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PAHOCOLLOD234

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Published also in Spanish with the title:Informe del Director: Cuadrienal 1986-1989, Anual 1989

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Report of the DirectorQuadrennial 1986-1989

Annual 1989

Official Document No. 234

PAN AMERICAN HEALTH ORGANIZATIONPan American Sanitary Bureau · Regional Office of the

WORLD HEALTH ORGANIZATION525 Twenty-third Street, N.W.

Washington, D.C. 20037, U.S.A.

TO THE MEMBER COUNTRIES OF THEPAN AMERICAN HEALTH ORGANIZATION

In accordance with the Constitution of the Pan American Health Organi-zation, I have the honor to submit the 1986-1989 quadrennial and 1989annual report on technical cooperation activities of the Pan American Sani-tary Bureau, Regional Office of the World Health Organization. Within thecontext of regional health-for-all strategies and of policies set by the PanAmerican Health Organization's Governing Bodies, the report analyzes thesalient activities in the Organization's technical cooperation program duringthe quadrennium.

This report is complemented by other documents that are also submittedfor the consideration of the XXIII Pan American Sanitary Conference: HealthConditions in the Americas (1990 edition) and the Financial Report of the Directorand Report of the External Auditor, 1988-1989.

This report has been produced with the same structure as the biennialProgram Budgets in order to facilitate the analysis of the activities carried outby the Organization.

Respectfully,

Carlyle Guerra de MacedoDirector

CONTENTS

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

INTRODUCTION ............................................................ xi

1. GOVERNING BODIES .................................................... 1

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

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

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

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

Introduction ................................................................ 9Managerial Process for National Health Development ............................ 10Technical Cooperation among Countries and Projects at the Country Level ......... 11Health Situation and Trend Assessment ................... 1.................... 11Health Policies Development ................................................. 14Organization of Health Services Based on Primary Health Care ................... 17

Health Services Development ............................................... 17Essential Drugs and Vaccines ............................................... 21Oral Health .............................................................. 23Clinical, Laboratory, and Radiological Technology for Health Services ............ 26Health Education and Community Participation .............................. 28

Women, Health, and Development ............................................ 30Emergency Preparedness and Disaster Relief Coordination ........................ 31Human Resources Development .............................................. 36

Policy and Coordination ................................................... 37Human Resources Administration .......................................... 38Human Resources Training ................................................ 38

Health Information Support ................................................. 39Official and Technical Publications .......................................... 39Scientific and Technical Information ........................................ 39Information and Public Affairs .............................................. 43

Research Promotion and Development ........................................ 45

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

Introduction ............................................................... 48Food and Nutrition ......................................................... 49

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

V. ADMINISTRATION ....................................................... 75

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

VI. PAHO/WHO TECHNICAL COOPERATION AT SUBREGIONAL ANDCOUNTRY LEVELS .................................................... 79

Introduction .............................................................. 79

Caribbean Area ........................................................... 80

Caribbean Cooperation in Health .......................................... 80

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

Central America ........................................................... 107

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

Belize ................... 1.............................................. 110Costa Rica .............................................................. 111

Contents

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

South America ............................................................ 121

Andean Cooperation in Health ............................................ 121

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

Southern Cone Health Initiative ........................................... 132

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

North America ............................................................ 140

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

Index .................................................................... 148

SPECIAL REPORTS

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

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PAN AMERICAN HEALTH ORGANIZATION:HISTORY AND STRUCTURE

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

Origin: The Pan American Sanitary Bureau had its origin in a resolution of theSecond International Conference of American States (Mexico, January 1902) recommend-ing that "a general convention of representatives of the health organizations of the differentAmerican republics" be convened. That convention met in Washington, D.C., on 2-4December 1902 and established a permanent directing council-the International SanitaryBureau-which was the predecessor of the current Pan American Health Organization. TheFifth International Conference of American States (Santiago, Chile, 25 March-3 May1923) changed the name of the International Sanitary Conferences and of the InternationalSanitary Bureau to Pan American Sanitary Conferences and Pan American SanitaryBureau, respectively. In 1924, the Pan American Sanitary Code, signed in Havana andratified by the governments of the 21 American republics, assigned broader functions andresponsibilities to the Bureau as the central coordinating agency for international healthactivities in the Americas. The XII Pan American Sanitary Conference (Caracas, 1947)adopted a reorganization plan whereby the Bureau became the executive agency of the PanAmerican Sanitary Organization, the Constitution of which was officially approved by theDirecting Council at its first meeting in Buenos Aires later that year.

In 1949, the Pan American Sanitary Organization and the World Health Organizationagreed that the Pan American Sanitary Bureau would serve as the Regional Office of theWorld Health Organization for the Americas. In 1950, the Pan American Sanitary Organi-zation was recognized as a specialized inter-American organization with full autonomy inthe accomplishment of its purposes. Thus, the Organization became a component of boththe United Nations and the inter-American systems.

The XV Pan American Sanitary Conference (San Juan, Puerto Rico, 1958) changedthe name of the Pan American Sanitary Organization to the Pan American Health Organi-zation. The name of the Pan A-merican Sanitary Bureau remained unchanged.

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

Structure: The Pan American Health Organization comprises the following:

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

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viii Report of the Director

The Directing Council-consisting of one representative of each Member Govern-ment-meets once a year and acts on behalf of the Conference in years when that bodydoes not meet. It reviews and approves the Organization's program and budget.

The Executive Committee-composed of representatives of nine Member Govern-ments elected by the Conference or the Council for staggered three-year terms-meets twiceyearly to consider technical and administrative matters, including the program and budget,and submits its recommendations to the Conference or Council. The Subcommittee onPlanning and Programming of the Executive Committee was reorganized in 1984 toenhance the participation of the governments in programming the Organization's activi-ties. It is made up of delegates from seven countries, meets twice yearly, and reports directlyto the Executive Committee.

The Pan American Sanitary Bureau, which acts as the Executive Secretariat and isheaded by the Director, carries out the directives of the Governing Bodies.

Budget: The Organization has a biennial budget made up of quotas from MemberCountries of the Pan American Health Organization, the World Health Organizationallocation for the Regional Office of the Americas, and extrabudgetary funds.

Disbursements during the 1986-1987 biennium were $US243,000,000, of which over42% ($US102,200,000) were from PAHO Member Countries, 22% ($US54,000,000) werefrom WHO, and 36% ($US86,800,000) were from extrabudgetary sources.

During the 1988-1989 biennium disbursements rose to $US311,000,000, of whichroughly 38% ($US117,500,000) were from PAHO Member Country funds, 19%($US58,000,000) were from WHO, and 43% ($US135,500,000) were from extrabudgetarysources.

Member Governments:

Antigua and BarbudaArgentinaBahamasBarbadosBelizeBoliviaBrazilCanadaChileColombiaCosta RicaCuba

DominicaDominican RepublicEcuadorEl SalvadorGrenadaGuatemalaGuyanaHaitiHondurasJamaicaMexicoNicaragua

PanamaParaguayPeruSt. Kitts and NevisSaint LuciaSt. Vincent and the

GrenadinesSurinameTrinidad and TobagoUnited States of AmericaUruguayVenezuela

Participating Governments:

France, Kingdom of the Netherlands, and United Kingdom of Great Britain andNorthern Ireland

Observers:

Portugal and Spain

viii Report of the Director

PAHO: History and Structure ix

PAHO/WHO Country Representations:

ArgentinaBahamasBarbados

(Also directly served by thisRepresentation: Antigua andBarbuda, Dominica,Grenada, St. Kitts andNevis, Saint Lucia, St. Vin-cent and the Grenadines.Eastern Caribbean: Anguilla,British Virgin Islands, Mont-serrat. French Antilles: Gua-deloupe, Martinique, St.Martin and St. Bartholomew,French Guiana)

BelizeBoliviaBrazilChileColombiaCosta RicaCubaDominican RepublicEcuadorEl SalvadorGuatemalaGuyanaHaitiHonduras

Jamaica(Also directly served by thisRepresentation: Bermuda,Cayman Islands, Turks andCaicos Islands)

MexicoNicaraguaPanamaParaguayPeruSurinameTrinidad and TobagoUruguayVenezuela

(Also directly served by thisRepresentation: NetherlandsAntilles)

PAHO/WHO Field Office, El Paso, Texas, U.S.A.English-speaking Caribbean Program Coordination, Barbados

Central Office

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

PAHO/WHO Regional and Subregional Centers, Institutes, and Programs

Latin American Center on Health Sciences Information (BIREME), BrazilCaribbean Epidemiology Center (CAREC), TrinidadPan American Zoonoses Center (CEPANZO), ArgentinaPan American Center for Sanitary Engineering and Environmental Sciences (CEPIS), PeruCaribbean Food and Nutrition Institute (CFNI), JamaicaLatin American Center for Perinatology and Human Development (CLAP), UruguayPan American Center for Human Ecology and Health (ECO), MexicoInstitute of Nutrition of Central America and Panama (INCAP), GuatemalaPan American Foot-and-Mouth Disease Center (PANAFTOSA), BrazilHealth Training Program for Central America and Panama (PASCAP), Costa Rica

PAHO: History and Structure ix

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INTRODUCTION

The 1980s has been the most pivotaldecade since the Second World War in termsof social and economic development policies.By the end of 1989, the world's political andeconomic conditions that had been takenfor granted since the 1940s had been irre-versibly altered.

The economic contraction in the devel-oped countries of the West rippled throughthe developing countries in the form ofshrinking markets, mounting inflation, andstringent loan policies. Debt-ridden govern-ments in the Region halted developmentprojects and slashed social spending. The cri-sis also had deep repercussions in the democ-ratization process that was taking place atthe time. Even in the prosperous industrial-ized areas of the Americas, unprecedentedaffluence, space-age technology, and extraor-dinary medical and scientific breakthroughsvied for headlines alongside urban homeless-ness, environmental hazards, massive fiscaldeficits, drug addiction, violence, andAIDS.

For the vast majority of the people ofLatin America and the Caribbean, the 1980sbecame the "lost decade," a term coined bybanks and international development orga-nizations to sum up the dashed hopes andthe erosion of gains in infrastructure, indus-try, and health that had been achieved overthe past 30 years.'

The protracted economic crisis shookthe foundations of prevailing developmentmodels and seriously jeopardized the role ofthe State in providing for the welfare of itscitizens. The social services sector-includingpublic health-was particularly hard hit.Moreover, since there is a lag between eco-

' Economic and Social Progress in Latin America, Inter-American Development Bank, Washington, D.C., 1988.

nomic deterioration and the detection of itseffects, many of the consequences in healthmay not yet be fully apparent.

Faced with the surrounding economicdeterioration, the Region's health ministriesconcentrated much of their effort towardreforming the deployment of resources inorder to maximize coverage of preventiveservices. The challenge was sizable anddemanded great perseverance from healthpersonnel during the 1986-1989 period. Yet,despite seemingly insurmountable odds, theysuccessfully protected past gains and, insome instances, even achieved significantimprovements in key health indicators.

The Regional Economy

Economic reports on the developingcountries in the Americas paint a picture ofsetbacks or stagnation for most of thedecade. The last quadrennium was no excep-tion: as many development projects groundto a halt, inflation and the foreign debt bur-den grew in tandem with the population inneed of public services.

The governments, including several newcivilian and democratic administrations thatinherited enormous problems, tackled theforeign debt crisis within the framework ofharsh formulas prescribed by internationallenders. Debt repayment plans called forexport increases, import cuts, and sharpreductions in public spending.

Efforts to expand the volume of exportsyielded dramatic results. Yet, the expectedincrease in earnings was virtually nullified bythe falling prices of export commodities. Infact, although export volume for the Regionincreased a remarkable 35% from 1981 to1988, balance sheets showed that countrieswere treading water: total income from

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exports remained unchanged or actuallydropped, 2 and 40% of those earnings went tofinance the debt service.

Fiscal policies, credit shortages, andmonetary devaluations sharply curtailedimports, and national production of substi-tutes-for which start-up imports and a sta-ble investment climate would have beennecessary-did not replace them. Instead,the investment-to-GDP ratio in Latin Amer-ica and the Caribbean was the lowest of allthe regions with the exception of Africa. Asa result, obsolescence and decapitalizationruled the day, and the health sector was notspared.3

Economic adjustment policies wereimposed at great social cost: in 1980, 30% ofthe population was poor, whereas in 1989,an estimated 40% of the Region's popula-tion-170 million people-lived in poverty.Half of the poor had incomes too meager tobuy enough food.

The cumulative regional trend was dis-couraging. With some notable exceptions,per capita availability of goods and servicesin 1987 was only 87.5% of that existing in1980.4 With a gross domestic product growthrate of 1.4% over the decade, Latin Americaand the Caribbean lagged behind the rest ofthe world's regions, which, except for sub-Saharan Africa, had growth rates of at least2.5%. 5

The low economic growth rate causedunemployment and underemployment torise, while inflationary pressure, fueledpartly by monetary expansion to financepublic deficits, was increasingly felt in manycountries.6 In several, notably Argentina,Brazil, Nicaragua, and Peru, inflation soaredout of control, placing scarce products out ofthe average person's reach. Simultaneously,per capita food availability dropped in 13 of

2 Ibid.3 The World Bank Annual Report, World Bank, Washing-

ton, D.C., 1989.4 IDB, op. cit.

World Bank, op. cit.6 IDB, op. cit.

17 countries studied by the Economic Com-mission for Latin America and the Carib-bean (ECLAC). Food imports declined andconsumer food prices spiraled upwards,while governments slashed food subsidies.

Effects on the Health Sector

Ever-tightening resources make publicplanning difficult-including in the healthsector. Although the budget percentagesallocated to health ministries generally didnot change much for the Region as a whole,they were severely reduced in more than adozen countries. 7 Moreover, the real value ofthe resources declined yearly across theboard, as did total government social expen-ditures. Consequently, less money was avail-able to maintain and stock public healthprograms, clinics, and hospitals. Healthworkers' real wages dropped; scarce fundsmade it difficult to cover the rising cost ofcritical imports like vaccines, equipment,and pharmaceuticals; 8 and investments formaintaining or improving equipment andhealth facilities plummeted.

Maintaining existing levels of serviceswas difficult, and expanding programs,almost unthinkable. Yet, expansion wascalled for: the natural population growthincreased the number of people requiringservices; in addition, more than 150 millionpeople who were unemployed or had lowerdisposable incomes were not covered bysocial security, nor could they afford privatecare.

If circumstances remain as they are, inthe year 2000, only 10 years from now,almost half the population of the Region-some 250 million people-will lack regularaccess to health services. If the governments

7 IDB, op. cit.8 P. Musgrove (ed.), "Economic Crisis and Health: The

Experience of Five Latin American Countries," DocumentCD34/24, Annex II, prepared for the XXXIV Meeting ofthe PAHO Directing Council, Washington, D.C., Septem-ber 1989.

xii Report of the Director

Introduction xiii

are to meet their goal of providing equalaccess to health care for all of their people,they will have to double their coverage inthe coming decade, precisely when they areleast able to do so.

Health Trends

Daunting as the task of doubling thecoverage may be, the health sector's chal-lenges go well beyond the sheer number ofpersons to be served.

One of the reasons that public healthservices have been taxed by increaseddemand has been the demographic shiftfrom rural to urban centers that has resultedfrom preceding development policies. Theeconomically active population is now con-centrated in the cities, where the jobs andservices are based. By this century's close, itis expected that more than 75% of theRegion's population will live in urban set-tings, and that half of that urban populationwill be concentrated in 15 cities of more thanfour million people each.

This radical shift brings with it a changein health profile, for what is termed urban-ization is actually fast-growing rings of pov-erty surrounding major cities. The residentsof these poverty belts live in squalor, inunplanned and overcrowded settlementswith no basic services such as water, sanita-tion, vector control, and health clinics. Theyare beset by the problems typical of impover-ished urban concentrations: low infant birthweight, abandoned children, environmentalhazards, drug abuse, malnutrition, and ahost of other diseases stemming from inade-quate income and services.

Economic conditions in rural areas havenot improved either. According to ECLAC,agricultural real wages fell steadily in 16countries studied. Simultaneously, the criti-cal demand for services in urban areas, cou-pled with resource and personnel shortages,meant that most health programs did notmake major inroads in reaching dispersedagricultural population groups.

Although the health sector can do littleto solve poverty itself, it deals daily with pov-erty's consequences. Almost 700,000 people,most of them children, die each year fromdiseases that would be wholly preventable ifthese persons had clean water, enough food,and access to simple, inexpensive vaccinesand early, basic preventive and curative care.Gastroenteritis and diarrheal diseases aloneare linked to 200,000 of these deaths. Noexpensive new pharmaceuticals need bedeveloped; the technology already is there.The problem is how to provide access toexisting services and technology and how toobtain the political commitment and fund-ing support to expand effectively and effi-ciently in times of crisis.

Another change also has made itself feltin the demands on health services. Gradu-ally but steadily, the population of LatinAmerica and the Caribbean is aging. Pro-longed life expectancy is a sign of significantachievement by the Region, but that verysuccess also means that public health andmedical services must adapt to the increasingprevalence of chronic diseases that wereonce the province of the wealthy who couldafford private care. This implies new train-ing, epidemiologic studies, more complexservices, and public information activities-all of which require funding.

The Work of the Organization Duringthe Quadrennium

One of the principal tenets on which theOrganization's activities are based is thatuniversal access to health services should beseen and acted upon as a fundamental rightof every citizen, whose well-being should bethe very purpose of national developmentpolicies.

Putting these principles into practice,especially during an economic crisis, calls forunflagging efforts to preserve existing pro-grams while discovering creative ways toachieve the goal of equity. Part of the strat-egy is to obtain the political resolve at the

Introduction xiii

xiv Report of the Director

national and local levels to make the neces-sary changes and increase financing forhealth programs. The health sector itselfmust also find ways of making more efficientuse of the resources it already has in hand.

At the request of its Member Govern-ments, PAHO marshaled its resources toemphasize a several-pronged strategy overthe quadrennium: while tackling the com-plex organizational reforms needed toincrease the efficiency and scope of the deliv-ery of basic health services, the Organizationspearheaded the mobilization of national,subregional, and external resources for spe-cific projects that are achievable in theshorter term. A chief approach towardaccomplishing the mobilization of resourceswas the identification of priority programs ofcommon interest to groups of countries,which translated into intensified coopera-tion in jointly chosen fields and better coor-dination among national-level institutionsand organizations.

Transformation of National HealthSystems

The core of PAHO's quadrennial strat-egy to promote the transformation of exist-ing national health systems was set out inthe "Orientation and Program Priorities forPAHO during the Quadrennium 1987-1990." Adopted in 1986, this documentaddressed institutional obstacles-many ofwhich are the product of excessive centrali-zation-that hinder the expansion of healthservices' delivery. The programming priori-ties established were to develop the healthservice infrastructure with emphasis on pri-mary health care, to provide responses topriority health problems present in vulnera-ble groups, and to administer the knowledgerequired to carry out the former.

The key to the first priority was themove to develop and strengthen local healthsystems. Local health systems should pro-vide comprehensive primary services that are

flexible enough in scope to serve specificcommunity needs. This approach also seeksto decentralize decisions about howresources and services are managed in orderto establish responsibility and accountabilityat the local level; in other words, it sets up alevel of local authority that is lacking inhighly centralized systems. Given that socialparticipation is critical for this approach towork, democratization is both a key to itssuccess and a byproduct of its implemen-tation.

The vulnerable groups that have beensingled out for special efforts include chil-dren, pregnant women, the very poor, andthe elderly, as well as adolescents who areexposed to the additional risks of violenceand drug abuse in periurban settlements.Among these groups, children received spe-cial attention through programs for immuni-zation, control of diarrheal diseases andacute respiratory infections, and monitoringof growth and development. If the campaignto eradicate the wild poliovirus by the end of1990 is successful-and evaluation resultsindicate that this target will be met-theRegion will be the first in the world to havedone so. Inroads also have been madeagainst measles, another serious and pre-ventable childhood disease; the Caribbean,Canada, Costa Rica, Cuba, and the UnitedStates have set 1995 as the target date foreliminating its indigenous spread.

The effort to harness knowledge by pro-moting a greater availability and better useof information includes researching, analyz-ing, and disseminating information. Further-more, the Organization boosted its publicinformation efforts through video andbroadcast technology to make succinct, visu-ally immediate health information availableto the public at large. It is hoped that a bet-ter-informed public will change its behaviorin the pursuit of health. Likewise, a well-informed population is better able to breakthe barrier of silence and exercise its demo-cratic rights in demanding appropriatehealth services where it lives.

xiv Report of the Director

Introduction xv

Where the Region Stands

The main approach during 1986-1989was to target concrete, achievable goalswhile tackling the more difficult process oftransforming the structures of health caredelivery systems. In addition to guaranteeingtangible progress, this approach capitalizeson specific accomplishments to maintainmomentum and morale. There were a num-ber of accomplishments that would be grati-fying even in the best of times; they areparticularly noteworthy given the crisis envi-ronment in which they were realized.

Among PAHO Member Governments'most significant gains is the fact that theyconceived of and cooperated in carrying outa common health strategy-an achievementin its own right, since crises often bringabout competition for resources. The adop-tion of the "Orientation and ProgramPriorities" as a framework for health devel-opment was linked to the subregional initia-tives for coordinated solutions to problems.The Plan for Priority Health Needs in Cen-tral America has achieved substantial suc-cess in obtaining financial support due tointernational concern about the subregion'scritical situation and the consonant enthu-siasm for the initiative's strategic motto,"Health as a Bridge for Peace." The otherinitiatives made progress in some of theirtarget areas, and will continue to be majorvehicles for PAHO/WHO's technicalcooperation.

An important indicator of the Organiza-tion's achievements during the quadren-nium is the vote of confidence expressed bythe sizable external funding that wasreceived over the period. By the close of thequadrennium, the extrabudgetary contribu-tions to PAHO's health programs came closeto matching the combined contributions tothe PAHO and regional WHO regular pro-gram budgets. Raising funds of that magni-tude at a time when many internationalprograms face cutbacks testifies to the inter-national community's confidence in the

Organization as a catalyst for regional healthdevelopment policies.

Regarding the development of healthservice infrastructures, several health minis-tries established operational agreements withsocial security institutes to reduce the dupli-cation of services and provide coveragewhere neither had done so before. Progressalso was made in the complex task of estab-lishing epidemiologic profiles on which tobase preventive interventions and localhealth systems. Most governments alsoadvanced in determining health manpowerneeds and, with PAHO/WHO's coopera-tion, in implementing appropriate trainingprograms.

In order to combat priority health prob-lems among vulnerable groups, most Mem-ber Governments improved their vac-cination coverage of children under one yearof age; lowered infant mortality due to diar-rheal diseases, acute respiratory infections,and poor perinatal care; and significantlydecreased the incidence of urban rabies.Achievements in overall nutrition were lessmarked, largely because of the economic sit-uation. However, notable improvementswere made in addressing specific nutritionalproblems, such as endemic goiter, for whichtargeted health interventions are possible.

The health service areas that were mostaffected by the economic crisis were hospital-based care, water and sanitation services,and vector control, areas for which suppliesand equipment that are often imported rep-resent expensive recurrent costs. The lack offunds also curtailed the construction andmaintenance of large facilities for hospitalcare and for water and sewage treatment.

Significant challenges will continue toface the Region's health sector over the com-ing decade: health hazards from increasingexposure to environmental contaminants, acontinual struggle to guarantee universalaccess to health services, the persistent prob-lem of controlling preventable diseases thatstill take an unnecessary toll in morbidityand mortality, the growing problem of meet-

Introduction xv

Report of the Director

ing the health needs of the elderly, and theincreasing impact from the abuse of alcohol,tobacco, and illicit drugs.

As the following chapters will makeclear, the Region has shown that much canbe done even in the worst of times. Yet, noneof these areas fall within the health sector'ssole purview. The challenge of crafting via-ble new development policies is now on thetable for the countries of the Americas. Suchdevelopment policies will have to includeparticipatory democracy, must consider the

implications of a changing world and theirimpact on the environment, and shouldredefine the role of the State in the provisionof social services.

The health sector's progress hinges, to asignificant extent, on the outcome ofnational development decisions. Yet, in for-warding its goals of safeguarding the healthof the population and obtaining universal,equitable access to services, the health sectoris simultaneously contributing toward thelarger purpose of national development.

xvi

CHAPTER I

GOVERNING BODIES

Three Governing Bodies guide the workof the Pan American Health Organization.The Pan American Sanitary Conference,PAHO's supreme governing body, is com-posed of a representative from each MemberGovernment and meets every four years. Itelects the Director of the Pan American San-itary Bureau, defines PAHO's general poli-cies, and serves as the main forum in whichthe governments debate major public healthissues.

The Directing Council, too, is made upof one representative of each Member Gov-ernment and meets yearly during the threeintervening years that the Conference doesnot. The Council reviews and approves thebudget for PAHO's programs and matters ofimportance to the Organization and itsMember Governments.

The Executive Committee is constitutedby representatives from nine Member Gov-ernments elected by the Conference or theCouncil for staggered three-year terms. TheCommittee meets twice yearly to reviewtechnical and administrative matters andsubmits its recommendations to the Councilor Conference; it also drafts the agendas fortheir meetings.

By agreement with the World HealthOrganization, the Conference and theCouncil also serve as the World HealthOrganization's Regional Committee for theAmericas.

In the course of their regular meetingsduring the quadrennium, each of the Gov-erning Bodies of PAHO passes a set of reso-lutions recommending actions to MemberGovernments and the Director of PASB.The main resolutions adopted during the

period provide guidelines for national andregional programs and reflect the chief con-cerns of Member Governments regardingthe status of public health in the Region.

PAN AMERICAN SANITARYCONFERENCE

The XXII Pan American Sanitary Con-ference (XXXVIII Meeting of the WHORegional Committee for the Americas) washeld at PAHO/WHO's Washington, D.C.,headquarters in 1986. Member Govern-ments elected Dr. Carlyle Guerra de Macedoto a second four-year term as Director tostart in 1987 (Resolution II).

Noteworthy among Conference resolu-tions was one approving the document "Ori-entation and Program Priorities for PAHOduring the Quadrennium 1987-1990" (Reso-lution XXI), which set the basic four-yearprogram guidelines for the Organization andits Secretariat. The resolution furtherrequested that special attention be given tothe following: strengthening health servicesinfrastructures; developing the health sec-tor's financial analysis and resource manage-ment capabilities; improving national healthinformation systems; and defining the rolesof health workers, recognizing the impor-tance of community participation and inte-grating health manpower education andtraining.

The Conference endorsed the initiative"Caribbean Cooperation in Health" (Reso-lution XI) that PAHO, the Caribbean Com-munity (CARICOM), and the Conferenceof Ministers Responsible for Health in the

1

2 Report of the Director

Caribbean developed jointly. The Confer-ence also supported the "Joint Plan ofAction for the Andean Subregion" (Resolu-tion XXII) designed by the Organization andthe Hipólito Unanue Agreement, in whichthe mobilization of resources for priorityareas was emphasized.

DIRECTING COUNCIL

During the quadrennium, the DirectingCouncil held three meetings: XXXII (1987),XXXIII (1988), and XXXIV (1989). Resolu-tion XV adopted at the XXXIII Meeting ofthe Directing Council was one of the Coun-cil's strongest actions to ensure implementa-tion of the Organization's priority tostrengthen health systems infrastructures.Stating its conviction that the challenge ofimproving the health of most needy popula-tion groups should be met despite theRegion's economic crisis, the Council calledon Member Governments to redouble theirefforts to define policies, strategies, pro-grams, and activities toward developing localhealth systems. The Resolution placed spe-cial emphasis on the adequate allocation ofresources and on administrative decentral-ization as ways to strengthen the operatingcapacity of local systems. The Director,meanwhile, was requested to undertake awide range of activities in this area, includ-ing technical cooperation, information dis-semination, evaluation, and programsupport of national efforts.

Program Budget

In 1987, at its XXXII Meeting,the Directing Council appropriated$US 138,806,000 to support PAHO programsduring the 1988-1989 biennium (ResolutionII). At its XXXIV Meeting in 1989, theCouncil appropriated $US145,599,550 forthe 1990-1991 budget period. By increasingthe efficiency and effectiveness of its opera-tions, managing its resources carefully, and

attracting more extrabudgetary resources,the Organization kept its budgetaryincreases at modest levels, particularly com-pared to other international agencies.

Quota Contributions

The status of Member Countries' quotacontributions was a matter of grave concernfor PAHO's Governing Bodies. As a result ofthe prolonged economic and debt crises,some governments did not meet their inter-national treaty obligation to pay yearlymembership quotas. Over the quadrennium,the Governing Bodies noted a disturbingincrease in the number of PAHO MemberGovernments that were in arrears.

Consequently, the Governing Bodiesconsidered applying Article 6.B of thePAHO Constitution, which requires sus-pending the voting privileges of a MemberGovernment that falls in arrears in anamount exceeding the sum of its annual quo-tas for two full years. Several resolutionsvoiced the Council's concern that this sanc-tion might be called for. In 1989, the Councilrequested that the Director notify two Mem-ber Governments that their voting privilegeswould be suspended unless their payment-plan requirements were fulfilled by the open-ing of the XXIII Pan American SanitaryConference in 1990. The Council, however,also commended those governments thathad made impressive efforts to meet theirback obligations to PAHO.

