 The NHA has developed strategies for reorienting 3.4.2.8.1 Can you cite an example that health services using health promotion criteria. was achieved as a result of such 3.4.2.1. Has the NHA established payment mecha- an agreement? nisms to encourage health promotion in public insurance systems? 3.4.3 The NHA has promoted the strengthening of primary health care (PHC). If so, has the NHA 3.4.2.1.1. Evaluated the results of these Does the NHA: payment mechanisms in terms 3.4.3.1 Promote population-based models of care of fostering health promotion in for which health teams trained in health health services? promotion are responsible? 3.4.3.2 Promote incentives that encourage health 3.4.2.2 Has the NHA established payment mecha- teams to address health issues through nisms to foster health promotion in the pri- health promotion? vate insurance systems? 3.4.3.3 Provide health teams with the resources and If so, has the NHA authority needed to implement health pro- 3.4.2.2.1 Evaluated the results of these motion programs for target populations? payment mechanisms in terms 3.4.3.4 Establish formal incentives in PHC to de- of fostering health promotion in velop programs in health promotion that health services? are geared towards communities and indi- 3.4.2.3 Has the NHA drawn up a plan for devel- viduals? oping public health infrastructure that en- courages health promotion? 3.4.4 Has the NHA strengthened its human resources de- 3.4.2.4 Has the NHA drafted guidelines for the ac- velopment by using a health promotion approach? creditation of health professionals that pro- Does the NHA: vide for training in health promotion? 3.4.4.1 Encourage training centers related public 3.4.2.5 Has the NHA drafted guidelines for the ac- health to include health promotion content creditation of health facilities that provide in an effort to instill positive attitudes to- for health promotion activities? wards health promotion among students 3.4.2.6 Has the NHA encouraged health promo- pursuing a career in health? tion interventions in the health insurance 3.4.4.2 Include a component on health promotion plans? in continuing education programs for 3.4.2.7 Has the NHA promoted the use of clini- health personnel? cal protocols validating effective practices in health promotion in personal health 3.5 Technical Assistance and Support to the services? Subnational Levels to Strengthen Health If so, Promotion Activities 3.4.2.7.1 Can you cite an example of such a protocol that is currently in Standard use? The NHA: 3.4.2.8 Has the NHA promoted agreements that • Has expertise in health promotion and shares this expertise include a health promotion component and with subnational levels. explicitly state the responsibilities of com- • Ensures consistency of information with scientific evidence munities, patients and providers? as well as adapting this information to the needs of the sub- If so, national levels.

328 • Encourages the subnational levels to make resources, facili- 3.5.2.2 Has the NHA evaluated the results of the ties, and equipment available that maximize the impact above plan and taken action based on the of and access to health promotion and education in the results of this evaluation? country. 3.5.2.3 Is there access to facilities and equipment that permit the development of educational 3.5.1 The NHA has the capacity and expertise to strengthen materials? health promotion initiatives at the subnational levels. If so, is there access to: Does the NHA have expertise in the following areas: 3.5.2.3.1 Graphic design software? 3.5.1.1. Health promotion at the workplace? 3.5.2.3.2 Professionals trained in the use 3.5.1.2. Health education? of this technology? 3.5.1.3. Working with groups? 3.5.2.4 Is there coordination between actors who 3.5.1.4. Social marketing? have the capacity to implement health pro- 3.5.1.5. Collaboration and advocacy with commu- motion activities? nication media? If so, 3.5.1.6. Communication techniques? 3.5.2.4.1 Can you cite examples of coor- 3.5.1.7. Development of educational materials for dinated action with these actors health promotion suitable for various in the past year? cultures? If so, 3.5.3 The NHA uses media and technologies at the national 3.5.1.7.1 Has an evaluation been con- level to maximize the impact of health promotion and ducted in the past 12 months of access to it in the country. the education materials cur- Are the following resources utilized: rently in use to determine 3.5.3.1 Radio programs? whether they represent current 3.5.3.2 Community educational theater? knowledge and best practices 3.5.3.3 Television programs? for formulating health promo- 3.5.3.4 Video-conferencing? tion messages? 3.5.3.5 Professionals trained in the use of these 3.5.1.7.2 Have the materials been evalu- media? ated to assess their cultural ap- propriateness for each country? EPHF 4: Social Participation in Health 3.5.1.8 Have the subnational levels been informed of materials and expertise available at the Definition national level and the willingness to sup- port subnational efforts in health promo- This function includes: tion? • Strengthening the power of civil society to change their 3.5.1.9 Have the subnational levels received sup- lifestyles and play an active role in the development of port in implementing specific health pro- healthy behaviors and environments in order to influence motion activities in the past 12 months? the decisions that affect their health and their access to ad- equate health services. 3.5.2 The NHA evaluates the need for health education spe- • Facilitating the participation of the community in decisions cialists at the subnational levels. and actions with regard to programs for disease prevention 3.5.2.1 Has the NHA prepared a plan to develop and the diagnosis, treatment and restoration of health in capacity in health education at the subna- order to improve the health status of the population and tional level. promote environments that foster healthy lifestyles.

329 Indicators 4.1.2 The country has an agency that acts as an ombudsman in matters related to health. 4.1 Empowering Civil Society for Decision- 4.1.2.1 Is this entity independent of the State? Making in Public Health 4.1.2.2 Is this entity empowered to take legal and/or public action to protect people and Standard their right to health in relation to personal The NHA: health care, both public and private? • Guarantees permanent mechanisms for consulting with the 4.1.2.3 Is this entity empowered to take legal civil society to receive and respond to public opinion on and/or public action to protect people and those behaviors and environmental conditions that impact their right to health in relation to popula- public health. tion-based health services? • Promotes the development of entities that protect the rights 4.1.2.4 Does this entity have the capacity to engage of persons as members of civil society, consumers and users in social and civic action in health on behalf of the health system. of persons with limited resources and who • Reports, in a timely manner, to civil society, the health sta- are victims of discrimination? tus of the population and the performance of public and private health services. 4.1.3 The NHA reports to the public on the health situation 4.1.1 The NHA ensures the existence and operation of and on the performance of personal and population- mechanisms for consulting citizens and obtaining based health services. community feedback on matters of public health. 4.1.3.1 Is this report issued at least every two years? 4.1.1.1 Has the NHA established formal entities to 4.1.3.2 Are the report’s findings distributed to consult civil society?8 communication media? If so, do these entities exist and operate: 4.1.3.3 Are the report’s findings distributed to 4.1.1.1.1 At the national level? community groups? 4.1.1.1.2 At the intermediate level? 4.1.3.4 Are there formal channels available for the 4.1.1.1.3 At the local level? public to give feedback on the findings? 4.1.3.5 Are changes in policy, resulting from defi- 4.1.1.2 Does the NHA have other means for ob- ciencies identified in the report, communi- taining the opinion and feedback from civil society? cated to the public? If so, do these operate: 4.1.1.2.1 At the national level? 4.2 Strengthening of Social Participation 4.1.1.2.2 At the intermediate level? in Health 4.1.1.2.3 At the local level? Standard 4.1.1.3 Does the NHA have mechanisms in place The NHA: allowing it to respond to the opinions given by civil society? • Promotes the building of partnerships in health at all levels. • Develops and uses mechanisms at all levels to inform and If so, are these mechanisms in place: educate civil society about their rights and responsibilities 4.1.1.3.1 At the national level? in health. 4.1.1.3.2 At the intermediate level? • Maintains an accessible information system containing a di- 4.1.1.3.3 At the local level? rectory of organizations that work, or could potentially 8 Examples of these entities are complaints offices, consultative health work, in public health initiatives, as well as provides access boards or commissions, and the health commissions of community to information on “best practices” in social participation in organizations. health.

330 • Defines the objectives and goals of public health at the dif- 4.2.2 The NHA has staff trained to promote community ferent levels in conjunction with the community, promot- participation in personal and population-based health ing the development of public health projects managed by programs. civil society. • Periodically evaluates its capacity to strengthen social par- If so, is this staff adequately trained in: ticipation in health and introduces in a timely manner 4.2.2.1 Methodologies that facilitate group partici- changes recommended by these evaluations. pation? 4.2.2.2 Planning and coordination of community 4.2.1 The NHA has established a policy that considers social action in health? participation the key to setting and meeting its goals 4.2.2.3 Leadership, group work, and conflict reso- and objectives in public health. lution? 4.2.1.1 Does the NHA take into consideration so- 4.2.2.4 Development of strategies for social partic- cial participation when defining its public ipation in health? health goals and objectives? 4.2.2.5 Building partnerships within the commu- nity? If so, is this social participation considered: 4.2.1.1.1. At the national level? 4.2.1.1.2. At the intermediate level? 4.2.3 The NHA encourages and promotes the development 4.2.1.1.3. At the local level? of best practice in social participation in health. 4.2.1.2 Does the NHA take into account input If so, does the NHA: provided by civil society through social par- 4.2.3.1 Have a directory of organizations that can ticipation in health? collaborate in developing population-based 4.2.1.3 Has the NHA established formal entities and personal community health initiatives? that strengthen social participation in 4.2.3.2 Disseminate information about successful health? social participation initiatives? If so, do these entities operate: 4.2.3.3 Allocate resources for the development of 4.2.1.3.1 At the national level? public health programs managed by civil 4.2.1.3.2 At the intermediate level? society? 4.2.1.3.3 At the local level? If so, 4.2.1.4 Does civil society participate in decision- 4.2.3.3.1 Can you mention a civil society making that affects the administration of group that has received such health services? funding in the past year? If so, is this done: 4.2.3.4 Does the NHA facilitate the organization of 4.2.1.4.1 At the national level? meetings, seminars, workshops and other 4.2.1.4.2 At the intermediate level? venues to discuss community health issues? 4.2.1.4.3 At the local level? If so, is this done: 4.2.1.5 Can you cite an example in which a public 4.2.3.4.1 At the national level? health objective was defined through social 4.2.3.4.2 At the intermediate level? participation? 4.2.3.4.3 At the local level? 4.2.1.6 Does the NHA have programs that inform 4.2.3.5 Does the NHA assist other organizations and educate the public about its rights to with the preparation of these meetings? health? If so, are these programs: If so, 4.2.1.6.1 At the national level? 4.2.3.5.1 Can you recall at least one ex- 4.2.1.6.2 At the intermediate level? ample of this type of meeting in 4.2.1.6.3 At the local level? the past year?

331 4.2.3.6 Is there access to adequate facilities–includ- participation mechanisms for decision-making in pub- ing meeting rooms, audiovisual equipment, lic health. and supplies—to convene a wide range of Does this support include: meetings for social participation in health? 4.3.1.1 Providing Information to the subnational If so, are these facilities available: levels on experiences in this area? 4.2.3.6.1 At the national level? 4.3.1.2 Convening advisory groups and executive 4.2.3.6.2 At the intermediate level? committees with a focus on social partici- 4.2.3.6.3 At the local level? pation and partnership building? 4.3.1.3 Evaluating the results of social participation 4.2.4 The NHA evaluates its capacity to promote social par- in health and partnership building within ticipation in health. the community? 4.3.1.4 Creating formal bodies to consult civil soci- 4.2.4.1 Does it evaluate this capacity annually? ety? 4.2.4.2 Are changes suggested by the findings of 4.3.1.5 Designing systems to obtain public opinion the evaluations incorporated into future in health? strategies? 4.3.1.6 Designing and implementing systems to re- 4.2.4.3 Are policy changes resulting from the eval- spond to public opinion in health? uations communicated to partners in social 4.3.1.7 Designing public accountability mecha- participation? nisms?9 4.3.1.8 Implementing effective mechanisms for 4.3 Technical Assistance and Support to the conflict resolution in the community? Subnational Levels to Strengthen Social 4.3.1.9 Building community networks? Participation in Health 4.3.1.10 Implementing intervention methods that pro- Standard mote community organization in health? The NHA: 4.3.1.11 Supporting the organization of social par- ticipation activities at the local level? • Provides assistance as needed to the subnational levels in de- 4.3.1.12 Facilitating partnerships to improve com- veloping and strengthening of mechanisms for participation munity health? in decision-making in health. • Provides assistance as needed to the subnational levels in EPHF 5: Development of Policies creating and maintaining partnerships with civil society and and Institutional Capacity for Planning organized community groups. and Management in Public Health • Supports the subnational authorities in building relation- ships with the community. Definition • Supports community leadership efforts to identify and uti- lize best practices in public health through partnerships. This function includes: • Uses evidence-based technical support to help the subna- • The definition of national and subnational public health tional levels improve their capacity to encourage social par- objectives which should be measurable and consistent with ticipation. a values-based framework that favors equity. • Encourages the development of local community groups • The development, monitoring and evaluation of policy de- and provides technical support for this development cisions in public health through a participatory process. process.

9 “Accountability” refers to the formal process whereby the NHA 4.3.1 The NHA advises and supports the subnational levels periodically conveys to the community the results of its activities in the development and strengthening of their social and obtains its opinion to improve its performance in the future.

332 • The institutional capacity for the management of public 5.1.1.2.1. Are these health goals and ob- health systems, including strategic planning with emphasis jectives based on the current on building, implementing and evaluating initiatives de- health status profile? signed to focus on health problems of the population. 5.1.1.2.2. Are these health goals and ob- • The development of competencies for evidence-based deci- jectives based on previously de- sion-making, planning and evaluation, leadership capacity fined health priorities? and effective communication, organizational development 5.1.1.2.3. Are these health goals and ob- and resource management. jectives consistent with other • Capacity-building for securing international cooperation in national development objectives public health. within the framework of social policy? Indicators 5.1.1.2.4. Does adequate financing exist to execute plans and programs 5.1 Definition of National and Subnational aimed at attaining the health Health Objectives goals and objectives? 5.1.1.2.5. Does the NHA seek the input Standard from community representa- The NHA: tives in defining health goals • Defines national and subnational objectives to improve the and objectives? health of the population, taking the most recent health pro- 5.1.1.2.6. Does the NHA identify those file into account. individuals and organizations • Identifies, in conjunction with key actors, health priorities responsible for achieving the de- that take into account the heterogeneity of the country, rec- fined health goals and objec- ommending measurable health objectives and proposing a tives? joint effort to attain these objectives. 5.1.1.2.7. Does the NHA develop per- • Ensures the coherence of national and subnational health formance indicators that mea- objectives. sure the level of achievement of • Identifies and develops indicators of improvement and the defined health goals and measures of their success as part of an extensive and contin- objectives? uous plan to improve health status. • Promotes and facilitates the development of partnerships If so, with key groups involved in the financing, purchasing and 5.1.1.2.7.1 Does this measure- delivery of health services. ment process include indica- tors for each of the policies, 5.1.1 The NHA heads a national health improvement activities and/or components process aimed at developing national and subnational of the plan? health objectives. 5.1.1.2.8 Are other organizations that 5.1.1.1 Does the NHA seek the input of key actors contribute to or benefit from in identifying priorities at the national and improvements in the national subnational levels? health profile involved in the 5.1.1.2 Does the NHA develop a plan with na- development of these indica- tional goals and objectives that is closely re- tors? lated to national health priorities for a de- fined period? 5.1.2 The NHA uses indicators to measure success in meet- If so, ing health objectives.