Subregional Initiatives

As noted above, the XXII Pan AmericanSanitary Conference endorsed PAHO subre-gional initiatives in the Caribbean and inthe Andean Region. At its XXXIII Meeting,the Council adopted Resolution X, endors-ing the guidelines and strategies jointlydeveloped by the countries of the AndeanSubregion and instructing the Director tocollaborate with the Andean countries in


Governing Bodies

mobilizing international support for thisjoint endeavor.

Disease Prevention and Control

The Governing Bodies adopted severalresolutions which promoted concerted cam-paigns to prevent, control, or eradicate cer-tain infectious diseases and to increaseawareness regarding substance abuse andother behavior resulting in ill health. Thecampaign to eradicate the indigenous trans-mission of the wild poliovirus from theAmericas by 1990 was the subject of severalresolutions of the Directing Council. TheCouncil also approved resolutions calling forprompt measures in response to the growingproblem of AIDS, for which program theOrganization received increased financialsupport. The need to strengthen malariacontrol programs and the observed spread ofAedes albopictus in certain areas of the Re-gion prompted the Directing Council to ap-prove resolutions that also underscored theneed to control or eradicate Aedes aegypti.

Tobacco and drug abuse received grow-ing attention from the PAHO GoverningBodies. At its XXXIII Meeting, the DirectingCouncil approved Resolution XVIII, pro-moting drug abuse prevention, and Resolu-tion XXII, encouraging the fight againsttobacco use. Similarly, at its XXXIV Meet-ing, the Council approved the Regional Planof Action for the Prevention and Control ofthe Use of Tobacco (Resolution XII), as wellas Resolution XIV on the fight against drugaddiction, drug abuse, and drug trafficking.

Women, Health, and Development

The Governing Bodies of PAHO havenoted repeatedly the injustices and waste ofpotential resources that arise when womenare denied full partnership, with equal rightsand equal access, in all areas of the strugglefor human and national development. Ineach of its meetings throughout the qua-

drennium, the Council adopted resolutionsreflecting its concern regarding this issue,and its desire that substantial improvementsbe achieved in this regard.

Disasters and EmergencyPreparedness

Each year, the Region of the Americassuffers damages from hurricanes, earth-quakes, volcanic eruptions, floods, droughts,and armed conflicts. Since the mid-1970s,PAHO has pioneered disaster preparednessin the world. Resolution X adopted at theXXXII Meeting of the Directing Council(1987) focused on the technical aspects ofdisasters and health, and Resolution VIadopted at the Council's XXXIV Meetingaddressed the effects of Hurricane Hugo andcommended the Director for the Organiza-tion's response to emergency situations inthe countries.

Additional Issues

The implications of the "lost decade" forhealth programs in Latin America and theCaribbean were considered at every meetingof the Governing Bodies throughout the1980s. At its XXXIV Meeting in 1989, theDirecting Council, in Resolution XV, under-scored the importance of PAHO's ongoingstudy of the repercussions that the economiccrisis has had on health conditions in theRegion.

Resolution XIII adopted at the XXXIIIMeeting of the Directing Council (1988)requested that before the end of 1990, Mem-ber Governments set national goals toreduce maternal mortality by the year 2000,and that those countries registering morethan five maternal deaths per 10,000recorded live births set the goal of reducingthat mortality rate by at least 50%.

During its XXXIII Meeting, the Direct-ing Council also addressed the Organiza-tion's policy and lines of action in regard to

3


food and nutrition (Resolution XVI). Recog-nizing the persistence of serious food andnutrition problems in the Region, the Coun-cil urged Member Governments tostrengthen multisectoral policies and strate-gies for improving nutritional status, particu-larly among low-income populations andgroups at high biological risk. Seven aspectsof the Organization's technical cooperationwere emphasized, including planning, exe-cuting, and evaluating food and nutritionstrategies; nutritional surveillance; food dis-tribution; and the control of iodine, iron,and vitamin A deficiencies.

EXECUTIVE COMMITTEE

In addition to analyzing technical andpolicy issues and making recommendations

to the Directing Council and the Pan Ameri-can Sanitary Conference for final consider-ation and action, the Executive Committeereviewed a variety of matters regarding theOrganization's management, including sev-eral amendments to the Staff Rules of thePan American Sanitary Bureau, progressreports on the implementation of the newlycreated system for hiring personnel underlocal conditions of employment, actionsrequired for administration of the buildingfund, and recommendations concerning thecontent of the fellowships program. TheCommittee also took action on the reportsof its Subcommittee on Planning and Pro-gramming; its Subcommittee on Women,Health, and Development; and its StandingSubcommittee on Inter-American Nongov-ernmental Organizations in Official Rela-tions with PAHO.


CHAPTER II

GENERAL PROGRAM DEVELOPMENTAND MANAGEMENT

EXECUTIVE MANAGEMENT

PAHO Executive Management providesleadership to the Organization and guidanceto its Secretariat. Organization leadershipentails monitoring programs to ensure thatthey are regularly updated to meet the needsof the countries they serve and to keep pacewith developments in health technologiesand methods. In guiding the Organization'sSecretariat, Executive Management has thetasks of fostering dialogue and cooperationamong multilateral, bilateral, and privateagencies active in the health field, and ofpromoting international and national com-mitment to improve health in the Region.

Maintaining the Organization on asound financial footing is a critical ExecutiveManagement responsibility that involvesclose monitoring of the Organization's finan-cial status. This scrutiny was especially nec-essary during the 1986-1989 quadrennium,in which serious budgetary deficits anderratic payment of quota contributions werematters of constant concern. The new pro-gramming and financial systems that havebeen introduced over the past four yearshave enabled management to protect theprograms, activities, and strategic approachof the Organization during the 1980s.

REGIONAL DIRECTOR'SDEVELOPMENT PROGRAM

The Regional Director's DevelopmentProgram is a fund that is allocated in thebudget with the purpose of giving the Direc-

tor of PASB the flexibility to finance specialactivities in priority areas in which timing isof the essence and for which budgetary allo-cations could not be foreseen. Because of theshortfall in financial contributions to theOrganization, the Director reduced by 36%,or $US1,947,000, the amount originallyapproved for this purpose by the GoverningBodies for the period 1986-1989.

The Director used the remaining fundsto respond to unanticipated problems in thehealth sectors of Member Countries; to takeadvantage of new opportunities for or pro-mote approaches to technical cooperation;to support innovative concepts, approaches,or technology in health; and to promote,coordinate, or accelerate initiatives.

In this period, almost 62% of theseremaining funds were used for the first twopurposes, including the provision of specialsupport to several countries ravaged by theeffects of hurricanes Gilbert and Joan. Of thebalance, most was devoted to specific activi-ties of an urgent nature related to the initia-tion and execution of the Organization'sregional and subregional initiatives.

GENERAL PROGRAMDEVELOPMENT

During the 1986-1989 quadrennium,significant headway was made along variouslines of general program development to im-prove administrative management, increasethe Organization's efficiency and effective-ness, and ensure the Pan American SanitaryBureau's capacity to respond to changing

5


conditions in the countries and to the man-dates of the Governing Bodies, as containedin the document "Orientation and ProgramPriorities for PAHO during the Quadren-nium 1987-1990." Special attention wasdevoted to the improvement and automa-tion of the American Region Planning, Pro-gramming, Monitoring, and EvaluationSystem (AMPES), the joint PAHO/WHO-national government reviews of technicalcooperation activities in each country, thedevelopment of the Organization's staff, andthe strengthening of its Country Represen-tations.

As part of the AMPES process, consulta-tions were held at the country level in 1986and 1988 to draw up the general programbudgets for 1988-1989 and 1990-1991,respectively, which include PAHO/WHOtechnical cooperation activities during thoseperiods.

In addition to streamlining AMPES pro-cedures, evaluation of PAHO/WHO's pro-grams was incorporated into the system, aswere mechanisms that permit activities inprogress to be adjusted according to theavailability of human and financialresources. Overall, greater decentralizationwas sought, which in turn required eachorganizational unit to have the appropriatemanagerial infrastructure, while the Organi-zation maintained a centralized system to setpolicies and priority programs.

Efforts also focused on improving theProgram Budget and Monitoring and Evalu-ation Subsystems by establishing the prac-tice of specifying the results that eachprogram hoped each of its projects wouldachieve. The description of expected resultsthen serves as the basis for monitoring andevaluating programs.

Work done to improve the short-termphase of AMPES was geared toward creatingan integrated management information sys-tem, which will be refined over the course ofthe coming quadrennium. In this domain,progress was made in defining and program-ming an automated system to produce andassemble a PAHO/WHO Annual Operating

Program Budget (APB) plan and a four-month work plan (PTC). Microcomputer-based systems are now used to prepare eachunit's APB and PTC, which are then incor-porated in a single, Organization-wide database on the mainframe computer.

As part of the general program manage-ment process, joint evaluations of PAHO/WHO's technical cooperation were held inmost of the countries of the Region. Themeetings sought to refine the orientation oftechnical cooperation programs in eachcountry and to increase the efficiency withwhich PAHO/WHO resources are used.

Regarding the development of PAHO/WHO staff, top priority was given to stafftraining at all levels and to effective use oftraining resources and other supportmechanisms.

Activities designed to strengthenPAHO/WHO Country Offices are discussedin Chapter III of this report, under the sec-tion "Managerial Process for NationalHealth Development."

EXTERNAL COORDINATION FORHEALTH AND SOCIALDEVELOPMENT

PAHO/WHO's intensive effort to mobi-lize external financing for health projects hasachieved dramatic progress in the last fouryears. In 1989, extrabudgetary funds reachedall-time highs, amounting to more than 40%of the Organization's total spending.

As a result of its work to mobilize exter-nal resources, PAHO/WHO's relationshipwith major external funding sources that areactive in the Region was strengthened dur-ing the quadrennium. Annual meetings wereheld with multilateral organizations such asthe World Bank, the Inter-American Devel-opment Bank (IDB), the United NationsDevelopment Program (UNDP), the UnitedNations Children's Fund (UNICEF), andthe United Nations Population Fund(UNFPA).

PAHO/WHO also developed a network


General Progra Development ad Management

of contacts with contributors to PAHO'ssubregional initiatives (Plan for PriorityHealth Needs in Central America, AndeanCooperation in Health, Caribbean Coopera-tion in Health) and to special priorityprojects and programs (women, health, anddevelopment; polio eradication; and AIDSprevention and control). In support of theinitiatives in Central America and theCaribbean, the Organization formed delega-tions of national and PAHO/WHO officialsto seek potential financial backers in NorthAmerica and Europe.

The main external financing sources forhealth projects were the multilateral lendinginstitutions (IDB, World Bank), the Euro-pean Economic Community (EEC), and thegovernments of Canada, Denmark, the Fed-eral Republic of Germany, Finland, France,Italy, Japan, the Kingdom of the Nether-lands, Norway, Sweden, the United King-dom, and the United States. In addition toWHO, other agencies in the United Nationssystem, such as UNDP, UNFPA, andUNICEF, provided significant support, asdid nongovernmental sources, including theW. K. Kellogg' Foundation, the CarnegieCorporation of New York, and RotaryInternational.

The Organization participated in twomajor meetings designed to mobilizeresources for the Region and to improve thecoordination of international cooperation inhealth projects at the country and subre-gional levels. In 1988, PAHO/WHO and theGovernment of Spain cosponsored the IIMadrid Conference on Central America insupport of the plan known as "Health, aBridge for Peace," which was attended byrepresentatives of more than 35 govern-ments and nongovernmental agencies. In1989, the Government of Italy and PAHO/WHO cosponsored a Ministerial Conferenceon Italian Cooperation in Health in LatinAmerica and the Caribbean, at which 22ministers of health of the Region werepresent.

PAHO/WHO continued to prepare,publish, and distribute guidelines for mobi-

lizing resources and updated directories ofmajor official and nongovernmental fundingsources active in the Region. To further sup-port Member Countries, PAHO/WHOorganized seminars and workshops on finan-cial mobilization techniques that wereattended by officials in charge of interna-tional cooperation in the Central Americancountries, representatives of 11 EasternCaribbean countries, PAHO/WHO residentfellows, and participants from the Andeancountries, Argentina, Guyana, Saint Lucia,and Trinidad and Tobago.

INFORMATION COORDINATION

During the 1986-1989 quadrennium,information requirements and capabilitieschanged substantially, as did plans to accom-modate them. The Office of InformationCoordination made progress in consolidat-ing the information processing resources ofthe Organization at Headquarters. The over-all computational capacity was increased byupgrading the mainframe computer and theword processing capability and by adding aminicomputer and a set of microcomputers.

The introduction of compact disk, read-only memory (CD-ROM) technology al-lowed large amounts of bibliographic infor-mation to be made available to installationsin a number of countries at very low cost.During the quadrennium this project wasprototyped, placed in operation, and trans-ferred to BIREME.

Completion of the Financial Manage-ment System (FMS) remained the highestpriority within the applications developmentarea. The Office of Information Coordina-tion worked closely with the Budget andFinance and Accounts units to define andprogram the system. The "Budget" moduleof the FMS was completed, as were the"Expenditure Accounting" and "GeneralLedger" modules. They are now in operationand require only minor modifications. Thesemodules were designed to interface witheach other and other PAHO systems, and

General. Program Development and Management 7


work will continue on these interdependen-

cies in the next period.In 1989 linkage was established between

the Field Financial Management System(FFMS), which is being used in several loca-tions, and the Headquarters FMS. Thisallows transactions occurring in the field tobe quickly reflected at Headquarters.

The Human Resources System's initialdata base, containing curricula vitae of pro-spective employees, was made available tousers of PAHO's on-line system. Additionalcapabilities and linkages were developed asresources allowed, but completion of the sys-tem is expected to take several years.

An electronic mail capability was nearlyready for use at the end of the quadrennium.

Once installed, it will allow users of theWANG systems within PAHO/WHO tocommunicate easily with offices and institu-tions outside Headquarters. This applicationemploys techniques and programming thatwere developed by another United Nationsagency.

The introduction of a large number ofmicrocomputers and the need to share infor-mation led to the Organization's decision toinstall a Headquarters-wide local area net-work (LAN). Work on this project began in1989.

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CHAPTER III

HEALTH SYSTEMS INFRASTRUCTURE

INTRODUCTION

The Health Systems Infrastructure Areawas reorganized in 1986 to bring togetherthe Health Services Development, HealthPolicies Development, Human ResourcesDevelopment, Scientific and TechnicalHealth Information, and Health Situationand Trend Assessment programs. The Area'sprograms concentrated on designing strate-gies for delivering integrated, interprogram-matic technical cooperation to MemberGovernments.

The economic and social crisis in theRegion, the sustained democratizationprocess, the governments' need to reformu-late development strategies, and the processof modernizing the role of the State were allfactors that influenced attempts to reformthe delivery of health services during thequadrennium. Within the health sectoritself, past attempts to achieve equity ofaccess by simply increasing the number ofexisting services proved infeasible. As aresult, health sector leaders were largely sup-portive of the Area's integrated approach, inwhich the quality and efficiency of services,as well as their managerial reform, weregiven top consideration.

The Area's programs hence conductedtheir technical cooperation activities guidedby the strategies of decentralizing manage-ment and promoting local health systems,coordinating information gathering andintervention methods with other sectors,improving the management of information,and recognizing and incorporating multi-causal analysis in the design of healthprojects.

In adopting Resolution XV of theXXXIII Meeting of the Directing Council,

the countries of the Region agreed that thehealth sector should be reorganized by devel-oping local health systems. The Health Ser-vices Development Program was maderesponsible for coordinating this strategy,and the entire group of programs making upthe Health Systems Infrastructure Area wasoriented accordingly. Personnel requirementprofiles and training programs sponsored bythe Human Resources Development Pro-gram focused on developing the cadre ofhealth care workers needed to make possibleuniversal access to decentralized primarycare services. The Health Policies Develop-ment Program concentrated on the areas ofplanning, financing, and health technologyinnovations. A major part of the Health Sit-uation and Trend Assessment Program'seffort was lent to developing applied epide-miologic methods that would both improvenational analytic capabilities and incorpo-rate epidemiologists into policy making. TheScientific and Technical Health InformationProgram provided support to all of theseactivities, as well as those of other technicalprograms not included in the Area, byselecting, publishing, and distributing infor-mation vital to the democratization ofknowledge that goes hand in hand with theestablishment of effective local healthsystems.

To foster cooperation with other sectorswhose work has a bearing on health, theArea identified key institutions with whichto undertake joint projects. Notable amongthese undertakings was the University andHealth in Latin America and the Caribbeanfor the Twenty-first Century (USALC-XXI)project, in which the universities of LatinAmerica and the Caribbean and the Unionof Latin American Universities participated

9


in reviewing the solutions that such disci-plines as economics, political science, engi-neering, and environmental sciences couldoffer to health problems.

The Area also pursued increased collab-oration between the health sector and thesocial security sector, which, as a majorfinancer and provider of health services, isan indispensable participant in the reform ofservices and the extension of coverage. TheArea's programs also sponsored meetings toobtain the participation in health projects ofsuch organized groups as labor unions, medi-cal associations, and political parties.

The management of information wascritical in all of these endeavors. There was avast increase in the quality and quantity ofinformation and expertise in the Region overthe quadrennium. It was therefore necessaryto identify new information gaps and deter-mine how the Area could fill them. Theneeds that came to light were related toadministrative and epidemiologic methodol-ogy. Thus, the production and distributionof documentation on strategies toward theefficient planning and management of ser-vices was an area that received attentionfrom all of the programs. Their effortsresulted in numerous scientific and technicalpublications issued in Spanish, English,French, and Portuguese. Several of them-most notably The Challenge of Epidemiology,AIDS: Profile of an Epidemic, and Recomenda-ciones de la Comisión Internacional de Protec-ción Radiológica-had an even greater impactthan had been foreseen.

The development and extension ofinformation network systems and technolo-gies (LILACS/CD-ROM and BITNET) werealso very well received. Based on PAHO/WHO's own data base and acquired data,and aided by the development of MicroISISsoftware, the information network systemscontributed greatly to the availability andcoordination of information in thecountries.

The majority of the countries in whichan analysis had been carried out by the endof the quadrennium expressed willingness to

improve their health systems' coverage usingthe strategy of networks of local health sys-tems. Some of them made concrete technicaland legislative progress in carrying out thesepolicies.

MANAGERIAL PROCESS FORNATIONAL HEALTHDEVELOPMENT

During the quadrennium, most of thecountries of the Region made progress inreorienting technical cooperation activitiestoward building health system infrastruc-tures and health services aimed at fulfillingthe requirements of high-risk prioritygroups. PAHO/WHO cooperated in theseefforts and in assessing the progress achievedtoward the goal of universal primary healthcare by the year 2000. Areas of focusincluded the analysis and management ofthe political dimensions of health and theinstitutional organization of health systems,with special emphasis on forging relationswith social security institutions and the pri-vate sector.

A key element of PAHO/WHO's coop-eration was its improvement of the organiza-tion and administration of the CountryOffices, which are responsible for coordinat-ing PAHO/WHO technical cooperation tonational programs. The procedures for for-mulating technical cooperation programswere made more efficient by the introduc-tion of automated systems in all CountryOffices to facilitate project planning,programming, and execution. In manyCountry Offices, the staff profile was modi-fied to better accommodate nationalrequirements.

PAHO/WHO staff members were giventraining in administrative and technical mat-ters to improve their proficiency. Specialemphasis was also placed on improvingadministrative services, communications,and secretarial support, and on decentraliz-ing the administrative control of fellowships,seminars, and courses.

10

Health Systems Infrastructure

Documentation centers were bolsteredto increase the availability and timeliness ofmuch-needed information. The documenta-tion centers made available periodical sub-scriptions, book purchases, and photo-copies of scientific articles, and providedsuch assistance as bibliography preparation,advisory services, and staff training.

The physical infrastructure was up-graded by seeking new buildings for Coun-try Offices or remodeling the facilities inuse.

As computers were gradually intro-duced, so was the field financial manage-ment system, which was operational inseveral Country Offices and Centers by theend of 1989. The system is designed toimprove the reliability of budgetary andfinancial/accounting information and toreduce the workload involved in processingthis information at Headquarters.

TECHNICAL COOPERATIONAMONG COUNTRIES ANDPROJECTS AT THE COUNTRYLEVEL

Technical cooperation among develop-ing countries is one of the most useful meansof promoting the coordination of efforts bythe Organization's Member Countries, whileensuring that they benefit from each other'sexperiences in handling common healthproblems. During the 1986-1989 period, theOrganization promoted such technical coop-eration in the form of the sharing of man-power, expertise, and financial resources andthe development of joint projects. The areasin which such efforts were concentrated werepromoting health research and technologydevelopment, designing systems to ensurethe availability of critical supplies and equip-ment, coordinating interventions for healthproblems common to several countries, andsharing human resources developmentprojects.

During the quadrennium, the Organiza-tion gathered and disseminated documenta-

tion that would facilitate technicalcooperation undertakings between its Mem-ber Governments. It also conducted multi-national meetings, workshops, and seminarsand awarded fellowships to national officialsso that they could observe cooperation pro-grams in progress.

The Central American, Caribbean,Andean Area, and Southern Cone initia-tives provided a framework in which pro-grams and activities related to joint healthproblems could be more easily established.With the Organization's participation, theLatin American Economic System (SELA)Meeting in 1989 chose the health sector topromote programming and negotiationmeetings on technical cooperation amongdeveloping countries in the field of health.

Although the results have been slow toaccrue because of the lack of tradition insuch ventures, programs such as those thatwere forged between Mexico and the UnitedStates, between Mexico and Belize, andamong participants in the Central Americanand Caribbean initiatives were auspiciousbeginnings.

HEALTH SITUATION AND TRENDASSESSMENT

The Health Situation and Trend Assess-ment Program was created in 1986 inresponse to the need for strengthening andexpanding the practice of epidemiology inthe countries of the Region, in view of themajor epidemiologic changes observed inLatin America and the Caribbean. Alongwith the persistence of diseases typical ofpoverty and underdevelopment, there hasbeen a rise in health problems common todeveloped nations, such as diseases of theelderly, environmental contamination, andaccidents and violence. The protracted eco-nomic crisis made an epidemiologic assess-ment of needs even more critical, as healthsectors sought a sound basis on which todetermine how to best deploy theirresources.

11

11 RPeport oftle Director

The aims of the Program are gearedtoward generating and utilizing knowledgerelated to the assessment of the health statusof the population, its determinants, andtrends, in order to contribute to the defini-tion of priorities and the formulation ofhealth policies and strategies for interven-tion. An additional goal is the evaluation ofthe impact of these policies and strategies,and of health interventions in particular, sothat they may be adjusted or redesigned asnecessary. These objectives include enhanc-ing the availability, quality, and timeliness ofsuitable data and the promotion of theirappropriate utilization for ongoing analysesas well as for special research projects. TheProgram's work, as set out in its 1984-1989medium-term program, was carried out bystaff at Headquarters, in several countries,and at the Caribbean Epidemiology Center(CAREC).

In the understanding that epidemiologyis one of the public health disciplines that iskey to the achievement of the objectivesstated above, the Program supportednational meetings convened to review andrefocus the practice of epidemiology, to for-mulate recommendations for its expansionand strengthening, and to revise the ensuingimplications for training and the generationof knowledge. This effort has been carriedout in almost all the countries of the Region.Several countries, including Argentina, Bra-zil, and Venezuela, created national commis-sions on epidemiology to follow up on thesemeetings' recommendations, with specialattention to requirements of local health ser-vices. The conclusions and recommenda-tions of these meetings have contributed tothe preparation of national plans of action tostrengthen the practice of epidemiology and,in turn, have served as input for the ongoingadjustment of the Program's technicalcooperation.

Emphasis has been placed on directtechnical cooperation with Member Gov-ernments for strengthening the practice ofepidemiology in the health services, includ-ing the revision, expansion, and adjustment

of the organization and functions of epidemi-ology units in light of ongoing decentraliza-tion processes. Particular efforts weredevoted to improving the utilization of epi-demiologic concepts, principles, and meth-ods to perform analysis of the healthsituation and trends and surveillance of oldand new health problems. Cooperation wasprovided for the identification of trainingneeds in epidemiology and related disciplinesand for the formulation of strategies toaddress those needs, especially in regard totraining in and for the health services.

Priority attention was also given to stim-ulating and supporting epidemiologicresearch and the discussion and dissemina-tion of research results. To facilitate thesediscussions, scientific meetings were sup-ported in several countries. At the presenttime, this sort of meeting represents the bestavailable mechanism for consolidating thepractice of epidemiology and promoting theutilization of epidemiologic knowledge asinput for policy formulation and health ser-vices organization and evaluation.

In addition, regional initiatives weredevised to promote research, support train-ing, and enhance the dissemination of tech-nical information.

The Program's main efforts regardingthe generation of knowledge were gearedtoward promotion and support of researchprojects on health profiles. Individualresearch projects were designed to systema-tize procedures traditionally used to analyzemortality data and to gain experience withsome infrequently used procedures, such asyears of life lost prematurely. PAHO/WHOHeadquarters and field personnel workedwith national researchers to carry out thestudies. Of the eleven projects begun in1985, nine were completed, while the othertwo continued. A major meeting was held in1988 in Washington, D.C., to summarize theresults of this two-year effort to study mor-tality. The conclusions of the meeting weredistributed Region-wide and had majorimpact on mortality analyses.

A second line of epidemiologic research


has been promoted to enhance the under-standing of the epidemiologic transition andits relationship to the socioeconomic condi-tions of different geographically definedpopulation groups, in order to facilitatehealth services planning and evaluation.Along this line, in August 1989 a meetingwas held in Brasilia at which senior research-ers from 10 countries discussed appropriatemethods and approaches for studying therelationship between health and overall liv-ing conditions.

Training in epidemiology cannot bedeveloped in isolation from its practice inthe health services. Moreover, by integratingthe teaching of epidemiology with the provi-sion of services, a pattern of practice that hasbeen largely unresponsive to changes in thehealth requirements of the population wouldbe gradually transformed. Faculty from pub-lic health schools in Medellín, Mexico City,and Rio de Janeiro met in San José, CostaRica, in July 1986 to discuss a proposal call-ing for the development and adoption of atraining model in which a work-study strat-egy would accomplish the twofold objectiveof transforming epidemiology's practice andtraining. Through the cooperation of theLatin American and Caribbean Associationfor Education in Public Health (ALAESP)and the United States Association ofSchools of Public Health (ASPH), an initia-tive was completed, in collaboration withthe Human Resources Development Pro-gram, to address the need for leadership inthe health sector and the complexity of thedecisions undertaken by health workers.Within this context, a meeting was held inCaracas in 1987 with participants from vari-ous institutions, including schools of publichealth in the United States. The meetingdealt with improving national health careinformation systems and the need tostrengthen epidemiologic training andresearch in schools of public health.

In Taxco, Mexico, in November 1987, ameeting jointly organized by ALAESP,ASPH, the United States Centers for Dis-ease Control (CDC), and PAHO/WHO,

and attended by representatives of epidemi-ology training centers in Latin America andthe Caribbean, agreed on the need todevelop a conceptual framework for thedetermination of health phenomena thatincorporates the relationship between bio-logical and social processes. It was alsowidely agreed that all aspects of the field ofepidemiology should be considered, includ-ing studies of the health situation, epidemio-logic surveillance, research on causes, andservice evaluation. Special mention wasmade of the need to emphasize the applica-tion of epidemiologic thinking in an integralapproach to public health and to avoidreducing epidemiology to a simple techniquefor validating hypotheses that are formu-lated on the basis of individual clinicalapproaches.

The Program participated in program-ming, carrying out, and evaluating a 10-week course in epidemiology for thecountries of the Central American Isthmus,which has been held annually since 1987 inSan José, Costa Rica, in collaboration withthe Government of Spain.

The Program further promoted researchand training through the wide disseminationof information. This effort centered aroundquarterly publication of the EpidemiologicalBulletin, with current pressruns of 4,000 inEnglish and 8,500 in Spanish. In addition,bibliographies and other reference materialson epidemiology and health statistics wereassembled and made available to countries,and special-purpose documents were pro-duced and distributed, including reports ontechnical meetings.

In response to the growing demand fortechnical information in the countries,PAHO/WHO increased the disseminationof epidemiologic and statistical information.A first step in the Program's project to col-lect, analyze, organize, and distribute biblio-graphic information on epidemiology andrelated material was the publication of thebook The Challenge of Epidemiology, Issuesand Selected Readings in 1988.

Specific reports on technical meetings

13


were produced and distributed, such as theones generated by the ALAESP meeting inTaxco, Mexico, and the meeting on Guide-lines and Procedures for Mortality Analysisin Washington, D.C.

In the area of health information, theProgram maintained a data base on mortal-ity, population, and reported cases of dis-eases subject to the International HealthRegulations, and incorporated populationdata obtained through an agreement withthe Latin American Center on Demography(CELADE). Data were collected from Mem-ber Countries and processed for publicationin the World Health Statistics Annual. TheProgram responded to external and internalrequests for information from PAHO techni-cal units, the IDB, the United States Congress,newspapers, researchers, and MemberGovernments.

The Program also coordinated an inter-disciplinary working group with otherPAHO/WHO programs to prepare the 1990edition of Health Conditions in the Americas,in which the Organization and its MemberCountries present detailed statistical analy-ses of the major health trends in the Region.

A special project within the Health Situ-ation and Trend Assessment Program hasbeen the International Classification of Dis-eases (ICD), which involved several lines ofwork.

The first concerned the promotion ofICD in a comprehensive manner, taking intoaccount its instruments and its uses. Themain strategy was the strengthening of a net-work of national centers. The work of thesecenters concerned the utilization of ICD andthe generation of information to reinforcevital and health statistics. The network ofcenters and related institutions wasexpanded with the incorporation of Cuba,and discussions were initiated toward estab-lishing centers in the English-speakingCaribbean and in Central America.