333 5.1.2.1 Are these indicators monitored and evalu- • Periodically monitors and evaluates the process to develop ated through a participatory process? policy and takes the necessary action to show the potential impact of policies on the health of individuals. If so, does this participatory process: 5.1.2.1.1 Include key actors involved in 5.2.1 The NHA assumes leadership in developing the na- the financing of health care? tional health policy agenda. 5.1.2.1.2 Include key actors involved in health care purchasing (man- If so, agement of health care financ- 5.2.1.1 Is the above agenda consistent with the na- tional objectives as defined by the NHA ing)? and its partners, and as described in Indica- 5.1.2.1.3 Include key actors involved in tor 5.1.1? health care delivery? 5.2.1.2 Does the above agenda have the endorse- 5.1.2.1.4 Contribute to the implementa- ment and approval of the highest level of tion of a comprehensive na- the Executive branch? tional health policy? 5.2.1.3 Does the above agenda have the endorse- ment and approval of the Legislative 5.1.3 The NHA evaluates current and potential partners to branch? determine their degree of support and commitment to 5.2.1.4 Does the NHA request and take into ac- the development, implementation, and evaluation of count input from other key decisionmakers the national efforts to improve health. responsible for generating a health policy agenda? 5.1.3.1 Is this partner evaluation process carried 5.2.1.5 Does the NHA request and take into ac- out in the public health sector? count input from civil society to formulate 5.1.3.2 Is this partner evaluation process carried a national health policy agenda? out in the private health sector? 5.1.3.3 Do the results of the latest partner evalua- 5.2.2 The NHA coordinates social participation activities at tion indicate that the partners are properly the national level to help set the national health policy identified and suitably prepared to assume agenda. their responsibilities in the health improve- ment process at the national level? If so, do these activities include: 5.2.2.1 Generating public health agreements and 5.1.3.4 Are the results of the partner evaluation consensus in areas of national importance? used to develop partnerships with key ac- 5.2.2.2 Facilitating for a the public discussion of tors in the private and public sectors? concerns, testimonies and consensus-build- ing on public health issues? 5.2 Development, Monitoring and Evaluation 5.2.2.3 Communicating with national committees of Public Health Policies and advisory groups responsible for policy development? Standard 5.2.2.4 Negotiating public health legislation that The NHA: supports the defined national health policy • Takes the lead in defining public health policies and in- agenda? volves the Executive and Legislative branches of govern- 5.2.2.5 Sharing this national health policy agenda ment, key leaders and civil society in the process. with other interested parties at the national or subnational levels? • Develops a pluralistic approach to inform and influence the genesis of sustainable national public health and regulatory If so, do these include: policies in the country. 5.2.2.5.1 Unions?

334 5.2.2.5.2 Professional associations? • Provides the resources and strategies necessary for attaining 5.2.2.5.3 Private groups? these standards of excellence. 5.2.2.5.4 Local health jurisdictions? • Has the necessary personnel skilled to effectively communi- 5.2.2.5.5 Consumer groups? cate the vision and implementation strategies through on a 5.2.2.5.6 Community organizations? system-wide basis. 5.2.2.5.7 Nongovernmental organizations? 5.3.2 Evidence-based decision-making 5.2.2.6 Developing policies that translate into pub- • Has the necessary competencies and resources to collect, lic health laws and regulations? analyze and evaluate data from different sources to develop If so, the capacity for evidence-based management, including 5.2.2.6.1 Can you cite a specific example support for planning, decision-making and evaluation of of such a law or regulation interventions. drafted in the past year? • Facilitates access to pertinent data sources that support decision-making and ensure that these sources are used at 5.2.3 The NHA monitors and evaluates current public the subnational levels health policies in order to measure their impact. • Guarantees the systematic analysis of information about the Does the NHA: results of its operations and has the necessary personnel 5.2.3.1 Alert decisionmakers and civil society of the with the capacity to conduct this analysis. impact that may result from implementing • Uses operations research on health systems to inform the public health policies? decision-making process. 5.2.3.2 Use this evaluation of current public health policies to define and implement health 5.3.3 Strategic planning policies? • Has the institutional capacity to apply a strategic focus for 5.2.3.3 Have personnel with the necessary expertise health planning based on relevant and valid information. to develop and implement evidence-based • Generates and ensures the feasibility of strategic plans public health policies? through measures that build partnerships with civil society geared to meeting health needs. If so, does this expertise include: • Ensures that the necessary steps have been taken to coordi- 5.2.3.3.1 Proposing public health policy? nate planning and collaborative efforts with other agencies 5.2.3.3.2 Proposing public health legisla- and civil society. tion? • Ensures coordination and consistency between the national 5.2.3.3.3 Convening of public fora to de- and subnational planning levels of public health in imple- fine public health policies? menting diverse strategies by the subnational levels. 5.2.3.3.4 Prioritizing public health policy issues? 5.3.4 Organizational development • Establishes an organizational culture, process and structure 5.3 Development of Institutional Capacity for that learns and operates through continuous feedback on the Management of Public Health Systems the changes in the external environment. • Facilitates the involvement of and access by institutional Standard personnel and civil society in providing feedback to help The NHA: solve public health problems. • Has the necessary competencies in inter-institutional rela- 5.3.1 Leadership and communication tions, conflict management, teamwork and organizational • Ensures that its leadership is capable of moving the health development to move the institution towards a clearly de- system in the direction of a clearly articulated vision with fined vision and provide a response based on standards of clearly defined standards of excellence. excellence.

335 5.3.5 Resource management 5.3.2.1.1 Possess the necessary capacity to • Ensures the availability of resources necessary to develop collect, analyze, integrate and skills indispensable to its operations including financial, evaluate information from dif- technical and human resources that can be efficiently allo- ferent sources? cated based on changing priorities. 5.3.2.1.2 Have information systems that • Has the capacity to manage the resources needed to ensure can process collected data and efficiency, quality and equity in accessing health care. build a comprehensive database • Empowers its personnel to strengthen the capacity of to be used in be used in the providers and managers at all levels of the health system in planning process? designing, implementing and effectively managing support systems to ensure an integrated health system. If so, does the database provide information on: 5.3.2.1.2.1 Existing resources 5.3.1 The NHA is developing the institutional capacity to in the health sector? exercise leadership in health management. 5.3.2.1.2.2 Cost analysis? 5.3.1.1 Is the necessary institutional capacity in 5.3.2.1.2.3 Service output? place at the NHA that allows it to exercise 5.3.2.1.2.4 Quality of services? its leadership in the public health system? 5.3.2.1.3 Use information from different sources to improve decision- If so, does this capacity include: making in managing public 5.3.1.1.1 Tools for consensus-building? health systems at all levels? 5.3.1.1.2 Promoting intrasectoral collab- 5.3.2.1.4 Stimulate and facilitate the use oration? of information on community 5.3.1.1.3 Conflict resolution methods? health status in its decision- 5.3.1.1.4 Expertise in communication? making? 5.3.1.1.5 Mobilization of resources? 5.3.2.1.5 Have the qualified personnel to 5.3.1.1.6 Promoting intersectoral collab- use this information for evi- oration? dence-based decision-making? Does the NHA: 5.3.1.2 Use its leadership role If so: to steer the public health sys- 5.3.2.1.5.1 Is this information tem towards its objectives? presented in an coherent 5.3.1.3 Have the necessary manner? skilled personnel to effec- tively communicate its vision 5.3.2.2 Use scientific methodologies for health sys- and strategies on a system- tems research to inform the decision-mak- wide basis? ing and evaluation processes? 5.3.2.3 Have supervisory and evaluation systems to ensure that goals and objectives are met? 5.3.2 The NHA is developing institutional capacity for evi- 5.3.2.4 Have clear, well-defined performance mea- dence-based decision-making. surements that are an integral part of the Does the NHA: health system? 5.3.2.1 Have evidence-based managerial capacity If so, do these performance measurements for planning, decision-making and the eval- include: uation of activities? 5.3.2.4.1 Systematic data collection and If so, does the NHA: analysis?

336 5.3.2.4.2 Continuous improvement of Does the NHA: health system performance? 5.3.4.1 Have a clear, shared organizational vision? 5.3.2.4.3 Can you cite an example of such 5.3.4.2 Ensure that it has the organizational cul- a performance measurement? ture, processes and structure to continually learn from changes in the external environ- 5.3.2.5 Does the NHA have the qualified personnel ment and to adequately respond to those able to effectively communicate the results changes? of its operations? If so, has the NHA: 5.3.3 The NHA has the institutional capacity for strategic 5.3.4.2.1 Examined its organizational planning. culture? 5.3.3.1 Does the NHA have personnel with the 5.3.4.2.2 Conducted a performance as- necessary expertise and capacity to define sessment of its organizational and implement strategic planning? development process? 5.3.3.2 Does the NHA use strategic planning in its If so, activities and operations? 5.3.4.2.2.1 Is this assessment If so, used to respond to changes in 5.3.3.2.1 Has the NHA carried out a the external environment? Does the NHA: strategic planning process in the 5.3.4.3 Define standards of excellence? past year? If so, does the NHA: If so, did the process: 5.3.4.3.1 Implement the necessary strate- 5.3.3.2.1.1 Define the vision gies to meet these standards? and mission of the NHA? 5.3.4.3.2 Provide the necessary resources 5.3.3.2.1.2 Analyze the strengths to meet these standards? and weaknesses of the NHA? 5.3.4.3.3 Facilitate the implementation of 5.3.3.2.1.3 Identify the threats these standards in daily prac- to and opportunities for the tice? NHA? 5.3.4.3.4 Have an organizational culture 5.3.3.2.1.4 Define the objec- that facilitates empowerment of tives and strategies of the personnel for their ongoing NHA? development? 5.3.3.2.1.5 Build partnerships to carry out its strategic plan? 5.3.5 The NHA has the institutional capacity for managing 5.3.3.2.1.6 Define tasks and resources. responsibilities needed to carry out the process? 5.3.5.1 Does the NHA have the institutional ca- 5.3.3.2.1.7 Undergo an itera- pacity to manage its resources? tive and systematic evalua- If so, tion? 5.3.5.1.1 Does it have the authority to re- allocate its resources as priorities 5.3.3.2.2 Does the NHA coordinate these and needs change? planning and collaborative ac- tivities with other agencies? If so, 5.3.5.1.1.1 Can you cite spe- 5.3.4 The NHA has a permanent organizational develop- cific examples of this reallo- ment process. cation in the last year?

337 5.3.5.1.1.2 Does the NHA 5.4.1.3 Have the necessary capacity to implement use its capacity for resource joint cooperation projects with countries management to ensure effi- inside and outside the Region? ciency, quality and equity in If so, do this capacity include: the health services? 5.4.1.3.1 Joint cooperative programs with 5.3.5.1.1.3 Does the NHA international agencies? have trained staff in technol- 5.4.1.3.2 Specific and short-term joint ogy management who can cooperative projects? offer advice on the selection 5.4.1.3.3 Projects of cooperation between and management of appro- countries? priate technologies? 5.4.1.4 Guarantee that all cooperative projects are systematically and jointly evaluated with 5.4 Management of International Cooperation their respective international partners? in Public Health If so, 5.4.1.4.1 Does the NHA have profession- Standard als at all levels of the health sys- The NHA: tem that are able to participate • Has the capacity and expertise necessary to negotiate with in this evaluation? international agencies and institutions that collaborate in public health. 5.5 Technical Assistance and Support to the • Has the capacity to design and implement medium- to Subnational Levels for Policy Development, long-term cooperation programs, as well as projects of a Planning, and Management in Public Health more limited scope and duration. • Has information systems in place that match national needs Standard with the international cooperation ventures available and The NHA: actively search for cooperation projects that make it possi- ble to better address national health priorities. • Advises and provides technical support to the subnational • Is in a position to develop cooperative programs, inside levels of public health on policy development, planning and or outside the Region, that can be systematically jointly management activities. evaluated. • Promotes and facilitates the use of planning processes at the subnational levels, as well as integrates planning with other 5.4.1 The NHA has the capacity and resources to direct, ne- community initiatives that impact public health. gotiate and implement international cooperation in • Ensures that its managerial capacity supports the develop- public health. ment of public health at the subnational levels and advises those levels on management practices to ensure sustainable Does the NHA: mechanisms for good communication. 5.4.1.1 Have the necessary resources and technol- • Establishes linkages with training institutions to improve ogy to search databases of international co- the sustainable management capacity of personnel at the operation opportunities that will enable it subnational levels. to better address national priorities in health? 5.5.1 The NHA advises and provides technical support to 5.4.1.2 Have knowledge of the policies, priorities, the subnational levels for policy development, plan- conditions and requirements of the various ning, and the management of activities in public international cooperation agencies for the health. allocation of resources? Does this support include:

338 5.5.1.1 Training in methods for public health plan- 5.5.2.2 Respond rapidly to deficiencies revealed at ning? the subnational levels? 5.5.1.2 Training in methods for formulating public 5.5.2.3 Can you cite a specific example of such a health policies? mechanism that has been implemented in 5.5.1.3 Training in methods to ensure sustainable the past two years? management? EPHF 6: Strengthening of Institutional If so, does the NHA: 5.5.1.3.1 Have training programs to pro- Capacity for Regulation and Enforcement mote sustainable management in Public Health that strengthens the institu- Definition tional capacity of the subna- This function includes: tional levels? 5.5.1.3.2 Provide in-service training? • The institutional capacity to develop the regulatory and en- 5.5.1.3.3 Provide formal continuing edu- forcement frameworks that protect public health and mon- cation? itor compliance within these frameworks. 5.5.1.3.4 Establish linkages with schools • The capacity to generate new laws and regulations aimed or organizations that offer train- at improving public health, as well as promoting healthy ing programs in sustainable environments. management to strengthen in- • The protection of civil society in its use of health services. stitutional capacity at the sub- • The execution of all of these activities to ensure full, proper, national levels? consistent and timely compliance with the regulatory and 5.5.1.4 Advise on effective strategies to identify and enforcement frameworks. address subnational priorities in health? Indicators 5.5.1.5 Have the necessary resources to assist sub- national levels with strategic planning activ- ities? 6.1 Periodic Monitoring, Evaluation and 5.5.1.6 Facilitate the development of local health Revision of the Regulatory Framework planning processes? Standard: 5.5.1.7 Promote the integration of local health The NHA: planning process with other similar initia- tives? • Periodically reviews the current laws and regulations that 5.5.1.8 Strengthen the decentralization of manage- protect public health and ensure healthy environments, ment in public health? based on the best national and international information 5.5.1.9 Provide assistance to promote the continu- available. ous improvement of management at the • Prepares and reviews laws and regulations proposed for fu- subnational levels? ture use. • Proposes updates to the wording and content to ensure laws 5.5.2 The NHA has the necessary systems in place to rapidly and regulations reflect current scientific knowledge in pub- and accurately detect needs to improve management lic health and correct any undesirable effects of the legisla- tion. at the subnational levels. • Requests information from lawmakers, legal experts and Does the NHA have mechanisms and policies in place civil society, particularly subject to regulation or directly af- at all levels to: fected by the legislation under review. 5.5.2.1 Detect deficiencies in management capacity • Monitors legislative proposals under discussion and advises at the subnational levels? lawmakers on them.

339 6.1.1 The NHA has expertise in drafting laws and regula- Does the NHA: tions to protect public health. 6.1.4.1 Offer advisory services and assistance to lawmakers for the drafting of the necessary Does this expertise include: legal revisions based on the results of the 6.1.1.1 Its own legal counsel? review? 6.1.1.2 Legal counsel contracted externally for spe- 6.1.4.2 Actively engage in advocacy to facilitate the cific reviews? necessary legal revisions that protect the 6.1.1.3 Personnel familiar with legislative and regu- health and safety of the population? latory procedures for the passage, amend- ment and rejection of laws and regulations 6.2 Enforcement of Laws and Regulations in public health? Standard: 6.1.2 The NHA reviews the laws and regulations to protect The NHA: the health and safety of the population. • Exercises oversight of public health activities within its ju- Does the NHA: risdiction to ensure the adherence to clearly written guide- 6.1.2.1 Include draft legislation in the above re- lines. view? • Coordinates with other sectors to oversee activities that have 6.1.2.2 Consider whether the legislation is consis- impact on public health. tent with current scientific knowledge in • Monitors oversight activities and procedures that correct public health? abuses of authority or the failure to exercise authority if 6.1.2.3 Consider the positive and negative impact pressured by influential groups. of these laws and regulations? • Adopts a regulatory stance not only centered on education 6.1.2.4 Complete the review in a timely manner? about public health law and the prevention of infractions, 6.1.2.5 Conduct this review periodically? but also on the punishment of violators after the fact. 6.1.2.6 Involve other regulatory mechanisms in the • Promotes the compliance of health regulations through ed- above review? ucating and informing consumers and integrating enforce- ment activities at all levels of the health system. 6.1.3 The NHA seeks input for the evaluation of health laws • Implements a clear policy formulated to prevent corruption and regulations. as a practice that can permeate enforcement and ensures its periodic monitoring by independent entities to correct ir- Is this input sought from: regularities. 6.1.3.1 Key lawmakers who support the develop- ment of public health? 6.2.1 The NHA has systematic processes in place to enforce 6.1.3.2 Legal advisors? the existing laws and regulations. 6.1.3.3 Other government agencies? 6.1.3.4 Civil society? Does the NHA: 6.1.3.5 Representatives of community organiza- 6.2.1.1 Have clear, written guidelines that support tions? enforcement in public health? 6.1.3.6 Users’ associations, interest groups, and 6.2.1.2 Identify the personnel responsible for en- other associations? forcement procedures? 6.2.1.3 Supervise the enforcement procedures that 6.1.3.7 Individuals and organizations directly af- are utilized? fected by these laws and regulations? 6.1.3.8 Interested international organizations? If so, does the NHA: 6.2.1.3.1 Seek to identify the abuse or 6.1.4 The NHA spearheads initiatives to amend laws and misuse of its enforcement au- regulations based on the results of the evaluation. thority?

340 6.2.1.3.2 Monitor compliance with the If so, enforcement guidelines? 6.2.3.4.1 Is the existence of these penalty mechanisms made known to 6.2.1.4 Does the NHA act in a timely manner to NHA personnel at all levels? correct the abuse or misuse of its authority? 6.2.1.5 Does the NHA have an incentive system in 6.3 Knowledge, Skills, and Mechanisms place for enforcement personnel to help en- for Reviewing, Improving and Enforcing sure that they exercise their authority in an Regulations appropriate manner? 6.2.1.6 Does the NHA monitor the timeliness and Standard efficiency of its enforcement procedures? The NHA:

6.2.2 The NHA educates society about public health regu- • Has a competent team of advisors who have thorough lations and encourages compliance knowledge (both national and international) of regulatory procedures that govern the adoption, amendment, and re- Does the NHA: scinding of public health laws. 6.2.2.1 Widely inform the public about the impor- • Ensures that mechanisms and resources are available to en- tance of compliance with health laws and force laws. regulations and the applicable procedures • Periodically evaluates national knowledge and competen- for doing so? cies, as well as oversight and enforcement capacities in re- 6.2.2.2 Have established procedures that inform gards to public health laws and regulations. those individuals and organizations affected by health laws and regulations? 6.3.1 The NHA has the institutional capacity to exercise its 6.2.2.3 Have an incentive system to foster compli- regulatory and enforcement functions. ance with laws and regulations? Does the NHA: If so, 6.3.1.1 Have a competent team of advisors to de- 6.2.2.3.1 Does this incentive system in- velop the regulatory framework and draft clude recognition and certifica- regulations? tion of quality and certification 6.3.1.2 Have the knowledge, skills and resources to with respect to compliance with exercise the regulatory function in public laws and regulations? health? If so, does the NHA: 6.2.3 The NHA develops and implements policies and plans 6.3.1.2.1 Have sufficient human re- for preventing corruption in the public health system. sources to exercise the regula- Are these policies and plans: tory function? 6.2.3.1 Periodically evaluated by independent enti- 6.3.1.2.2 Have the institutional resources to draft the regulations? ties and adjusted when needed in accor- 6.3.1.2.3 Have adequate financial re- dance with the results of the evaluation? sources to exercise its regulatory 6.2.3.2 Consistent with national priorities on the and enforcement functions? subject of corruption? 6.2.3.3 Considering measures needed to prevent 6.3.2 The NHA has procedures and resources to enforce the the influence of external pressure groups on regulations. the NHA? 6.2.3.4 Capable of responding to corruption in the Does the NHA: public health system by utilizing a penalty 6.3.2.1 Have an entity that exercises its enforce- mechanism? ment function?

341 6.3.2.2 Have sufficient human resources for en- 6.4 Support and Technical Assistance to the forcement? Subnational Levels of Public Health in 6.3.2.3 Have sufficient institutional resources to Developing and Enforcing Laws and Regulations enforce regulations? 6.3.2.4 Have financial resources to carry out Standard: enforcement? The NHA: 6.3.2.5 Provide orientation to enforcement person- • Orientate and supports the subnational levels in how to best nel with regard to procedures they should comply with current laws and regulations within their juris- follow? diction. • Prepares protocols, answers questions and provides techni- If so, cal assistance and training to the subnational levels in best 6.3.2.5.1 Is orientation on the regulatory practices for enforcement procedures. framework provided? • Assists the subnational levels in difficult and complex en- 6.3.2.5.2 Does this orientation include forcement activities. setting priorities for enforce- • Periodically evaluates the technical assistance and support it ment in specific situations? provides to the subnational levels in regulation and enforce- ment. • Introduces improvements based on the results of the above 6.3.3 The NHA ensures the availability of training courses evaluations. for enforcement personnel.

Does the NHA: 6.4.1 The NHA provides assistance to the subnational levels 6.3.3.1 Train/orient new staff on enforcement? for drafting laws and regulations to protect public 6.3.3.2 Ensure the availability of training courses health. on enforcement? Does the NHA: 6.3.3.3 Include in these courses content on best 6.4.1.1 Provide protocols to the subnational levels practices in enforcement? for the decentralized drafting of laws and 6.3.3.4 Ensure that continuing education for en- regulations? forcement personnel is offered on a regular 6.4.1.2 Offer advisory services to the subnational basis? levels on the drafting of laws and regula- 6.3.3.5 Help its enforcement personnel develop in- tions? terpersonal communication and personal 6.4.1.3 Provide training to the subnational levels in safety skills (e.g., handling difficult situa- decentralized regulation? tions and people)? 6.4.1.4 Offer technical assistance to specialized per- sonnel at the subnational levels for the drafting of complex laws and regulations? 6.3.4 The NHA evaluates its capacity and expertise for drafting laws and regulations in public health. 6.4.2 The NHA offers orientation and support to the sub- 6.3.4.1 Has the NHA made progress toward im- national levels to enforce the public health laws and proving its capacity for reviewing and draft- regulations in their jurisdiction. ing laws and regulations based on the find- Does the NHA: ings of the most recent evaluation? 6.4.2.1 Furnish protocols to the subnational levels 6.3.4.2 Can you cite an example of such improve- that describe best practices in enforcement? ment in capacity for reviewing and drafting 6.4.2.2 Advise the subnational levels on imple- laws and regulations? menting enforcement procedures?

342 6.4.2.3 Assist the subnational levels with training in • Conducts the evaluation in collaboration with subnational enforcement procedures? levels for the delivery of clinical care at all points entry to 6.4.2.4 Assist specialized personnel at the subna- the health system. tional levels who handle complex enforce- • Determines the causes and effects of barriers to access, gath- ment activities? ering information on the individuals affected by these bar- 6.4.2.5 Periodically evaluate the technical assistance riers and identifies best practices to reduce those barriers it provides to the subnational levels on the and increase equity of access to necessary health services. enforcement of public health laws and reg- • Uses the results of this evaluation to promote equitable ac- ulations? cess to necessary health services for the population of the If so, country. 6.4.2.5.1 Does it use the findings of these • Collaborates with other agencies to ensure the monitoring evaluations to improve the qual- of access to necessary health services by vulnerable or un- ity of its technical assistance? derserved population groups.

EPHF 7: Evaluation and Promotion 7.1.1 The NHA conducts a national evaluation of access to of Equitable Access to Necessary necessary population-based health services. Health Services 7.1.1.1 Do indicators exist to evaluate access? 7.1.1.2 Is the national evaluation based on a prede- Definition: fined package of population-based services This function includes: accessible to the population? • The promotion of equity of access by civil society to neces- 7.1.1.3 Is information available from the subna- sary health services. tional levels to implement the national eval- • Actions designed to overcome barriers when accessing pub- uation? lic health interventions and help link vulnerable groups to 7.1.1.4 Is the national evaluation conducted in col- necessary health services (does not include the financing of laboration with the subnational levels? health care). If so, • The monitoring and evaluation of access to necessary health 7.1.1.4.1 Is the national evaluation con- services offered by public and/or private providers and using ducted in collaboration with the a multisectoral, multiethnic and multicultural approach to facilitate working with diverse agencies and institutions to intermediate levels? reduce inequities in access to necessary health services. 7.1.1.4.2 Is the national evaluation con- • Close collaboration with governmental and nongovernmen- ducted in collaboration with the tal agencies to promote equity able access to necessary local levels? health services. 7.1.1.4.3 Is the national evaluation con- ducted in collaboration with Indicators: other governmental entities? 7.1.1.4.4 Is the national evaluation con- 7.1 Monitoring and Evaluation of Access ducted in collaboration with to Necessary Health Services other nongovernmental enti- ties? Standard: 7.1.1.5 Is the national evaluation conducted at least The NHA: every two years? • Monitors and evaluates access to the personal and popula- tion-based health services delivered to the population of the 7.1.2 The NHA conducts a national evaluation of access jurisdiction at least once every two years. to personal health services.

343 7.1.2.1 Is the national evaluation based on the def- 7.1.3.8 Residence? inition of a predefined package of personal 7.1.3.9 Transportation? health services accessible to the population? 7.1.3.10 Level of education? 7.1.2.2 Does the national evaluation examine prob- 7.1.3.11 Income? lems related to cost of services and the pay- 7.1.3.12 Insurance coverage? ment systems for these services? 7.1.3.13 Nationality? 7.1.2.3 Does the national evaluation examine the 7.1.3.14 Sexual orientation? coverage of personal health services by pub- 7.1.3.15 Physical disability? lic and private entities, insurance compa- 7.1.3.16 Mental disability? nies and other payers? 7.1.3.17 Type of disease? 7.1.2.4 Does the national evaluation examine 7.1.3.18 Does the evaluation utilize methodologies access by distance to the nearest health capable of detecting disparities (e.g. ade- facility? quate disaggregation of data, sampling and 7.1.2.5 Is the national evaluation conducted at least surveys) aimed at population groups that every two years? the NHA wishes to target? 7.1.2.6 Is the national evaluation conducted in col- 7.1.3.19 Does the evaluation identify best practices laboration with the intermediate levels? to reduce the barriers and enhance the eq- 7.1.2.7 Is the national evaluation conducted in col- uity of access to necessary health services? laboration with the local levels? If so, 7.1.2.8 Is the national evaluation conducted in col- 7.1.3.19.1 Does the NHA disseminate in- laboration with the personal health services formation on best practices to delivery system? all levels and recommend their 7.1.2.9 Is the national evaluation conducted in col- use within the health services laboration with other governmental entities? delivery systems? 7.1.2.10 Is the national evaluation conducted in col- laboration with other nongovernmental 7.1.4 The NHA uses the results of the evaluation to pro- entities? mote equity in access to essential health services. 7.1.2.11 Is the national evaluation conducted in col- laboration with social security health agen- 7.1.4.1 Does the national evaluation include input cies to ensure the monitoring of access to from those affected by the barriers to ac- personal health services by vulnerable or cess? underserved10 populations? 7.1.4.2 Does the NHA use the national evaluation to define conditions for accessing the neces- 7.1.3 The NHA investigates and lifts barriers to access in the sary health services? health services. 7.1.4.3 Does the NHA apply regulations that en- sure these conditions for access to necessary Has it identified barriers related to: health services by the population? 7.1.3.1 Age? 7.1.3.2 Gender? 7.2 Knowledge, Skills and Mechanisms to 7.1.3.3 Ethnicity? Improve Access to Necessary Health Services 7.1.3.4 Culture and beliefs? by the Population 7.1.3.5 Religion? 7.1.3.6 Language? Standard: 7.1.3.7 Literacy? The NHA:

10 This refers to situations in which people are assured health ser- • Works with subnational levels to communicate information vices coverage but nevertheless encounter barriers to receiving the to the population on personal and population-based health health care they need. services, including their rights to health.

344 • Encourages and supports initiatives to introduce innovative nity greater access to personal and population-based and proven methods of health services delivery (such as mo- health services. bile care units, health fairs, health care campaigns and op- 7.2.3.1 Does the NHA improve its capacity to de- erations, and/or telemedicine) that improve access to neces- liver necessary health services based on the sary health services. results of this evaluation? • Periodically evaluates its capacity to facilitate access to nec- If so, does the NHA have personnel trained essary health services by the population and makes im- to evaluate this capacity: provements based on the results. 7.2.3.1.1 At the national level? 7.2.3.1.2 At the intermediate levels? 7.2.1 The NHA has specialized personnel in community 7.2.3.1.3 At the local levels? outreach programs to increase the use of the health services. 7.3. Advocacy and Action to Improve Access Does it have personnel devoted to: to Necessary Health Services 7.2.1.1 Identifying and tracking service utilization patterns? Standard: 7.2.1.2 Identifying problem cases in terms of barri- The NHA: ers to access to necessary health services? • Delivers information to decisionmakers, key actors and the If so, does this personnel identify these general public about specific barriers that impede access to problem cases necessary health services. 7.2.1.2.1 At the national level? • Collaborates and forms partnerships with the other key ac- 7.2.1.2.2 At the intermediate levels? tors within the health service delivery system, implementing 7.2.1.2.3 At the local levels? programs that promote access to necessary health services. • Advocates the adoption of laws and regulations that in- 7.2.2 The NHA has personnel capable of informing the creases access by those most in need of necessary health public about access to the health services. services. Does this personnel have competencies in: • Collaborates with universities and other training institu- 7.2.2.1 Reducing linguistic and cultural barriers? tions to orientate human resource development, focusing 7.2.2.2 Targeting activities to vulnerable or under- on the knowledge and skills needed to improve access to served populations? necessary health services. 7.2.2.3 Informing providers about prevention pro- • Utilizes evidence-based information on public health to grams? develop policies that improve access to necessary health 7.2.2.4 Bringing services to high-risk populations? services. 7.2.2.5 Developing national early detection pro- • Identifies gaps in the distribution of human resources avail- grams? able to underserved populations and develops remedial 7.2.2.6 Helping vulnerable or underserved popula- strategies. tions obtain necessary health services? 7.2.2.7 Introducing innovative methods of service 7.3.1 The NHA engages in advocacy with other actors to delivery that promote access to necessary improve access to necessary health services. health services (e.g., mobile clinics, health Does the NHA: fairs, etc.)? 7.3.1.1 Inform key decisionmakers, representatives 7.2.2.8 Collaborating with social security agencies and the general public about barriers that to ensure the monitoring of vulnerable or impede access to necessary health services? underserved populations? 7.3.1.2 Advocates the adoption of policies, laws or regulations that increase access to necessary 7.2.3 The NHA periodically evaluates its expertise and ca- health services by vulnerable and under- pacity to provide mechanisms that offer the commu- served populations?

345 7.3.1.3 Establish and maintain formal relationships 7.3.2.8 Is there a system in place at the subnational with other actors capable of addressing the level that assists communities in developing problems of access to necessary health links to promote equitable access to the services? necessary health services? 7.3.1.4 Collaborate with universities and other training institutions in an effort to increase 7.4 Support and Technical Assistance to the the availability of human resources in nec- Subnational Levels of Public Health to Promote essary health service delivery? Equitable Access to Necessary Health Services 7.3.1.5 Recruit public health workers from all lev- els to enroll in continuing education pro- Standard: grams that promote equitable access to nec- The NHA: essary health services by the population? • Assists the subnational levels with identifying access needs of vulnerable and underserved populations matching needs 7.3.2 The NHA takes direct action to improve access to nec- to availability of health services. essary health services. • Supports the subnational levels in creating and disseminat- ing public service announcements to inform the population Does the NHA: about the availability of necessary health services. 7.3.2.1 Coordinate national programs aimed at re- • Assists the subnational levels in establishing innovative part- solving problems in access to necessary nerships and coordinating with service providers to pro- health services? mote access to necessary health services. 7.3.2.2 Identify those areas that lack human re- • Supports the subnational levels in collaborating and coordi- sources and work towards correcting this nating with complementary programs designed to attract deficiency? vulnerable or underserved populations to necessary health 7.3.2.3 Identify gaps in the human resources services. needed to deliver necessary health services to vulnerable or underserved populations? 7.4.1 The NHA assists the subnational levels in promoting 7.3.2.4 Identify strategies to fill gaps in the distri- equitable access to necessary health services. bution of these human resources? Does the NHA assist the subnational levels in: 7.3.2.5 Identify successful interventions that can 7.4.1.1 Defining a basic package of personal and increase access to necessary health services? population-based health services that If so, does the NHA should be available to the population? 7.3.2.5.1 Use this information on suc- If so, does the NHA assist the subnational cessful interventions to make levels in: informed policy decisions in 7.4.1.1.1 Coordinating the roles and re- this area? sponsibilities of service pro- 7.3.2.6 Evaluate the effectiveness of interventions viders in the delivery of this ba- aimed at improving access to necessary sic package of necessary health health services? services? 7.3.2.7 Create incentives that encourage service 7.4.1.1.2 Creating and disseminating public service announcements providers to reduce disparities in equity of that inform the population, par- access to necessary health services? ticularly vulnerable or under- If so, do these incentives target:: served populations, about the 7.3.2.7.1 Population-based health services? availability of this basic package 7.3.2.7.2 Personal health services? of necessary health services?