The second line of work concerned thenext revision of ICD, its family of classifica-tions, and other classifications related tohealth. Successive drafts of the 10th revision

have been circulated, and essentially all ofthe suggestions of the Region of the Ameri-cas have been taken into account in the lat-est drafts. The preparation of the Spanishversion of the 10th revision was initiated inparallel and is presently well advanced, andfield trials of the index are under way. Inaddition, trials of the different drafts andstudies of comparability between ICD-9 andICD-10 (bridging studies) were carried out.

The third line of work concerned theimprovement in basic data that are orientedespecially toward improvement of the instru-ments used, above all those dealing withmortality.

The fourth line of work was the investi-gation of new or alternative methods for thecollection and analysis of data. Regardingdata collection, nonconventional methodswere investigated for their utility in provid-ing simplified epidemiologic surveillance,improving vital statistics, and addressing theperceived needs of communities, as well asfor the validation of information, as was sup-ported by the Revision Conference for ICD-10 held in Geneva in 1989. With regard toalternative methods of analysis, studies werecarried out on multiple cause analysis andthe search for new indicators.

HEALTH POLICIES DEVELOPMENT

The Health Policies Development Pro-gram was created at the start of the quadren-nium to lend technical cooperation in thedevelopment of health systems infrastruc-ture. Its purpose is to foster a comprehensiveand integrated approach to analyzing anddeveloping health policies.

The Program emphasized developingand strengthening the capacity of nationalhealth sectors to interact with all those sec-tors that have a bearing on health policiesand at the same time improving coordina-tion among agencies providing health ser-vices in order to achieve greater effec-tiveness. It stressed the need to make health


Health Systems Infrastructure 15

planning consonant with national develop-ment policies and to enhance the effective-ness of national legislation regarding therights and duties of the State, individuals,and private institutions in promoting, pro-tecting, and restoring health. Other areas ofProgram concern were analyzing the rela-tionship between a country's economy andits health conditions, increasing efficiencyand equity in the economic and financialmanagement of health services, and promot-ing the development of health technology,while increasing its accessibility andeffectiveness.

Given the nature of the Program, itworked closely with social security agenciesand other governmental and private institu-tions in addition to the health ministries.Other PAHO/WHO Regional Programscollaborated on activities related to theirareas of work, as did other internationalorganizations.

In collaboration with the HumanResources Development Program, work wascarried out with the governments of Argen-tina, Brazil, Colombia, Mexico, Peru, andVenezuela to strengthen the operational andleadership capacity of their health sectorsand to reform their national health systemsthrough dialogue with social security in-stitutes, the private sector, universities,parliaments, labor organizations, andcommunities.

In Central America, the workers' healthcomponent of PAHO/WHO's Environmen-tal Health Program cooperated in a projectto expand workers' health services providedby the ministries of health and the socialsecurity institutes by supporting coordina-tion efforts between those entities.

The governments of Brazil, Guatemala,Honduras, Jamaica, Mexico, Paraguay, andPeru received the Program's assistance instrengthening their ability to draft, carryout, and evaluate health policies, plans, pro-grams, and projects. In general, such cooper-ation entailed providing support to nationalgroups, developing information systems forplanning purposes, and assisting the govern-

ments in negotiating projects with interna-tional or bilateral funding agencies.

The Program developed a technicalcapacity in the area of public health legisla-tion, a service that expanded greatly due tothe interest of national health authorities. Incooperation with the Library of Congress inthe United States, BIREME, and the Facultyof Law of the University of the West Indies,the Program created the LEYES data base,which contains summaries of the health leg-islation of the countries of Latin Americaand the Caribbean. Incorporated inLILACS/BIREME's MicroISIS system, thisdata base served as a reference source forcountries that were reforming their healthlegislation.

The Program also provided specializedtechnical support in applying economic andfinancial analyses to health problems andservices. This support was useful in the insti-tution of a national health insurance plan inTrinidad and Tobago, the implementation offood and nutrition programs in Brazil, andcost-effectiveness analyses of the campaignto eradicate wild poliovirus in CentralAmerica.

The formation and maintenance ofnational groups specializing in the develop-ment of health technology was a primaryconcern of the Program. Such groups wereorganized in the ministries of health, socialsecurity agencies, and universities of Argen-tina, Brazil, Colombia, Costa Rica, Cuba,Mexico, and Uruguay. Toward the end ofthe quadrennium the Program began similarprojects in other countries.

With support from political science cen-ters in the Region, a preliminary survey wascompleted in 15 countries to determine theirhealth policy agendas, identify principal pro-tagonists and their positions, and assess thecapacity for health policy research andteaching. The information gathered will beused to establish follow-up activities in thesecountries and guide the expansion of similarstudies to others.

The Program systematized a methodol-ogy for formulating, implementing, and eval-



uating projects, areas in which manycountries required cooperation as theysought to improve project management.

The Program also promoted, in collabo-ration with the Health Services Develop-ment Program, the design, modeling, andapplication of automated information sys-tems on health equipment. In cooperationwith the Health of Adults Program, a con-sensus conference was held that producedrecommendations on the use of technologi-cal options for managing chronic renal in-sufficiency and served as a model for re-viewing complex issues surrounding othertechnologies.

The Program's research activities centeron two of the priority areas of PAHO/WHO's Research Grants Program (healthfinancing and technological developmentprocess in health) for which it has directresponsibility. It also provides support to thearea of health policy process, which is theresponsibility of the Office of Analysis andStrategic Planning Coordination.

The implications for health policies ofthe return to a democratic form of govern-ment during an economic crisis wereexplored through a comparative researchproject begun in Argentina, Brazil, and Uru-guay, which have recently gone through thattransition. The IDB cooperated in anothercomparative research project in Brazil, Ecua-dor, Honduras, Mexico, and Uruguay thatexplored the impact of the economic crisison health conditions and services. The Pro-gram supported a similar study in the Carib-bean, conducted by the Institute ofSocioeconomic Studies of the University ofthe West Indies, as well as studies of sectoralfinancing that were undertaken in Argen-tina, Brazil, Mexico, and Peru.

The Program engaged in numeroustraining activities, including drawing up atraining plan on technologic developmentthat was put into practice in several coun-tries. In cooperation with the OAS Centerfor Economic and Social DevelopmentResearch, the Program sponsored an inter-American course on social policy and plan-

ning with emphasis on health that was heldin Buenos Aires in 1987 and 1989. Similartopics were covered in the Seminar on Insti-tutional Aspects in Formulating, Implement-ing, and Evaluating Health Policies, whichthe Program conducted in San José, CostaRica, in 1987, in cooperation with the LatinAmerican Development AdministrationCenter (CLAD) and ECLAC's Latin Ameri-can Institute for Social and Economic Plan-ning. Sixteen countries participated.

The material the Program has gatheredand systematized on health developmentprojects was presented at five intercountryseminars. The training package consisted oftexts, exercises, computer programs, audiovi-sual aids, and teaching guides, and should beavailable for wide distribution starting in1990. In addition, health planning coursesoffered by national educational institutionswere supported in Brazil, Jamaica, Mexico,Nicaragua, and Venezuela, and the WorldBank Economic Development Institute col-laborated on two seminars on health eco-nomics and financing, held in Brasilia (1987)and Barbados (1989).

In view of the health sector's relativeinexperience with many of the subjectsaddressed by the Program, more than adozen reference texts were produced toincrease knowledge of the theories andmethods involved. A series of articles andfour texts on health economics and financ-ing were published, as was a book on meth-odologies for evaluating health technologies.Publication was begun of a Spanish editionof the Bulletin of the International Society forEvaluation of Health Technology.

The Program has carried out regularevaluations of its activities. Its impact is hardto assess at this early stage, however, espe-cially since it acts in coordination with somany other programs and institutions.Although the economic crisis during the sec-ond half of the 1980s bore witness to theprudence of the Program's proposals toreform traditional planning methods, resis-tance was encountered from those whounderestimate the weight of the socioeco-

16


nomic and political components of healthproblems and interventions to solve them.Many health professionals and authoritiesalso were reluctant to accept the participa-tion of other sectors in the design of healthinterventions.

Nonetheless, over the quadrenniumthere was a marked increase in interest onthe part of authorities, specialists, teachers,and researchers in subjects related to healthpolicy analysis and development. This samekind of interest also began to emerge inother development sectors, especially amongthose active in health projects. Interest wasexpressed not only in discourse but also inthe actions of governments, in training pro-grams for health workers, and in theresearch areas assigned priority by the coun-tries. The receptivity in the countries towardthe proposals drawn up and activities carriedout by the Program is another indicator ofthe positive results that have been achieved.The linkage between health and social secu-rity institutions, the documentation systemon health legislation, the approaches tomanaging development projects, the pro-posals for strategic and situational planning,the application of economic analysis tohealth problems, and the sector's approachesto technology management are all examplesof progress made. Another indicator is thehigh demand at the end of the quadrenniumfor repetition of the courses sponsored bythe Program.

Finally, it is notable that most of thepublications supported by the Program werealready out of print by 1989. Moreover, thetraining modules on development projects,although they were still in the prototypestage, were reproduced several times inresponse to specific requests from RegionalPrograms and PAHO/WHO Representa-tives' Offices.

Requests from Member Governmentsfor cooperation in analyzing and developingpolicies greatly exceed the Program's abilityto respond at the regional level. It thereforeadopted a policy of supporting the PAHO/WHO Representations with personnel and,

above all, with technical information andtraining to enable the staff to carry out mostof the activities of direct cooperation.

ORGANIZATION OF HEALTHSERVICES BASED ON PRIMARYHEALTH CARE

Health Services Development

PAHO/WHO received two mandatesfrom its Governing Bodies that emphasizedthe need for reorganization of health servicesby the Member Governments. ResolutionXXI of the XXII Pan American SanitaryConference (1986) approved the Organiza-tion's programming priorities for 1987-1990,establishing the need to develop the healthinfrastructure as a fundamental componentin the application of the strategy of primarycare. Resolution XV of the XXXIII Meetingof the Directing Council (1988) recognized"the urgent need to accelerate the transfor-mation of the national health systems" andrequested the Director of PASB to supportthe processes of decentralization and devel-opment of local health systems in thecountries.

Having identified the development oflocal health systems as the most suitablemeans of attaining universal primary care,the Organization entrusted the Health Ser-vices Development Program with carryingout activities in support of that policy. TheProgram's main objective was to promoteand support national efforts to establish net-works of local health systems that areresponsive to the specific needs of the com-munities they serve.

To that end, the Organization held con-sultations with national health leaders anddrafted Document CD33/14, which pro-posed a framework for the development oflocal health systems. During 1988 and 1989,information was gathered on the results ofon-going experiments in the establishmentof local health systems in a number of coun-tries. Five subregional meetings were held in

17


which 360 representatives from 35 MemberCountries took part, sharing experiencesand contributing new concepts andmethodologies.

To foster a Region-wide debate on theideas discussed and methods to put theminto effect, the documents and conclusionsof these meetings were published and distrib-uted to the countries (15,000 copies in Span-ish, 5,000 in English). In addition, the bookPrimary Health Care and Local Health Systemsin the Caribbean was published for theEnglish-speaking Caribbean.

The Program decided to emphasize a fewareas critical to the development of localhealth systems, with the aim of hasteningthe reorganization process. These areas weresocial participation, local strategic program-ming, decentralization, and pharmaceuticalsupply systems.

Two expert meetings were organized todiscuss social participation. They defined aprogram of cooperation with 17 countries toconduct surveys to assess the existing degreeof social participation. Subsequent meet-ings-one for Latin America and one for theCaribbean-issued recommendations toguide the development of local health sys-tems and the technical cooperation offeredby the Organization and other agenciesactive in health. Spain and UNDP, as part ofits management capacity developmentproject, cooperated in a number of consul-tant group meetings.

Since the proposal for developing healthservices based on the primary care strategyrequires interdisciplinary and interprogram-matic action, which in turn necessitatescoordination among international agencies,the Program organized a consultative meet-ing on "Decentralization of the State andSocial Services," in cooperation with theLatin American and Caribbean Institute forEconomic and Social Planning, UNESCO'sRegional Office for Education in LatinAmerica and the Caribbean, ECLAC,UNDP, and the United Nations Center forHuman Settlements. Another step towardintersectoral coordination involved coopera-

tion with the Central American Institute forBusiness Administration (INCAE), withwhich training and research activities wereconducted.

Health care in major urban centers con-tinued to be a cause for concern in theRegion, and efforts to provide it meritedhigh priority. In cooperation with Rio deJaneiro State, Brazil, the Program conducteda meeting on the subject that was attendedby health care authorities from large metro-politan areas in the Americas and Europe.Participants stressed the need to decentralizehealth care in large cities by creating local,neighborhood-based health systems gearedtoward health promotion and comprehen-sive primary care. The approach recom-mended is in accord with the concept ofdeveloping healthy cities by coordinatingthe efforts of all segments of civil society andgovernment to create a more humanehabitat.

Regarding the role of hospitals, the Pro-gram sponsored a meeting in Buenos Aires,Argentina, of the directors of 50 hospitals inthe Region to analyze the participation ofhospitals in the development of local healthsystem service networks. The Program alsocoordinated a meeting on hospital evalua-tion and accreditation with the Joint Com-mission on Health Services Accreditation,American Medical Association, AmericanHospital Association, and the governmentsof Argentina, Brazil, Colombia, Costa Rica,Cuba, Mexico, Peru, the United States,Venezuela, and the Caribbean countries.

A meeting of specialists in hospitaldesign and maintenance was held inHavana, Cuba. In this same country, evalua-tion of the quality of local health systems hasbegun, using methodologies that may beapplied by the Program to future coopera-tion efforts.

The subject of hospital infections wasalso analyzed at the regional level, since thisproblem has a relationship to both the qual-ity and increased cost of care. A meetingorganized with the cooperation of 10 UnitedStates universities, Latin American and

18 Report of the Direíctor

LOCAL HEALTH SYSTEMS

During the 1980s, the health sectors of most of the countries d the Americas becameacutely aware that their own highly centralized structures-set up in a different era-wereinadequate to accomplish their goal of providing universal access to primary health care,and often were a hindrance. How to reform these structures to make them more responsive,flexible, and efficient was a pressing concern at the outset of the 1986-1989 quadrennium.

When the Ministers of Health met at the XXII Pan American Sanitary Conference inSeptember 1986, they called on the Director to give "spcial attention to strengthenrnghealth services infrastru ctures." The next two years were marked by a concerted effort onthe part of national health authorities and PAHO/WHO staff to study the feasibility of anddraw up guidelines for developing and strengthening local health systems,

An important outcome of that effort was the drafting of the document "Developmentand Strengthening of Local Health Systems," in which the main conepts and rationale fornational networks of local health systems were elaborated and which was adopted inSeptember 1988 by the XXXIII Meeting of the PAHO Directing Council. The Councilproclaimed the "urgent need to accelerate the transformtation of national health systems'and called on the Organization to support the countries by, among other things, encourag-ing "exchanges of experiences between countries . . on advances in the development oflocal health systems.. ." (Resolution XV).

Emergence of the concept of local health systems coincided, not surprisingly, with theincreasing political democratization under way in many countries of the Region. A mainapproach of local health systems-to decentralize the management of health services-bothrelies on and promotes the active participation of the community. Administrative decen-tralization affords local health systems the flexibility to address the specific needs of thecommunity they serve. By assigning to each of the local health systems responsibility fordelivering health services to a given population within a dearly defined geographic jurisdic-tion, that system can be held accountable more easily for the efficiency and quality of thoseservices.

Another objective of local health systems is to integrare health programs, therebyproviding comprehensive health care at each level.

Simultaneously, the assignment of specific geographic areas of responsibility to localhealth systems expedítes the coordination of efforts with other sectors and agencies whoseactions have a bearing on health programs. This coordination aims to make efficient use ofall the resources available in a given area, avoiding duplication of efforts and permittinggaps in coverage to be detected more readily. A good managemtent measure in any event,intersectoral coordination is especially important when economic conditions require thatoptimal use be made of all the resources that can be tapped.

In accordance with Resolution XV, subregional workshops were held at which partici-pants from the countries discussed concrete measures, including financial, legal, and techni-cal requirements, for developing local health systems.

By the end of the decade, the Region had moved from recognizing that something hadto be done to transform the health sector infrastructure to devising working definitions oflocal health systems for most of the countries. The groundwork has thus been laid toactually put those systems into effect throughout the Region during the last decade of thecentury.

19


Caribbean countries, and specialized centersformulated recommendations and a plan ofwork to be conducted jointly by the coun-tries and PAHO/WHO.

Technical guides for analyzing the devel-opment of installed hospital capacity werefinalized and will be published in coopera-tion with the research center on physicalresources in health of the University ofBuenos Aires, the National Hospital Fund ofColombia, and the University of Campinhas(Brazil).

The role of nursing in the provision ofhealth services and in improving hospitalcare was also a matter of concern during thequadrennium. Cooperative activities werecarried out through an agreement with thePan American Federation of Nursing Profes-sionals (FEPPEN), a nongovernmental orga-nization in official relations withPAHO/WHO.

The Program also supported nationalhealth service reform efforts by developingproposals to be presented to funding agen-cies, such as IDB and the World Bank.

Another subject of priority interestrelated to the development of local primaryhealth care services was pharmaceutical sup-ply. A consultative document was preparedand a meeting was held at Quito, Ecuador,in which most of the Region's countries tookpart. The need to ensure greater availabilityof basic drugs was reiterated. It was con-cluded that to design effective drug policies,local health services systems must be able tocarry out epidemiologic analyses, programtheir own activities, and decide their ownintervention priorities.

The UNDP-financed managementcapacity development project for CentralAmerica completed its first phase, and itssignificant contributions to national effortswere recognized in an external evaluationconducted by UNDP. The activities carriedout included design of minicomputer meth-odologies and programs for the developmentof managerial capacity; promotion of wom-en's leadership in health administration (ajoint effort with INCAE); seven subregional

training events; technical and financial sup-port for the organization of local health sys-tems, management information systems, anddecentralization; and the production ofteaching materials.

The first phase of the project "Strength-ening and Development of Engineering andMaintenance Services in Health Facilities"for the Central American subregion wascompleted at a cost of $US3.5 million. It wasconducted in coordination with nationalmaintenance projects in Belize, Guatemala,and Nicaragua. Each of the subregion'scountries put into operation a model hospi-tal for which a Master Program for Adminis-tering Engineering and MaintenanceServices was designed. Technical documen-tation centers were organized in each of thesubregion's countries, and approximately1,100 officials were trained in nine subre-gional and national courses on priority top-ics in the area of maintenance. Eleventechnical manuals were prepared to allow forfollow-up and support of maintenance tasks,and spare parts, tools, vehicles, microcompu-ters, and technical books were acquired for aprice of $US1.4 million. Joint purchase ofthese materials resulted in savings of approx-imately 20%.

In the area of research and the manage-ment of knowledge, the experience gainedthrough technical cooperation activitiesmade it possible for the Organization tocompile ample reference materials and casehistories, which will be published in Spanishin the PAHO Scientific Publications Seriesas "Local Health Systems: Concepts, Meth-ods, Experiences."

Evaluations of ongoing decentralizationand local health system development effortsin Brazil (Niteroi), Colombia (Cali), andMexico (Monterrey) were carried out incooperation with the W. K. Kellogg Founda-tion. Likewise, in cooperation with WHO,studies were begun of local experiences inBrazil, Chile, Ecuador, Guatemala, andJamaica.

The Program increased its support ofhealth services research in an effort to help

20


countries obtain a current profile of prob-lems associated with quality of care, effi-ciency, equity, and productivity of services.Two consultative meetings, in which eightcountries participated, were held to deter-mine ways of reinforcing health servicesresearch, particularly the gathering of infor-mation on the modes of operation of localhealth systems. In one of the recommenda-tions from these meetings, the need forinvestigators to exchange information aboutthe findings of ongoing research or projectswas stressed. To this end, the Program beganjoint publication with WHO, the RockefellerFoundation, and the Health ServicesResearch Foundation of the United States ofthe thrice-yearly Health Services Research Bul-letin. Production of a series of educationalmodules on conducting health servicesresearch also was begun with IDRC (Can-ada) and WHO, and a compilation of scien-tific articles on the subject was started. It willbe published in book form as part of thePAHO Scientific Publications Series.

One of the main objectives of the reor-ganization of the health sector by decentral-izing its administrative management andestablishing local health systems is to makeuse of all resources available for health carewithin a given geographic area. Accomplish-ing this goal entails building operationalrelationships between autonomous entities,especially health ministries and social secu-rity agencies, a process that was a focus ofProgram cooperation with the countries. Animportant example of this kind of activitywas seen in Costa Rica, where joint pro-gramming in local health systems com-menced. This country's experience madepossible the formulation of a cooperationagreement between PAHO/WHO and IDBin support of the project.

The effectiveness of the Program wasevaluated by means of an analysis of progressin health services development in all coun-tries of Latin America and the Caribbean.Approximately 80% expressed their determi-nation to make revisions tending towarddecentralization of management systems.

Practically all of them had passed corres-ponding legal measures to support the decen-tralization process. Fifteen countries hadrevised their health care models and 12 oth-ers were contemplating doing so at the endof 1989. Most countries had concrete work-ing definitions of local health systems, whichwas evidence of the governments' politicalcommitment to establish them and rein-forced the need for PAHO/WHO to con-tinue to support their work in this area.

Essential Drugs and Vaccines

The objective of the Essential Drugs andVaccines Program is to support the develop-ment of health services through activitiesthat improve the availability, quality, andutilization of essential drugs and vaccines.

The Program was most active in theCentral American Isthmus, where humanand financial resources were mobilizedthrough the Plan for Priority Health Needs.The Central American health ministriesagreed to specific subregional projects onpharmaceutical policies, drug regulation andquality control, supply systems, the produc-tion of essential drugs, and the establish-ment of joint purchasing mechanisms.Numerous activities have been carried out aspart of annual work programs approved bythe national coordinators in the participat-ing countries, including direct technicalcooperation, national and subregional work-shops and courses, improvements in theinfrastructure of hospital and health centerpharmacies and warehouses, provision ofsupplies and equipment, and preparation ofdocuments and technical guides.

The joint purchasing of pharmaceuticalsthrough the Essential Drugs Revolving Fundfor Central America made it possible toimport these products at favorable prices.Nevertheless, the fund's impact was dimin-ished by the severe economic crisis affectingthe subregion, the difficulties the countriesexperienced in making foreign exchangereimbursements to the revolving fund, and

21


the opposition of the local pharmaceuticalindustry in some countries. All these factorsled to a marked drop in purchase volume in1988. Therefore, in 1989 a study waslaunched on reorienting the fund towardacquiring raw materials for national pro-ducers in order to stimulate subregional pro-duction. The Central American EconomicIntegration Bank will participate in thisendeavor to facilitate payments.

In the Andean Subregion, the Programconcentrated on Bolivia, Colombia, andEcuador. With the collaboration of WHO'sEssential Drugs Action Program, prepara-tory technical cooperation was carried outand projects were designed to develop andstrengthen national drug programs, includ-ing such aspects as pharmaceutical policies,regulation, quality control, production, anddrug supply systems.

The Program's development within theSouthern Cone Health Initiative wasdelayed by external factors. In recognition ofthe slight progress made, national authori-ties adjusted the schedules of joint projects ata meeting of technical groups in October1989. Agreements were reactivated withregard to projects in public health legislationand regulation; exchange of informationabout pharmaceutical products and chemi-cals; promotion of the exchange of immuno-biologicals, blood derivatives, and devicesrequired for blood transfusion; a data bankon installed capacity for specialized analyses;and studies on drug utilization.

To ensure that the vaccines acquired forcountries in the Region through theExpanded Program on ImmunizationRevolving Fund met international specifica-tions, the Program collaborated in qualitycontrol procedures. PAHO/WHO's refer-ence laboratories in Argentina (CEPANZO),the United States (Center for Biologics Eval-uation and Review, FDA), and Mexico(National Institute of Virology) analyzedvaccines when necessary. The Program alsoprovided technical support for the produc-tion and quality control of biologicals in thecountries that manufacture them, and gave

courses in several countries on cold chainmanagement for the vaccines used in theExpanded Program on Immunization (EPI).

Several countries made advances in leg-islation governing blood transfusion ser-vices, and others held courses on blood banklaboratory work. The United Kingdom'sOverseas Development Agency collaboratedin courses held in the English-speakingCaribbean.

In support of the reorientation and reor-ganization of health services, one of themain objectives of the Program's technicalcooperation during the quadrennium was topromote the development of modern phar-maceutical services, in which pharmaciesare active members of the health team.These services aim to rationalize the supplyand use of drugs and improve the quality ofdrug therapy by educating professionals andpatients.

Other activities of note were the regionalcourses on hospital pharmacy administra-tion conducted in 1987 and 1988 in CostaRica in collaboration with national institu-tions, the publication of the practical hand-books Bases for the Development and SanitaryImprovement of Hospital Pharmacies and Man-ual of Hospital Pharmacy Administration, andthe projects under way in several CentralAmerican hospitals. The updating of druglists and preparation of therapeutic formula-ries for health-sector institutions in Andeanand Central American countries alsoreceived support.

Drug information centers, which areimportant elements of pharmaceutical ser-vices, began operation in the Central Ameri-can and Andean countries and in theDominican Republic. The centers' effective-ness was hampered by a shortage of full-timeprofessional staff.

The Latin American Network of DrugQuality Control Laboratories, establishedwith PAHO/WHO support in 1984, becamea major instrument for developing nationallaboratories through cooperation, informa-tion exchange, and standardization of normsand procedures. Among the activities car-

22


ried out in support of national laboratorieswere meetings of laboratory directors, atwhich the network's biennial program wasdefined; updates of the bibliographicresources of member institutions; prepara-tion of a training program and teachingmaterials on laboratory administration; pub-lication of Standards of Good Laboratory Prac-tice; preparation of regional pharmaceuticalreference standards; and establishment of anexternal quality control program. This lastproject was supported by the U.S. Food andDrug Administration (FDA). Despite thesepositive efforts, many of the laboratories stillhave not developed national monitoring andcontrol programs of marketed pharmaceuti-cal products, due in part to the poorlydefined role of laboratories in the healthsector.

Another of the Program's activitiesaimed at upgrading the quality of pharma-ceutical services is the provision of trainingcourses on good manufacturing practicesand quality assurance for professionals inindustry, universities, and government. Sixcountries have held such courses usingaudiovisual material prepared by the Pro-gram, and have benefited from the coopera-tion of an expert on assignment from theFDA.

In summary, the Essential Drugs andVaccines Program significantly expanded itsrange of activities during the quadrenniumto encompass the various aspects of this sec-tor, including pharmaceutical policy, pro-duction, supply systems, quality control andregulation, pharmacologic information, andtraining. Promoting the development ofpharmaceutical services within the frame-work of local health systems was a priorityactivity.

Oral Health

The Oral Health Program's chief activityduring the quadrennium was to promote theintegration of oral health services with otherhealth services and the extension of dental

care coverage and dental disease preventionefforts. The Program provided technicalcooperation to 26 countries in reducing oralhealth problems. This collaboration rangedfrom advisory services for the developmentof dental care systems and establishment ofinstitutions for teaching oral health to initia-tion of infection control and educationalprograms regarding oral manifestations ofHIV infections.

Epidemiologic surveys indicate thatdental caries and periodontal diseases areprevalent in the Region. In many countriesthe prevalence of dental caries is still almostdouble the target level established by WHOfor the year 2000, and there is evidence ofthe extensive occurrence of periodontal dis-ease in children. Whereas the incidence ofdental caries decreased significantly in thedeveloped countries, such a trend was notrecorded in the developing countries of theAmericas except in those locations wherefluorides have been used extensively andcontinuously. The high prevalence, com-pared to other WHO Regions, of oral cancer(particularly in Brazil, where it is estimatedto represent 20% of all cancers) was a causeof concern, as was the recent recognition ofsignificant oral lesions and conditions associ-ated with HIV infection. Estimates of thepopulation in need of orthodontic treatmentwere as high as 60% of children in somecountries.

A major focus of the Program was toprevent dental caries, especially among chil-dren and adolescents. Programs that sup-plied systemic fluorides by fluoridating wateror salt were promoted, and other possiblevehicles for fluoride, such as milk, were stud-ied. Major advances were made in Brazil,which fluoridated water supplies in Rio deJaneiro and Sao Paulo; in Venezuela, where70% of the population now drinks fluori-dated water; in Argentina, which decided tofluoridate water supplies in the city ofBuenos Aires; and in Guatemala, whichdecided to do the same in Guatemala City.

Salt fluoridation programs commencedin Costa Rica and Jamaica, making the bene-



fits of fluoride available nationwide at anominal cost (less than $USO.01 per capitaper year), which, in the case of Jamaica, wasabsorbed in the cost of the product. Similarprograms were being initiated in Colombia,Mexico, and Peru at the close of the qua-drennium. These programs evolved from thecollaborative efforts of PAHO/WHO, whichlent technical and financial support, and thegovernmental and private sectors in eachcountry. In Costa Rica, Mexico, and Peru,the W. K. Kellogg Foundation providedadditional support.

The potential of salt fluoridation toreach the entire population of a country at acost low enough to be absorbed by govern-mental agencies or salt producers was thebasis for resolutions adopted by the Minis-ters responsible for health in the English-speaking Caribbean. The production offluoridated table salt in Jamaica has nowmade this product available to the Carib-bean countries. Another benefit is that thefluoridation and the iodization of salt can bedone simultaneously, thus combating dentalcaries and endemic goiter at the same time.