346 7.4.1.2 Identifying gaps at the subnational levels in • Maintains an up-to-date inventory of filled and vacant equity of access to necessary health services? posts at all levels of the public health system, both govern- 7.4.1.3 Identifying barriers that impede access to mental and nongovernmental, as well as estimates of the necessary health services? number of volunteer workers who provide services at each 7.4.1.4 Developing strategies to reduce such level. barriers? • Completes an evaluation at least once every two years of the 7.4.1.5 Coordinating with complementary pro- number, type, geographical distribution, wage structure, grams that promote community outreach minimum education requirements, licensing, recruitment activities and equitable access to necessary and retention of specialized public health personnel. health services? • Projects future health manpower needs in terms of quantity and quality. EPHF 8: Human Resource Development and Training in Public Health 8.1.1 The NHA identifies current needs with respect to public health workers. Definition: This function includes: 8.1.1.1 Does the NHA have information on the number of workers needed to discharge es- • The development of a public health workforce profile in sential public health functions and deliver public health that is adequate for the performance of public public health services: health functions and services. • Educating, training, developing and evaluating the public If so, does this information exist: health workforce to identify the needs of public health ser- 8.1.1.1.1 At the national level? vices and health care to efficiently address priority public 8.1.1.1.2 At the intermediate level? health problems and adequately evaluate public health 8.1.1.1.3 At the local level? activities. 8.1.1.2 Does the NHA maintain a profile of work- • The definition of licensure requirements for health profes- ers needed to discharge essential public sionals in general and the adoption of ongoing programs health functions and deliver public health that improve the quality of public health services. services: • Formation of active partnerships with professional develop- ment programs to ensure that all students have relevant If so, does the profile exist: public health experience and continuing education in the 8.1.1.2.1 At the national level? management of human resources and leadership develop- 8.1.1.2.2 At the intermediate level? ment in public health. 8.1.1.2.3 At the local level? • The development of skills necessary for interdisciplinary, 8.1.1.3 Does the NHA define competencies re- multicultural work in public health. quired to discharge the essential public • Bioethics training for public health personnel, emphasizing health functions and deliver public health the principles and values of solidarity, equity, and respect for services: human dignity. If so, are these competencies defined for: Indicators: 8.1.1.3.1 The national level? 8.1.1.3.2 The intermediate level? 8.1 Description of the Public Health 8.1.1.3.3 The local level? Workforce Profile 8.1.2 The NHA identifies gaps in the composition and Standard: availability of the public health workforce that must be The NHA: filled.

347 8.1.2.1 Does the NHA establish criteria for defin- 8.1.4.2 Mechanisms for filling vacancies based on ing the future needs of the public health priorities? workforce? 8.1.4.3 An in-depth analysis of filled and vacant 8.1.2.2 Are current needs for a public health work- posts? force compared with future needs? 8.1.4.4 Information from the national and subna- 8.1.2.3 Does the NHA establish criteria to mini- tional levels? mize existing gaps in the public health 8.1.4.5 An estimate of volunteer workers within the workforce? public health system? 8.1.4.6 Identification of areas for potential growth? 8.1.3 The NHA periodically evaluates the profile of the country’s public health workforce. 8.1.5 The NHA’s evaluation of the quantity and quality of the workforce takes advantage of input from other Does the NHA: institutions. 8.1.3.1 Have access to data on the wage structure and other pecuniary benefits? Does this input come from: 8.1.3.2 Have access to data on the geographical dis- 8.1.5.1 Other government agencies? tribution of the public health workforce? 8.1.5.2 Subnational levels? 8.1.3.3 Have access to data on the distribution of 8.1.5.3 Academic institutions? the public health workforce categorized 8.1.5.4 Leaders and experts in public health? according to type of employment (non- 8.1.5.5 Nongovernmental organizations? governmental, private, public)? 8.1.5.6 Professional associations? 8.1.3.4 Have access to data on the educational pro- 8.1.5.7 Civil society? file required for specific posts? 8.1.5.8 International agencies? 8.1.3.5 Have access to data on the competencies re- 8.1.5.9 The Ministry of Education? quired for specific posts? 8.1.5.10 The Ministry of Labor? If so, 8.1.3.5.1 Does the NHA evaluate existing 8.2 Improving the Quality of the Workforce competencies to ensure that the existing workforce is capable of Standard: performing transcultural tasks? The NHA: If so, • Ensures that public health workers and managers meet the 8.1.3.5.1.1 Does the NHA de- educational level and certification required by law in accor- velop strategies to achieve a dance with pre-established criteria. workforce competent to work • Coordinates training programs and collaborates with edu- with communities of diverse cational institutions devoted to public health training, rec- cultures and languages? ommending a basic public health curriculum for the train- ing programs offered at the various levels of public health. 8.1.3.6 Does the NHA have a management infor- • Periodically assesses teaching programs, performance evalu- mation system capable of monitoring the ation systems and continuing education courses to ensure above data? that they contribute to developing human resources for public health. 8.1.4 The NHA uses a pre-existing profile to maintain an • Offers incentives and implements plans that improve the up-to-date inventory of the posts needed to discharge quality of the country’s public health workforce. public health functions and deliver services. • Actively searches for qualified workers to exercise leader- Does this inventory include: ship, recruiting and offering incentives for them to remain 8.1.4.1 A preexisting profile of posts? with the organization.

348 • Encourages leaders in public health to create effective part- If so, nerships for action in all areas of public health and fosters 8.2.1.9.1 Does the NHA periodically eval- the political and environmental conditions necessary to ac- uate these plans? complish this.

8.2.2 The NHA has strategies to strengthen leadership in 8.2.1 The NHA has strategies in place to improve the qual- public health. ity of the workforce. Does the NHA: Does the NHA: 8.2.2.1 Provide opportunities for leadership devel- 8.2.1.1 Follow guidelines or norms to accredit and certify educational credentials in hiring of opment in the public health workforce? public health workers? 8.2.2.2 Actively identify potential leaders in the public health workforce? If so, 8.2.1.1.1 Does the NHA evaluate com- If so, does the NHA: pliance with these criteria 8.2.2.2.1 Encourage the retention of the throughout the country? leaders identified? 8.2.1.2 Have policies in place that ensure the 8.2.2.2.2 Offer incentives to improve lead- adequate training of public health workers ership capacity? allowing them to exercise their responsibili- 8.2.2.3 Have mechanisms in place that identify and ties? 8.2.1.3 Collaborate and coordinate with academic recruit potential leaders? institutions and scientific professional asso- 8.2.2.4 Establish agreements with academic institu- ciations to develop a basic public health tions and other organizations devoted to curriculum? developing leadership in public health? 8.2.1.4 Encourage participation by the public 8.2.2.5 Have strategies and mechanisms in place to health workforce in continuing education link decision-making with ethical princi- activities to improve the quality of the ples and social values in the context of pub- workforce? lic health leadership? 8.2.1.5 Offer or coordinate training for public health workers needing more experience? 8.2.3 The NHA has a system to evaluate the performance of 8.2.1.6 Have evaluation activities, at least every public health workers. three years, that permit an evaluation of the effectiveness of its recruitment policies, the Does this system of performance evaluation: quality of its hiring process and its capacity 8.2.3.1 Indicate the performance expectations for to retain public health workers? each worker over a given period? 8.2.1.7 Have strategies that motivate its personnel 8.2.3.2 Define measurable work outcomes for each in their respective career paths? 8.2.1.8 Prepare and implement plans for educating staff member? public health workers in bioethics, with 8.2.3.3 Communicate to public health workers emphasis on principles and values such as performance expectations over a given solidarity, equity and respect for human period? dignity? 8.2.3.4 Analyze its results and propose improve- 8.2.1.9 Prepare and implement plans to improve ments to it? the quality of the country’s public health 8.2.3.5 Utilize the results of the evaluation to better workforce? assign responsibilities and retain workers?

349 8.3 Continuing Education and Graduate 8.4 Improving Workforce to Ensure Culturally- Training in Public Health Appropriate Delivery of Services

Standard: Standard: The NHA: The NHA: • Establishes formal ties with academic institutions having • Trains health workers in the delivery of high quality, cultur- graduate programs in public health to facilitate access by the ally-appropriate services to diverse user populations. public health workforce to continuing education. • Makes an effort to form public health teams that include • Evaluates and encourages academic institutions to adapt workers from the ethnic and cultural groups served. their programs and teaching strategies to meet the needs of • Makes an effort to reduce social and cultural barriers by the essential public health functions and future challenges. population in accessing user-oriented health services by the • Shares the results of the evaluation of its continuing educa- population (e.g., health center admitting offices staffed by tion and graduate training programs and obtains feedback multilingual personnel trained as intercultural facilitators). from public health workers on this issue. • Continuously evaluates the ethnic and cultural diversity of public health workers and takes the necessary steps to elim- 8.3.1 The NHA provides orientation and promotes contin- inate ethnic and cultural barriers. uing education and graduate training in public health. 8.4.1 The NHA adapts its human resources to deliver ser- Does the NHA: vices suited to the different characteristics of its users. 8.3.1.1 Facilitate formal agreements that permit ac- cess to continuing education, with aca- Does the NHA: demic institutions having public health 8.4.1.1 Factor in gender issues into its workforce programs? training programs? 8.3.1.2 Encourage academic institutions to offer 8.4.1.2 Train its workforce to deliver services to programs in public health that meet the culturally-diverse populations? needs of the public health workforce? 8.4.1.3 Utilize the concept of delivering culturally- 8.3.1.3 Annually survey public health workers who appropriate services to the community have participated in continuing education when planning and implementing public health activities? activities? 8.3.1.4 Survey institutions that employ these work- If so, does the NHA utilize these practices: ers on the knowledge and skills acquired 8.4.1.3.1 At the national level? through continuing education and graduate 8.4.1.3.2 At the intermediate levels? training activities? 8.4.1.3.3 At the local levels? 8.4.1.3.4 Can you cite an example of the If so, use of culturally-appropriate 8.3.1.4.1 Does the NHA share the results service delivery at any level? of these surveys with the aca- demic institutions to encourage 8.4.1.4 Does the NHA identify barriers to attain- quality improvement of the aca- ing the desired diversity in its public health demic programs offered to pub- workforce to make it consistent with the lic health workers? characteristics of the population being served? 8.3.1.5 Have strategies and mechanisms in place to ensure the retention of public health work- If so, does the NHA: ers who have been trained and their reinte- 8.4.1.4.1 Try to eliminate these barriers gration into the workforce commensurate preventing the desired diversity with their acquired skills? in its public health workforce?

350 8.4.1.5 Does the NHA have policies in place that If so, does the NHA support those pro- ensure the recruitment of culturally-appro- grams at: priate public health workers? 8.5.1.2.1 The intermediate level? If so, are these policies applied: 8.5.1.2.2 The local level? 8.1.4.5.1 At the national level? 8.5.1.3 Have strategies in place that ensure the 8.1.4.5.2 At the intermediate level? presence of continuing education programs 8.1.4.5.3 At the local level? at the subnational levels? 8.4.1.6 Does the NHA try to eliminate cultural If so, are they: barriers by employing public health work- 8.5.1.3.1 At the intermediate level? ers capable of improving access to public health services by the country’s social and 8.5.1.3.2 The local level? cultural groups (e.g., utilizing intercultural 8.5.1.4 Facilitate agreements between the sub- facilitators or bilingual staff)? national levels and academic institutions that ensure continuing education for the 8.5 Technical Assistance and Support public health workforce at the subnational to the Subnational Levels in Human level? Resources Development 8.5.1.5 Develop capacity at the subnational level to Standard: support decentralized planning and work- The NHA: force management? • Collaborates with the subnational levels in conducting a comprehensive inventory and evaluation of human EPHF 9: Ensuring the Quality resources. of Personal and Population-based • Offers guidelines to the subnational levels on ways to reduce gaps in the quality of public health workforce. Health Services • Ensures the availability of continuing education programs for public health workers at all levels, including training in Definition: the management of diversity and the improvement of lead- This function includes: ership skills. • Facilitates linkages between public health workers at all lev- • The promotion of systems that evaluate and improve els with national and international academic institutions to quality. ensure access to varied and up-to-date continuing education • The development of standards for quality assurance, quality courses. improvement and oversight of compliance of service providers. 8.5.1 The NHA assists the subnational levels in developing • The definition, explanation and assurance of user rights. their human resources. • A system for health technology assessment that supports the Does the NHA: decision-making process at all levels and contributes to 8.5.1.1 Offer the necessary guidance to the subna- quality improvement. tional levels to reduce gaps identified in the • Using evidence-based methodology to evaluate health inter- national public health workforce evalua- ventions. tion? • Systems to evaluate user satisfaction and application of its 8.5.1.2 Support the development of culturally- and results to improve the quality of health services. linguistically-appropriate programs and workforce training at the subnational levels? Indicators:

351 9.1 Definition of Standards and Evaluation 9.1.2.2 Actively seek input from the subnational of Quality of Population-based and Personal levels in developing these standards? Health Services 9.1.2.3 Actively seek input from nongovernmental organizations in developing these stan- Standard: dards? The NHA: 9.1.2.4 Have instruments that measure the per- formance of population-based health ser- • Establishes appropriate standards that permit the evaluation vices against the defined standards? of quality of population-based and personal health services using data from all levels of the health system. If so, do these instruments: • Uses these standards and scientifically-proven instruments 9.1.2.4.1 Measure processes? to measure the quality of personal and population-based 9.1.2.4.2 Measure results? public health services. 9.1.2.4.3 Identify the performance goals • Adopts results-oriented analytical methods that include sci- for quality improvement? entific identification of the parameters to be evaluated, the 9.1.2.4.4 Identify procedures for data col- data to be collected and the procedures to follow in the col- lection? lection and analysis of those data. 9.1.2.4.5 Identify procedures for data • Has access to an autonomous entity that accredits and eval- analysis? uates quality and is independent of health services. 9.1.2.5 Disseminate the results of the quality evalu- ation to the providers of population-based 9.1.1 The NHA has a policy that promotes continuous services? quality improvement in the health services. 9.1.2.6 Disseminate the results of the quality eval- Does this policy include: uation to the users of population-based 9.1.1.1 A comparison of national performance services? goals with standards for population-based 9.1.2.7 Have an autonomous entity that accredits and personal health services? and evaluates quality independently of 9.1.1.2 The use of varied methodologies to im- providers of population-based health prove quality? services? 9.1.1.3 Quality improvement processes in all NHA 9.1.3 The NHA sets standards and periodically evaluates the divisions or departments? quality of personal health services throughout the 9.1.1.4 Measurement of the degree to which de- country. fined goals and objectives have been met? 9.1.1.5 Activities that evaluate staff attitudes to- To evaluate quality, does the NHA: ward user satisfaction? 9.1.3.1 Have the authority to accredit and oversee 9.1.1.6 Activities to develop policies and proce- the quality of personal health services? dures on quality improvement of popula- 9.1.3.2 Promote the definition of standards that tion-based and personal health services? evaluate the quality of personal health ser- 9.1.1.7 Measurement of user satisfaction? vices throughout the country? 9.1.3.3 Actively seek support from the subnational 9.1.2 The NHA sets standards and periodically evaluates the levels to set these standards? quality of population-based health services (public 9.1.3.4 Actively seek input from nongovernmental health practice) throughout the country. organizations to set these standards? 9.1.3.5 Have instruments that measure the per- To evaluate quality, does the NHA: formance of personal health services against 9.1.2.1 Promote the definition of standards that the defined standards? evaluate the quality of population-based health services throughout the country? If so, do these instruments:

352 9.1.3.5.1 Measure processes? 9.2.1.7 Log of comments, complaints and sugges- 9.1.3.5.2 Measure results? tions? 9.1.3.5.3 Identify the performance goals Are the results of the evaluation: for quality improvement? 9.2.1.8 Used for continuous quality improvement 9.1.3.5.4 Identify procedures for data of health services? collection? 9.2.1.9 Used to improve the performance of health 9.1.3.5.5 Identify procedures for data analysis? workers? 9.1.3.6 Disseminate the results of the qual- 9.2.1.10 Communicated to civil society along with ity improvement evaluation to the any resulting policy changes? providers and users of personal health services? 9.2.2 The NHA regularly evaluates user satisfaction with 9.1.3.7 Have an autonomous entity that ac- population-based health services. credits and evaluates quality indepen- Does this evaluation include: dently of personal health services 9.2.2.1 Collaboration with decisionmakers11 in- providers? volved in these population-based services? 9.2.2.2 Input from decisionmakers on those factors 9.2 Improving User Satisfaction to be evaluated? with Health Services 9.2.2.3 Collaboration with members of civil society affected by these population-based services? Standard: 9.2.2.4 Input from members of civil society on the The NHA: factors to be evaluated? • Commits to the ongoing measurement and improvement 9.2.2.5 Formal mechanisms for users to provide of user satisfaction resulting from continuous quality input to the NHA in a timely and confi- improvement. dential manner? • Focuses on the user in orientating activities to improve staff Does the NHA: performance and develop policies and procedures to ac- 9.2.2.6 Use the results of the evaluations to develop complish this improvement at all levels. plans for improving the quality of programs • Clearly defines the rights and responsibilities of users of and service delivery? health services as well as disseminates this information. 9.2.2.7 Use the results of the evaluation to develop • Periodically evaluates improvements in user satisfaction plans that improve access to population- with health services and acts on the results to improve qual- ity of services. based services? • Provides feedback on user satisfaction with health services 9.2.2.8 Communicate the results of this evaluation to the subnational levels, users and other key actors. to all participants involved in the evaluation process? 9.2.1 The NHA actively encourages community participa- 9.2.2.9 Publish a report summarizing the main re- tion to evaluate public satisfaction with health services sults of the user satisfaction evaluation? in general. If so, Is input for this evaluation obtained from: 9.2.2.9.1 Is this report widely distributed? 9.2.1.1 Local/community organizations? 9.2.1.2 Community surveys? 9.2.3 The NHA evaluates the degree of user satisfaction with 9.2.1.3 Focus groups? the personal health services available in the country. 9.2.1.4 The Internet? 9.2.1.5 Surveys of users of health services? 11 This involves a broad spectrum that includes providers, in- 9.2.1.6 Surveys of users at point of service? dustry affected by specific regulations, etc.

353 Does this evaluation include: • Periodically evaluates and improves national and subna- 9.2.3.1 Collaboration with decisionmakers in- tional skills and knowledge with regard to the adoption, uti- volved in personal health services? lization and assessment of technologies. 9.2.3.2 Input from decisionmakers on the factors to be evaluated? 9.3.1 The NHA develops and promotes health technology 9.2.3.3 Collaboration with members of civil society management systems. affected by personal health services? 9.3.1.1 Has the NHA set up one or more entities 9.2.3.4 Input from members of civil society on the for technology management and health factors to be evaluated? technology assessment as part of an inte- 9.2.3.5 Formal mechanisms for users to provide grated network? input to the NHA in a timely and confi- If so, do these entities: dential fashion? 9.3.1.1.1. Provide information for deci- Does the NHA: sion-making processes that lead 9.2.3.6 Use the evaluation results to develop plans to the formulation of health to improve the quality of programs and policies? service delivery? 9.3.1.2 Does the NHA use the above information 9.2.3.7 Use the evaluation results to develop plans to formulate better recommendations on to improve access to personal health available technology to the providers and services? users of health services? 9.2.3.8 Communicate the results of this evaluation to all participants involved in the evaluation 9.3.2 The NHA ensures the proper functioning of its system process? for technology management and health technology 9.2.3.9 Publish a report summarizing the main re- assessment. sults of the user satisfaction evaluation? Does the NHA: If so, 9.3.2.1 Define the roles of key individuals respon- 9.2.3.9.1 Is this report widely distributed? sible for the operations of the technology management and health technology assess- 9.3 Systems for Technology Management and ment systems? Health Technology Assessment that Support 9.3.2.2 Define the responsibilities and tasks of the Decision-making in Public Health above key individuals? 9.3.2.3 Establish channels of communication for Standard: the above key individuals? The NHA: If so, • Establishes technology management and health technology 9.3.2.3.1 Does the NHA use these chan- assessment systems that function as part of an integrated nels of communication to also network. obtain information from the • Uses evidence available on safety, effectiveness and cost- subnational levels? effectiveness of health interventions in order to recommend the adoption and use of health technologies. 9.3.3 The NHA utilizes the methodologies available for sys- tematic technology assessment. • Promotes the use of health technology assessment and evi- dence-based practices at all levels of the health system in- Does this evaluation cover: cluding public and private insurers, service providers and 9.3.3.1 Safety? consumers. 9.3.3.2 Effectiveness?

354 9.3.3.3 Cost-effectiveness? • Provides and trains the subnational levels in the use of tech- 9.3.3.4 Usefulness? nology management and health technology assessment 9.3.3.5 Utility cost (cost utility)? tools, including evidence-based practices, for use in the de- 9.3.3.6 Social acceptance? livery of personal and population-based health services. • Supports the subnational levels in evaluating its technology 9.3.4 The NHA promotes the development of technology management and health technology assessment systems by management and health technology assessment sys- using functional criteria supported by available scientific tems based on the data provided by a national network evidence. of decision-making entities. • Supports the subnational levels in conducting a formal eval- uation of user satisfaction with personal and population- Does this network include: based health services. 9.3.4.1 Public health insurers? 9.3.4.2 Private health insurers? 9.4.1 The NHA provides technical assistance to the subna- 9.3.4.3 Public health providers? tional levels for the collection and analysis of data on 9.3.4.4 Private health providers? the quality of population-based public health services. 9.3.4.5 Users? 9.3.4.6 Academic institutions and training centers? Does this data on quality cover: 9.4.1.1 Organizational structure and capacity to 9.3.4.7 Professional associations? deliver population-based health services at 9.3.4.8 Scientific societies? the subnational levels? 9.4.1.2 Procedures and practices for health services 9.3.5 The NHA regularly evaluates its national capacity delivery at the subnational levels? for technology management and health technology 9.4.1.3 Outcomes of services delivered by health assessment. providers at the subnational levels? Does the NHA: 9.4.1.4 Degree of user satisfaction with population- 9.3.5.1 Issue recommendations to improve this based health services at the subnational capacity? level? 9.3.5.2 Periodically evaluate the capacity at the subnational levels for technology manage- 9.4.2 The NHA provides technical assistance to the subna- ment and health technology assessment? tional levels for the collection and analysis of data on 9.3.5.3 Issue recommendations to improve the ca- the quality of personal health services. pacity at the subnational level levels for Does the data on quality cover: technology management and health tech- 9.4.2.1 Organizational structure and capacity to nology assessment? deliver personal health services at the sub- national levels? 9.4 Technical Assistance and Support to 9.4.2.2 Procedures and practices for health services the Subnational Levels to Ensure Quality delivery at the subnational levels? Improvement in Personal and Population-based 9.4.2.3 Outcomes of services delivered by health Health Services providers at the subnational levels? 9.4.2.4 Degree of user satisfaction with personal Standard: health services at the subnational level? The NHA: 9.4.3 The NHA provides technical assistance at the subna- • Provides assistance to the subnational levels in the collection tional levels on the use of technology management and and analysis of data on quality of health services which in- assessment instruments. cludes data on structure, processes and outcomes of services delivered by health providers. Does the NHA:

355 9.4.3.1 Provide technical assistance to the subna- • Encourages schools of public health, universities and tional levels to measure management per- other independent research centers to study health formance at these levels? problems identified on the public health research agenda. If so, is this assistance for: • Identifies traditional medicine, cultural diversity issues and 9.4.3.1.1 Population-based health ser- alternative medicine as being priorities for research. vices? • Collaborates in implementing the public health research 9.4.3.1.2 Personal health services? agenda, and collects and disseminates information to inter- ested key actors in the health system. 9.4.4 This assistance to the subnational levels covers all areas of health technology assessment.

Does the assistance include health technology assess- 10.1.1 The NHA has developed a public health research ment terms of: agenda. 9.4.4.1 Safety? Does the agenda: 9.4.4.2 Effectiveness? 10.1.1.1 Address the current gaps in knowledge that 9.4.4.3 Cost-effectiveness? impede the NHA from meeting national 9.4.4.4 Usefulness? priorities in health? 9.4.4.5 Utility cost (cost utility)? 10.1.1.2 Take into account the need for evidence- 9.4.4.6 Social acceptance? based information on which to base policy decisions in public health? 10.1.1.3 Address the need for evidence-based infor- EPHF 10: Research in Public Health mation to improve the management of public health services? Definition: 10.1.1.4 Address the need for evidence-based infor- This function includes: mation to ensure feasibility and sustainabil- ity of research on the agenda? • Rigorous research aimed at increasing knowledge to support 10.1.1.5 Identify existing funding sources to con- decision-making at the various levels. duct research on the agenda? • The implementation of innovative solutions in public 10.1.1.6 Include input in setting priorities from key health whose impact can be measured and assessed. actors in public health (in the academic, • Intra- and intersectoral partnerships with research centers nongovernmental, private, and community and academic institutions to conduct timely studies that spheres). support decision-making at all levels of the health system. Does the NHA: Indicators: 10.1.1.7 Collaborate with institutions engaged in public health research to put together an agenda and plan its execution? 10.1 Development of a Public Health 10.1.1.8 Discuss this research agenda with national Research Agenda and international institutions that fund public health research? Standard: 10.1.1.9 Include cultural diversity and a gender ap- The NHA: proach in the public health research • Develops a priority agenda for research in public health agenda? based on needs perceived by the population and key actors 10.1.1.10 Have an entity that develops the public in public, as well as identifies and mobilizes funding sources health research agenda and conducts the re- to permit this research. search included in it?

356 10.1.2 The NHA periodically evaluates progress in terms of 10.2.1.2 Have the ability to conduct independent adherence to the essential public health research research on relevant public health, in the agenda. absence external research groups?

Does the NHA: If so, 10.1.2.1 Communicate the results of this progress 10.2.1.2.1 Is this research interdiscipli- evaluation to all those involved in imple- nary? menting the agenda? 10.2.1.2.2 Does it take gender and cultural 10.1.2.1.1 At the national level? diversity into account? 10.1.2.1.2 At the subnational levels? 10.2.1.3 Has NHA established an approval proce- 10.1.2.2 Promote the dissemination and use of the dure for conducting research in its facilities findings from the research agenda? and on the population? If so, are the findings disseminated and If so, does this procedure include: used: 10.2.1.3.1 A research priority evaluation 10.1.2.2.1 At the national level? from the perspective of national 10.1.2.2.2 At the subnational levels? priorities and avoiding the du- plication of efforts? 10.2 Development of Institutional 10.2.1.3.2 A formal mechanism that ad- Research Capacity heres to internationally ac- cepted norms for monitoring of Standard: ethical aspects of the research? The NHA: 10.2.1.3.3 A formal and transparent mech- anism for funding budgets allo- • Assumes a proactive role in collaborating and coordinating cated to units responsible for with the scientific community working in areas relevant the research? to public health, serving as lead in the interaction with 10.2.1.3.4 A formal and transparent mech- researchers. anism for remunerating re- • Conducts independent research relevant to public health searchers? and has the necessary capacity to prepare timely proposals and research agendas in public health. 10.2.2. The NHA has adequate qualitative and quantitative • Ensures that procedures exist for the approval of all research involving human subjects. analytical tools for conducting research on public • Ensures access to adequate analytical tools, including up-to- health problems. date databases, computer technology and physical infra- Does the NHA: structure. 10.2.2.1 Have research databases that are updated • Has the capacity to procure funding for research activities. with qualitative and quantitative informa- • Is able to show how recent research findings have been used tion relevant to public health research? to improve public health practice. 10.2.2.2 Have statistical software available for ana- lyzing high-volume data12? 10.2.1 The NHA is developing institutional capacity in pub- 10.2.2.3 Have experts available who can utilize the lic health research. above software for analyzing high-volume Does the NHA: data? 10.2.1.1 Have technical teams to interact with 12 This refers to statistical packages used for the management of researchers working on public health population surveys or population databanks; for example, SPSS, priorities? SAS, ARIEL, STATA, etc.

357 10.2.2.4 Have computer support available for ana- 10.3.1.5 Research on health services delivery? lyzing high-volume data? 10.3.1.6 Research on community health? 10.2.2.5 Have capacity for qualitative and quantita- tive data analysis? 10.3.2 The NHA advises the subnational levels on how to 10.2.2.6 Have capacity to communicate research properly interpret research findings. findings to key actors in the health system for use in decision-making? Does the NHA train the subnational levels to: 10.2.2.7 Have regular, internal seminars to present 10.3.2.1 Critically analyze scientific information? and discuss research findings relevant to de- 10.3.2.2 Translate public health research findings cision-making? into practice? 10.2.2.8 Have any public health research projects that have been financed during the past 24 10.3.3 The NHA has a large network of institutions and in- months (the research may be conducted by dividuals who are dedicated to or benefit from public groups external to the NHA)? 10.2.2.9 Can you cite an example, during the past health research findings. 24 months, in which the findings of research conducted or sponsored by the 10.3.3.1 Does the network disseminate research NHA were used to address a relevant health findings to members of the scientific com- problem? munity in public health? Does the network include: 10.3 Technical Assistance and Support to the 10.3.3.1.1 Decisionmakers? Subnational Levels for Research in Public Health 10.3.3.1.2 Schools of public health? 10.3.3.1.3 Subnational levels of the NHA? Standard: 10.3.3.1.4 Medical schools? The NHA: 10.3.3.1.5 Other institutions involved to • Establishes a broad network for the dissemination of re- public health research? search findings at all levels, including innovative and new 10.3.3.1.6 Other extrasectoral actors? public health practices. • Encourages the participation of public health workers from 10.3.3.2 Does the NHA promote the participation the subnational levels in national public health research of public health works from the subnational projects to bolster the subnational capacity for research levels in national research projects? methodology. • Facilitates the human resource development in the field of If so, do these public health workers partic- research, particularly that of operations research. ipate in: 10.3.3.2.1 The design of research projects? 10.3.3.2.2 Data collection? 10.3.1 The NHA advises the subnational levels on operations 10.3.3.2.3 Analysis of the results? research methodologies in public health.

Does this training include: 10.3.3.3 Does the NHA encourage the use of re- 10.3.1.1 Research on outbreaks of epidemics? search findings by the subnational levels to 10.3.1.2 Research on outbreaks of food poisoning? improve public health practice? 10.3.1.3 Research on the risk factors for chronic diseases? If so, 10.3.1.4 Evaluation of the effectiveness of public 10.3.3.3.1 Can you cite an example of such health interventions? a use in the past two years?

358 EPHF 11: Reducing the Impact of 11.1.1 The NHA has an national institutional plan for re- Emergencies and Disasters on Health13 ducing the impact of emergencies and disasters on health. Definition: 11.1.1.1 Is the emergency component of the na- This function includes: tional health sector plan part of the national • Policy development, planning and execution of activities in emergency plan? the prevention, mitigation, preparedness, early response and 11.1.1.2 Does the plan include a national map of rehabilitation programs to reduce the impact of disasters on risks, threats and vulnerability to emergen- public health. cies and disasters? • An integrated approach with respect to the damage and eti- 11.1.1.3 Does the national plan for the health sector ology of any and all emergencies and disasters that can af- include subnational plans? fect the country. 11.1.1.4 Is there a unit within the NHA dedicated to • Involvement of the entire health system and the broadest emergency preparedness and disaster man- possible intersectoral and inter-institutional collaboration agement in health? to reduce the impact of emergencies and disasters. If so, • The procurement of intersectoral and international collab- 11.1.1.4.1 Does the NHA have an emer- oration to respond to health problems resulting from emer- gency and disaster unit with its gencies and disasters. own budget?