In Bermuda, a program of multiple fluo-ride treatments to prevent dental caries inschoolchildren was conducted by thePAHO/WHO Program and the Ministry ofHealth with initial support from the W. K.Kellogg Foundation. The incidence of dentalcaries was reduced by over 80% after 11years.

The need to incorporate oral health ser-vices into local health systems was addressedwithin PAHO/WHO by including the Pro-gram in the planning of activities conductedby the Health Services Development Pro-gram. In Member Countries, the OralHealth Program collaborated to improve theefficiency and efficacy of oral health caredelivery systems by coordinating teachingprograms with oral health care services forunderserved populations and promoting theuse of professional, auxiliary, and commu-nity personnel. By the end of 1989 virtuallyall the English-speaking Caribbean coun-

tries, Guyana, and Suriname had organizeddental programs for children, utilizing auxil-iaries trained in dental auxiliary schoolsestablished in Jamaica, Guyana, Suriname,and Trinidad and Tobago.

Local service programs in Chile, Mex-ico, and Venezuela demonstrated the eco-nomic viability of providing comprehensiveprimary oral health care in communitieswith limited public and private resources.Cuba introduced "family dentists," whohave responsibility for preventive, primary,and comprehensive oral health care in spe-cific geographic zones.

The need for basic information on oralhealth status and the availability of nationalresources to carry out programs receivedattention during the quadrennium. The Pro-gram initiated a survey to obtain that infor-mation and to identify areas in whichcollaboration between countries could beimproved. It also developed a series of indi-cators that all countries can use to assesstheir populations' oral health status. Agree-ments were made to take advantage of thesubregional initiatives to pool resources forthe development of oral health activities.Components of oral health were integratedinto the maternal and child health, nutri-tion, equipment maintenance, and AIDSprograms.

It became evident during the 1986-1989period that the ratio of dentists to popula-tion in many countries was approaching thatof developed nations, and that governmenthealth systems' capacity to absorb profes-sional dental personnel was becoming lim-ited. A review that compared the increase inprofessional dental human resources tonational population growth in 12 countriesbetween 1961 and 1984 clearly indicated theneed to make better use of such resources,especially in underserved areas.

The availability and dissemination ofinformation, meanwhile, were enhanced bylinking the resources of the library of theArgentina Dental Association and those ofthe dental school of the University of Sáo

24


Paulo with BIREME. The arrangement nowpermits access to Spanish and Portugueselanguage bibliographic information in virtu-ally every country in the Region. The elec-tronic communication network will beextended to include dental information cen-ters in Canada and the United States.

The Program endeavored to involve thenongovernmental sector in building oralhealth programs. Assistance was provided tothe Organization of Faculties, Schools, andDepartments of Dentistry of the Union ofLatin American Universities (OFEDO/UDUAL) to enhance its role as a regionalentity uniting dental educational institu-tions in North and South America. A spe-cific agreement of collaboration was signedbetween OFEDO/UDUAL and the Ameri-can Association of Dental Schools.OFEDO/UDUAL conducted five technicalcommission meetings and two congresses. Italso held a meeting in Ecuador attended byrepresentatives of 36 dental schools and theassociations of schools of medicine and nurs-ing. The Program collaborated withOFEDO/UDUAL in conducting a prospec-tive analysis of dental education.

Evidence of the new approach that inte-grates training with service was seen in ElSalvador and Uruguay (where an estimated50% of student time will be spent in commu-nity settings) and in the growth of commu-nity-based programs in Argentina, CostaRica, Mexico, Peru, and Venezuela.

The Program also participated in thedesign and development of curricula and inthe establishment of training programs fordental professionals at the UniversidadComplutense in Madrid. Staff and facultyfrom that school participated in Spanish-lan-guage courses in the United States and othercountries of the Region, and in a travelingseminar that enabled those responsible forproducing curriculum changes to observethe new dental curricula adopted in Spanish-speaking countries of the Americas.

An International Center at the Facultyof Dentistry, University of Puerto Rico, was

created for the purpose of enabling Spanish-speaking dental professionals from NorthAmerica and Latin America to exchangeexperiences.

Two major international meetings wereheld with the International Dental Federa-tion (FDI), the chief nongovernmental orga-nization that collaborates with WHO/PAHO in oral health. On both occasions,Chief Dental Officers from the Region andthe deans of dental schools met to coordi-nate the activities of the educational andservice sectors. The Program and FDI con-ducted two surveys to provide informationon areas for future activities in theAmericas.

To stimulate the development ofresearch and the use of appropriate technol-ogy, two workshops were held from whichdocuments were issued that outlined areasfor activity and support needs in the forth-coming period. The development of appro-priate technology has been most notablewith regard to dental equipment, which 17countries now produce or assemble.

In the area of traditional medicine,investigations were carried out regarding theuse of local substances for oral hygiene, painrelief, and infection control. Active compo-nents of these remedies were analyzed toconfirm their bacteriocidal or bacteriostaticeffects.

The Program collaborated with thePAHO/WHO AIDS Program, the U.S.National Institutes of Health, the Centersfor Disease Control, and the WHO Collabo-rating Center on Oral Manifestations ofHIV Infection in preparing informationalmaterials and courses on the oral healtheffects of HIV infection. Oral lesions can bean important indicator of the health statusof individuals infected with HIV, and oralhealth care personnel can play a role intreatment regimens.

Other achievements supported by theProgram included the completion of epide-miologic and oral health status studies inBrazil and Ecuador, the establishment of

25Health Systems Infrastructure


Divisions of Oral Health in both countries,and the completion of the first dental schoolfor the English-speaking Caribbean in Trini-dad and Tobago. In Ecuador, the creation ofan institute for the development of researchin oral health led to the establishment inQuito of the WHO Collaborating Center inOral Health.

Other WHO Regions, particularlyEurope and the Western Pacific, expressedinterest in the experiences and developmentsin the Americas with respect to dental edu-cation, prevention, the use of technology,and the combination of teaching with ser-vice and research.

Clinical, Laboratory, and RadiologicalTechnology for Health Services

Laboratory Services

As national health systems were reorga-nized to facilitate the establishment of localhealth systems, laboratory services wereexpanded and adapted accordingly. PAHO/WHO convened a task force and funded afield study to evaluate the most effective andsimple laboratory tests needed to supportprimary health care. The Organization alsopromoted the establishment of national lab-oratory network systems that are based onreferral services. Fourteen countries (Brazil,Chile, Colombia, Costa Rica, Cuba, Domin-ican Republic, Ecuador, El Salvador,Grenada, Guatemala, Mexico, Peru, Uru-guay, and Venezuela) have initiated suchnational laboratory networks. To supportthe laboratories, PAHO/WHO trained per-sonnel and provided assistance to nationalworkshops in laboratory administration andmanagement and in specialties such asimmunology, clinical chemistry, virology,food bacteriology, enteric bacteriology, andacute respiratory infections.

The Organization supported nationalpublic health laboratories and institutes in

their capacity as diagnostic centers and intheir new roles as referral centers for infec-tious diseases of public health impact and forclinical, hospital-based health laboratoryservices.

In 1986, all Member Countries were rep-resented in a regional meeting to promotethe production and quality control of diag-nostic reagents. Simultaneously, four LatinAmerican institutions-Adolfo Lutz andOswaldo Cruz in Brazil, Instituto de SaludPública of Chile, and Gerencia General deBiológicos y Reactivos of Mexico-estab-lished an exchange network to distributereagents to 19 countries. Argentina, Cuba,and Spain also participated informally withtheir reagent-producing institutes. In 1989,Brazil, Chile, Cuba, and Mexico receivedsupport in developing a UNDP-fundedproject for production of viral reagents. In1986, 23 countries were participating in qual-ity assessment schemes for clinical chemistry,hematology, blood grouping, microbiology,and parasitology. By 1989, 29 countries wereenrolled in at least one of the external qual-ity assessment schemes, which also includedsyphilis testing (VDRL) and humanimmunodeficiency virus (HIV) testing. Since1986, PAHO/WHO has promoted labora-tory testing for HIV of blood for transfu-sions. Subregional meetings in SouthAmerica and Central America and aRegional Meeting on New Technologies forHIV Detection in the Dominican Republicwere held in 1989. The meetings broughttogether the directors of public health andblood bank laboratories and research scien-tists to review state-of-the-art testing for HIVinfections and to recommend approachesthat individual countries should adoptaccording to their epidemiologic situation.

Given that laboratory work impliesexposure to biological, chemical, and physi-cal agents, the program supported the pro-duction of biosafety documents andcosponsored workshops on the subject.Argentina, Chile, Costa Rica, and theDominican Republic published biosafety

26


documents for their laboratory networks,and PAHO/WHO distributed the "NationalCommittee for Clinical Laboratory Stan-dards (US) Guidelines for the Protection ofLaboratory Workers from Infectious DiseasesTransmitted by Blood, Body Fluids, and Tis-sues" to all the countries of the Region.

Information exchange was promotedthrough the distribution of more than 2,400technical documents to national healthauthorities and 51 institutions in 19countries.

The need to train laboratory personnelin new technologies created a greaterdemand for PAHO/WHO assistance.Increased funds from granting agencies weresought for this purpose. National investmentin equipment maintenance and local produc-tion of quality control reagents were pro-moted as measures to reduce laboratoryexpenditures on imported supplies.

Radiological Technology

Cooperation in radiological technologyfor health services encompasses activitiesrelated to diagnostic imaging, radiation ther-apy, nuclear medicine, and radiation protec-tion. Use of the WHO-designed simplifiedradiography unit known as the Basic Radiol-ogy System (BRS), which can cover morethan 80% of all needs for radiological exami-nations, was promoted, especially in localhealth systems. Despite the completion ofvery encouraging evaluations of the BRSunits in Chile and Colombia in 1986, onlyabout 25 units have been installed in theRegion. Another significant project, with apotential impact on cancer cures, was theWHO/International Atomic Energy Agency(IAEA) postal dosimetry intercomparisonfor high energy radiotherapy units, whichbetween 1988 and 1989 alone verified thecalibration of over 200 cobalt units and lin-ear accelerators.

Visits were made to Argentina, Barba-dos, Belize, Brazil, Chile, Costa Rica, Cuba,Haiti, Mexico, the Netherlands Antilles,

Peru, and Venezuela to review their radio-logical programs on equipment and safety. Apractical course in Spanish on radiotherapydosimetry was directed and organized in SanAntonio, Texas, USA, for Latin Americanmedical physicists, and a video of the coursewas produced to help improve the qualityand effectiveness of the Region's radiationtherapy. Lectures were presented at seminarsin diagnostic radiology in Argentina, Brazil,Costa Rica, Mexico, and Venezuela; inradiotherapy, in Peru; in medical physics, inArgentina and Brazil; and in radiation pro-tection, in Mexico, Chile, and Peru. Closecooperation was established with the WHO/IAEA Secondary Standards Dosimetry Lab-oratories (SSDL) in Argentina, Brazil, Chile,Mexico, and Venezuela, and with the threeWHO Collaborating Centers for RadiationEmergencies in Argentina, Brazil, and theUnited States. The PAHO Spanish transla-tion of the recommendations of the Inter-national Commission on Radiological Pro-tection was edited (PAHO Scientific Publica-tion No. 497, 1986), and radiological healthpublications, especially those of PAHO, weredistributed.

In 1987 a serious contamination acci-dent occurred in Goiania, Brazil, resulting inthe death of four persons. In the aftermathof this accident, the WHO CollaboratingCenter on Radiation Emergencies in Brazilplayed a prominent role. In 1989 two otherradiation accidents were investigated. Thefirst one, in February 1989, involved acobalt-60 industrial irradiator in El Salva-dor, where one person died and another hadboth legs amputated. The second accidentoccurred in Bolivia in September of that yearand involved an industrial gammagraphicsource of iridium-192; two persons sufferedhand injuries. In both cases, medicalassistance was secured through the WHOCollaborating Centers for Radiation Emer-gencies in Argentina and the U.S.A. Techni-cal assistance was also provided in 1989 aftertwo minor radiation incidents-one in theDominican Republic and the other one in

27


Trinidad-which both involved brachy-therapy sources and did not require medicaltreatment. These events have demonstratedthe need to strengthen radiation safety legis-lation in the countries of the Region.

Health Education and CommunityParticipation

Local health services based on primaryhealth care operate within the context inwhich the population lives and works. As away to promote healthier lifestyles, theHealth Education and Community Partici-pation Program assisted ministries of healthin developing public information, healthpromotion, education, and community par-ticipation projects. These projects aim atmotivating and enabling individuals, fami-lies, and communities to protect theirhealth, prevent disease, make good use ofexisting health services, and take an activepart in planning and developing improvedcommunity health care activities. Emphasiswas placed on situational analyses, planning,implementation, monitoring, and evaluationat the local level to reorganize existing ser-vices for greater flexibility and administra-tive accountability to the communitiesserved. Simultaneously, the promotion ofcommunity participation aimed at improv-ing accuracy in identifying priority healthproblems and vulnerable groups.

PAHO/WHO appointed an interpro-grammatic group to draft a strategy for socialparticipation in establishing local health sys-tems. Based on the guidelines that ensued,17 countries began to conduct feasibilitystudies.

In 1986, the Ottawa Charter for HealthPromotion was developed and endorsed by221 representatives of 38 countries fromaround the world at a meeting on healthpromotion, held in Ottawa, Canada. Thecharter promoted a "new public health"whereby the health services would collabo-rate with other sectors and consider thebroader context of social, political, eco-

nomic, and physical environments. It alsostressed the need to develop personal andadvocacy skills among participating popula-tion groups.

In February 1988, 49 spokesmen from 11countries in the Americas participated in atechnical meeting held in Washington, D.C.,to define priorities in health promotion, edu-cation, and community participation. Themeeting recommended that health promo-tion and education; community action,mobilization, and participation; self-care;appropriate communication strategies; andskill development continue to be stressed. InAugust of the same year, PAHO/WHO pro-vided leadership and expertise for the XIIIGlobal Conference on Health Education,cosponsored by the International Union forHealth Education, PAHO, and WHO, andheld in Houston, Texas. The meeting's 1,500participants from 111 countries reiteratedthat health is intricately tied to the multiplesocial and political factors that affect devel-opment, and that countries should reorienthealth and education services to betterrespond to these influences. Given the diver-sity of countries and experiences that wererepresented, participants also urged thathealth workers "think globally and actlocally" to better coalesce the forces neces-sary to resolve shared problems throughoutthe world.

PAHO/WHO subsequently published aseries of documents outlining mechanismsfor instituting social participation. A studyprotocol was designed to assist national gov-ernments in determining the feasibility ofintroducing new approaches and methodo-logies to include social participation in thedelivery of all types of local services thataffect health conditions.

To introduce these concepts to key deci-sion-makers and obtain their commitmentto incorporate them into the priorities of theformal health system, PAHO/WHO held aseries of workshops for nationals andPAHO/WHO staff throughout the Region.As a result, the Organization has alreadyreceived many requests for technical and

28


financial assistance in developing efforts tostrengthen social participation in healthpromotion.

PAHO/WHO also promoted opera-tional research in the Bahamas, Colombia,Costa Rica, and Jamaica. Participatoryresearch was chosen as the method because,by its very nature, it promotes the organized,active participation of the community andfacilitates the advocacy of the community inexercising its rights and in expressing itsneeds in a clear and direct way to the appro-priate institutions. Although intersectoralcollaboration was emphasized in theseprojects, it was difficult to achieve and sus-tain because of the long-standing tradition ofsectoral independence.

PAHO/WHO prepared and dissemi-nated basic conceptual documents and oper-ational instruments to orient similaractivities in other countries. The essence ofthese documents and the results of studiesconducted in many of the countries werepublished in a book. A framework for con-ducting research about social participationin local health systems was developed as astandard addendum to PAHO's guidelinesfor research grant applications.

PAHO/WHO provided technical coop-eration to include community participationin the following program areas: appropriateuse of essential drugs, maternal and childhealth, environmental health, veterinarypublic health, adult health, health educationfor school-aged children, and training ofhealth personnel in educational methodolo-gies. Examples of these efforts include thedevelopment of pilot projects for communityeducation in essential drugs in El Salvador,Guatemala, and Honduras and the estab-lishment of guidelines for promoting com-munity participation in malaria programs inGuatemala, Honduras, and Panama.

PAHO/WHO also offered its technicalexpertise in health education to nongovern-mental organizations such as the Interna-tional Union for Health Education, theSociety for Professional Health Educators,the National Council for International

Health, and the Association for theAdvancement of Health Education. TheProgram collaborated with governmentaland nongovernmental organizations such asthe Canadian Public Health Association,IDRC, and Canadian International Devel-opment Agency in Canada and the Ameri-can Public Health Association, CDC,Health Resources and Services Administra-tion, and Office of Disease Prevention andHealth Promotion in the United States, aswell as with international groups such asUNICEF, UNESCO, UNDP, UNFPA, andthe OAS. The Organization and UNICEFare producing materials for their child sur-vival programs, and health is being includedin regional and global "Education for All"efforts of UNICEF, UNESCO, UNDP, andthe World Bank.

The Program encouraged the develop-ment of training capabilities in health pro-motion, education, information, and relatedfields for a wide range of health personnel.Training programs for instructors, communi-cations experts, and health service officialsfocused on priority health problems such asdiarrheal diseases, malaria, sanitation, andmaternal and child health care.

Original publications, reference docu-ments, guides, manuals, and audiovisualmaterials were developed, tested, and dis-seminated to all Member Countries.PAHO/WHO facilitated the interchange ofhealth education specialists among countriesin the Region. It also promoted the devel-opment of health training programs forteachers, communicators, and other key per-sonnel involved in efforts to inform and edu-cate the general public and specificpopulation groups such as children and ado-lescents. To accomplish this, the Organiza-tion worked with the Carnegie Corporationof New York to formulate, program, andimplement a project to strengthen the role ofschools in promoting health. The projectfocused on Eastern Caribbean countries,where it brought health workers into theschools to explain the importance of self-care, healthy lifestyles, and participation in

29

30 Report of rhe Director

community development efforts. Trainingprograms were set up through teacher train-ing colleges.

WOMEN, HEALTH, ANDDEVELOPMENT

The Women, Health, and DevelopmentProgram seeks to promote improvement ofthe social and health status of women; facili-tate analysis and evaluation of policies, pro-grams, and laws that affect them; sponsorresearch and publish and disseminate rele-vant findings; foster the design and imple-mentation of alternative models of healthservices for women; and encourage the par-ticipation of women's groups in the reform ofhealth policies.

During the 1986-1989 period, the Pro-gram's focus was largely aimed at establish-ing its presence within the structure ofPAHO/WHO and among other interna-tional organizations, bilateral agencies, andwomen's groups. In addition, it promotedthe need for national-level women's pro-grams to be established in the MemberCountries. Having achieved a fair degree ofsuccess in these initial undertakings, includ-ing the mobilization of significant extra-budgetary funds for women's projects inCentral America, the Program shifted itsfocus in the last quarter of 1989 towarddeveloping a four-year plan-the "Criteria toOrient Technical Cooperation on Women,Health, and Development"-that calls forthe initiation of concrete projects within thecountries of the Region.

The Pan American Sanitary Conferenceand the Directing Council of PAHO/WHOdiscussed the importance of advancing theProgram and passed resolutions to that effectat all of their meetings during the quadren-nium. The Advisory Committee of theDirector on Women, Health, and Develop-ment, established in 1985, became fullyoperational in 1986. Following the recom-mendations of the Governing Bodies, theposition of Regional Adviser of the Program

on Women, Health, and Development wascreated in 1987. Each of the PAHO/WHOCountry Representations designated a focalpoint to coordinate the Program's activities,and a subregional Coordinator for the Pro-gram in Central America was posted in SanJosé, Costa Rica.

PAHO/WHO supported the organiza-tion of multisectoral National Commissionson Women, Health, and Development,which were established in all the countries.The PAHO/WHO project "Women inHealth and Development of Central Amer-ica" was funded by Norway, Spain, and Swe-den, and received the collaboration ofUNFPA, UNIFEM, UNICEF, UNDP, andECLAC. In addition, in mid-1989 the Pro-gram entered into cooperation agreementswith Spain's Institute of Women, the Uni-versity of Iowa (United States), and IICA,among other institutions, to carry out itsactivities in Central America.

In 1989, the PAHO/WHO TechnicalDiscussions on Women, Health, and Devel-opment took place at Headquarters and atthe Country Representations. Delegatesfrom the National Commissions, nongov-ernmental institutions, and women's organi-zations participated.

The Program made a number of contri-butions in the areas of research and informa-tion dissemination. It completed anepidemiologic profile of women's health inthe Region of the Americas, which will bepublished as a PAHO/WHO Scientific Pub-lication, and in condensed form as a chapterin Scientific Publication No. 524, HealthConditions in the Americas (1990 edition). Itrepresents the most up-to-date systematicanalysis of the health status of women in theRegion.

Most of the countries, meanwhile, pro-moted diagnostic studies on the status ofwomen's health, the results of which will beused to develop more effective policies inthat area. In some Central American coun-tries, studies were completed on existing leg-islation in order to identify discriminatorylegal criteria that constitute obstacles to the



full economic and social participation ofwomen. The Program promoted discussionof the impact of legislation on women'shealth by sponsoring a series of meetings anddisseminating their contents.

The topic of women, health, and devel-opment was considered a priority area forfunding by the PAHO/WHO ResearchGrants Program. Twelve research proposalswere presented from 1987 to 1989, but manyof them had inadequate protocols. It wasdecided that greater effort was required topromote adequate research proposals, andthe Research Grants staff collaborated withthe Program in developing a multicenter pro-posal to study the relationship between theeconomic crisis, work, and women's health.The Health Policies Development Program,meanwhile, collaborated in the design of aprotocol for research on the use and abuse oftherapeutic and clinical-surgical technologyfor women. In coordination with the Healthof Adults Program, a preliminary survey ofthe mental health status of women in theAndean countries was carried out in Bolivia,Colombia, Ecuador, Peru, and Venezuela.

Support also was given to the develop-ment of specialized information systems andnetworks on women in each of the geo-graphic subregions that are the foci ofPAHO/WHO-sponsored health initiatives(Andean area, Caribbean, Central America,and Southern Cone). A feasibility study forthe Central American Information Systemon Women, Health, and Development(SIMUS) delineated methodological andtechnical guidelines for similar studies inother subregions and countries. Based onthe results of the study, a cooperation projectto foster the growth of SIMUS was draftedand was submitted to UNFPA forconsideration.

The Institute of Women of Spainentered an agreement with the Program tosupport a series of publications on women,health, and development. Two annotatedbibliographies on the subject were pub-lished, as was the book Midlife and OlderWomen in Latin America and the Caribbean,

which was produced in coordination withthe Health of Adults Program and theAmerican Association of Retired Persons.

The Program collaborated with thecountries in the preparation of manuals onthe health problems and risk behaviors ofadolescent women, and supported the prepa-ration of materials on the participation ofwomen in primary health care, a topic onwhich little research had been done.

To facilitate the mobilization of women'sgroups to participate in health projects, adirectory on women in Central America,which lists women's organizations and theirprojects, was published with the support ofthe Institute of Women of Spain. Compila-tion of a similar directory was begun inMexico.

EMERGENCY PREPAREDNESS ANDDISASTER RELIEF COORDINATION

During the 1986-1989 quadrennium,natural disasters dealt hard blows to LatinAmerica and the Caribbean. HurricanesGilbert, Joan, and Hugo swept across theCaribbean, Mexico, and Central America,and the recurrent floods in South Americahad serious health consequences.

Despite the achievements of the nationalhealth sector emergency preparedness pro-grams, the Region's vulnerability to naturaldisasters did not diminish. In fact, the mas-sive population shift from rural to urbanareas, coupled with the growing threat oftechnological disasters-factors that arebeyond the scope of the health sector to rem-edy-heightened the existing vulnerability.Yet, although disasters continue to threatendevelopment by destroying infrastructure,burdening health services, and divertingscarce resources to emergency or rehabilita-tion measures, they sometimes provide anoccasion for reform and long-term improve-ments in the health system.

During the last quadrennium, support-ing and strengthening the technical pro-grams in the health ministries continued to


REGIONAL PROGRAM ON WOMEN, HEALTH, ANDDEVELOPMENT

Women make up half of the population of the Americas. They bear and raise theRegion's new generations and are the adults with main responsibility for feeding,clothing, and ensuring the health of its children. Those children under 15 years of agerepresent from one-third to two-fifths of the total population of Latin America and theCaribbean, depending on the subregion, and are the future work force of the countries.

Even if one omits the fact that women also care for men and the elderly withintheir family circles, the responsibility of women is enormous, as is society's implicitreliance on them. To the extent that key health indicators such as infant mortalityrates and nutritional status are used as indicators of a nation's social and economicdevelopment, they also reflect the work and role of its women.

Yet governments have been slow at best in adopting policies that enhance the well-being of what in fact represents the majority of their populations. Even in the UnitedStates, where the economic crisis of the 1980s was felt less severely than in othercountries of the Region, fully one-fourth of children live in poverty. Most of them livein households headed by women, whose economic opportunities are notably fewer,demand less skill, and are not as well remunerated than those of men. In LatinAmerica and the Caribbean, the economic picture is far worse. Yet precise informationon the relative health risks of female persons is sorely lacking.

The paucity of thorough studies on women is in itself a tell-tale sign of the neglectthat they face in the formulation of national development policies. The statistics thatdo exist tend to concentrate on the biological role of the woman as mother. Thosefigures alone are an indication that, despite the number of maternal and child healthprograms that exist, much remains to be done. Preventable maternal mortality, to citeone critical indicator of social progress, is still very high in many countries of theRegion. Pregnancy, birth, and the perinatal period still figure among the five primarycauses of mortality among women between the ages of 15 and 44 in Latin America andthe Caribbean. If the maternal mortality rates prevalent in 1980 were used to calculatethe number of deaths that would occur between 1980 and 2000, the deaths of roughly amillion women would result. If the rates prevalent in more developed countries wereapplied to the same population, 60,000 deaths would be expected.

PAHO/WHO's Governing Bodies have noted repeatedly that women in theRegion are subjected to injustices and denied equal rights and partnership in thedevelopment process. At every meeting it held during the quadrennium, the DirectingCouncil adopted resolutions in which it noted its concern about the status of womenand their health and urged that measures be taken to correct the situation.

The PAHO/WHO Women, Health, and Development Program got off the groundduring the 1986-1989 quadrennium, being set up as a Regional Program that reports tothe Assistant Director of the Organization. In late 1989 the Regional Program devel-oped a plan of work for the next quadrennium, "Criteria to Orient Technical Coopera-tion for Women, Health, and Development," that sets out to close the gap ininformation on women by carrying out research and making its results available to allnational health programs. Well-researched data will not only help dispel the deeply

32

ingrained resistance to improving the status of women that still exists in many coun-tries, but will provide concrete intervention points for health programs.

The work plan stresses the need to consider the effects of both the biologicalfunction of women and their social roles on their health, on that of their children, andon the larger economic development potential of the Region. While promoting suchstudies and information dissemination, the main orientation of the Regional Programwill be to strengthen advocacy for women among health, university, and other socialinstitutions. Simultaneously, it will sponsor workshops and other activities aimed atenhancing ways of empowering women at the community level.

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be one of the principal objectives of theEmergency Preparedness and Disaster ReliefCoordination Program. With the Program'ssupport, every country in the Region desig-nated a health sector disaster coordinator orfocal point responsible for predisaster plan-ning and coordination of health sector reliefactivities. In some cases, as in the smallerCaribbean islands, coordinators assumedthese duties in addition to other responsibili-ties. Many ministries of health establishedadequately staffed and funded preparednessoffices or units at an appropriate level withintheir organizational structures. However, ina number of countries, neither a specificbudget nor posts were established, and toofew countries placed their units at levels suf-ficiently high to be compatible with thecross-departmental activities and executivedecision making they require. Such measuresare essential in a serious commitment tocarry out preparedness activities.

Because health disaster preparednessoverlaps with and depends on the activitiesof other sectors, the participation of keysectors was sought. Among these werecivil defense; the ministries of planning, inte-rior, defense, and foreign affairs; and non-governmental organizations. Representativesfrom these sectors were invited to participatein PAHO/WHO-sponsored intercountryworkshops and seminars. While the overallleadership of the health ministries in healthdisaster preparedness was stressed, PAHO/WHO's technical cooperation and materialsupport were made available to all nationalinstitutions working in this area.

The Organization held a series of work-shops for ministries of foreign affairs andpromoted the development of guidelines todefine the role of diplomats at home andabroad during emergencies. When disastersoccur, decisions concerning health mattersare often made at the highest political levels,instead of at the technical level. Repeatedobservation of this tendency underscoredthe need for the Program to increase aware-ness and understanding of health prioritiesand solutions among both the public and

political leaders. The Program targeted thatmessage toward these groups through thewide distribution of print and audiovisualmaterial.

Another principal objective of the Pro-gram was to train health personnel in emer-gency response procedures. The effectivenessof a nation's response to disasters dependslargely on the readiness and qualifications ofsurvivors who first respond, local leaders,and the health services in the affected com-munity. The more prepared local health ser-vices and communities are, the better theoverall national response will be. The qual-ity and timeliness of the national responsealso depend on the capacity of the centrallevel to support and coordinate the localresponse.