Indicators: 11.1.2 The NHA acts as coordinator for the entire health sec- tor in the implementation of emergency and disaster 11.1 Emergency Preparedness and Disaster preparedness measures. Management in Health Does the NHA: Standard: 11.1.2.1 Have a communications network in place The NHA: that functions in emergencies? • Promotes an understanding of social and health benefits If so, that reduce the impact of emergencies and disasters in all 11.1.2.1.1. Are the operations of this com- sectors, including the private sector and the community. munications network periodi- • Facilitates intra- and intersectoral coordination in imple- cally evaluated? menting measures that reduce the impact of disasters and 11.1.2.2 Have a transport system in place to func- emergencies on the health infrastructure (health services, tion in emergencies and disasters? water and sanitation systems); these include prevention, mitigation, preparedness, early response and rehabilitation If so, as it relates to public health. 11.1.2.2.1 Are the operations of this trans- • Trains both health and non-health workers alike in the re- portation system periodically duction impact of emergencies and disasters on health. evaluated? • Protects against various threats to physical and operational infrastructure (e.g. hospitals, health centers, water and 11.1.3 The NHA provides training to its health workers in sewage systems, etc.) emergency and disaster preparedness. • Provides public education through mass media campaigns Is the NHA’s personnel trained: and health education activities. 11.1.3.1 To develop guidelines that deal with emer- 13 Emergency and disaster reduction in health includes prevention, gencies and disasters within the health mitigation, preparedness, early response and rehabilitation. sector?

359 11.1.3.2 To coordinate activities within the health 11.2 Development of Standards and sector? Guidelines that Support Emergency 11.1.3.3 To coordinate activities with other sectors? Preparedness and Disaster Management 11.1.3.4 In the prevention and control of communi- in Health cable and noncommunicable diseases re- sulting from an emergency or disaster? Standard: 11.1.3.5 In the protection against mental illness re- The NHA: sulting from an emergency or disaster? • Prepares standards and guidelines for constructing, updat- 11.1.3.6 To ensure food safety following disasters? ing and maintaining health infrastructure and services, with 11.1.3.7 In sanitation and environmental health fol- emphasis on emergency and disaster preparedness and the lowing disasters? reduction of physical and organizational vulnerability. 11.1.3.8 To undertake vector control in emergencies? • Develops and maintain norms and standards for health fa- 11.1.3.9 To manage health services in emergencies? cilities in areas prone to disasters. 11.1.3.10 To carry out emergency simulation exercises? • Produces lists of essential drugs and other health supplies 11.1.3.11 To conduct rapid risk and needs assess- necessary in emergencies and disasters. ments? • Participates in the development of guidelines for the health 11.1.3.12 To request, obtain and distribute critical components of emergency plans. equipment/and health supplies for emer- • Develops and promotes standards and guidelines to support gencies and disasters? preparedness in emergencies and disasters, particularly out- 11.1.3.13 In the operation of communications sys- breaks of communicable disease. tems and situation rooms in emergencies? 11.1.3.14 In the operation of emergency transport 11.2.1 The NHA implements strategies to reduce the impact systems? of emergencies and disasters on health. 11.1.3.15 To disseminate health information through mass media and other means? Does the NHA: 11.1.3.16 To ensure transparency and efficiency in the 11.2.1.1. Develop sanitation standards for the na- administration of post-disaster aid? tional emergency plan? 11.1.3.17 In the preparation of emergency rehabilita- 11.2.1.2. Develop standards and guidelines that help tion projects for the health sector? prepare for the consequences of emergen- cies and disasters? 11.1.4 The NHA implements strategies to include emer- If so, do these standards and guidelines gency preparedness and disaster management compo- address: nents in professional education. 11.2.1.2.1 Outbreaks of communicable Does the NHA: disease? 11.1.4.1 Collaborate with health science schools to 11.2.1.2.2 Sanitation of lodgings, shelters include emergency preparedness and disas- and camps? ter management components in the cur- 11.2.1.2.3 Norms and regulations for the riculum? donating essential drugs and nec- 11.1.4.2 Collaborate with the schools of public essary supplies? health to include emergency preparedness 11.2.1.2.4 Vector control? and disaster management components in 11.2.1.2.5 Equipment, drugs and supplies the curriculum? necessary for emergencies and 11.1.4.3 Collaborate with schools related to health disasters? to include emergency preparedness and dis- 11.2.1.2.6 Basic sanitation? aster management components in the cur- 11.2.1.2.7 Food security and safety? riculum? 11.2.1.2.8 Mental health in emergencies?

360 11.2.1.2.9 Construction and maintenance • Coordinates and collaborates with the national civil defense of health infrastructure and agency or other agencies with multisectoral responsibilities. services? • Coordinates other key disaster entities, units or commis- sions. If so, do the standards and • Collaborates and coordinates with the existing health sector guidelines on constructing emergency and disaster programs of other countries in the and maintaining the health region. infrastructure refer to: • Establishes and maintains partnerships with national sub- 11.2.1.2.9.1 Hospital services? national and international organizations that deal with 11.2.1.2.9.2 Outpatient serv- emergencies. ices? • Works with other agencies to develop protocols necessary 11.2.1.2.9.3 Water services? for communication. 11.2.1.2.9.4 Solid waste services? 11.2.1.3 Develop standards and guidelines to deal 11.3.1 The NHA coordinates with other agencies or institu- with the consequences of emergencies and tions to reduce the impact of emergencies and disasters? disasters. If so, do the standards and guidelines take Do these other agencies/institutions include: into account: 11.3.1.1 National emergency offices? 11.2.1.3.1 The physical infrastructure of 11.3.1.2 Subnational emergency offices? the health facilities? 11.3.1.3 The transportation sector? 11.2.1.3.2 The management of health 11.3.1.4 The public works sector? facilities and organizations in 11.3.1.5 The housing sector? emergency and disaster situa- 11.3.1.6 The telecommunications sector? tions? 11.3.1.7 The education sector? 11.2.1.3.3 Health services delivery in 11.3.1.8 The Ministry of Foreign Relations? emergencies? 11.3.1.9 The police and armed forces? If so, does the health service de- 11.3.1.10 Fire departments? livery ensure: 11.3.1.11 The Area Coordinator for the United 11.2.1.3.3.1 The availability Nations? and distribution of person- 11.3.1.12 UN Children’s Fund (UNICEF)? nel? 11.3.1.13 UN High Commissioner for Human Rights 11.2.1.3.3.2 Alternative ways (OHCHR)? of operating critical care 11.3.1.14 UN High Commissioner for Refugees units? (UNHCR)? 11.2.1.3.3.3 Criteria for setting 11.3.1.15 Food and Agriculture Organization (FAO)? priorities that meet the 11.3.1.16 Pan American Health Organization (PAHO)? demand for emergency care 11.3.1.17 The National Red Cross? Red Cross Fed- services? eration (RCF)? Red Cross Committee (RCC)? 11.3 Coordination and Partnerships with 11.3.1.18 Professional associations? other Agencies and/or Institutions in 11.3.1.19 Other nongovernmental organizations? Emergencies and Disasters 11.3.1.20 Other agencies or commissions? 11.3.1.21 Does it coordinate with the national civil Standard: defense or other agencies with multisectoral The NHA: responsibilities?

361 If so, 11.4.1 The NHA helps the subnational levels to reduce the 11.3.1.21.1 Do the agencies and institutions health impact of emergencies and disasters. work together to develop the Does the NHA: necessary protocols to dissemi- 11.4.1.1 Facilitate technical assistance to the local nate information through the levels to strengthen local capacity to mobi- mass media? 11.3.1.22 Does the NHA establish and maintain in- lize activities in emergencies or disasters? ternational partnerships to deal with emer- 11.4.1.2 Support the subnational levels in strength- gencies? ening local capacity to collaborate with other sectors in emergencies or disasters? If so, does the NHA: 11.4.1.3 Help the subnational level establish links with 11.3.1.22.1 Collaborate and coordinate other local emergency service providers? with existing health sector emergency and disaster pro- If so, are these emergency services in: grams of other neighboring 11.4.1.3.1 Health? countries? 11.4.1.3.2 Other sectors? 11.3.1.22.2 Collaborate and coordinate with national, subnational and inter- 11.4.2 The NHA collaborates with the subnational levels to national organizations and insti- build capacity for reducing the impact of emergencies tutions that deal with emergency and disasters on health. and disaster preparedness? Does this collaboration include: 11.4.2.1 Assistance to the subnational levels in iden- 11.4 Technical Assistance and Support tifying local leaders to promote efforts to the Subnational Level to Reduce the Impact aimed at reducing the impact of emergen- of Emergencies and Disasters on Health cies or disasters on health? 11.4.2.2 Design of standards and guidelines at the Standard subnational levels for emergency prepared- The NHA: ness and disaster management? • Promotes, provides and facilitates technical assistance to the 11.4.2.3 Definition of the responsibilities for each subnational levels to build local capacity for mobilizing and level in emergencies or disasters? coordinating efforts that reduce the impact of emergencies 11.4.2.4 Analysis of the vulnerability of the health and disasters on health. infrastructure for which these levels are re- • Provides support to the subnational levels to build capacity sponsible in emergencies and disasters? for intersectoral collaboration in emergencies and estab- 11.4.2.5 Preparation of emergency and disaster risk lishes links with emergency service providers. maps for these levels? • Helps to identify leaders who will promote efforts that re- 11.4.2.6 Needs assessment at the subnational levels? duce the impact of emergencies at the local level. • Establishes standards and guidelines to reduce the impact of Does the NHA provide: emergencies and disasters at the subnational levels. 11.4.2.6.1 The necessary assistance to cor- • Provides technical assistance to the subnational levels to rect any deficiencies identified conduct a needs assessment with respect to reducing the im- by such an assessment? pact of emergencies and disasters on health, as well as con- 11.4.2.6.2 The necessary resources to cor- tributes resources necessary to strengthen areas of weakness rect deficiencies identified by in the capacity to respond to them in a timely manner. such an assessment?

362 APPENDIX B Sample National Measurement Report

Executive Report ences and opinions of the participating the public health services infrastructure professionals from relevant public areas in the country and the Region. Background of health in Country X.2 Description of the Process The Directing Council of the Pan Ame- For its application in Country X, the rican Health Organization (PAHO) ap- process and measurement instrument The Ministry of Health of Country X, proved an initiative aimed at strengthen- were submitted for the consideration of in collaboration with the local PAHO/ ing public health in the Americas and a group of decisionmakers at the NHA WHO Representative Office, held a improving the practice of public health, in order conduct an exercise to measure workshop to coordinate and organize 3 as well as strengthening the steering role the performance of EPHF. This exer- the preparatory phases of the EPHF of health authorities at all levels of the cise took place between X and X and in- measurement exercise. State by defining and measuring the volved the participation of a large group performance of essential public health of professionals from various areas of The PAHO/WHO Representative Of- functions (EPHF). This has improved public health in the country. fice in Country X, with the cooperation the dialogue between the actors in the of authorities from the Ministry of field of health and those of related disci- The event was organized by the Min- Health, coordinated and organized the plines at various levels in the Region.1 istry of Health of X, with the collabora- workshop on application of the instru- tion of the PAHO/WHO Representa- ment to measure the EPHF. The Min- The national authorities measured per- tive Office in that country and of the istry of Health and PAHO likewise de- formance of the EPHF using the instru- Division of Health Systems and Ser- cided to hold a training workshop for ment designed for this purpose and vices Development of PAHO. It was national facilitators who would be those held a workshop to discuss the experi- strongly backed by the Minister of responsible for the definitive applica- Health, who pledged his support for tion of the EPHF performance mea- this initiative, which seeks to strengthen surement instrument. 1 Resolution CD42.R14. Essential Public Health Functions. 42nd Directing Council 2 The list of participants in the event is pre- of PAHO. Washington, DC, 25 to 29 Sep- sented as an Annex. X representatives from the National tember 2000. 3 Id. Health Authority participated in the

363 training workshop for facilitators, which tion is based on the score obtained by As a convention, the following scale is resulted in the formation of a local team the variable being measured. proposed as a guide for the overall that was prepared to continue the pro- interpretation: cess and support the exercise. The questions for the measures and submeasures allow for only a “Yes” or 76 – 100% (0.76 to 1.0) Application of the “No” response. It is therefore important Quartile of optimal performance Instrument to understand how the collective re- sponse to each measure and submeasure 51 – 75% (0.51 to 0.75) X professionals (including health per- was obtained. For the purposes of this Quartile of above average performance sonnel, academicians, and other special- exercise, it was determined that if a re- ists) were selected and convened by the sponse could not be agreed on in a 26 – 50% (0.26 to 0.50) Ministry of Health, worked throughout group discussion, or if a second round Quartile of below average performance the X days of the exercise. X groups of voting yielded another tie, then the were formed, distributing the profes- response would automatically be “No” 0 – 25% (0.0 to 0.25) sionals in accordance with their profiles due to the existing uncertainty. Quartile of minimum performance and experience in specific operations. In order to record and process the re- In the final plenary session of the work- Each group was supported by a local fa- sults of the responses, a computer pro- shop, the results of the EPHF perform- cilitator (who helped build consensus for gram was used to tally the final score of ance measurement were shared with the a group response), a secretary (who kept each question directly and instanta- participants in order to identify areas of track of the responses and confirmed the neously, as a function of the responses intervention, focusing on processes and degree of consensus in the group), and a to its measures and submeasures. This results, and decentralized capacities, in- technical assistant (who recorded the re- calculation of the final score of every frastructure, and competencies. sponses). At the same time, an external variable is essentially the average of the facilitator from PAHO contributed to affirmative responses to the measures This was considered to be the most use- the effort by obtaining the comments and submeasures, except in the case of ful and important part of the measure- and suggestions of the participants to re- the exceptions mentioned in the instru- ment process, because it gave the partic- fine the terminology or make editorial ment. ipants an opportunity to express their improvements to the instrument. opinions and revealed strengths and The mechanics of the exercise involved The score assigned to the indicator is weaknesses. Thus, it was possible for having each facilitator read out loud the the weighted average of the results ob- the NHA to design an institutional de- definition, standards, measures, and tained for each of the respective mea- velopment plan to improve the EPHF submeasures of each function the group sures, and the simple weighted average in its immediate sphere of influence. was to discuss. The external facilitator, of the results of all the indicators deter- supported by the local facilitator from mines the score for the performance of Overall Analysis the Ministry, ensured that the result of that particular essential public health of Results the voting reflected a consensus by the function. participating group. The results of the exercise were analyzed Since this was the first time the EPHF by the competent authorities of Coun- Results of the Measurement were measured in the Region, a uniform try X, taking into account the unique scoring method was used, in which all characteristics and circumstances of the Description of the Scoring the essential functions, indicators, and exercise of the essential public health and Measurement measures have the same relative weight. functions established by the health au- Mechanism Lending the same degree of considera- thorities. It should also be noted that in tion to all the measurements facilitates interpreting the results, it might be nec- The score for each indicator that was the analysis and subsequent decisions essary to compensate for possible biases part of the measurement for each func- by the country. in the groups analyzing each function.