Only 10 years ago, the concept of disas-ter preparedness was still new, and traininghad to begin with the top-level managers.During the quadrennium, however, the Pro-gram was able to take advantage of the mul-tiplier effect by training trainers and localfirst responders and health services staff. Forexample, in 1988 (an average year), 147meetings/courses/workshops were held, inwhich 7,507 people participated, at a cost of$US400,000.

In 1989 the promotion of intersectoralparticipation was exemplified by the firstJapanese International CooperationAgency-Japan/Peru Center for EarthquakeEngineering Research and Disaster Investiga-tion-PAHO/WHO course on the design,repair, and management of hospitals in seis-mic areas. Thirty engineers, architects, andhospital administrators from 11 countries inthe Region were chosen to attend. Theirselection was based partially on their hold-ing positions that would allow them to repli-cate the course nationally.

The development of training material isindispensable if newly trained "multipliers"are to reproduce the courses and workshopsin their own environment. During the qua-drennium, the Program's training materialwas expanded to include video programs,new slide presentations, and several techni-



cal publications. In addition, in collabora-tion with the Office of Information andPublic Affairs, the Program built an exten-sive library of video footage and slides ofdisasters that was not only used to preparetraining materials but also served as an insti-tutional data bank.

The Emergency Preparedness and Disas-ter Relief Coordination Program assumed amajor coordinating role in the aftermath ofmost of the recent disasters in the Region.To streamline emergency response activities,an emergency center was established atHeadquarters. The low-cost center has thecapability to rapidly add lines for telephones,facsimiles, electronic mail, and computers.The Organization also adopted the policy ofrapidly mobilizing PAHO/WHO staff fromoutside an affected country when communi-cations are interrupted and preliminaryinformation suggests major damage hasoccurred. In the Caribbean, an inter-islandPAHO/WHO Disaster Response Team wasformed and is on stand-by during the hurri-cane season. This team approach in thesmaller islands of the Caribbean, establishedthrough the efforts of the Caribbean Pro-gram Coordinator, received full supportfrom the countries involved.

To handle emergency communicationsin a sudden-impact disaster, the Organiza-tion purchased portable satellite earth sta-tions (INMARSAT), which help the affectedcountries communicate with internationalorganizations and the international donorcommunity. PAHO/WHO trained a team ofoperators who were then able to travel withthis emergency communications equipmentto Jamaica in 1988 and Montserrat in 1989in the aftermaths of hurricanes Gilbert andHugo.

The Organization also focused its disas-ter response capabilities on assisting in therapid assessment of health needs, providingtechnical advice to interested donors, andcooperating with the affected government inmanaging relief donations of health supplies,which can be a monumental task, given thelarge volume of unsolicited medical supplies

that arrives in many cases. To address theproblems of international health relief assis-tance, in 1987 the Member Countriesendorsed a series of recommendations thatnow constitute the Organization's regionalpolicy. To the same end, PAHO/WHOundertook the design of a computerized sys-tem to inventory and track the distributionof essential medical supplies. Governmentsthat provide significant relief assistance inthe Region (Italy, Japan, and the UnitedStates, for example) participated in the sys-tem's design.

It is difficult to determine at a glance thelevel of development of a national health sec-tor disaster preparedness program, or howone country's program compares to that ofanother. The operational criteria for measur-ing progress must be improved and basicindicators established to evaluate a pro-gram's development. An evaluation matrix,developed with the assistance of experts fromCIDA, was employed in an attempt to evalu-ate program progress in some countries.However, it did not elicit an effectiveresponse. It is believed that a team of inde-pendent evaluators, assisted by nationalresource persons, would develop a moreaccurate picture of each country's progress,including specific strengths and weaknesses.Plans for future activities within each coun-try could then be tailored to existing needs.

The United Nations designated the1990s as the International Decade for Natu-ral Disaster Reduction. However, the pro-posed plan of work included no significanthealth component or activity. PAHO, insupport of WHO, has actively promoted thehealth sector's priorities and interests beforethe United Nations, through the PermanentRepresentatives' Group for Latin Americaand the Caribbean, to ensure that theDecade's Expert Committee balances its pri-marily basic-research approach with asocial/health orientation. PAHO/WHOplayed the key role in encouraging thehealth sector to actively participate in theestablishment of National Committees forthe Decade and to ensure that its concerns,


36 Report ofthe Directo

needs, and priorities are considered by thenational programs for the Decade.

Adequate preparedness for disasters canbe the portal through which public and com-munity activities and services that arerequired in normal times are improved ordeveloped. A country's level of health pre-paredness for disasters is a reflection of theoverall quality and effectiveness of its healthservices and coverage in normal times. Thepreparedness status can hence only be asgood as the organization and resources ofthe health sector allow. An encouraginglevel of preparedness has been achieved todate. However, the progress is fragile andmay still be affected by changes in the leader-ship of national health ministries. Contin-ued, significant support is required fromPAHO/WHO and other agencies untilnational disaster programs have consoli-dated their staffing and funding presencewithin health institutions.

HUMAN RESOURCESDEVELOPMENT

The adequate supply and effective distri-bution of well-trained manpower is one ofthe most important determinants of the suc-cess of public health programs. As part of itsoverall assessment of needs for the quadren-nium, the Organization reviewed the statusof health manpower in the Region andfound that the distribution of health profes-sionals was skewed in several ways.

Highly trained professionals continuedto concentrate in urban areas, to the detri-ment of services in rural zones. Withinurban areas, they clustered in private-sectorjobs and in hospitals, instead of clinics andother peripheral health units. Liberal univer-sity admissions policies, meanwhile, meantthat more professionals were graduating justwhen the economic crisis was lowering thepublic sector's ability to employ staff compet-itively. The rate of employment growth inthe health services, which had increasedmore rapidly than that of other sectors in

previous decades, stagnated or declined in1986-1989. In some countries, recent grad-uates in medicine faced underemployment orunemployment, a trend that may worsen.

At the same time, the supply of dentists,graduate nurses, and other nonmedicalhealth professionals was insufficient to meetthe needs of the team approach required forcomprehensive primary care. Medical train-ees, meanwhile, were being produced ingreater numbers than ever before, but theirtraining was often inadequate. This trainingwas geared toward specialized, hospital-based care, despite the fact that most coun-tries have a surplus in that area and ashortage of family practitioners and doctorstrained in infectious disease epidemiology.

The difficult task of trying to matchtraining with needs has required the adop-tion of explicit policies that address the issue.At the outset of the quadrennium (1986),the Organization began to restructure itsown technical cooperation program as a wayto assist Member Governments to take cor-rective action. The Human Resources Devel-opment Program grouped its componentactivities under three broad headings-pol-icy and coordination, health personneladministration, and training-that reflectedthe importance of tailoring professional edu-cation and training programs to the require-ments of reforming the public health servicedelivery system. As a corollary, the Program,whose educational orientation had been pre-dominantly technical, began to consider thesocial and economic determinants that influ-ence the health care work force.

The document "Orientation and Pro-gram Priorities for PAHO during the Qua-drennium 1987-1990," approved at the XXIIPan American Sanitary Conference in 1986(Resolution XXI), stressed the importance of"the search for a better definition of the rolesof health workers, for better means of man-power education and training, and forgreater efficiency in their recruitment, con-tinuing education, and use, particularly formanaging services at the intermediate andhigher levels."



These concerns were addressed in theProgram's medium-term plan, which focusedon promoting personnel administration withemphasis on the formulation and analysis ofpolicies, improvements in information, rein-forcement of research in this field, andadvanced training of specialists; developingcontinuing education for health workersthat provides training or reorientationresponsive to reforms in the health services;developing a training system based on prior-ity needs; reorganizing training in publichealth to meet the leadership needs in epide-miology and administration; and collabo-rating with Member Countries in adminis-tering, monitoring, and strengthening theuse of the Organization's scholarships aimedat promoting the goal of universal and equi-table health services.

Policy and Coordination

The Program strengthened its workinglinks with nongovernmental agencies such asthe Union of Latin American Universities(UDUAL), the Pan American Federation ofAssociations of Faculties and Schools ofMedicine (FEPAFEM), the Latin AmericanAssociation of Faculties and Schools of Med-icine (ALAFEM), the Latin American andCaribbean Association for Education inPublic Health, the American Public HealthAssociation and its branch dealing withschools of public health, the Latin AmericanAssociation of Faculties and Schools ofNursing (ALADEFE), the Pan AmericanFederation of Nursing Professionals (FEP-PEN), the Organization of Faculties,Schools, and Departments of Dentistry ofthe Union of Latin American Universities(OFEDO/UDUAL), the Latin AmericanAssociation of Social Medicine (ALAMES),and most national associations throughoutLatin America that deal with the develop-ment of human resources in health.

To include universities, a program called"University and Health in Latin America

and the Caribbean for the Twenty-first Cen-tury" was established with the Union ofLatin American Universities in 1987. Meet-ings were held with sectors that do not tradi-tionally deal with health, such as economics,political science, environmental sciences,and engineering, to discuss subjects that arecritical to solving health problems.

The difficulties encountered in adoptingpolicies that coincide with the goals estab-lished in the health sector were due in partto the lack of coordination between the edu-cation and the health sectors. This gap wasbridged by establishing mechanisms such asthe Interinstitutional Commission onHuman Resources Training in Mexico, theteaching-care integration councils in Boliviaand Chile, and the Interministerial Commis-sion on Health Planning and Coordinationin Brazil.

A project in Argentina, which is beingcarried out with World Bank financing,includes a component of policy coordinationand analysis in human resources. In Brazil,PAHO/WHO supported the National Con-ference on Human Resources in Health,which was later reflected in the country'snew Constitution.

The Program produces two majorsources of scientific and technical informa-tion. The quarterly, Educación Médica ySalud, completed its twenty-third year ofuninterrupted publication in 1989, and theHuman Resources Development Series pub-lished documents, reports, fascicles, man-uals, and handbooks.

At the subregional level, the HealthTraining Program for Central America andPanama (PASCAP), which is the Program'soperating arm for the Central Americansubregion and is based in Costa Rica, com-pleted its tenth year of vigorous support forthe Plan for Priority Health Needs in Cen-tral America. PASCAP designed the person-nel training component in priority areassuch as maternal and child health, essentialdrugs, food and nutrition, and malaria con-trol, and also was responsible for carryingout specific activities in human resources



that are described in the section on the Cen-tral American countries in Chapter VI ofthis report.

Finally, as a mandate of the GoverningBodies, the Program conducted an evalua-tion of the Organization's fellowships pro-gram to determine how fellows put theirtraining to use in their countries of origin.

Human Resources Administration

PAHO/WHO continued to promote thedevelopment of a human resources informa-tion system for training and deploymentstrategies. The system was based on collect-ing primary data and explored the possibilityof using general population censuses. Thefindings varied substantially from country tocountry, and there were situations in whichit still was impossible to update availableinformation. Still, the quality of the dataanalyses was significantly improved regard-ing the ways in which workers join the laborforce, conditions of employment or autono-mous practice, and the quantitative andqualitative aspects of training. Research pri-orities on the structure and composition ofthe work force were defined, and a study wasinitiated on family medicine as a practicealternative.

The Program promoted interest amongnational groups to find ways to make healtheducation a continuing process linked toroutine in-service responsibilities. The Pro-gram provided technical and financial sup-port to eight national working groups thatwere responsible for designing methodolo-gies. Their results were published as fasciclesand work guides and were disseminatedthroughout the hemisphere.

One of the Program's goals is to form aLatin American Collaborative Network thatwill research and propose alternative meth-ods for training health workers on the job.The Program also designed training for acore of specialists on how to analyze healthmanpower problems specific to Latin Amer-ica and how to prepare institutions responsi-ble for deploying such specialists.

Human Resources Training

A new methodology-prospective analy-sis-was introduced in training health pro-fessionals. The method is based on creatingstandard-setting scenarios for the futurewithin the framework of the goal of univer-sal access to primary health care. Each insti-tution's position and the factors critical forprogress are then established by consensus.The context in which the educationalprocess is conducted, the socioeconomic andhealth situation, the structure of the servicesof which it is a part, and the prevailing edu-cational practices are considered in this anal-ysis, and these elements are recognized asdeterminants in the resulting professionalorientation.

By the end of the quadrennium thismethodology had been applied in more than100 medical schools, a similar number ofnursing schools, and about 50 dentalschools, and in many cases the results servedas points of departure for academic andadministrative adjustments in the respectivetraining institutions.

The Expanded Textbook and Instruc-tional Materials Program continued to col-laborate in personnel training. It doubledthe number of book titles offered andincreased the number of continuing educa-tion manuals for in-service personnel. Origi-nal materials prepared by national LatinAmerican authors tripled, and distributionof these books rose by more than 40%. Themost important reorientations of the Pro-gram were the inclusion of material on pri-mary care among its subjects and theexpansion of the textbook distribution sys-tem to the health service system.

Meetings were held to discuss coopera-tion with other sectors, in which health anddevelopment, health situations and trends,sector financing, the health work force, tech-nological development in health, and healthservices organization were reviewed.

The Program continued to supporttraining in the critical areas of administra-tion and epidemiology. The training require-ments and uses of the latter were the subject

38


of a broad review. The Program also contin-ued to sponsor the participation of youngprofessionals in apprenticeship projectsthrough technical cooperation activities car-ried out by PAHO/WHO's regional pro-grams. Thirty-five residents took part in thisprogram during the quadrennium; onreturning to their own countries theyrejoined their institutions, several of them inpositions related to international health.Three of the former residents were later con-tracted by UNICEF and PAHO/WHO.

HEALTH INFORMATION SUPPORT

Official and Technical Publications

The publications of PAHO reflected theOrganization's technical priorities and work,and reached an audience of 100,000 institu-tions and individuals.

The Editorial Service of the Scientificand Technical Health Information Programwas entrusted with commissioning, choos-ing, producing, and disseminating publica-tions on subjects deemed pertinent, timely,valid, and practical to health workers andadministrators. It sought to fill gaps bybringing to light information that would notbe available unless PAHO published it andthat reflected the Organization's work andsupported its technical programs.

The publications produced during 1986-1989 comprised official documents, periodi-cals, scientific books, and technical papers.These products included original works gen-erated by technical officers and distinguishedprofessionals from the countries, transla-tions into Spanish of original materials fromWHO/Geneva and other sources, and jointpublications with organizations such as theAmerican Public Health Association, U.S.National Institutes of Health, AmericanMedical Association, World Bank, andAmerican Association of Retired Persons.

Special emphasis was placed on directtechnical cooperation with those countriesthat expressed interest in improving theirnational publications. The Program spon-

sored national meetings of editors and mem-bers of the editorial boards of biomedicaland health journals and workshop-seminarson editing scientific articles in Chile, CostaRica, Cuba, Nicaragua, Peru, and Venezuelaand in the Mexico-United States borderstates.

Editorial boards were established for theScientific Publications Series and the period-ical publications Boletín de la OSP, Bulletin ofPAHO, and Educación médica y salud. Begin-ning in 1986, one issue each year of theBoletín was dedicated to a single theme: men-tal health in 1986, health economics in 1987,AIDS in 1988, and drug abuse in 1989. TheBulletin followed suit starting with the specialissue on AIDS.

During the quadrennium the publica-tions program issued 32 titles in its ScientificPublications Series and 26 titles under theTechnical Papers Series. The latter series wasbegun in 1986 to disseminate informationfor which timeliness was essential. In theOfficial Documents Series the program pro-duced 8 titles: the annual reports of theDirector, final reports of the meetings of theGoverning Bodies, and the Handbook ofResolutions (Table 1).

In the area of publication distributionand sales, there were three salient develop-ments. Sales were decentralized in Argen-tina, Brazil, Canada, Mexico, Peru, Spain,and the United States. Promotion and mar-keting activities were expanded, which led toan increase in sales. Finally, a new computer-ized distribution list, billing, and inventorysystem was designed that markedly increasedefficiency.

Scientific and Technical Information

The Scientific and Technical HealthInformation Program is also responsible fororganizing and operating the Latin Ameri-can and Caribbean Health Sciences Infor-mation Network. BIREME is the specializedPAHO/WHO Center in charge of theregional system that links national systemswith PAHO's, thus enabling information



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

Serial No. Title

Scientific Publications

479 VI International Conference on the Mycoses480 Enfermedades ocupacionales. Guía para su diagnóstico494 Manual para el análisis de la fecundidad495 Criterios de planificación y diseño de instalaciones de atención de la salud en los paises en desarro-

llo, vol. 4496 Estudios médicos independientes: Su efecto potencial en el sistema de atención de la salud497 Recomendaciones de la Comisión Internacional de Protección Radiológica498 Tuberculosis Control: A Manual on Methods and Procedures for Integrated Programs498 Control de la tuberculosis: Manual sobre métodos y procedimientos para los programas integrados499 Control de calidad en radioterapia. Aspectos clínicos y fisicos500 Health Conditions in the Americas, 1981-1984 (two volumes)500 Las condiciones de salud en las Américas, 1981-1984 (dos volúmenes)501 Salt Fluoridation502 Towards the Eradication of Endemic Goiter, Cretinism, and lodine Deficiency503 Zoonoses and Communicable Diseases Common to Man and Animals. Second Edition503 Zoonosis y enfermedades transmisibles comunes al hombre y a los animales. Segunda edición504 Patterns of Birthweights504 Caracteristicas del peso al nacer505 The Challenge of Epidemiology. Issues and Selected Readings505 El desafio de la epidemiología. Problemas y lecturas seleccionadas506 Guias para la calidad del agua potable, volumen 2507 El control de las enfermedades transmisibles en el hombre, 14a. edición508 Guías para la calidad del agua potable, volumen 3509 The Right to Health in the Americas. A Comparative Constitutional Study509 El derecho a la salud en las Américas. Estudio constitucional comparado510 Crecimiento y desarrollo. Hechos y tendencias511 IV Seminario Regional de Tuberculosis512 Diagnóstico de malaria513 Compendio de enfermedades alérgicas e inmunológicas514 AIDS: Profile of an Epidemic514 SIDA: Perfil de una epidemia515 Guía para evaluar el estado de nutrición516 Vigilancia alimentaria y nutricional en las Américas517 Health Economics. Latin American Perspectives517 Economia de la salud. Perspectivas para América Latina518 Anestesia en el hospital de distrito519 Los sistemas locales de salud: conceptos, métodos y experiencias520 Insuficiencia renal crónica, diálisis y trasplante. Primera Conferencia de Consenso521 Cirugía general en el hospital de distrito522 Abuso de drogas

Official Documents

211 Informes finales. 96a y 97a Reuniones del Comité Ejecutivo de la OPS. XXII Conferencia SanitariaPanamericana. XXXVIII Reunión, Comité Regional de la OMS para las Américas/Final Reports.96th and 97th Meetings of the PAHO Executive Committee. XXII Pan American Sanitary Con-ference. XXXVIII Meeting, WHO Regional Committee for the Americas

212 Handbook of Resolutions of the Governing Bodies of the Pan American Health Organization, vol. 3212 Manual de Resoluciones de los Cuerpos Directivos de la Organización Panamericana de la Salud,

vol. 3215 Annual Report of the Director, 1986215 Informe Anual del Director, 1986219 Informes finales. 98a y 99a Reuniones del Comité Ejecutivo de la OPS y de la XXXII Reunión del

Consejo Directivo de la OPS. XXXIX Reunión, Comité Regional de la OMS para las Américas/Final Reports. 98th and 99th Meetings of the PAHO Executive Committee and of the XXXIIMeeting of the Directing Council of PAHO. XXXIX Meeting, WHO Regional Committee for theAmericas

221 Annual Report of the Director, 1987221 Informe Anual del Director, 1987



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

Serial No. Title

225 Informes finales. 100a y 101a Reuniones del Comité Ejecutivo de la OPS y de la XXXIII Reunión delConsejo Directivo de la OPS. XL Reunión, Comité Regional de la OMS para las Américas/FinalReports. 100th and 101st Meetings of the PAHO Executive Committee, XXXIII Meeting of theDirecting Council of PAHO. XL Meeting, WHO Regional Committee for the Americas

228 Annual Report of the Director, 1988228 Informe Anual del Director, 1988232 Informes finales. 102a y 103a Reuniones del Comité Ejecutivo de la OPS y de la XXXIV Reunión del

Consejo Directivo de la OPS. XLI Reunión, Comité Regional de la OMS para las Américas/FinalReports. 102nd and 103rd Meetings of the PAHO Executive Committee, XXXIV Meeting of theDirecting Council of PAHO. XLI Meeting, WHO Regional Committee for the Americas

Technical Papers

1 Malaria en las Américas. Análisis crítico2 Control del hábito de fumar. Taller subregional para el Cono Sur y Brasil3 Protección del paciente en radiodiagnóstico4 Investigaciones sobre servicios de salud. Indice de trabajos5 Malaria en las Américas. Informe de la IV Reunión de Directores de los Servicios Nacionales de

Erradicación de la Malaria en las Américas6 Polio Eradication Field Guide6 Guia práctica para la erradicación de la poliomielitis7 Pautas simplificadas. Control de las enfermedades de transmisión sexual8 Atención médica de casos graves y complicados de malaria. Reunión técnica informal de un grupo

internacional de especialistas patrocinada por la OMS9 Control del hábito de fumar. Segundo taller subregional. Area Andina

10 Problemas nutricionales en pa;ses en desarrollo en las décadas de 1980 y 199011 Assessing Needs in the Health Sector after Floods and Hurricanes11 Evaluación de necesidades en el sector salud con posterioridad a inundaciones y huracanes12 Fecundidad en la adolescencia. Causas, riesgos y opciones13 National Health and Social Development in Costa Rica: A Case Study of Intersectoral Action14 Los servicios de salud en las Américas. Análisis de indicadores básicos15 Protección contra la radiación ionizante de fuentes externas utilizadas en medicina16 Education and Training Needs for Medical Entomology in the Americas16 Necesidades para la educación y el adiestramiento de entomólogos médicos en las Américas17 Administración de emergencias en salud ambiental y provisión de agua18 Vigilancia del crecimiento y desarrollo del niño. Curso integrado de salud maternoinfantil19 Malaria en las Américas. Informe de la V Reunión de Directores de los Servicios Nacionales de Erra-

dicación de la Malaria y Directores Generales de Salud en las Américas20 Smoking Control. Third Subregional Workshop, Caribbean Area22 A Profile of the Elderly in Trinidad and Tobago23 Strengthening Health Research in the Americas through International Collaboration24 A Profile of the Elderly in Guyana25 Por una mejor alimentación. Evaluación de programas destinados a mejorar el consumo alimentario

y el estado nutricional de familias pobres en Brasil26 A Profile of the Elderly in Argentina

Periodicals

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

and documentation resources to be shared at reinforce existing national networks, includea reduced cost. the national systems as part of projects to

During the quadrennium the Program's develop health services, and obtain financialgoals were to establish national systems in support from foundations and other agenciesthose countries where they did not exist, to further develop information networks.



The regional system's main serviceswere the Latin American Health SciencesLiterature (LILACS) data base, the Biblio-graphic Exchange Service, and provision ofaccess to other national and internationaldata bases. LILACS contains publicationsgenerated by health professionals in theRegion and by PAHO/WHO. The docu-ments are processed according to a method-ology that BIREME developed andtransferred to the countries through coursesand periods of in-service training. TheNational Information Centers gather andprocess the literature generated in theircountries and send BIREME the processedproduct. BIREME then generates the database in compact disk form (CD-ROM) anddistributes copies of LILACS/CD-ROM freeof cost to all cooperating institutions, towhich it earlier provided CD-ROM readingequipment. CD-ROM readers were given to160 institutions in 19 countries, and theLILACS/CD-ROM data base was deliveredto all of them. LILACS/CD-ROM is alsodistributed to institutions outside theRegion. As of the end of 1989, 12 countriesregularly contributed to LILACS, and plansexisted to extend participation to all thecountries, continue negotiations to incorpo-rate literature generated in Spain and Portu-gal, and start a promotional campaign to sellLILACS/CD-ROM as a way of generatingincome.

The institutions forming part of theNational Information Centers shared biblio-graphic resources through the BibliographicExchange Service, which provides photo-copies on request of documents that an insti-tution lacks. During the period 1986-1989,BIREME delivered 300,000 photocopies ofjournal articles to libraries in the RegionalSystem. The telefax network of 17 machinesin 11 countries facilitated document ex-change between the System's units and willbe expanded over the next quadrennium.

Biomedical journals produced in LatinAmerica and the Caribbean faced difficultiesstemming from three major shortfalls: aninsufficient number of original articles to

make their regular publication possible;inadequate content validation because of thelack of editorial boards or a system of peerreview; and a shortage of funds to financetheir publication. The Program sought tosupport national scientific publications byholding meetings with groups of editors andmembers of editorial boards of biomedicaljournals in Chile, Costa Rica, Cuba, Peru,and Venezuela. At these meetings, problemareas and international cooperation wereexamined. It also sponsored courses andworkshops on research communicationmethods, with special emphasis on editingscientific articles, in Costa Rica, Cuba, Mex-ico, Peru, Venezuela, and the states alongthe Mexico-United States border.

In 1986, PAHO/WHO signed a newagreement with the U.S. National Library ofMedicine to become an InternationalMEDLARS Center, enabling it to providethe additional service to the countries of on-line access to data bases. Simultaneousefforts were made to increase the basic jour-nal collections in each country, with the goalof establishing a reference base that satisfies80% of the most frequent demands for bio-medical information. On-line access toMEDLARS outside the United Statesrequires services that the biomedical institu-tions in most of the countries find expensive.The Program hence focused on developingBITNET (Because It's Time NETwork) in aneffort to provide an affordable alternative. In1988, PAHO/WHO and the NationalLibrary of Medicine sponsored a telecommu-nications research protocol called BITNIS(BITNET NLM Intercommunication Sys-tem). Designed by the University of Chile'sSchools of Medicine and Engineering, theproject sought to use BITNET as a carrier foraccessing MEDLARS to reduce telecommu-nications costs. Two versions of BITNIShave proved to be efficient, to have fewrestrictions, and to be affordable.

During the 1986-1989 quadrennium thePAHO Headquarters library experiencedmajor changes. Among them were thelibrary's incorporation into the Scientific



and Technical Health Information Programin 1986 and its internal restructuring undernew leadership in 1987.

The Library provides information ser-vices, bibliographic searches, periodicalscontrol, photocopying, selective distributionof documents, and technical cooperationwith Headquarters programs, PAHO/WHORepresentations, and the Pan AmericanCenters.

Regarding information processing, docu-ments of the Headquarters' technical pro-grams and the documentation centers in thePAHO/WHO Country Offices began to beincluded in the MicroISIS computerized pro-gram. This software made it possible for thefirst time to share resources and activelyexchange biomedical information in theRegion by cooperative indexing and dissemi-nation on compact disk.

Information and Public Affairs

The Office of Information and PublicAffairs changed dramatically over the 1986-1989 quadrennium. By the end of theperiod, an in-house video production unithad been created, and this new video capa-bility, together with the related strategy ofemploying satellite technology for telecon-ferencing, significantly augmented the Orga-nization's capacity to reach large audienceswith health information. The success of thisapproach and its support by Member Coun-tries led to the decision in late 1989 todevelop a project-Communicating for'Health-that will build comprehensive mul-timedia communications campaigns for thepublic in the countries of the Americas.

The Office organized two telecon-ferences on AIDS in collaboration with thePAHO/WHO Program for the Preventionand Control of AIDS. The I Pan AmericanTeleconference on AIDS, held in Quito,Ecuador, in 1987, was transmitted by satel-lite to an audience of 45,000 in 30 countriesin the Americas. Broadcast in English, Span-ish, French, and Portuguese, the telecon-

ference provided general information on theAIDS pandemic for health workers, decisionmakers, members of the media, and the gen-eral public. The II Pan American Telecon-ference on AIDS was broadcast from Rio deJaneiro, Brazil, in December 1988 to audi-ences throughout the Americas as well as inEurope, the Middle East, and Africa. It cov-ered the key issues in AIDS prevention andcontrol for an audience of medical andhealth care personnel, social scientists, andothers who design, carry out, and monitorAIDS control and treatment projects. Thecontents of both the conferences were editedand distributed in English, French, Portu-guese, and Spanish to Member Countries.

On 1 July 1989, the Office sponsored theAmericas-wide television special on health"Salud para todos." The first event of itskind, "Salud para todos" was an entertain-ment television program that was broadcastlive from Miami, Florida, to over 30 coun-tries in the Americas and Europe, reachingan audience of more than 100 million view-ers. It featured popular entertainers fromLatin America and Spain who interspersedhealth messages on such topics as infantmortality, environmental contamination,the role of women in health services, drugabuse and tobacco use, and childhoodimmunization programs with musical anddance performances. A series of documenta-ries on health conditions in the Americas,produced by the Office, was shown duringthe program.

The Office produced some 60 short,timely documentaries and educational video-tapes on key health issues during the qua-drennial period. The Office's video crewtraveled extensively in the Americas to doc-ument health conditions, risk factors, tech-nical projects, and special events. Thesevisual records were then edited by the Officeinto video productions for general distribu-tion. Several of the productions with a lesstechnical content were broadcast as publicinformation programs by television stationsin the Region.

The Office's core functions of media


HEALTH AND COMMUNICATIONS TECHNOLOGY

When PAHO/WHO launched its campaign to build a modern communicationscapability in 1986, many asked what advanced communications technology had to dowith primary health care. Since then, the Office of Information and Public Affairs hasshown that a lot can be accomplished in that area.