364 Figure 1 Results of the Measurement by Function4

1.00

0.90 0.87 0.79 0.80

0.70 0.68 0.64 0.62 0.61 0.57 0.60 0.54 0.49 0.50 Scale 0.40 0.37

0.30

0.20 0.13 0.10

0.00 EPHF1 EPHF2 EPHF3 EPHF4 EPHF5 EPHF6 EPHF7 EPHF8 EPHF9 EPHF10 EPHF11

The figure 1 provides an overview of Health), for EPHF 8 (Human Re- Research, and Control of Risks and the performance of each of the 11 sources Development and Training in Threats to Public Health) were the EPHF in Country X. Public Health), and for EPHF 10 (Re- highest. This could be interpreted as the search in Public Health). The internal result of the importance the country has This overview of the performance of the structure of each of these functions will placed on surveillance, in terms of both 11 essential public health functions be analyzed in greater detail further on. training and operations. measured by the instrument shows high levels for EPHF 2 (Public Health Sur- It is important to note in this report that The function with the second highest veillance, Research, and Control of both the highest and lowest scores de- score was Function 11 (Reducing the Risks and Threats to Public Health), for scribed in the overall analysis should be Impact of Emergencies and Disasters EPHF 7 (Evaluation and Promotion of studied with extreme care, avoiding the on Health). The group that analyzed it Equitable Access to Necessary Health drawing of conclusions about the degree had little knowledge of the subject, and Services), and for EPHF 11 (Reducing of importance of each score when the the issue of evacuating the population the Impact of Emergencies and Disas- NHA makes health decisions. Actually, directly involved in these situations ters on Health). Medium performance a high-scoring function could show that dominated the discussion. This is an ex- levels were seen for EPHF 1 (Monitor- what remains to be done to achieve a ample of possible biases that, as noted ing, Evaluation and Analysis of Health score of 100% is extremely important in above, make it necessary to exercise cau- Status), for EPHF 3 (Health Promo- high-level decision-making. tion in interpreting the results. tion), for EPHF 5 (Development of Policies and Institutional Capacity for Moreover, low scores could reflect a low At the other end of the spectrum, the Planning and Management in Public degree of performance in certain key very low score in Function 8 (Human Health) and for EPHF 4 (Social Partic- areas of the measurement instrument Resources Development and Training ipation in Health). The lowest levels that may not necessarily coincide with in Public Health) may reflect the mani- were observed for EPHF 6 (Strengthen- priorities in the health policy of Coun- fest dissatisfaction by the group with ing of Institutional Capacity for Reg- try X. the conditions for staff development. ulation and Enforcement of Public In the overall performance analysis of Function 10 (Research in Public Health) 4 The list of the essential public health func- the 11 EPHF (figure 1), the results for also received a score that places it in the tions is presented as an Appendix. EPHF 2 (Public Health Surveillance, below-average performance quartile,

365 which might reflect concerns over the EPHF 1 Monitoring, Analysis and Evaluation of the Health apparently little attention devoted to Situation of the Population research. 1.00 1.00 0.88 The low score assigned to each of these 0.90 0.83 EPHF 8 and 10 might reflect neglect of 0.80 investments in human capital and the 0.70 scientific apparatus to sustain the devel- 0.60 0.50

opment of public health in the country. Scale This hypothesis would warrant a more 0.40 exhaustive analysis within the context 0.30 0.25 of a process aimed at improving public 0.20 0.13 0.10 health, given the medium- and long- 0.00 term implications of investment in this 12345 area. Indicators

Likewise, Function 6 (Strengthening of Indicators: 1. Guidelines and processes for monitoring health status Institutional Capacity for Regulation 2. Evaluation of the quality of information. and Enforcement in Public Health) 3. Expert support and resources for monitoring health status. scored in the below-average perform- 4. Technical support for monitoring and evaluating health status. 5. Technical assistance and support to the subnational levels of public health. ance quartile. This explains the concern manifested even before the beginning of the exercise about including additional aspects of regulation, specifically with regard to insurance companies. conclusions reached by the different case, there is a marked consistency in groups during the exercise. the positive results. What can be deduced from the scores obtained in these three Functions (6, 8, What is striking in this profile are the Contrary to what was seen in Function and 10) is that they can be used to iden- low scores of the first two indicators, 1, here it seems that the analysis was fa- tify certain gaps or weaknesses that which describe the process and out- vorable to one of the processes involved: might warrant priority attention from come of the monitoring, analysis, and the process carried out within the or- the health authority. evaluation of the health situation, ganization of the health services, not- notwithstanding the fact that the insti- withstanding the recognition that there In general, the remaining functions ob- tutional capacity to exercise this func- is little development of decentralized tained scores that place them in the tion well is considered to be optimal capacity for the exercise of this function quartile of above-average performance, (indicators 3, 4 and 5). This could be (Indicator 5). not the optimum described as the final interpreted as an institutional manage- objective of the process. ment problem, rather than one of re- It should be noted that the processes sources and infrastructure. involving the work of the health au- In order to delve further into the analy- thority outside the sector (Indicators 2 sis of the results, the figures on the pro- As noted in the overall analysis, the and 3) obtained a moderately unsatis- file of indicators for each function are score for this function indicated virtu- factory score. This may pose a chal- provided below, accompanied by com- ally optimal performance, a result of the lenge to the health authority in terms ments. It should be noted that the re- high scores for each indicator. It is of strengthening its leadership in the marks on these results were made dur- worth asking whether some degree of extrasectoral dynamic affecting the ing the workshop and were a first bias might have been present in the quality of life; to some extent it ex- attempt at analysis. They reflect the group that did the analysis it. In any plains the interest expressed prior to

366 the meeting to further promote the de- EPHF 2 Public Health Surveillance, Research, and Control of Risks terminants of the quality of life, which and Harm to Public Health was proposed as a potential area for ex-

1.00 pansion in the instrument. 0.92 0.88 0.91 0.90 0.83 0.79 0.80 As with the first function, the exercise 0.70 reveals a remarkably high degree of dis- 0.60 satisfaction with performance, in con- 0.50 trast to the recognition of the effort to Scale 0.40 improve the decentralized capacity to 0.30 carry out the two processes implied in 0.20 this function. 0.10 0.00 12345Despite the unsatisfactory performance Indicators in both processes, it might be interest- ing to delve further into the consider- Indicators: able difference in the scores for citizen 1. Surveillance system to identify threats and harm to public health. empowerment and social participation. 2. Capacities and expertise in public health surveillance. 3. Capacity of public health laboratories. 4. Capacity for timely and effective response to control public health problems. The profile for this function reveals 5. Technical assistance and technical support for the subnational levels of public health. weaknesses in the development of the institutional capacity for management, in contrast to the moderately satisfac- tory performance in defining objectives and public health policies; it also reveals a low score with regard to strengthening EPHF 3 Health Promotion the subnational levels for decentralized planning and management. 1.00 0.94 0.90 If these deficiencies actually do exist, 0.80 0.70 0.66 they might explain the performance gap 0.59 between some processes and the avail- 0.60 0.53 0.49 0.50 able installed capacity, as noted in Func- Scale 0.40 tions 1, 4, 7, and 10. 0.30 0.20 The deficiencies in this Function refer 0.10 to the health authority’s capacities and 0.00 the exercise of its inspection and en- 12345 Indicators forcement roles, in tandem with its reg- ulatory role.

Indicators: 1. Support for health promotion activities, the development of norms, and interven- The little effort recognized for strength- tions to promote healthy behaviors and environments. ening regulatory and enforcement ca- 2. Building of sectoral and extrasectoral partnerships for health promotion. 3. National planning and coordination of information, education, and social communica- pacities at the subnational levels is note- tion strategies for health promotion. worthy; this could warrant in-depth 4. Reorientation of the health services toward health promotion. 5. Technical assistance and support to the subnational levels to strengthen health promo- analysis, given its implications for the tion activities. exercise of the steering role of health

367 and the territorial expanse and demo- EPHF 4 Citizen Participation in Health graphic diversity of the country. 1.00 0.90 0.83 The profile of this function reflects, yet 0.80 again, the aforementioned gap between 0.70 the exercise of processes and the abilities 0.59 0.60 to perform them. 0.50 Scale 0.40 0.29 Also evident is the remarkable difference 0.30 between satisfaction with advocacy for 0.20 improving access and dissatisfaction 0.10 with knowledge of the conditions of ac- 0.00 123cess and possible interventions to im- Indicators prove access. It would be advisable to an- alyze these in depth. Furthermore, it is Indicators: evident that the efforts to strengthen de- 1. Empowering citizens for decision-making in public health. centralized capabilities to address prob- 2. Strengthening of social participation in health. 3. Technical assistance and support to the subnational levels to strengthen social partici- lems of access are regarded as optimal. pation in health. The profile of this function reflects the national evaluation group’s strong dissat- isfaction with the performance of the health authority in human resource de- velopment. There is a remarkably low score for continuing education efforts and for support to the subnational levels. EPHF 5 Development of Policies and Institutional Capacity for Planning and Management in Public Health It would be necessary to provide a con- text and perform an in-depth analysis of 1.00 the results in these five indicators in 0.90 0.80 order to validate their objectivity and 0.80 0.73 understand the underlying factors if a 0.68 0.70 pertinent intervention strategy is to be 0.60 developed. 0.50 Scale 0.40 Once more, there is a clear asymmetry 0.30 0.26 0.22 between the normative processes (Indi- 0.20 cator 1) and the executive processes (In- 0.10 0.00 dicators 2 and 3), with the latter lagging 12345behind. Also evident is the occasional Indicators disjunction between the quality-assur- ance capacity at the decentralized levels Indicators: and the action taken to improve user 1. Definition of national and subnational health objectives. 2. Development, monitoring, and evaluation of public health policies. satisfaction. 3. Development of institutional capacity for the management of public health systems. 4. Negotiation of international cooperation in public health. 5. Technical assistance and support to the subnational levels for policy development, These are clear examples indicating that planning, and management in public health. the analysis of the exercise of these

368 functions should rely on in-depth FESP 6 Strengthening of Institutional Capacity for Regulation knowledge of the national situation and and Enforcement in Public Health be geared to identifying determinants for the preparation of pertinent inter- 1.00 vention strategies. 0.90 0.85 0.80 As noted above, this function yet again 0.70 reflects the gap between installed capac- 0.60 ity and its utilization in research. 0.50 0.45 Scale 0.40 0.32 0.31 The low score for the indicators of this 0.30 function may reflect limited efforts by 0.20 the health authority to support the 0.10 process of generating knowledge, im- 0.00 1234 plementing a national research agenda, Indicators or making use of the research findings of other actors. Indicators: 1. Periodic monitoring, evaluation, and modification of the regulatory framework. More in-depth analysis may be called 2. Enforcement of laws and regulations. 3. Knowledge, skills, and mechanisms for reviewing, improving, and enforcing the for with regard to possible relationships regulations. between the low results obtained in 4. Technical assistance and support to the subnational levels of public health in devel- oping and enforcing laws and regulations. Function 8 (human resources develop- ment) and this research function.

The profile of this function reflects yet again the gap between the normative (Indicator 2) and executive (Indicator EPHF 7 Evaluation and Promotion of Equitable Access to Necessary Health Services 1) capacities, and between developed capacity and its utilization in work 1.00 1.00 1.00 processes. Given the characteristics of 0.90 the group that analyzed it and the 0.80 knowledge available to it, a review of

0.70 the results obtained in previous itera- 0.60 0.51 tions of the instrument is recom- 0.50

Scale mended. 0.40 0.30 0.20 0.20 Identification of Priority 0.10 Intervention Areas 0.00 1234 for the Institutional Indicators Development Plan

Indicadores: In preparing a plan to develop the insti- 1. Monitoring and evaluation of access to necessary health services. 2. Knowledge, skills, and mechanisms for improving access by the population to tutional capacity of the health authori- necessary health services. ties to improve the exercise of the 3. Advocacy and action to improve access to necessary health services. 4. Technical assistance and support to the subnational levels to promote equitable ac- EFPH pertaining to them (the immedi- cess to health services. ate objective of this exercise in perform-

369 ance measurement), two basic premises EPHF 8 Human Resources Development and Training in have been observed: Public Health

1.00 1) Development efforts should be in- 0.90 stitutional in nature. This implies a 0.80 comprehensive approach, rather 0.70 than isolated interventions targeting 0.60 the actors and areas of each func- 0.50

Scale tion. To this end, all the functions 0.40 have been merged into three strate- 0.30 0.28 0.20 gic intervention areas: 0.20 0.17 0.10 0.00 0.00 • Final achievement of outcomes 0.00 12345 and key processes, the substantive Indicators component of the work of the health authority in public health, Indicators: and thus, the primary goal of inter- 1. Description of the public health workforce. ventions to improve performance. 2. Improving the quality of the workforce. 3. Continuing education and graduate training in public health. 4. Upgrading human resources to ensure culturally appropriate delivery of services. • Development of capacities and 5. Technical assistance and support to the subnational levels in human resources infrastructure, understood as the development. human, technology, knowledge, and resources situation necessary for the optimal exercise of the public health functions appertain- EPHF 9 Ensuring the Quality of Personal and Population- ing to the health authority. based Health Services

1.00 • Development of decentralized 0.90 competences, in terms of faculties 0.80 0.75 0.77 and capacities directed to support- 0.70 ing the subnational levels or to 0.60 transferring responsibilities to 0.51 0.50 them, so as to strengthen the de-

Scale 0.42 0.40 centralized exercise of the health 0.30 authority with regard to public 0.20 health, consistent with the re- 0.10 quirements of State moderniza- 0.00 1234 tion and sectoral reform. Indicators 2) Interventions for institutional devel- Indicators: opment must seek to overcome 1. Definition of standards and evaluation to improve the quality of population-based weaknesses by taking advantage of and personal health services. 2. Improving user satisfaction with the health services. strengths. In order to rate perfor- 3. Systems for technological management and health technology assessment to sup- mance in the different indicators as port decision-making in public health. 4. Technical assistance and support to the subnational levels to ensure quality im- strengths or weaknesses, a reference provement in the services. value is needed; this needs to be

370 identified for each country at differ- EPHF 10 Research in Public Health ent points in the process, as a func- 1.00 tion of the level of performance and 0.90 development goals. The basic crite- 0.80 ria for establishing the reference 0.70 values are: a) that the weaknesses di- 0.60 0.56 agnosed not be accepted or consoli- 0.50 0.44 dated and, b) that they represent an Scale 0.40 achievable challenge and a reason- 0.30 able incentive for continuing efforts 0.20 0.11 at improvement. 0.10 0.00 123Nevertheless, for the purposes of these Indicators pioneering applications of the instru- ment, and in order to facilitate consoli- Indicators: dation of the results of all the evalua- 1. Development of a public health research agenda. tions in the countries of the Region 2. Development of institutional research capacity. 3. Technical assistance and support for research in public health at the subnational (with a view to formulating a regional levels. plan of action), as a convention, the ref- erence value has been set as the average of the overall results in the 11 func- tions. The majority of deficiencies thus remain qualified as weaknesses to be overcome.

The workshop discussed whether the EPHF 11 Reducing the Impact of Emergencies and Disasters on Health reference value for X should be 50% or more. The view was that on this occa- 0.97 1.00 0.92 sion the country’s track record and na- 0.90 tional public health resources warranted 0.80 raising the value closer to 70%. In any 0.69 0.70 case, this presentation of results uses the 0.57 0.60 reference value adopted for the regional 0.50

Scale exercise, without prejudice to the future 0.40 ability of the national authorities to 0.30 change it when preparing their develop- 0.20 ment plan. 0.10 0.00 1234 What follows is the classification of the Indicators indicators as strengths or weaknesses resulting from the application of the Indicators: aforementioned reference value, along 1. Reducing the impact of emergencies and disasters. 2. Development of standards and guidelines that support emergency preparedness with comments, for example, on possi- and disaster management in health. ble areas for priority intervention in the 3. Coordination and partnerships with other agencies and/or institutions. 4. Technical assistance and support to the subnational levels to reduce the impact of three components of institutional de- emergencies and disasters on health. velopment that have been identified.

371 The main weaknesses that the priority satisfaction, inspection activities to en- erence to improve monitoring and eval- interventions should probably focus on force existing regulations, and manage- uation of the health situation). For ex- in order to improve the processes and ment to reduce the impact of emergen- ample, the development of standards results of the exercise of the essential cies and disasters. and promotional interventions should public health functions corresponding serve as the basis for improving com- to the health authority would be, first, The interventions to improve processes munication strategies for promotion; those related to developing human re- and outcomes are generally of a mana- social participation actions could be sources and the research agenda and gerial type. They involve adopting used to empower citizens in decision- improving the quality of information measures for installed capacity to be making. Obviously, implementation of used in monitoring and evaluating the used more efficiently and to improve the regulations must be the starting health situation and access. These were operations and results. Such actions can point for actions aimed at improving indicated as being in the range of mini- be based on the identified strengths in regulatory enforcement. mum performance. Second would be areas related to these weaknesses, such those involving empowerment of the as: operation of the surveillance and re- The main weaknesses that the prior- citizens, communication for health pro- sponse system for the control of public ity interventions to develop human, motion and the improvement of user health problems (this can serve as a ref- technical and infrastructure capacities

Area of Intervention Final Achievement of Results and Key processes

EPHF Indicators Classification 1 1.1 Guidelines and processes for monitoring health status 0.25 D 1 1.2 Evaluation of the quality of information 0.13 D 2 2.1 Surveillance system to identify threats and harm to public health. 0.92 F 2 2.4 Capacity for timely and effective response to control public health problems 0.83 F 3 3.1 Support for health promotion activities, the development of norms, and interventions to promote healthy behaviors and environments 0.94 F 3 3.2 Building of sectoral and extrasectoral partnerships for health promotion 0.59 F 3 3.3 National planning and coordination of information, education, and social communication strategies for health promotion 0.53 D 3 3.4 Reorientation of the health services toward health promotion 0.66 F 4 4.1 Empowering citizens for decision-making in public health 0.29 D 4 4.2 Strengthening of social participation in health 0.59 F 5 5.1 Definition of national and subnational health objectives 0.68 F 5 5.2 Development, monitoring, and evaluation of public health policies 0.80 F 6 6.1 Periodic monitoring, evaluation, and modification of the regulatory framework 0.85 F 6 6.2 Enforcement of laws and regulations 0.35 D 7 7.1 Monitoring and evaluation of access to necessary health services 0.20 D 7 7.3 Advocacy and action to improve access to necessary health services 1.00 F 8 8.1 Description of the public health workforce 0.28 D 8 8.2 Improving the quality of the work force 0.20 D 8 8.3 Continuing education and graduate training in public health 0.00 D 8 8.4 Upgrading of human resources to ensure culturally appropriate delivery of services 0.17 D 9 9.1 Definition of standards and evaluation to improve the quality of population-based and personal health services 0.75 F 9 9.2 Improving user satisfaction with the health services 0.42 D 10 10.1 Development of a public health research agenda 0.11 D 11 11.1 Reducing the impact of emergencies and disasters 0.57 D 11 11.2 Development of standards and guidelines that support emergency preparedness and disaster management in health 0.97 F 11 11.3 Coordination and partnerships with other agencies and/or institutions 0.69 F

372 Final Achievement of Results and Key Processes

1.00 0.90 0.80 0.70 0.60 0.57 0.50 Scale 0.40 0.30 0.20 0.10 0.00 1.1 2.1 3.1 3.3 4.1 5.1 6.1 7.1 8.1 8.3 9.1 10.1 11.2 1.2 2.4 3.2 3.4 4.2 5.2 6.2 7.3 8.2 8.4 9.2 11.1 11.3 Indicators ReferenceWeaknesses Strengths

Area of Intervention Capacity and Infrastructure Development

EPHF Indicators Classification 1 1.3 Expert support and resources for monitoring health status 1.00 F 1 1.4 Technological support for the monitoring and evaluation of health status 0.83 F 2 2.2 Capacities and expertise in public health surveillance 0.79 F 2 2.3 Capacity of public health laboratories 0.88 F 5 5.3 Development of institutional capacity for the management of public health systems 0.26 D 5 5.4 Negotiation of international cooperation in public health 0.73 F 6 6.3 Knowledge, skills, and mechanisms for reviewing, improving, and enforcing the regulations 0.31 D 7 7.2 Knowledge, skills, and mechanisms for improving access by the population to programs and services 0.51 D 9 9.3 Systems for technology management and health technology assessment to support decision-making in public health 0.51 D 10 10.2 Development of institutional research capacity 0.56 D

should target in order to improve the ment of technology resources to im- be, first, those which are in the range processes and results of the exercise of prove performance in functions where of minimum performance; and second, the essential public health functions cor- capacities are deficient. those related to technical support to the responding to the health authority subnational levels in health promotion, would be, first, those related to increas- The main weaknesses that the priority research, and decentralized oversight. ing the institutional capacity of manage- interventions related to the develop- ment, regulation and control, and, sec- ment of human resources and the ca- Interventions in this area of institu- ond, those related to improving access pacity for planning and management at tional development generally have to do to the services, technology management, the subnational levels should focus on with the delegation of functions, along and research. The interventions to in- in order to improve the processes and with the strengthening of the capacity crease institutional capacity are more results of the exercise of the essential to exercise them, and technical support likely to involve investment in training, public health functions corresponding from the central levels for optimal per- acquisition of expertise, and procure- to the health authority would probably formance by the subnational levels.

373 Development of Capacities and Infrastructure

1.00 0.90 0.80 0.70 0.60 0.57 0.50 Scale 0.40 0.30 0.20 0.10 0.00 1.4 2.3 5.4 7.2 10.2 1.3 2.2 5.3 6.3 9.3 Indicators ReferenceWeaknesses Strengths

Area of Intervention Development of Decentralized Competencies

EPHF Indicators Classification 1 1.5 Technical assistance and support to the subnational levels of public health 0.88 F 2 2.5 Technical assistance and support to the subnational levels of public health 0.91 F 3 3.5 Technical assistance and support to the subnational levels to strengthen health promotion activities. 0.49 D 4 4.3 Technical assistance and support to the subnational levels to strengthen social participation in health 0.83 F 5 5.5 Technical assistance and support to the subnational levels in policy development, planning, and management in public health 0.22 D 6 6.4 Technical assistance and support to the subnational levels of public health in developing and enforcing laws and regulations 0.45 D 7 7.4 Technical assistance and support to the subnational levels of public health to promote equitable access to health services 1.00 F 8 8.5 Technical assistance and support to the subnational levels in human resources development 0.00 D 9 9.4 Technical assistance and support to the subnational levels of health to ensure quality improvement in the services 0.77 F 10 10.3 Technical assistance and support for research in public health at the subnational levels 0.44 D 11 11.4 Technical assistance and support to the subnational levels to reduce the impact of emergencies and disasters on health 0.92 F

Conclusion ment, based on their professional ex- and improving the methodology for ap- pertise and the shared experience in is- plying it, pursuant to the resolution of The test application in X was a success, sues pertaining to the EFPH. the Directing Council of PAHO. It is as reflected in the strong interest and furthermore assumed that it will serve motivation of the participants and their This experience will be of assistance in the country as a baseline for future im- contributions to improve the instru- adapting the measurement instrument plementation and evaluation activities.

374 Development of Decentralized Competencies

1.00 0.90 0.80 0.70

0.60 0.57 0.50 Scale 0.40 0.30 0.20 0.10 0.00 2.5 4.3 4.3 8.5 10.3 1.5 3.5 5.5 7.4 9.4 11.4 Indicators ReferenceWeaknesses Strengths

Annex 1 List of Essential Public Health Functions

Essential Public Health Functions

EPHF 1 Monitoring, Evaluation, and Analysis of the Health Situation of the Population EPHF 2 Public Health Surveillance, Research, and Control of Risks and Harm to Public Health EPHF 3 Health Promotion EPHF 4 Citizen Participation in Health EPHF 5 Development of Policies and Institutional Capacity for Planning and Management in Public Health EPHF 6 Strengthening of Institutional Capacity for Regulation and Enforcement in Public Health EPHF 7 Evaluation and Promotion of Equitable Access to Necessary Health Services EPHF 8 Human Resources Development and Training in Public Health EPHF 9 Quality Assurance in Personal and Population-based Health Services EPHF 10 Research in Public Health EPHF 11 Reducing the Impact of Emergencies and Disasters on Health1

1 Reducing emergencies and disasters in health includes prevention, mitigation, preparedness, response, and rehabilitation.

375 Annex II List of Participants in the Workshop

No. Name Position and Institution 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45

376 Annex III Results and Indicators for each Function

Essential Function No. 1: Monitoring, Evaluation and Analysis of Health Status FINAL SCORE EPHF No. 1 0.00

1.1 Guidelines and Processes for Monitoring Health Status 0.00

1.1.1 Has the NHA developed guidelines for measuring and evaluating the population’s health status? 0.00 Have the guidelines or other instruments for monitoring health status: 1.1.1.1 Been developed for use by the health system at the national level? 0 1.1.1.2 Been developed for use by the health system at intermediate levels? 0 1.1.1.3 Been developed for use by the health system at local levels? 0 1.1.1.4 Described suitable methods for collecting data and selecting appropriate sources of information which provide that data? 0 1.1.1.5 Described the roles of the national and subnational levels in collecting data? 0 1.1.1.6 Provided access to information by civil society and organized community groups in a manner that protects the individual’s privacy? 0 1.1.1.7 Included a process that continuously improves information systems to better meet user needs at both national and subnational levels (decision-makers, program directors, etc.)? 0 If so, does the process: 0.00 1.1.1.7.1 Include uniform standards at all levels (national and subnational) of the information system? 0 1.1.1.7.2 Include procedures that provide information to national and international agencies that form part of the health system? 0 1.1.1.7.3 Include a periodic review of standards and procedures that evaluate their relevance in view of the technological advances and changes in health policy? 0 1.1.1.8 Described procedures for communicating information to the mass media and general public? 0 1.1.1.9 Protected the confidentiality of information through the use of specific protocols for accessing data? 0 1.1.1.10 Described the procedures to organize a health status profile that contains information on national health objectives? 0

1.1.2 Does the NHA identify and annually update the data collected in a country health status profile? 0.00 Does this profile include: 1.1.2.1 Social and demographic variables? 0 1.1.2.2 Mortality data? 0 1.1.2.3 Morbidity data? 0 1.1.2.4 Data on risk factors? 0 1.1.2.5 Information on lifestyles? 0 1.1.2.6 Data on environmental risks? 0 1.1.2.7 Data on access to personal health services? 0 1.1.2.8 Data on contact with population-based health services? 0 1.1.2.9 Data on utilization of population-based and personal health services? 0 1.1.2.10 Data on cultural barriers in accessing health care? 0

1.1.3 Does the NHA use the health status profile: 0.00 1.1.3.1 To monitor the health needs of the population? 0 1.1.3.2 To evaluate inequities in health conditions? 0 1.1.3.3 To monitor trends in health status? 0 1.1.3.4 To monitor changes in the prevalence of risk factors? 0 1.1.3.5 To monitor changes in utilization of health services? 0 1.1.3.6 To determine the adequacy and significance of reported data? 0 1.1.3.7 To identify the population’s priorities and needs in terms of access to services, participation in health promotion activities, resource allocation, focusing on the elimination of inequities in access and improving health services? 0 1.1.3.8 To define national health objectives and goals? 0 1.1.3.9 To evaluate compliance with national health objectives and goals? 0 1.1.3.10 To improve the efficiency and quality of the health system in discharging the essential public health functions by the NHA? 0 1.1.3.11 Can you cite an example where this profile has been used? 0

1.1.4 Does the NHA disseminate information on the health status of the population? 0.00 Does the NHA: 1.1.4.1 Produce an annual report? 0 1.1.4.2 Disseminate this report and its information to interested parties? 0 1.1.4.3 Present this report to groups of key decision-makers in the country? 0 (continued)

377 1.1.4.4 Regularly organize seminars or other activities that explain and raise awareness of key decision-makers about the implications of the information on the health status of the population contained in the annual report? 0 1.1.4.5 Provide data on trends in health outcomes, comparing them with standards and goals specifically mentioned in the profile? 0 1.1.4.6 Provide communities with a common set of measures that help them make comparisons, prioritize community health problems and determine allocation of resources? 0 1.1.4.7 Periodically solicit and evaluate suggestions that improve the content, presentation and dissemination of the health profile? 0 1.1.4.8 Regularly evaluate how the recipients of the health profile report use the information? 0

1.2 Evaluation of the Quality of Information 0.00 1.2.1 Is there a unit that evaluates the quality of the information generated by the health system? 0.00 1.2.1.1 Is the unit outside the direct control of the NHA? 0 1.2.1.2 Does the unit conduct periodic audits of the information system that assesses the country’s health status? 0 1.2.1.3 Does the unit suggest modifications to the system in areas recognized as being weak or in need of improvement? 0 1.2.1.4 Does the NHA take into consideration the suggestions made by the evaluation unit for improving the measurement of health status? 0

1.2.2 Is there a national organization for statistics of which the NHA is a part? 0.00 Do the NHA and the national organization for statistics: 1.2.2.1 Meet at least once a year to propose modifications to the information systems to make these systems more compatible? 0 1.2.2.2 Take the proposed modifications into account to improve the NHK’s information systems? 0 1.2.2.3 Propose specific measures to improve the quality and usefulness of information from the NHA? 0 1.2.2.4 Know the percentage of medically certified deaths known? 0 If so, 1.2.2.4.1 Does the NHA consider that this percentage makes the mortality data reliable? 0

1.3 Expert Support and Resources for Monitoring Health Status 0.00 1.3.1 Does the NHA use or have access at the national level to personnel with expertise in epidemiology and statistics? 0.00 Does this personnel have expertise in the following areas: 1.3.1.1 Was this personnel trained in epidemiology at the Doctoral level? 0 1.3.1.2 Sampling methodologies for collecting qualitative and quantitative data? 0 1.3.1.3 Consolidating data from various sources? 0 1.3.1.4 Data analysis? 0 1.3.1.5 Interpreting results and formulating scientifically valid conclusions based on the data analyzed? 0 1.3.1.6 Translating data into clear and useful information to produce comprehensible and well-designed documents for different audiences? 0 1.3.1.7 Design and maintenance of disease registries (e.g. cancer registries)? 0 1.3.1.8 Communicating health information to decision-makers and members of community organizations? 0 1.3.1.9 Research and quantitative analysis? 0

1.3.2 Does the NHA use or have access to personnel with expertise in epidemiology and statistics at the intermediate levels? 0.00 Does this personnel have training and expertise in the following areas: 1.3.2.1 Sampling schemes for data collection? 0 1.3.2.2 Consolidating data from various sources? 0 1.3.2.3 Data analysis? 0 1.3.2.4 Interpreting results and formulating scientifically valid conclusions based on data analyzed? 0 1.3.2.5 Translating data into clear and useful information? 0 1.3.2.6 Design and maintenance of disease registries (e.g., cancer registries)? 0 1.3.2.7 Communicating health information to the population? 0 1.3.2.8 Communicating health information to decision-makers? 0 1.3.2.9 Was this personnel trained in public health at the Master’s degree level? 0

1.4 Technical Support for Monitoring and Evaluating Health Status 0.00 1.4.1 Does the NHA utilize computer resources to monitor the population’s health status? 0.00 Does the NHA: 1.4.1.1 Utilize computer resources to monitor the health status of the country’s population at the intermediate levels? 0 1.4.1.2 Utilize computer resources to monitor the health status of the population at the local level? 0 1.4.1.3 Have personnel trained in the use and basic maintenance of these computer resources? 0 1.4.1.4 Use a system that includes one or more computers with high-speed processors? 0

378 1.4.1.5 Have programs with commonly used utilities (word processors, spreadsheets, graphic design and presentation software)? 0 1.4.1.6 Have the capacity to convert data from various sources to standard formats? 0 1.4.1.7 Have a dedicated line and high-speed access to the Internet? 0 1.4.1.8 Have electronic communication with the subnational levels that generate and utilize information? 0 1.4.1.9 Have sufficient storage capacity to maintain the databases on the country’s health profile? 0 1.4.1.10 Meet the design requirements for compiling vital statistics? 0 1.4.1.11 Have rapid access to specialized maintenance of the computer system? 0 1.4.1.12 Annually assess its need for upgrading its computer resources? 0 1.4.1.13 Can you give an example in which computer resources were used to monitor health status? 0

1.5 Technical Assistance and Support to the Subnational Levels of Public Health in Monitoring, Evaluating and Analysis of Health Status 0.00 1.5.1 During the past 12 months, has the NHA advised one or more subnational levels on data collection and analysis? 0.00 1.5.1.1 Has the NHA advised the subnational levels on the design of instruments for collecting relevant health data? 0 1.5.1.2 Have all subnational levels been informed of the NHK’s availability to advise them on data collection methodology? 0 1.5.1.3 Have the subnational levels been informed of the NHK’s availability to advise them on methodology for the analysis of data collected locally? 0 1.5.1.4 During the past 12 months, has the NHA actually advised one or more subnational levels on the methodology to analyze data collected locally? 0

1.5.2 During the past 12 months, has the NHA constantly disseminated information periodically to users at the subnational levels? 0.00 1.5.2.1 Has feedback been sought from these users of this information? 0 1.5.2.2 Have these users been advised on how to interpret these analyses? 0 1.5.2.3 During the past 12 months, has the NHA advised those responsible for producing the community health profile at the subnational levels? 0 1.5.2.3.1 Have those responsible for publishing the community health profile been informed that provisions exist to advise them on this? 0

379 COLOPHON

This book has been produced by the Pan American Health Organization. Two-thousand copies have been printed in the English language in September 2002, in Washington, D.C., USA.