For instance, many parents learned for the first time of the vital importance ofimmunizing their children during a two-hour television special: "Salud para todos,"organized by PAHO and carried by television networks in 30 countries. Many childrenwatched the famous mouse character Topo Gigio overcome his fear of needles in a skiton the same show.

Well-known Latin American entertainers performed and gave health messagesrelated to such topics as infant mortality, environmental pollution, diarrheal diseases,women's role in health services, drug abuse, and smoking. These performers attracted alarge viewing audience that would not normally tune in to a health documentary andprobably had a greater impact on health behaviors than would have been the case ifthe same messages had been issued by health authorities. During the show, Mexicantelevision actor Humberto Zurita announced PAHO's plan to eradicate wild poliovirustransmission from the Americas by 1990 and offered a $US100 reward for any personreporting a confirmed case of the disease.

In another example, health workers in remote areas, who would never have hadthe financial means to attend international scientific meetings, were able to see, hear,and query the world's leading authorities on AIDS during the I and II Pan AmericanTeleconferences on AIDS. These two groundbreaking events used modern technol-ogy-television networks, international satellites, local reception sites in countries allover the Americas and Europe, and direct telephone links-to allow direct questions ofthe presenters, who thus reached much larger audiences than they could ever find atscientific meetings.

Thirty countries and over 45,000 participants at more than 300 sites throughoutthe Americas were linked by satellite on 14-15 September 1987 by the I Pan AmericanTeleconference on AIDS, which was transmitted in four languages.

relations, preparation and dissemination ofnontechnical publications, response to pub-lic inquiries, and the production of photo-graphic exhibits and slide shows were allupgraded.

The demand for information fromPAHO/WHO grew significantly during thequadrennium. In 1989, 8,000 informationrequests were received from television net-works, newspapers, radio stations, maga-zines, researchers, students, and the generalpublic. In responding to the media requests,the Office often arranged interviews with the

Director and PAHO/WHO technical staff.In support of the technical programs of

the Organization, the Office produced anumber of multimedia instructional pack-ages consisting of videotapes, publications,and slide shows. It also mounted 50 largephotographic exhibits that documentedhealth projects sponsored by PAHO/WHO.The Office collaborated with national orga-nizations and with UNICEF in producingvisual and print materials. The extensivephotographic documentation center that theOffice built up over the period served as a

44

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

resource for technical programs and countryoffices, which used photos for technical, sci-entific, and nontechnical publications, aswell as posters and other visual displays.Magazines, newspapers, and other publica-tions in the Region and in Europe also madeuse of photographs from the Office's libraryto illustrate the health situation in theAmericas.

The long-needed purchase of modernequipment allowed the Visual Aids Unit ofthe Office to significantly expand its com-puter-generated graphics capability. Desktop

publishing equipment and slide presentationworkstations were acquired or upgraded toenhance the quality of the Office's publica-tions and slide shows.

RESEARCH PROMOTION ANDDEVELOPMENT

During the quadrennium, methods forthe promotion and development of scienceand technology for health received concen-trated attention. Pivotal to this end were the

45


contributions of the PAHO/WHO AdvisoryCommittee on Health Research (ACHR)and its subcommittees on Biotechnology andon Health Systems and Services Research.The Program reoriented its support awayfrom isolated or fragmented initiatives,instead investing its limited resources inprocess-oriented approaches that favor tech-nical cooperation among countries.

In spite of the noted progress, the needstill exists to develop a comprehensive tech-nical cooperation program with the partici-pation-from design to execution-of all thetechnical programs. Given the difficultiesinherent to interprogrammatic work, this isa complex task, but one that will be under-taken in 1990 with the support of in-housecommittees and subcommittees instituted bythe Director, PASB, in support of researchcoordination activities.

One of these committees, the InternalAdvisory Committee on Health Research(IACHR) oversees the PAHO/WHOResearch Grants Program, which approved94 of the 364 grant applications it receivedduring the 1986-1989 period (Table 2).Given the number of rejected proposals,especially during the last two years, the

Committee was led to recommend thatcloser ties be established with nationalresearch councils and that specialists beenlisted to develop protocols for multicoun-try projects in priority research areas. By theend of 1989, working agreements had beenestablished with six national research coun-cils, and multicountry protocols were initi-ated in four of the Research GrantsProgram's priority areas.

In 1988 a study involving five countriesin Latin America was launched to identifytrends in research and scientific productionfrom 1978 to 1988 and their relationship tothe socioeconomic characteristics of therespective countries. Once completed, thestudy will have identified existing data banksthat can then be linked. Since the five coun-tries involved produce 90% of the scientificresearch in Latin America, the data banklinkage should permit major research trendsin the Region to be followed and analyzed.

The Program sponsored a number ofseminars aimed at improving the manage-ment of research and development. The sem-inars were attended by participants from 30countries and territories in the Region. Theycovered such topics as health research infor-

Table 2. PAHO research grants for projects approved during 1986-1989, by priority area.a

Aging and healthBiotechnologyEconomy and financingGrowth, development, reproductionHealth systems and servicesHealth and illness in adultsHealth and workHealth profilesLabor force in healthPolitical process and healthProcess of technological developmentHealth sanitation systems/servicesScientific activity in health

Total

1986-1987Number of Amount

projects ($US)3 20,0009 176,0213 87,5452 22,450

8 121,5276 43,7485 58,3403 57,8142 35,0007 90,1896 79,150

54 791,784

1988-1989Number of Amount

projects ($US)

2 40,0001 20,0006 100,3773 59,9644 68,7053 60,1001 10,0004 84,6914 75,8005 87,7602 41,5005 100,000

40 748,897

a As of 31 December 1989.

46


mation systems, research evaluation, meth-ods for setting research priorities, andtechnical cooperation in health science andtechnology.

The ACHR recommended the design ofa Regional Program in BiotechnologyApplied to Health and a Regional Programfor Health Systems and Services Research,selecting these areas because of their poten-tial value to health development and thepromotion of science and technology in theRegion. In both cases, scientific infrastruc-ture development is the long-term objective,and it is pursued by means of researchprojects addressing priority health needs.

In the area of biotechnology, 11 projectsto develop procedures for diagnosing blood-transmitted diseases were funded, and most ofthem were completed by 1989. One of theprojects led to the development of a diagnos-tic kit for AIDS that is now being validated intwo reference serum panels. In 1989 research-ers from three Latin American countriesdesigned a project to develop strategic tech-nology for the production of immunodiagnos-tic reagents. The project, financed by theOrganization and staffed by the participatinginstitutions, will last two years.

The Program has produced a varietyof documents and reports in the area ofhealth systems and services research, and theGoverning Bodies have repeatedly recog-nized the need to base the transformation ofhealth systems on a solid scientific founda-tion. However, it was not until 1985 thatPAHO/WHO made a concerted effort tostimulate research in this area, and, despitethis promotional activity, the response of thescientific community has been minimal. ASubcommittee of the Advisory Committeeon Health Research was therefore appointedto further this purpose. The Subcommitteefirst met in May 1989 and recommended aseries of guidelines that was approved bythe Advisory Committee, which also urgedthe Director of PASB to put them into effectpromptly.

The Research Coordination Unit andthe Health Services Development Programsubmitted a proposal to the Director inNovember 1989 to carry out a multicentric,18-country evaluation of the implementa-tion of local health systems. The designof country-specific protocols for the$US1,000,000 project is in progress and isscheduled for completion in 1990.

47

CHAPTER IV

HEALTH PROGRAMSDEVELOPMENT

INTRODUCTION

During the quadrennium, work in theHealth Programs Development Area waschanneled along two main approaches. First,attention concentrated on structuring theOrganization's technical cooperation so thatresources were applied effectively, had themaximum possible impact, and were pro-grammed and implemented to allow impactevaluations. Second, the subregional ap-proach was consolidated in order to bestaddress geographical and public health con-cerns through the coordinated efforts of sev-eral countries.

The systematization of technical cooper-ation emphasized setting target deadlines,ensuring adequate programming, and fol-lowing six basic strategies for the technicalcooperation with Member Countries. Thesesix strategies were the mobilization ofresources; dissemination of information;manpower training; development of norms,plans, and policies; research promotion; andthe provision of technical consultancy. Someof the principal activities in these six areasare described in detail under the various pro-gram headings.

All the Health Programs Developmentprojects focused on mobilizing financialresources. Significant increases in extra-budgetary funding were obtained andapplied to programs in the countries, and aconcerted effort was made to mobilizenational institutional and political resources.Results from these efforts include theincreased involvement of universities and

other national institutions in health projectspromoted by the programs.

The evaluation of technical cooperationactivities also improved. Emphasis contin-ued to be given to evaluating the pro-grammed activities' accomplishments; theevaluation of the impact of those activitieson the national health services and onhealth conditions, especially among vulnera-ble groups at greatest risk, showed gains aswell.

Support of the subregional initiativescontinued, especially for those projects thattargeted vulnerable groups such as mothers,children, and workers and priority healthprograms such as communicable diseases,food and nutritional deficiencies, environ-mental health, and the chronic diseases ofadulthood.

The programs made considerable pro-gress in certain specific areas: the eradi-cation of indigenous transmission of the wildpoliovirus is in sight, the urban rabies con-trol program has entered its final attackphase, and there is significant national sup-port for the campaign to eradicate foot-and-mouth disease.

Regional concern about environmentalcontamination, environmental health, anddrug abuse led PAHO/WHO to devotemore attention to these areas. There wasconcomitant effort placed on health promo-tion and the use and application of healthservices research. Finally, the increased cohe-sion and unity of vision in this area duringthe quadrennium have led to more interpro-grammatic collaboration and better support

48

Health Programs Development 49

to the program activities at the countrylevel.

FOOD AND NUTRITION

The work of the PAHO/WHO Foodand Nutrition Program is carried out by Pro-gram staff and two specialized centers-theCaribbean Food and Nutrition Institute(CFNI), based in Jamaica, and the Instituteof Nutrition of Central America and Pan-ama (INCAP) in Guatemala.

The Program addresses nutrition defi-ciency problems (protein-energy malnutri-tion and iron, iodine, and vitamin Adeficiencies), as well as health problems aris-ing from poor dietary habits. In light of thecontinuing economic crisis, PAHO's Direct-ing Council, at its XXXIII meeting in 1988,mandated the Program to promote ways ofensuring the availability of food for low-income and other vulnerable groups (Resolu-tion XVI). The resolution also called fortechnical cooperation in the areas of foodand nutrition surveillance systems, educa-tion and public information, research intobalanced diets that incorporate locally pro-duced foods, and preventive nutrition in themanagement of chronic diseases associatedwith diet.

The Joint (PAHO/WHO-UNICEF)Nutrition Support Program UNSP) was amajor vehicle through which food and nutri-tion activities were accomplished. InDominica, Haiti, Nicaragua, Peru, and St.Vincent and the Grenadines, the JNSP sup-ported national projects to improve thenutrition and health of women and childrenas part of primary care services. The JNSPprojects in Dominica, Nicaragua, and St.Vincent and the Grenadines concluded in1989, at which time similar ones were begunin St. Kitts and Nevis and Saint Lucia. TheJNSP also successfully carried out projects tocontrol iodine deficiency disorders (IDD) inBolivia, Ecuador, and Peru. In 1989 it per-formed a rapid assessment of the IDD situa-

tion in Central America, Mexico, andParaguay.

The Interagency (PAHO/WHO-FAO-UNICEF) Food and Nutrition SurveillanceProgram was launched in 1987 to provideinformation on health and nutrition foradvocacy purposes at the national and inter-national levels. Its aim was to promote thenutritional protection of vulnerable groupsand the development of national food andnutrition surveillance systems. Subse-quently, the International Conference onFood and Nutrition Surveillance in theAmericas, held in Mexico City in 1988, rec-ommended a set of measures in this regard(see PAHO Scientific Publication No. 516),including a regional training program onfood and nutrition surveillance. ThePAHO/WHO Food and Nutrition Programpresented such training at a meeting in Cali,Colombia, in 1989.

The Program and the centers acted inconcert with other international nongovern-mental agencies and donor governments incarrying out their activities. PAHO/WHOand IDB agreed to accord food and nutritionpriority status and prepared joint strategiesfor Latin America and the Caribbean. TheProgram also collaborated in the design andevaluation of World Food Program projectsdirected primarily toward poor and vulnera-ble groups. INCAP received funds fromUSAID, France, Switzerland, and Swedento support technical cooperation in maternaland child health, nutrition education, anddevelopment of human resources in healthand nutrition in Central America. CFNIreceived support from the InternationalCenter for Research on Women for projectsto control iron deficiency anemia in theCaribbean, and from IDRC for an educa-tional project to improve the nutritional sta-tus of children in the weaning age group.

CFNI focused much of its effort on mak-ing information on food and nutritionwidely available to health workers and com-munities. It continued to publish the journalCajanus, the newsletter Nyam News, and



manuals on the control of obesity andrelated chronic diseases, oral health, nutri-tion education, and community nutrition. Itregularly issued "Nutrient-Cost Tables" toinform the public of the most economicalfood purchases for building balanced diets.Its book Children of the Caribbean included asummary of the nutrition situation in theCaribbean and its impact on child survival.CFNI vigorously pursued cooperation withthe mass media to promote nutrition educa-tion. The radio series "With Healthy Liv-ing," partially supported by the Jamaicanprivate sector, was one of its most successfulundertakings and one of the most popularradio programs in Jamaica.

INCAP also gave attention to dissemi-nating information. Its library served over5,000 users in Central America and 1,500 inother countries. Its bibliography wasincluded in the LILACS system, and itgained access to such international databases as MEDLARS, MEDLINE, andDIALOG. The Center produced and dis-tributed bulletins dealing with supplemen-tary feeding ("Bulletin PROPAG"), childsurvival ("IRA News," "Mothers and Chil-dren," "Diarrhea Dialog"), and food tech-nology ("Amaranto").

The Food and Nutrition Program collab-orated with the Maternal and Child HealthProgram in producing a training module forthe promotion of breast feeding and shareddata with the United Nations Subcommitteeon Nutrition for inclusion in the publica-tions First World Nutrition Situation Reportand Update of the World Nutrition Situation. Italso produced scientific publications onendemic goiter, cretinism, and iodine defi-ciency disorders, and food and nutritionsurveillance.

The Program and its two centers carriedout a number of activities aimed at traininghealth workers in food and nutrition. Aspart of the Regional Operative Network ofFood and Nutrition Institutions (RORIAN),the Program, along with the United NationsUniversity and the Central American Insti-tute for Business Administration, organized

a course in 1988 on the application of thecase study method to improve the manage-ment of food and nutrition programs andother health projects. CFNI's support fortraining activities included its collaborationwith the first Dietetic Internship in theCaribbean; the Faculty of Agriculture of theUniversity of the West Indies; the College ofArts, Science, and Technology in Jamaica;and the Barbados Community College.CFNI also used the satellite distance teach-ing facility at the University of the WestIndies, Mona Campus, to offer in-servicetraining throughout the Caribbean. ThePAHO Regional Training Program in Foodand Nutrition Surveillance aided the Insti-tute of Nutrition and Food Technology ofChile, the Costa Rican Institute forResearch and Training in Nutrition andHealth (INCIENSA), and the University ofValle, Colombia, in the design of subre-gional training projects.

INCAP's School of Nutrition and Di-etetics was transferred to the University ofSan Carlos of Guatemala in 1987, but it con-tinued to offer postgraduate courses in nutri-tion and food science and technology.INCAP conducted a survey of manpowerneeds in the Central American subregionand collaborated in formulating and imple-menting national plans based on the survey'sresults.

The Program supported a study by theColombian Association of Dietitians andNutritionists on the academic profile andcompetence of professionals in those fields.A handbook to be used in conducting simi-lar studies in other countries was alsoissued.

The Regional Program and both INCAPand CFNI lent support to Member Govern-ments throughout the Region in developingfood and nutrition policies and strategiesand monitoring their execution. INCAP alsoevaluated food aid programs, including themanagement and storage of food supplies,dietary habits to increase the production ofbreast milk, oral rehydration therapy usinghome-made fluids, and feeding practices dur-

Report of the Director50

Health Programs Development 51~~~~~~~~~~~~~~~~~~~~~~~

ing episodes of infant diarrhea. CFNIresearched strategies to combat iron defi-ciency anemia, the sociological aspects ofstreet-food vending, and the impact ofmigration on food and nutrition status. InJamaica, the school meal program was evalu-ated, as was educational material used toimprove the nutritional status of children ofweaning age. The Center also studied thesocial and economic implications of Hurri-cane Gilbert in Jamaica.

ENVIRONMENTAL HEALTH

The PAHO/WHO EnvironmentalHealth Program is among the most crucialprograms of the Organization, since itencompasses services that have a direct andlasting impact on public health. The Pro-gram has five components: general environ-mental health, water supply and wastewaterand excreta disposal, solid waste manage-ment and household hygiene, preventionand control of environmental pollution, andworkers' health. Its activities are carried outby staff at Headquarters who are responsiblefor overseeing Region-wide activities, sani-tary engineers who are posted in severalcountries, the Pan American Center for San-itary Engineering and Environmental Sci-ences (CEPIS) in Lima, Peru, and the PanAmerican Center for Human Ecology andHealth (ECO) in Metepec, Mexico.

General Environmental Health

The General Environmental Healthcomponent of the Program coordinates withother institutions and PAHO/WHO pro-grams in carrying out activities such as train-ing sanitary and environmental engineers,mobilizing resources, establishing informa-tion systems, and preparing for natural andtechnological disasters.

In recognition of its important role inthe Region, the Program supported theefforts of the Inter-American Association of

Sanitary and Environmental Engineering(AIDIS), a professional association thatbrings together engineers from all countriesin the Americas. The Program commis-sioned a study in 1987 to strengthen AIDIS'institutional capacity to promote environ-mental health by setting up a viable financialplan, establishing its Executive Secretariat inSáo Paulo, Brazil, and developing itsnational chapters. AIDIS also held Regionalcongresses every two years and issued severalpublications with support from the Program.

To assist in providing educational oppor-tunities, the Program prepared the firstRegional Directory of education programsfor sanitary and environmental engineers,which it updated in 1989. It also sponsoredmeetings of professors in the discipline andtechnical cooperation agreements betweenLatin American universities and several inNorth America and Spain. CEPIS and ECOprovided nine-month to one-year intern-ships to young environmental health profes-sionals who then returned to work in theircountries of origin. Both CEPIS and ECOpublished and distributed texts, newsletters,manuals, and training materials on a widerange of relevant topics.

The Program collaborated with theOrganization's Emergency Preparedness andDisaster Relief Coordination Program inlending technical cooperation to nationalprograms in disaster-prone countries for thepurpose of preparing environmental healthfacilities and personnel for natural and tech-nological emergencies. When emergenciesoccurred, Program staff were assigned to thePAHO Emergency Response Team responsi-ble for advising the affected country onemergency measures and rehabilitation pri-orities, and coordinating international reliefin health.

Water and Sanitation

At the beginning of the quadrennium,PAHO's Governing Bodies (see Chapter 1)reviewed efforts being made by the countries

51Health Programs Development


of the Region to extend the coverage ofwater, sewerage, and sanitation services. Thereview covered progress during the first halfof the 1981-1990 International DrinkingWater Supply and Sanitation Decade and setstrategies for the final five-year period.Decade progress and its development werealso discussed at a consultative meeting ofdonor and funding agencies sponsored byPAHO/WHO and IDB in 1986, in which 22international and bilateral agenciesparticipated.

Data available in 1985 showed that 86%of the urban population of Latin Americaand the Caribbean had water supply ser-vices, and 60% of the same had access tosewerage services and sanitary installations.In rural areas, coverage of water supply was45%, and access to sanitation services was15%. Studies conducted in Peru of deficien-cies in operation and maintenance of watersupply and sanitation services showed thatabout 30% of rural water supply systemswere partly or totally inoperative five yearsafter their construction. A similar situationmay exist in other countries with similarcharacteristics. In urban areas, water lossesdue to poor maintenance and managerialpractices were over 40% of capacity (20-25%is considered normal in large distributionsystems).

By 1988, preliminary data from 25 coun-tries that included over 90% of the popula-tion of Latin America and the Caribbeanshowed that urban water supply coverage(including direct connections and easyaccess) had reached 88%, rural coverage was55%, urban sewerage and excreta disposalcoverage was 80%, and rural sewerage andexcreta disposal services covered 32% of thepopulation.

At the beginning of the InternationalDrinking Water Supply and SanitationDecade, Regional targets were set at 91%,56%, 69%, and 31% coverage for urbanwater supply, rural water supply, urban sew-erage and excreta disposal, and rural excretadisposal, respectively. The 1988 data indicatethat, by and large, these targets will have

been met or surpassed by the end of 1990-asignificant achievement, especially given thedeteriorating economic conditions. Yet,meeting the coverage goals set in 1980 willnot suffice. Water quality is still far from sat-isfactory: 75% of the water supplies were notdisinfected adequately to ensure that thewater was safe to drink, and quality controlprograms are understaffed and lack sufficientlaboratory support. Furthermore, the con-tinued growth of settlements on the periph-ery of urban areas means that the watersupply and sanitation sector will requirefunds, manpower, and supplies to offsetpotential future deficits in coverage and tomaintain the systems that are in place.

PAHO/WHO hence concentrated alarge part of its technical cooperation onhelping to develop low-cost technologies toextend coverage, training personnel in theproper maintenance of facilities to reduceleakage and loss in capacity, promoting effi-cient community water use, and institutingpreventive and treatment methods to pro-tect water from biological and chemicalcontaminants.

PAHO/WHO, the World Bank, and theUNDP collaborated on a set of instructionalmodules demonstrating low-cost technolo-gies for water supply and sanitation. CEPISand the University of Surrey (England)developed and tested low-cost technologykits for water quality improvement (includ-ing the DELAGUA field test kit, mixed oxi-dant disinfection, and slow sand filters withprefilters). Both the modules and the kitswere in use throughout the Region by theend of 1989. The Caribbean DevelopmentBank, meanwhile, collaborated withPAHO/WHO in setting up drinking waterquality control and improvement projects inthat subregion.

CEPIS received backing from IDRC,GTZ, and the World Bank for its researchproject with the National Drinking WaterSupply and Sewerage Services of Peru onmethods to treat and reuse wastewater.PAHO/WHO and CARICOM initiated aRegional Sewerage Studies project in the


Healrh Programs Development 53

Caribbean to determine appropriate stan-dards for wastewater discharge and technol-ogies to prevent contamination of coastalzones.

To support institutional developmentfor water supply and sanitation services, 24extrabudgetary projects designed and imple-mented by PAHO/WHO and nationalagencies were funded in the amount of$US21 million by IDB, the World Bank,GTZ, CIDA, the Caribbean DevelopmentBank, UNDP, and the countries themselves.The projects focused on institutional devel-opment of national and state water agencies,provision of decentralized water and sanita-tion services to rural communities, develop-ment of plans to supply water and sanitationin peripheral urban areas, and detection andreduction of water losses.

More than 1,000 technicians and engi-neers were trained by PAHO/WHO in leakdetection and water loss control in a projectfinanced by IDB and GTZ. CEPIS estab-lished groups known as "Technical Nuclei,"made up of specialists from Brazil, Colom-bia, Costa Rica, and Mexico, to prepareguidelines, manuals, and educational materi-als on water conservation and the optimiza-tion of existing facilities.

Solid Waste Management andHousehold Hygiene

Solid waste management requiredincreased attention due to expanding ratesof urbanization, including crowded settle-ments established on the periphery of largeurban areas. The Program concentrated onextending the coverage of urban sanitationservices and improving managerial practicesin the final disposal of municipal refuse. It isestimated that the proportion of solid wastedeposited in sanitary landfills increased to35% in the major cities of the Region by1989. The Program lent technical assistanceto drafting sanitation plans for a number ofcountries and promoted the formation of"National Urban Sanitation Systems," in

which municipalities, ministries, financialagencies and other institutions, and commu-nity groups participated to provide an inte-grated approach to improve the serviceswithin a national program. This approachwas designed by a group of specialists con-vened by the Program, and the results weremade available to the countries. CEPIS,meanwhile, carried out experimentalprojects to enable slum dwellers to dispose ofsolid waste themselves with minimal techno-logical assistance. The Program sponsoredcourses throughout the Region, throughwhich 1,523 professionals were trained insolid waste management.

Due to the limited resources available,most of the Program's activities in the area ofbettering household hygiene practices con-centrated on disseminating information andtraining nationals.

Prevention and Control ofEnvironmental Pollution

The Program's main objective was toassist national authorities in carrying outhealth risk assessments regarding chemicalhazards and in developing programs to pre-vent and control the contamination of theenvironment. The Program also aimed toincrease awareness of chemical pollutionhazards in the Region by carrying out stud-ies, making information available, trainingprofessionals, and fostering the establish-ment of interinstitutional networks such asthe PROECOS (see below). Evaluations car-ried out during the quadrennium revealedextensive, serious contamination that hasbeen exacerbated by rapid urban growth,industrial expansion, and agricultural devel-opment.

ECO organized three networks of insti-tutions to improve national capabilities toevaluate and remedy problems. By the endof 1989, the toxicology network was operat-ing in seven countries, the environmentalepidemiology network in fourteen countries,


54 Reporr of rhe Director

and the environmental health impact assess-ment network in nine countries.

ECO prepared modular training materi-als in fields such as toxicology, environ-mental epidemiology, rapid assessment ofenvironmental contamination, health effectsof exposure to various chemical agents, andpesticides and health. These materials wereused extensively in the Region. In the pastquadrennium, 152 workshops were orga-nized, which hosted 4,732 participants.

ECO supported the creation of nationalprojects in ecology and health (PROECOS)whose functions are to make informationavailable on the extent of environmentaldegradation and its health ramifications andto propose viable interagency projects toarrest its progression. Among the issues thePROECOS addressed were air pollution, useof pesticides, the environmental impact oflarge dam projects, and pollution by hydro-carbons, heavy metals, and hazardous chem-ical residues.

CEPIS established Technical Nucleimade up of specialists to examine the statusof and the control procedures for toxic sub-stances in surface waters and eutrophicationof tropical lakes and reservoirs. The groupsissued case studies, manuals, guidelines, andpolicy papers, and also conducted work-shops on the subject. CEPIS itself lent tech-nical assistance to several countries in theapplication of computer modeling programsfor the evaluation and control of hazardouscontaminants. It also coordinated a regionalprogram to prevent and control ground-water contamination, and provided supportto Latin American laboratories that partici-pate in the United Nations' Global Environ-mental Monitoring System for Water.

Both CEPIS and ECO carried out on-site training for professionals in the Region.The centers' visiting professionals programsdrew participants from Europe and Japan aswell as the Americas.

Other organizations and agencies, suchas IDB, the World Bank, the EnvironmentalProtection Agency and CDC of the UnitedStates, IDRC and CIDA of Canada, GTZ,and the Japanese International Cooperation

Agency, participated in Program activities inthis area.

At the close of the quadrennium, theProgram prepared a position paper on therelationship between health and the envi-ronment that delineated a plan of action forthe 1990s and will be used by the XXIII PanAmerican Sanitary Conference (1990) toestablish Region-wide policies and programorientations.

Occupational Health

More than 80% of the working popula-tion of Latin America and the Caribbeanlacks access to occupational health services.The Program's 1986-1989 goals in this areaconsisted of reviewing national occupationalhealth policies and legislation; promotingoccupational health services and expansionof coverage as part of primary health care;extending preventive occupational healthcare among the most vulnerable segments ofthe economically active population; and pro-viding technical cooperation to countries intraining personnel in occupational healthmeasures. The Program collaborates withseveral institutes specializing in occupationalhealth research and policies in Bolivia, Bra-zil, Chile, Colombia, Cuba, Peru, and theUnited States.

In Colombia, the Program participatedin drawing up a National OccupationalHealth Plan aimed at the expansion of cover-age of occupational health services withinthe health ministry's health services system.Legislation reviews were supported in severalcountries, and the Program collaboratedwith counterparts in Cuba to improve thequality of and access to occupational healthservices.

The groups of workers that the Programand national health services deemed mostvulnerable included agricultural workers inCentral America, miners in the Andean sub-region, and women. A review of the status ofworkers' health and its relationship to devel-opment in Central America and the Domin-ican Republic was presented to the V Special



Meeting of the Health Sector of CentralAmerica.

The Program also drafted and dissemi-nated manuals and guidelines on methods ofextending occupational health services aspart of the Regional primary health carestrategy, and sponsored a number of semi-nars and workshops to train national staff inthe subject. Survey forms were designed andused in several countries to gather the spe-cific work-related demographic, morbidity,and mortality data required for planning ofservices. Better baseline information was alsoobtained by the end of the quadrennium onunemployment, underemployment, work-related accidents, pesticide poisoning, occu-pational diseases, and the type of servicesavailable to social security participants andthose who lack such coverage.

The Program concentrated as well ongalvanizing cooperation between the minis-tries of health, social security institutes,labor ministries and inspection services,large companies, and other groups and agen-cies whose actions have a bearing on occupa-tional health.

Training in occupational health took theform of postgraduate courses that wereoffered by several countries, the inclusion ofoccupational health in standard publichealth curricula, and intensive specializedcourse work for intermediate-level techni-cians, trainers, labor leaders, and othersinvolved in extending coverage. Seminars onepidemiologic research in occupationalhealth were conducted with a view towardimproving the quality of research proposalsdesigned in Latin America. The Programfocused on building expertise in determiningthe causal relationship between work andpathology and the points at which preven-tive interventions are most effective.

MATERNAL AND CHILD HEALTH,INCLUDING FAMILY PLANNING

The Maternal and Child Health Pro-gram aims to safeguard the growth, develop-

ment, and reproductive health of thepopulation of the Region by reducing thechief causes of morbidity and mortalityamong mothers and children. These are peri-natal illnesses, diarrheal diseases, acute respi-ratory infections, childhood diseasespreventable by vaccination, and problemsassociated with pregnancy and childbirth.

The Program established a series ofobjectives to address these areas. The firstwas to assist the Member Countries inincreasing the coverage and quality of ser-vices-especially among underserved, high-risk groups-to regulate fertility; monitorpregnancy, deliveries, and the postpartumperiod; provide perinatal care; follow childgrowth and development; and provide carefor adolescents. The second was to supportnational vaccination programs toward thegoal of immunizing all infants under oneyear of age by 1990. Third, the Programsought to strengthen epidemiologic surveil-lance systems to ensure that reported cases ofpoliomyelitis were investigated immediatelyand that appropriate measures were taken tointerrupt transmission of wild poliovirus.Fourth, it reinforced diarrheal disease con-trol programs and promoted the use of oralrehydration therapy in homes and at all lev-els of care. Finally, the Program aimed toreduce childhood mortality from acute respi-ratory infections through prompt diagnosisand appropriate treatment, encouragingstandard therapies and the referral of seriouscases in lieu of the indiscriminate use ofantibiotics.

The PAHO Governing Bodies set sev-eral deadlines for the Program: to eradicatethe transmission of the wild poliovirus in theRegion by 1990, to eliminate the indigenoustransmission of measles in the Caribbean by1995, and to reduce maternal mortality to50% of present rates by the year 2000. Fur-ther policy directives include the goal ofeliminating neonatal tetanus and develop-ment of a program of integrated adolescentcare.

The Program delivered cooperation tothe countries of the Region in six main areas:dissemination of scientific and technical


THE ERADICATION OF POLIOMYELITIS

In May 1985, the Director of the Pan American Sanitary Bureau, Regional Director forthe Americas of the World Health Organization, proposed that the Western Hemispherelaunch a campaign to eradicate the indigenous transmission of wild poliovirus by 1990. TheXXXI Meeting of the PAHO Directing Council endorsed the proposal in September 1985.Given that an effective vaccine is available, it was considered unacceptable that any childshould suffer from the consequences of such a devastating disease.

The goal of eradicating poliomyelitis was seen as a springboard for strengthening theentire Expanded Program on Immunization. Its attainment would be used as well to rein-force the Region's health infrastructure, especially since the decentralization of resources forthe eradication campaign also strengthened local health systems.

The major impediments to polio eradication in the past had been the lack of sustainedpolitical and social will, managerial constraints, vaccine efficacy and stability problems, andthe inadequacy of epidemiologic surveillance. These impediments had to be addressedjointly by the governments and agencies that supported the initiative.

The agencies that immediately rallied behind the PAHO/WHO campaign were theUnited States Agency for International Development (USAID), the Inter-American Devel-opment Bank (IDB), UNICEF, Rotary International, and the Canadian Public HealthAssociation. Together, they contributed nearly $US100 million toward the five-year effort.

To ensure proper coordination of these agencies and institutions with the governments,an Inter-agency Coordinating Committee (ICC) was created at the regional level andreplicated with their representatives in the countries. With the external resources madeavailable by the ICC member agencies, managers and supervisors were trained at thevarious levels of the health system and were provided with transportation to carry out theirduties. PAHO/WHO also prepared and distributed the Polio Eradication Field Guide for useby national health personnel.

Vaccine cold chain was improved and vaccine efficacy constantly monitored to detectany problems. The monitoring system suggested that low vaccine efficacy might have beenresponsible for a major polio-3 outbreak in the northeast of Brazil in 1986. As a result, thevaccine was reformulated almost immediately. More recently, a similar problem wasdetected in Mexico as a result of the investigation of the last outbreak in which wildpoliovirus was isolated in 1989.

Surveillance was defined as the key for disease eradication and received priority in theoverall strategy. Standard case definitions were adopted by all countries, and indicatorswere developed to monitor the occurrence of the disease and allow for prompt controlmeasures.

A network of reporting units was organized that incorporates those health facilitiesmost likely to see cases of acute flaccid paralysis that could be due to poliomyelitis. A weeklyreporting system was established for these units that includes negative reporting-that is,they were to report to the central level every week, regardless of whether cases weredetected. By the end of 1989, nearly 4,500 such units were reporting regularly on thepresence or absence of cases.

In 1989, a reward of $US100 was announced for any person who reports and/orinvestigates a probable case of poliomyelitis that is confirmed as due to wild poliovirus.

56

A poliovirus surveillance system was set up that relies on the examination of stoolsamples from all probable cases of the disease. In the near future, environmental samplingwill be used. For this purpose, a network of eight laboratories was established, reinforced byexisting laboratories in the Region. Over the last three years more than 10,000 stoolspecimens were examined for the possible recovery of wild poliovirus, and the network wasin full operation in 1989. The number of positive specimens has declined steadily, andduring 1989 only 14 specimens yielded wild poliovirus-a decline from the already smallnumber of 38 during 1988. This information suggests that the circulation of wild poliovirusis limited to very few geographic areas and that it will indeed be possible to interrupttransmission by the end of 1990, as initially proposed. As a matter of fact, it is believed thatonly about 0.5% of the nearly 14,000 counties in the whole of Latin America were affectedwith polio cases at any time during 1989.

The gains in the Western Hemisphere toward eradicating a disease that not long ago wasthe scourge of thousands of children paved the way for the goal established by the WorldHealth Assembly, in May 1988, of global eradication of poliomyelitis by the year 2000.

The polio vaccination strategy relied heavily on organizing national vaccination daysto rapidly increase the immunity level of the population at risk. These national vaccinationdays-two were usually held within a one-month period-serve as a complement to theroutine immunization programs. They also serve to improve overall coverage of childhoodvaccinations, since they are all delivered simultaneously with the polio vaccine. The strat-egy proved effective not only in curtailing polio transmission but in raising the overall levelof coverage for all the EPI vaccines. Average regional EPI coverage achieved a historicalhigh in 1990: more than 60% with any of the EPI antigens.

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information; development of policies, plans,and standards; training of human resources;direct technical cooperation; research; andmobilization of national and internationalhuman and financial resources.

Information

The weakness of data bases in theRegion hampered surveillance and evalua-tion of operations and follow-up of projects.Therefore, between 1986 and 1989, theProgram promoted the design and use ofdata bases that would facilitate analysis anddecision-making by those responsible foroperation and management of activitiesat all levels. The most important advanceswere made by the Expanded Program onImmunization, the Program for Control ofDiarrheal Diseases, and the Program forControl of Acute Respiratory Infections. Thedevelopment of data bases was slower inthe area of human growth, development,and reproduction because of the subject'scomplexity.

The Program continued to publishnewsletters on perinatal health, polio, vacci-nation programs, respiratory diseases pre-vention, and diarrheal diseases, with averagepressruns of 15,000 copies per issue. Manualsand basic technical guidelines were printedthrough the Expanded Textbook andInstructional Materials Program (PALTEX).Each of the technical units produced anddisseminated training materials, includingmanuals, sets of slides, videos, and case stud-ies. Some of these materials were prepared incollaboration with the Schools of PublicHealth in Rio de Janeiro, Sao Paulo, BuenosAires, Cali, Medellín, Mexico City, andLima.

The Latin American Center for Perina-tology and Human Development (CLAP)continued publishing articles in some 42areas of research being conducted at theCenter itself and in the network of more

than 100 maternity clinics in the Region thatparticipate in collaborative studies.

Policies, Standards, and Programs

One of the strategies that has facilitatedthe adoption of policies, plans, and stan-dards in the technical program areas hasbeen the formation of interagency commit-tees. These committees allow technical andfinancial cooperation agencies to unite onobjectives and strategies, avoiding duplica-tions, confusion, and competition amongnational groups and facilitating the coun-tries' programming, negotiation, and infor-mation use.

The composition of the interagencycommittees depends on the interests of thevarious agencies in different technical areasand in different countries. The ExpandedProgram on Immunization has the mostdeveloped committee, which includes repre-sentatives from IDB, USAID, UNICEF,Rotary International, and the CanadianPublic Health Association (CPHA). It hasbeen used as a model in efforts to create simi-lar interagency committees in other techni-cal areas. Those of the diarrheal diseases andacute respiratory infections programs arebasically composed of USAID, UNICEF,and PAHO/WHO.

Maternal and child health programshave been assigned priority status as a mat-ter of policy by all countries of the Region.All units of the Program promoted the orga-nization of national groups representing avariety of institutions, including social secu-rity institutes, universities, and scientificsocieties. These groups collaborated in andsupported development and testing of tech-nical criteria for the design, administration,and proper operation of projects.

As a result of ongoing discussions andhealth status evaluations during the qua-drennium, PAHO/WHO will create a pro-gram and allocate a budget for adolescenthealth starting in 1990.


Health Prograrns Development 59

Research

Research in maternal and child health iscritical for improving primary health careservices, including devising reforms in thetypes of technology used and the way ser-vices are delivered. Around $US8 millionwere spent on human reproduction researchduring the quadrennium.

Research projects were carried out usingresources of the Organization itself-avail-able through the PAHO Research GrantsProgram-and funds the Program receivedfrom WHO's global programs, as well as lim-ited extrabudgetary monies. Areas ofresearch included the development of vac-cines against rotaviruses, the use of house-hold oral rehydration solutions and foodsgiven during and after diarrheic episodes,the operation of treatment units, and studyof lost vaccination opportunities. Findings ofthis last project enabled corrective measuresto be taken so that coverage could beincreased in several countries.

Research on high-risk areas for neonataltetanus made it possible to focus selectivelyon increasing vaccination coverage in areaswith the greatest numbers of cases. As aresult, it is hoped that the incidence of neo-natal tetanus will decrease significantly dur-ing the next four years.

CLAP continued to promote and con-duct epidemiologic and operational researchin fields such as prematurity, frequency ofcesarean sections, and low birth weight.CLAP also conducted eight workshops onresearch methodology that hosted about 200participants from different disciplines, andcollaborated with the Population Council toimprove the development of protocols andwith the CDC and the Resources Develop-ment Institute to conduct demographic andhealth surveys, including adolescent health,and disseminate their findings in most of thecountries in the Region.

The Human Growth, Development, andReproduction Unit supported 60 studies in21 countries in the Region. These studies

concentrated on child development, adoles-cent health, and causes of maternal andinfant mortality.

Direct Technical Cooperation

The Maternal and Child Health Pro-gram expanded its ability to provide directtechnical cooperation by increasing the hir-ing of consultants. In 1989, the number ofconsultants reached the highest level in theProgram's history, with 47 professionalsworking at the regional, intercountry, andcountry levels. In the same year, 10,004 con-sultant-days were provided (up from 6,000 in1986): 70% to Latin America, 12% to theCaribbean, and 18% to North America.Thirty countries from the Region, as well asAustralia, Belgium, Egypt, India, Italy,Japan, the Kingdom of the Netherlands, andthe United Kingdom, have furnished consul-tants. The technical cooperation providedby consultants covered a wide range of activ-ities, including the definition of national pol-icies and plans; the design, operation,monitoring, and evaluation of programs andprojects; human resources training anddevelopment activities; improvement ofinformation and logistic systems; and devel-opment of projects to seek extrabudgetaryfunding.

Human Resources Training andDevelopment

The training of human resources is oneof the Program's priority cooperation strate-gies, since health personnel are the mostvaluable resource available for reforminghealth systems. An estimated 40% of theProgram's money and effort is invested intraining at all levels. Training material pre-pared by the Program for Control of Diar-rheal Diseases was accepted in 107 nursingschools and 43 medical schools. Neverthe-less, it was difficult to change the basic train-



ing offered by health sciences schools,faculties, and similar institutions to make itmore consonant with the day-to-day realityof the graduates' work environment. Out-moded curricula, constant changes in thetechnologies used in primary care, and theabsence in many countries of an officialcareer pathway for public health profession-als create the continual need for remedialcourses for graduates just starting work inhealth units and the retraining of those whohave worked in them for some time.

The training opportunities offered bythe Program included postgraduate scholar-ships for study outside the countries, coursesfor senior and intermediate-level supervisors,administrative and technical training forhealth workers, and courses for health pro-moters and traditional midwives. Coursecontent ranged from technical and adminis-trative aspects of service delivery and super-visory and management skills to issues ofclinical care in areas of Program coverage.Available data show that during the qua-drennium between 12,000 and 14,000 peoplewere trained using materials prepared by theProgram.

CLAP offered postgraduate courses inperinatology, perinatal public health,research design and execution, and othersubjects. Together with courses in maternaland child health conducted by the publichealth schools in Chile, Colombia, andCuba, this instruction enabled more than1,000 professionals to be trained as programsupervisors. The expertise in management ofmaternal and child health and populationprograms and in supervisory skills exists inthe Region to provide the training necessaryfor program direction. Paradoxically, how-ever, the financial resources to make use ofthat expertise are lacking.

Resource Mobilization

Up to 1989, the Maternal and ChildHealth Program had a total annual budget of

$US29 million, of which about 10% camefrom regular funds and 90% from extra-budgetary funds. More than 85% of the Pro-gram's resources went directly to theMember Countries.

The scarcity of resources in the countriesbecame acute during the quadrennium. Theeffects of this crisis were seen in the stagna-tion or decline of national expenditures formaternal and child health programs. TheProgram therefore dedicated a significantamount of its efforts to obtaining interna-tional extrabudgetary funds. It succeeded inmobilizing $US100 million in commitmentsfrom a number of agencies (UNICEF,USAID, IDB, CPHA, and Rotary Interna-tional) for the 1987-1991 wild polioviruseradication campaign, of which $US27 mil-lion was assigned directly to programs exe-cuted by PAHO/WHO. These funds were inaddition to approximately $US450 millionthat the countries allocated for their univer-sal childhood immunization and polio eradi-cation efforts.

The diarrheal and acute respiratory dis-eases control programs gained substantialincreases in their extrabudgetary funds. Thehuman growth, development, and reproduc-tion program also succeeded in obtainingadditional funding thanks to private organi-zations in the United States, such as the W.K. Kellogg Foundation, Pew CharitableTrust, and Carnegie Corporation, anddonors such as the European EconomicCommunity, the governments of Italy andSweden, UNICEF, and especially the UnitedNations Population Fund.

The Program also optimized its use ofresources by coordinating activities withother PAHO/WHO programs such asHealth of Adults; Human Resources Devel-opment; Health Situation and Trend Assess-ment; Women, Health, and Development;and Food and Nutrition. In addition, jointactivities were conducted with the Organiza-tion's specialized centers, namely, CLAP,INCAP, CEPANZO, and BIREME, andwith PASCAP.

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Results

Some goals were fully achieved duringthe quadrennium and others only partially.Of the 36 countries and territories in theRegion about which information is includedin the publication Health Conditions in theAmericas, 1990 edition (Scientific PublicationNo. 524), 19 had infant mortality rates of lessthan 30 per 1,000 live births, 8 had ratesbetween 30 and 49, 7 had rates between 50and 99, and 2 still have infant mortality rateshigher than 100 per 1,000 live births. Of the25 countries that reported on maternal mor-tality, 6 (containing 35 million inhabitants)have rates lower than 50 per 100,000 livebirths; 11 (in which most of the Region'spopulation lives) have rates between 50 and100; and in the remaining 8 countries, witharound 50 million total population, thematernal mortality rate was higher than 100per 100,000 live births.

Coverage rates in the Region as a wholefor prenatal care, institutional deliveries,and contraception are on the order of 70%,75%, and 54%, respectively, while coveragesof attended deliveries and growth monitor-ing of children (under one year old andunder five years old) are 60% and 40%,respectively. The quality of care being pro-vided to mothers, children, and adolescentswill continue to be a source of concern.

In fulfillment of the Program's goal, thestandards for care during pregnancy anddelivery, newborn care, and family planningwere reviewed in 50% of the countries. Nev-ertheless, it is unknown to what extent thesestandards were incorporated in prenatal andperinatal care. More than 2,000 gynecology,obstetric, and pediatric services in 18 coun-tries were evaluated with support from theProgram. Seven countries conducted a sec-ond study to analyze proposed changes.

Vaccination coverage continued toincrease and in 1989 reached the highestlevel yet recorded in the Region: at least 60%for all vaccines. Very few countries had cov-erages of less than 50% for any vaccine. The

incidence of diseases preventable by vaccina-tion continued to fall; poliomyelitis droppedto its lowest level ever, with fewer than 130cases confirmed in the Region by the end of1989. Eradication of polio in 1990 seemsmore realistic than ever.

Efforts made during the last four yearshave succeeded in putting diarrheal diseasecontrol activities into operation in all thecountries of the Region. In addition, 20countries have prepared a profile which willenable them to evaluate their programs. Onaverage, access to oral rehydration salts was62% at the end of 1989, whereas use stood at39%. Fifteen of 18 countries producing oralrehydration salts surpassed their productiongoals, and most of the countries can nowsatisfy their needs for the salts locally.

All the countries consider acute respira-tory infections a priority problem, and 20have developed and implemented nationalrespiratory infection control programs withoperational plans, national standards, andtraining modules.

COMMUNICABLE DISEASES

The Communicable Diseases Programprovides assistance to Member Countries inestablishing and maintaining integrated con-trol programs to combat vector-borne, para-sitic, and other endemic infectious diseases.The main diseases the Program addresses aremalaria, leishmaniasis, schistosomiasis,American trypanosomiasis (Chagas' disease),filariases (including onchocerciasis), dengue,yellow fever, tuberculosis, leprosy, viralhepatitis, Argentine hemorrhagic fever,leptospirosis, plague, rickettsioses, taeniasis/cysticercosis, and helminthiases. The Pro-gram's activities were carried out byfurthering epidemiologic knowledge of thesediseases, which includes analyzing and classi-fying the risk factors involved in their trans-mission; supporting the services responsiblefor controlling their spread; and mobilizingnational, bilateral, and multilateral

61Health Programs Development


resources to support prevention and controlefforts.

The Program cooperated with theUNDP/World Bank/WHO Special Programfor Research and Training in Tropical Dis-eases, USAID, IDB, Swedish InternationalDevelopment Authority, U.S. ArmyResearch and Development Command, andother national and international institutionsto develop and review research proposals,train personnel, provide direct technicalcooperation to control efforts, and monitorand evaluate progress.

The intractable spread of malaria con-tinued to cause great concern. According tothe 36th report on the status of malaria pro-grams in the Americas, presented in 1988 tothe XXXIII Meeting of the PAHO DirectingCouncil, more than one million new cases ofmalaria occurred in the Americas in 1987, a6.2% increase over 1986. Despite controlefforts, reinfestations of the vector weredetected in some coastal areas where it hadearlier been eliminated.

The Program redoubled its efforts topromote active case detection and toimprove the epidemiologic mapping of rela-tive incidence and risk factors on whichmalaria control activities were based. It alsosupported research at a number of LatinAmerican institutions, including the Centerfor Malaria Research in Tapachula, Mexico,and the School of Malariology and Environ-mental Sanitation in Maracay, Venezuela.National efforts to integrate mosquito con-trol programs in routine primary health careservices-an appropriate strategy againstother vector-borne diseases as well-alsoreceived Program support.

In addition to malaria, the Program sup-ported research into leishmaniasis, Bancrof-tian filariasis, and onchocerciasis. Nationallaboratories responsible for diagnosing infec-tious and parasitic diseases were anotherfocus of attention, as the Program worked toupgrade their capabilities through staff train-ing, the establishment of reference centers,the provision of equipment and reagents,and assessment of their performance in diag-nosing viral diseases.

More than $US1.5 million were assignedannually to support national appliedresearch in tropical diseases. An attenuatedvaccine against Argentine hemorrhagic feverwas developed, and the results of a con-trolled field trial in nearly 6,000 volunteersdemonstrated its safety and immunogenicity.Information on its efficacy is pending.Progress was also made in developing testsfor the diagnosis of infection by T. cruzi andCryptosporidia. In Colombia, a hepatitis B(HB) vaccination was introduced in thehyperendemic area of Santa Marta as part ofa five-year program to immunize all infantsand susceptible children and adults. Proto-cols were developed to study the epidemiol-ogy of hepatitis B and assess its prevalence inthe countries of the Region. Other principalresearch topics included the biology andecology of malaria vectors, malaria diagnosismethods, the effect of malaria on pregnancy,the importance of Anopheles rangeli and A.nuneztovari in malaria transmission, andmethods for controlling A. albimanus.

In collaboration with research institu-tions from eight countries, the Program setup a network to train personnel in epidemi-ology, medical entomology, parasitology,immunology, environmental management,program management and administration,and social sciences. The University of Pan-ama, Autonomous University of NuevoLeón (Mexico), Oswaldo Cruz Foundation(Brazil), and University of South Carolina(U.S.A.) cosponsored related postgraduatecourses.

In addition to direct training, the Pro-gram expanded the base of scientific andtechnical information available to healthprofessionals by issuing monographs, man-uals, and other publications. Their wide dis-tribution also served to promote researchand the exchange of information on opera-tional aspects of infectious disease control.National programs to control dengue,malaria, and leprosy benefited greatly fromthis interchange of knowledge.

At the end of 1989, several problemswere still limiting the countries' ability tosuccessfully carry out disease control projects



for which the technical and scientific exper-tise exists. Chief among them was that policymakers were not using the available epidemi-ologic and technical information whendeciding how to assign resources. A relatedproblem is that epidemiologists, althoughemployed in the public sector, were generallynot consulted in determining what diseasecontrol projects should have priority andhow they should be organized (see the sec-tion on the Health Situation and TrendAssessment Program for additional observa-tions on this issue). National public healthworkers were also found to lack adequatetraining in medical entomology. Several pro-grams were developed to strengthen capabili-ties in this regard-including postgraduatecourses on epidemiology at the OswaldoCruz Foundation in Brazil and the Univer-sity of Valle in Colombia, and master'sdegree programs in entomology in Mexicoand Panama-but further manpower train-ing will be needed if efforts to control tropi-cal diseases in the Region are to succeed.

ACQUIRED IMMUNODEFICIENCYSYNDROME (AIDS)

The Program for the Prevention andControl of Acquired ImmunodeficiencySyndrome (AIDS) followed the guidelinesestablished by the WHO Global Program onAIDS for developing national preventionand control plans. To that end, it contractedexperts in epidemiology, program manage-ment, health education, laboratory support,and financing and administration to providetechnical assistance to Member Countries.

At the end of 1986, PAHO/WHO estab-lished a post of Regional Adviser for the Pro-gram, which launched its formal operationsin January 1987. The Program has main-tained surveillance of AIDS cases to monitorthe spread of the epidemic in the Region.Special strategies have included establishinglaboratory networks; improving laboratoryequipment and purchasing supplies andmaterials; providing consultancy services;

and monitoring and improving national andregional case surveillance.

To facilitate regional surveillance, aPAHO/WHO AIDS case definition wasfinalized and a regional surveillance work-shop was held in Washington, D.C., in July1989. Furthermore, PAHO/WHO staffassisted in a recent subregional meeting inthe Caribbean that focused on strengthen-ing surveillance efforts in Caribbean coun-tries through case reporting and sentinelstudies.

To provide guidance to Member Coun-tries, technical guidelines for AIDS preven-tion were developed by a group of expertsfrom throughout the Region and were dis-tributed widely. Due to the rapid scientificand technological advances with regard toAIDS prevention, these guidelines wererevised in December 1986 and again in April1987. PAHO/WHO staff carried out on-siteappraisals of national sexually transmitteddisease (STD) prevention programs and eval-uated AIDS committees set up in Brazil,Chile, Colombia, Ecuador, Guatemala,Jamaica, Mexico, Paraguay, and Trinidadand Tobago. PAHO/WHO staff and consul-tants also provided technical assistance toemerging national AIDS prevention andcontrol programs in each of the subregionsof the Americas.

Three subregional meetings for nationalAIDS program directors in Latin Americawere held to standardize criteria for programdesign and implementation. A workshop forCaribbean national program managers, heldat CAREC, provided collaboration in thesystematic review of national programachievements and the design of appropriatemedium-term plans.

Given the importance of health educa-tion in AIDS prevention, a special AIDSInformation, Education, and Communica-tion (IEC) Unit was organized to support thecountries in developing and strengtheningthis component of their national AIDSplans. The Unit distributed compact discscontaining MEDLINE-AIDS bibliographiesand scientific articles from seven major jour-nals. The Program also held health promo-


AIDS

The Problem

The graph that represents the spread Number of AIDS cases reported, by majorof AIDS in the Americas has the unmis- subregion of the Americas. 1980-1989takable shape of an epidemic. The curves 100,000for each of the subregions start in differ-ent years because the human immunode-ficiency virus type 1 (HIV-1) was 10Noh ooo000caintroduced at different times, but the sub-sequent pattern of increase is almost iden-tical throughout the Americas.

Disturbing as they are, the reported 1.000numbers of AIDS cases, which are used tochart the path of HIV-1 through the Carbbeanpopulation, measure only part of the 10oproblem. WHO estimates that actualcases exceed by two or three times thenumber of reported cases. In the Ameri-cas, rates of reporting range from 25% to100% of cases, and since the incubationperiod from infection with HIV to symp- CumulasevercenSubre ion cases Percent itomatic illness may last 10 years, even 1 Caribbean 1,941 1.3100% reporting of today's fully developed Latin America 207,89 1300 85.2AIDS cases tells us only what happened 1980 1982 1984 1986 1988in the past.

It is estimated that as many as 2.5million people in the Americas are currently infected with HIV. Most, if not all, ofthese people will go on to develop the disease and will need medical care. Thus, even iftransmission stopped today, the impact of the disease on the Region's health serviceswould be enormous.

The immune deficiency caused by HIV brings with it an increase in latent andopportunistic infections. This means that the public health sector may see gainsreversed in areas such as tuberculosis control. And infant mortality, which has beendeclining steadily, also may increase as more infants are born to infected mothers.

AIDS Prevention

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

64

Effective control measures require accurate information. Not long ago AIDS wasdismissed as a blight affecti ng homosexual men in cn narrowly circumnscribedareas, a belief that is still hlde by some ill-informed persons. Knowledge about thedisease, its incubation perio, and its mode of transmission has increased a great dealover the last several years. But surveillance systers are still :to often backed up byinadequate laboratory facilities.

Inaccurate case reporting is a function of other factors as well. Since AIDS patientsdie of opportunistic infections, such as pneumonias or other complications, t is thesediseases that are often reported as the cause of mortality, due to the relative newness ofAIDS and to its social stigma. One reason for inaccurate data concerning HIV nfec-tion rates is JIDS' long incubation period: people may unknowingly be infected withthe virus-and spreading it-for many years,

Better knowledge of the prevalence or incidence of HIV infection would requirestudies of seropositivity among various groups of people at risk. But the definition ofthe population at risk has undergone changes along with our understanding of thedisease. Cases resultingi from sexual transmission: of OV arnong homosexual andbisexual men and to their sexual partners stiUl account for the largest group, butheterosexual transmission of AIDS in the Americas is growing. In some countries equalnumbers of men and women are being infected. As more women become infected, anincrease in mother-to-child (perínatal) transmission will occur.

Recipients of blood transfusions and drug addicts who share needles make upanother high-risk group. A final group includes people exposed to contaminated redi-cal equipment and health care personnel exposed as a result of accidents duringmedical, surgical, atnd laboratory procedures.

Surveillance activities and case reporting are being focused on the groups at high-est risk. National governments have come a long way in a short time;, yet the bulk ofAIDS cases reported are still those recognized among patients seen in hospital settings.The problem facing heakh workers in controlling the disease is to gain access to andpromote behavior change among those groups who are by their very nature thehardest to reach and the most unlikely to change. I is the marginal populations ofmale and female prostitutes and drug users that may pose the greatest risk to them-selves and to others.

Another risk area-that of contaminated blood supplies-is one in which dear,targeted action can be and has been taken. Already, the number of countries reportingthat none of their cases were transmitted by blood increased from 17 in 1987 to 24 in1988, and the number of countries with over 10% of the cases reported as beingtransmitted by blood ased from two to zero between 1987 and 1988. But wide-spread screening of blood donots is a relatively recent phenomenon, and screeningeffciency varies from 100% in some countries to 30% in others where transfusionservices do not have the necessary infrastructure. At the end of 1988, some of theblood and blood products utilized in the public sector in some countries still were notscreened for the presence of V

65

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tion workshops, developed and field-testedmonitoring and evaluation guidelines, andconducted pilot studies for introducingAIDS education into schools.

Together with the Office of Informationand Public Affairs and other units, the Pro-gram organized the I Pan American Telecon-ference on AIDS, which was broadcast fromQuito, Ecuador, in September 1987 to 650sites in nearly all countries of the Americas,reaching an audience of 45,000 health careworkers. The II Pan American Telecon-ference on AIDS, in December 1988, wastransmitted via satellite from Rio de Janeiroto audiences from Canada to Chile. Theconference was also broadcast outside theRegion to Portugal, Kuwait, and five Africancountries.

The Program gathered and disseminatedrelevant health information materials toMember Countries and played a key role inthe development of the first AIDS Informa-tion Exchange Center for the English-speak-ing Caribbean countries, located atCAREC. Two other centers were establishedin Mexico City and Brasilia under the aegisof those countries' National AIDSCommissions.

In 1989 several workshops for trainerswere conducted, covering subjects such ascounseling, health promotion, condom mar-keting, the role of nurses in HIV preventionand control, and ways to ensure balancedmedia coverage and to mobilize youth in thefight against AIDS.

Program staff participated in the WorldSummit of Ministers of Health on Programsfor AIDS Prevention in London in January1988, and they played a major role in plan-ning, implementing, and evaluating the FirstInternational Symposium on Communica-tions and Information on AIDS, held inOctober 1988 in Ixtapa, Mexico. In collabo-ration with the Organization's Communica-ble Diseases Program, several internationalworkshops on AIDS laboratory technologywere conducted. The Program also repre-sented WHO before the United States Con-

gress and participated in numerous scientificmeetings, congresses, symposia, and work-shops on AIDS.

To secure funding for AIDS preventionand control programs, a donors meeting washeld in December 1988 in Barbados, spon-sored by the WHO Global Program onAIDS, the Caribbean ministers of health,and other organizations. The meetingresulted in $US15 million being pledged forsupport of the programs of 13 countries inthe Caribbean area. Since this first meeting,similar resource mobilization meetings havebeen held for the Central American subre-gion, the Dominican Republic, Haiti, andMexico, and have produced an additional$US16 million in pledges. The funds will beused for such activities as public education,care for HIV-infected persons, assurance ofsafety of donated blood and blood products,and surveillance and prevention of perinataltransmission of HIV. Collaboration withnongovernmental organizations such as theLions Club International and the Interna-tional Red Cross was undertaken through-out the period.

The Program entered into a $US5 mil-lion, five-year AIDS research contract withthe National Institute of Allergy and Infec-tious Diseases (NIAID) of the U.S. NationalInstitutes of Health. Proposals for futureresearch in the countries on risk behaviorsand sexual conduct were prepared at a meet-ing in Guatemala at which the WHO GlobalProgram on AIDS research instruments werereviewed. These instruments were lateradapted for use in Latin America and by theend of 1989 were being employed in researchprojects in Chile and Costa Rica. Otheractivities undertaken as part of the NIAIDcontract include an HIV seroprevalencestudy in STD clinics completed in theDominican Republic, a project to study het-erosexual transmission of HIV initiated inBrazil, and the development of research pro-tocols in Jamaica and Mexico.

More than $US13 million in funds fromthe WHO Global Program on AIDS were



applied in direct support of national pro-grams, and over $US4 million were dis-bursed for regional activities.

HEALTH OF ADULTS

The Health of Adults Program sup-ported actions to prevent and controlchronic noncommunicable diseases andtheir main risk factors; promote mentalhealth and prevent violent behaviors; pre-vent and control alcohol and drug abuse;integrate community rehabilitation activitiesinto primary health care; prevent blindnessand provide eye care; prevent accidents andinjuries; and promote comprehensive ser-vices for the elderly. To address these con-cerns, the Program used the strategies ofpromoting healthy lifestyles, primarilythrough individual and population-widehealth promotion; strengthening and adapt-ing health services to care for adults and theelderly; and rationalizing production anduse of high-cost, complex technology.

During the 1986-1989 quadrennium thechronic noncommunicable disease subpro-gram focused on an integrated approach topreventing and treating cancer, cardiovascu-lar diseases, diabetes, and other noncommu-nicable diseases, with special emphasis ontheir common risk factors. Surveys to deter-mine risk factors were carried out in urbancommunities in a number of countries as aninitial step in identifying the most effectiveinterventions. Although progress was madein creating greater awareness of chronic non-communicable disease problems, extensiveintegrated preventive programs have beendifficult to develop. Generally speaking, thecountries invest their limited resources inmedical care rather than preventive servicesfor adults. Changes in individual and collec-tive behaviors associated with noncommuni-cable disease incidence in Latin America andthe Caribbean have been difficult to bringabout, since they require nontraditionalactions within the health sector. In addition,

the Organization's resources are themselveslimited in this area.

Efforts to rationalize the production anduse of complex, high-cost technology arecritical to achieving more efficient and equi-table services for the elderly and the chroni-cally ill. The First Consensus Conference onChronic Renal Insufficiency, Dialysis, andTransplant, held in Venezuela in 1988 (seePAHO Scientific Publication No. 520), was alandmark meeting that addressed this newaspect of technical cooperation.

The Program gave priority to antismok-ing activities, as smoking is considered themost important risk factor for many chronicillnesses, such as cancer and cardiovascularand respiratory ailments. Major progress wasmade in this area. To promote nationalaction plans against smoking, subregionalworkshops were held in the Southern Cone,Andean area, English-speaking Caribbean,and Central America. The Organization'sGoverning Bodies approved resolutions sup-porting antismoking activities at the regionaland national levels. PAHO/WHO and theOffice of the Surgeon General of the UnitedStates undertook a joint project to prepare adocument on the problem of smoking in theRegion.

Other Program efforts against cancerinvolved upgrading and expanding programsfor early detection of uterine cancer, which isa serious problem in the Region. The epide-miologic profile of the disease and the orga-nization of the health services for its effectivecontrol were analyzed in each country inorder to improve detection and thus lowermortality rates from this cancer. By the endof the quadrennium, Barbados and the East-ern Caribbean islands, Brazil, Chile, Colom-bia, Costa Rica, Cuba, Nicaragua, andVenezuela had reoriented their programs.

The PAHO/WHO Latin AmericanCancer Research Information Project(LACRIP) continued to serve as the special-ized information network on cancer for theRegion. The Program supported the organi-zation of hospital cancer registries in all the



countries and, together with WHO's Inter-national Agency for Research on Cancer,promoted new incidence registries to makepossible more accurate epidemiologicresearch. The Program also supported theparticipation of health workers in interna-tional training courses in the use of epidemi-ologic tools for studying chronic non-communicable diseases.

The rehabilitation subprogram stressedthe importance of community-based rehabil-itation services and of integrating the dis-abled into society. Community-basedrehabilitation, as a component of primaryhealth care, is under way in 15 countries.Modular training material was preparedand distributed by PAHO/WHO to thecountries.

The mental health subprogram focusedon formulating national mental healthplans. In the 1986-1989 period, commit-ments were secured from the countries toorient their mental health plans towardalternative approaches to traditional psychi-atric care, including health promotion andcommunity preventive efforts.

The subprogram on the health of theelderly stressed among its priorities thedevelopment of a reliable information baseon the elderly in the Region, the promotionof policies and programs that address thisage group, and the training of health work-ers in gerontology and geriatrics. Notableamong the subprogram's achievements wasthe completion of a survey of the needs ofthe elderly in 13 countries. The findings infive of the countries have been published.The high quality of the data and the rigor-ous standardization process employed willmake the information invaluable in plan-ning services for the elderly. In addition, thecountries of the Region have begun exchang-ing experiences related to models of elderlycare, a first step toward the systematizationof policies that will be sought in the future.

The work of the accident preventionand control subprogram focused on epidemi-ologic research and dissemination of infor-mation within the scientific community to

increase awareness of the problem. The goalis to enable the health sector to jointlydevelop policies with other sectors responsi-ble for addressing this area.

The prevention of blindness subprogramdefined its priorities in the Region accordingto the most frequent causes of this disability,such as cataracts, glaucoma, refraction disor-ders, and trauma. In countries where para-sitic, infectious, and nutritional deficiencyproblems persist, priority was given to con-trolling these conditions. The inclusion ofeye care in basic health services was empha-sized, and the Arab Gulf Program for UnitedNations Development Organizations(AGFUND) supported the creation of pri-mary eye care programs in several countriesof Latin America and the Caribbean. Theestablishment of these programs was oftendifficult due to the scarcity of service person-nel trained in public health ophthalmology.The support of several nongovernmentalagencies was critical: the Royal Common-wealth Society for the Blind and Spain'snational organization of the blind (ONCE)enabled PAHO/WHO to provide continu-ous technical advice throughout the Region,and support received from Chibret Interna-tional was also noteworthy.

The alcohol and drug abuse preventionand control subprogram supported epidemi-ologic research to evaluate the status of sub-stance abuse in Member Countries and theestablishment of continuous surveillance sys-tems. Its activities also emphasized creatingawareness of the severity of the drug depen-dency and alcoholism problem and promot-ing national prevention and control efforts.Financial support was received from theUnited States for epidemiologic studies thatprovided a profile of drug addiction in theRegion.

VETERINARY PUBLIC HEALTH

The Veterinary Public Health Programaddresses several areas in which animalhealth affects human health and welfare:



food protection, zoonoses, foot-and-mouthdisease, and laboratory animal science.The Program works through two centers-the Pan American Zoonoses Center(CEPANZO) in Argentina and the PanAmerican Foot-and-Mouth Disease Center(PANAFTOSA) in Brazil-that offer special-ized technical advice, research, and trainingto Member Governments.

The Latin American Ministers of Agri-culture identified priority areas in veterinarypublic health at the V (1987) and VI (1989)Inter-American Meetings, at the MinisterialLevel, on Animal Health. The eradication offoot-and-mouth disease by the year 2000, theelimination of urban rabies in the principalcities of Latin America, and the develop-ment of integrated national food protectionprograms were the chief goals.

Food Protection

Food-borne diseases are frequent causesof morbidity in the Region and are responsi-ble for the largest portion of illness anddeath among Latin American children.Nonetheless, most countries lack a central-ized inspection and control system for foodsupplies. Food safety was hence reaffirmed asa priority by the Ministers of Health of theRegion in 1986 at the XXII Pan AmericanSanitary Conference (Resolution XVII). TheConference approved the Plan of Action(1986-1990) of the Regional Program ofTechnical Cooperation in Food Protection,which seeks to ensure that by the end of1990 more than half of the Region's coun-tries will have adopted policies, strategies,and technologies to ensure food safety.

The Program held subregional work-shops on planning and executing food pro-tection programs. An FAO-PAHO/WHOWorkshop on Food Legislation and Stan-dards Setting in Latin America, held inMexico in 1988, drafted a model Basic Food-stuffs Law that some countries, such as Gua-temala, Honduras, and Mexico, havealready used to update their national legisla-tion. Setting food safety standards that are

acceptable Region-wide was the focus of sev-eral other Program activities.

A project to make regional standardsuniform, begun by the State Standards Set-ting Committee of Cuba, the Pan Ameri-can Technical Standards Commission(COPANT), the Central American Indus-trial Technology Research Institute(ICAITI), and FAO, was supported by theProgram. FAO and PAHO/WHO held theirfirst joint international workshop on controland protection programs for imported foodand foods intended for export in Costa Ricain 1989. The Government of Spain, mean-while, supported development of legislationand food safety training activities in theDominican Republic and Guatemala.

The Program cooperated in developingfood protection information systems with anumber of countries, and sponsored the firstmeeting of the Working Group on Food Pro-tection Information Systems in 1988.

Food analysis services were another areaof cooperation that the Program offered,mainly through CEPANZO, and, to a lesserextent, through the Unified Food and DrugControl Laboratory (LUCAM) of Guatema-la's Ministry of Public Health and SocialWelfare. In addition to offering its tradi-tional services in food microbiology and par-asitology, CEPANZO set up a chemicalresidue analysis laboratory and began lend-ing technical assistance in that area duringthe quadrennium. It was also the regionalfocal point for the Program's technical sup-port in hazard analysis and critical controlpoints for food protection. The CaribbeanFood Quality Laboratories Network, with asimilar function, was established in 1989.

Official food inspection servicesthroughout the Region received supportfrom the Program through training courses,transmittal of specialized documentation,and direct technical cooperation.

In 1989, the Program convened the firstmeeting on epidemiologic surveillance offood-borne diseases, which led to creation ofthe Latin American Network for Epidemio-logic Surveillance of Food-borne Diseases. A



similar voluntary network was created inArgentina. A guide to epidemiologic surveil-lance of food-borne diseases and six modulesfor use in intensive training courses havebeen prepared.

The Program lent timely technical assis-tance to investigations of food poisoningoutbreaks in several countries, such as Gua-temala in 1987 (paralytic shellfish poisoning)and Peru in 1988 (the first outbreak in thatcountry of botulism in humans).

Technical and financial assistance tonational food protection efforts in theRegion was provided by the governments ofCanada, the Federal Republic of Germany,Japan, Spain, and the United States; inter-national credit and technical cooperationagencies such as the World Bank, IDB, andUNDP; and the industrial sector of thecountries.

Zoonoses and Foot-and-MouthDisease

Urban rabies continued to be a problemin Latin America, although there was a sig-nificant reduction in case numbers over thelast four years. Generally speaking, controlmeasures succeeded in large cities, while inmedium-sized ones urban rabies remains amatter of greater concern.

Three to four million people in theRegion were bitten annually by dogs; of thisnumber only 10% received complete post-exposure preventive treatment. From 1986to 1989, the average number of humanrabies cases in the Region was 200 per year.This represents a 27% drop compared to theprevious quadrennium, a considerableachievement given the estimated 20%increase in the dog population during thesame period. Specific mortality rates indi-cated that the most affected countries wereBolivia, El Salvador, Guatemala, and Mex-ico. During the reporting period no cases ofrabies in humans were recorded in Argen-tina, Canada, Chile, Costa Rica, Cuba, Pan-ama, Uruguay, or the Caribbean countrieswith the exception of the Dominican Repub-lic and Haiti. A number of countries in Cen-

tral America have undertaken joint rabiescontrol projects along their borders, as haveBrazil and Paraguay, Colombia and Vene-zuela, and Haiti and the DominicanRepublic.

Wild rabies represents a continuing chal-lenge for the rabies control programs. Cattlemost often contract rabies from the bites ofvampire bats, which are becoming a signifi-cant animal reservoir in urban as well as ruraland forested areas. Twenty-four persons diedof rabies after being bitten by vampire bats inOctober 1989 in a forested locality in Madrede Dios Department, Peru.

CEPANZO produced a reference stan-dard antirabies vaccine that laboratories inArgentina, Brazil, Chile, Colombia, andMexico evaluated. It was then approved atan inter-American technical meeting held inDecember 1988 for use as the regional stan-dard for the quality control of sucklingmouse brain vaccines.

The Arab Gulf Program for UnitedNations Development Organizations(AGFUND), EEC, Mérieux Foundation ofFrance, the French agency BIOFORCE,Sovereign Order of Malta, Rockefeller Foun-dation, University of Wisconsin, USAID,and CDC all provided funding support forthe campaign against rabies.

Brucellosis, most commonly seen indairy cattle, is a zoonosis that continued tobe a significant occupational disease amonglivestock workers. In the Southern Conecountries, the prevalence in cattle wasbetween 0.5% and 10%; in the Andean Sub-region, between 2% and 4%; in CentralAmerica, between 0.1% and 9%; and inCuba, the Dominican Republic, Haiti, andMexico, between 0.3% and 4.7%. The preva-lence in the United States was 0.25%. Mostof the Caribbean countries are free of thedisease, and in those affected the prevalenceis 0.1% or less. Canada has been free of thedisease since 1985.

Bovine tuberculosis is also present inmost of the countries in the Region,although its prevalence has decreased tobetween 0.01% and 12%. The low preva-lence rates of less than 2.0% in Canada,

70

Health Programs Development

Chile, Colombia, Costa Rica, Cuba, theDominican Republic, Honduras, Jamaica,Panama, Peru, the United States, Uruguay,and Venezuela warrant policy decisions toeradicate the disease. CEPANZO providedtechnical cooperation to improve the pro-duction of diagnostic biologicals for bovinetuberculosis and ensure quality control. Italso acts as an international BCG vaccinereference center.

Leptospirosis has become more commonin suburban areas, particularly followingheavy and frequent rains. The Programcooperated with Brazil in controlling out-breaks that occurred during the rainy seasonin 1986 and 1988 (in which the fatality rateswere 9.4% and 6.7%, respectively) and withCosta Rica when 264 human cases occurredin the wake of Hurricane Joan in 1989.

The Program placed special emphasis onhydatidosis and taeniasis/cysticercosis, para-sitic zoonoses that affect many MemberCountries. The hydatidosis control pro-grams in Argentina and Chile succeeded inreducing the prevalence of hydatid diseaseamong humans and lowered its frequency incanines. Priority was given to establishingPAHO/WHO technical cooperation relatedto taeniasis/cysticercosis in 1988, the yearthat immunodiagnostic methods requiredfor its surveillance and control were devel-oped. In 1989, a PAHO/WHO interprogramgroup was formed to draw up guidelines forconducting taeniasis/cysticercosis controland surveillance programs. A number ofcountries had adopted the guidelines by theend of the year.

The Program's efforts toward the eradi-cation of foot-and-mouth disease, conductedlargely through PANAFTOSA, were suc-cessful. Areas already free of the disease weremaintained free, except for a 1987 outbreakin Chile that was brought under control bythat country's veterinary services andPANAFTOSA. Colombia extended its dis-ease-free area to include part of its north-western region in 1987. PANAFTOSA,meanwhile, developed an oil-adjuvant vac-cine and transferred this new technology toparticipating countries.

Acting through the South AmericanFoot-and-Mouth Disease Control Commis-sion (COSALFA), the countries in theendemic area adopted common policies andstrategies for their national programs. Signif-icant morbidity reductions were achieved inaffected herds (the rate in 1989 was 5 per10,000, compared to 280 per 10,000 in the1970s), and vaccination coverage reached alevel of 81% of the bovine population.

The Hemispheric Foot-and-Mouth Dis-ease Eradication Committee (COHEFA) wasformed in July 1988 and met for the first timein April 1989. Composed of representativesof governments and the livestock industry,the committee has strengthened the diseasecontrol program by joining public and pri-vate sector efforts. This committee preparedand approved a plan of action that estab-lished strategies for each country, accordingto existing foot-and-mouth disease ecosys-tems. Three subregions were identified: thebasin of the Rio de la Plata/Southern Cone,the Andean Subregion, and Amazonia. Theeconomic situation of participating countrieshampered the execution of the plan, how-ever. The Program therefore concentratedon assisting governments in obtaining finan-cial support from such sources as the EECand IDB.

CEPANZO and PANAFTOSA trained1,425 professionals intramurally and extra-murally in skills related to vaccine produc-tion and quality control, diagnosis,epidemiology, administration of control pro-grams, and planning and evaluation. Thetraining service is valued by the countries,since it lends continuity to disease controlactivities and enables eradication programtechnologies and methodologies to beshared.

Laboratory Animal Science

Nonhuman primates are used to developand test vaccines against human diseases andto improve knowledge of disease pathogene-sis. In recent years, natural populations ofnonhuman primates have declined dramati-cally, due chiefly to the destruction of their

71

ELIMINATION OF URBAN RABIES IN LATIN AMERICA

Although a deadly disease, rabies can be prevented. Since most cases of humanrabies traditionally have been caused by bites from rabid dogs in large urban areas andsince vaccines exist to immunize dogs, public health programs have succeeded inreducing the incidence of human rabies significantly. The governments of Latin Amer-ica now consider it feasible to eliminate rabies altogether in their large cities and haveentered the last phase of a concerted, intersectoral campaign that sets 1992 as thedeadline to reach that goal.

The decision to eliminate rabies in large urban areas of Latin America called forreorienting many of the control programs that were in effect by broadening their scopeand pooling resources with other sectors.

The technical and administrative structures of vertical programs were decentral-ized to increase the coverage achieved by the resources available to rabies controlprograms. Simultaneously, agreements were made with local governments tostrengthen preventive and control activities. As examples, in Brazil, the Centers forthe Control of Urban Zoonoses, run by the county governments, were given greaterresponsibility for control measures; and in El Salvador, the health and agricultureministries joined efforts and succeeded in lowering the number of cases of humanrabies in the capital from 33 in 1984 to 1 in 1989.

Elimination of human rabies will depend directly on community participation,since to reduce the risk of bites by rabid canines, dog owners will have to comply withrabies vaccination programs. This has happened in the Dominican Republic, where5,000 volunteers were mobilized to assist the health sector in carrying out the rabiesvaccination campaign.

The consolidation of animal health service and university laboratories with thoseof the health ministries, another effective campaign strategy, has significantly extendedsurveillance and diagnostic coverage. In Colombia, for example, the Ministry of Healthand the Colombian Agriculture Institute coordinated their laboratory services to pro-vide nationwide diagnostic coverage.

One of the problems encountered in attaining total elimination of urban rabies isthe supply of biologicals, which is complicated by the fact that the Americas aredivided into areas that are free of foot-and-mouth disease and those that are not.National laws in countries that have eliminated foot-and-mouth disease prohibit theimportation of any vaccine from countries that produce it if they have not alsoeliminated the disease. This has often made it necessary to import vaccine-at a fargreater cost-from European producers instead of neighbors in the Americas.

PAHO/WHO provided guidance and served as an intermediary in obtainingfinancial support for national rabies control programs. Funds were obtained from suchsources as AGFUND, the Sovereign Order of Malta, the European Economic Com-munity, and the Mérieux Foundation. In the United States, the Rockefeller Founda-tion, the University of Wisconsin, the Centers for Disease Control, and the Agency forInternational Development have provided financial backing to Latin American rabieselimination programs.

The PAHO/WHO Veterinary Public Health Program geared its technical coopera-tion to areas in which the countries were not self-sufficient, such as laboratory services.

72

It stationed labratory experts in several countries from which it could simultaneouslymeet subregional needs, and increased its cooperation in areas such as epidemiologicsurvelllance, planning, and program management.

During the 1982-1985 quadrenrium, the average annual number of cases ofhurman rabies was 250. During the 1986-1989 quadrennium, a 20% reduction wasachieved, with an average of 20 cases of human rabies being reported annually. Rabiesin dogsJ, eanwhile, rose from an average of 13,530 cases annually during the firstquadrennium to an average of 15,651 cases yearly during the following quadrennium.This apparently contradictory increase of 15% is largely due to greater surveillance andreporting from rural and marginal urban areas.

To meet the 1992 deeadline for the elimination of rabies in large urban areas ofLatin Amerca, PAHO/WHOs three main strategies will consist of increasing thescope of dog vaccination campaigns, strengthening epidemiologic surveillance by use ofa weekly reporting system for human and dog rabies, and increasing medical servicesfor persons at risk of ontratiing rabies. Peripheral and rural areas will then be targetedfor future rabies elimination programs.

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natural habitat as farming and cattle ranch-ing have expanded.

The Program collaborated with MemberGovernments of countries that have naturalpopulations of monkeys to achieve their con-servation and rational use. Ways to increasetheir reproduction in captivity and in theirnatural habitat and to conserve virgin habi-tats were objects of Program study. The gov-ernments of Bolivia, Brazil, Colombia, andPeru established and/or reinforced nonhu-man primate conservation and managementunits, as well as captive breeding centers.

A new agreement was signed in 1986with the U.S. National Institutes of Healthto support the Peruvian Primatology Projectand expand its population and breedingstudy of Aotus sp. The Letter of Agreementbetween the Government of Peru andPAHO/WHO to conduct this project wasextended. An agreement between PAHO/WHO and Merck, Sharp & DohmeResearch Laboratories to rescue and con-

serve Saguinus labiatus populations in Peruwas approved in 1988. In 1989 USAIDsigned an agreement to finance a regionalproject to conserve and breed Aotus andother primate species important in researchto develop a vaccine against humanmalaria.

A meeting of the directors of primatecenters in the United States was held in 1986at the Primate Center of Peru. Following thismeeting, distinguished primatologists andconservationists attended a workshop andapproved the "Declaration on TechnicalCooperation between the Countries of theAmericas for the Conservation and Use ofNonhuman Primates."

In addition to its work with nonhumanprimates, the Peruvian Primatology Project'swork included participation in theExpanded Program on Immunization, train-ing of health promoters, construction of pri-mary schools, and mobilization of teachersfor health education.


CHAPTER V

ADMINISTRATION

The Office of Administration's objectivehas been to improve administrative supportto Headquarters and field offices, emphasiz-ing greater administrative flexibility andreductions in operating costs. As a result ofthis effort, administrative processes weredecentralized, more authority was delegatedto the PAHO/WHO Country Rep-resentations, and a new field financial man-agement system was installed at ten fieldoffices; this system provides more accurate,up-to-date information and better financialand program control over funds. In addi-tion, the use of machine translations, bettercommunication services, and more word-processing equipment helped cut costs atHeadquarters.

BUDGET AND FINANCE

During the 1986-1989 quadrennium,the PAHO Regular Budget totaled$US233,656,000 as compared to$US194,279,000 for the period 1982-1985,an increase of 20.3% in budget availability.The WHO Regular Budget allocations forthe Americas totaled $US112,146,837 ascompared to $US96,057,177 for the previousquadrennium, an increase of 16.7%.

Total income available for all PAHO/WHO programs, excluding transfers tothe Tax Equalization Fund, amountedto $US612,949,365 as compared to$US449,963,260 available during the 1982-1985 quadrennium, an increase of$US162,986,105. Collections of MemberGovernments' assessed quota contributionstoward PAHO's Regular Budget totaled

$US211,312,430 during 1986-1989, of which$US7,882,041 was transferred to the TaxEqualization Fund, leaving $US203,430,389available for program execution. Quotaassessments totaled $US232,799,000 duringthis four-year period.

Miscellaneous income derived fromthe Organization's investments andother sources of revenue increasedfrom $US10,945,775 in 1982-1985 to$US14,852,823 in 1986-1989. This increasecan be attributed to the continuation ofsound cash management practices andimproved control and short-term investmentof nonconvertible currency receipts.

Expenditures from trust funds totaled$US91,592,716 in 1986-1989 as compared to$US45,969,360 in the previous quadren-nium. The Organization was implementingover 400 extrabudgetary projects at the closeof 1989.

The Revolving Fund for the ExpandedProgram on Immunization (EPI) has assistedin the financing of vaccine procurementsfor Member Governments since 1977. Dur-ing the 1986-1989 quadrennium, expendi-tures from this special fund totaled$US26,442,436, reflecting a continuingincrease in vaccine procurement activities.The Organization also continued to assistMember Governments in the procurementof supplies and equipment for health-relatedactivities during 1986-1989, with purchasesunder this special program amounting toover $US19,000,000.

The Caribbean Epidemiology Center(CAREC) is financed jointly by PAHO/WHO and Participating Countries in theCaribbean subregion. Program expenditures

75


by CAREC totaled $US7,686,000 during1986-1989, and the Center's financial condi-tion at the close of the quadrennium wasvery sound. The Caribbean Food and Nutri-tion Institute (CFNI) also is financed jointlyby PAHO/WHO and Participating Coun-tries of the subregion. CFNI's total programexpenditures were $US4,822,000 during1986-1989, and the Institute's financial con-dition was satisfactory. The Institute ofNutrition of Central America and Panama(INCAP) had total program expenditures of$US21,342,000 during the years 1986through 1989, with expenditures from trustfund activities amounting to $US14,774,000.

GENERAL SERVICES ANDHEADQUARTERS OPERATINGEXPENSES

The Department of Conference andGeneral Services provides conference, trans-lation, interpretation, and building servicesat Headquarters. The Department is also thefocal point for general operations at Head-quarters, the PAHO Building Fund, andother special projects.

During the quadrennium, the Organiza-tion provided services to, or cooperated inthe organization of, 1,445 meetings held atHeadquarters and throughout the Region,which required contracting with editors,translators, and précis writers for a total of971 man-days. Special efforts were devotedto the organization and preparation of docu-mentation for the meetings of the Pan Amer-ican Sanitary Conference, the DirectingCouncil, and the Executive Committee andits subcommittees on Planning and Program-ming and on Women, Health, and Devel-opment. Organization, staffing, and docu-mentation services were also provided forthe two Inter-American Meetings, at theMinisterial Level, on Animal Health.

To support technical and administrativemeetings held at Headquarters and in thefield during the quadrennium, simultaneousinterpretation services in the four official

languages were provided for a total of 1,419interpreter-days. Among these were the livebroadcast, with simultaneous interpretationinto English, French, Portuguese, and Span-ish, of the two Pan American Telecon-ferences on AIDS.

The Department emphasized the fullimplementation of the machine translationproject, which uses the Organization's sys-tems for translating Spanish into Englishand English into Spanish. An l1-monthexperiment conducted in 1988 showed highrates of productivity and consistently quickturnaround.

The experiment's results led to a newpolicy, adopted in February 1989, wherebymachine translation became the primarymode of translation at PAHO/WHO.Throughout 1989, machine translationaccounted for the major share of the Spanishto English and English to Spanish transla-tion production. Translations into Frenchand Portuguese have not yet been incorpo-rated into the machine translation system.During 1989, 54.5% of translations were intoEnglish, 40.1% into Spanish, 2.9% intoFrench, and 2.5% into Portuguese.

PAHO/WHO has become a worldleader in the machine translation field. Itwas the first public international organiza-tion to use it, and it remains the only UNagency that uses machine translation in itsdaily operations.

During the quadrennium, major effortswere made to improve communication ser-vices, including telex, facsimile, telephone,and mail services between Headquarters andthe field offices. Facsimile technology intro-duced in 1986 was used increasingly throughthe quadrennium. The correspondingdecrease in the use of telex reduced transmis-sion costs by 23.5%, even though the num-ber of messages doubled. Despite a 142%increase in long-distance telephone callssince 1986, the introduction of a call-accounting computer program and a newpolicy of accountability in the use of thisservice resulted in lower long-distanceexpenditures in 1989 than in 1988. These


Administration 77

measures also allowed authorized staff toplace long-distance calls without operatorassistance.

PAHO/WHO has taken advantage ofcompetitive courier services, including thoseoffered by the U.S. Postal Service, bulk mail-ing of regular correspondence (at up to 44%lower costs), and concentration of its busi-ness with one courier company selectedthrough competitive bidding.

The formal capitalization of the PAHOBuilding Fund made it possible to plan thelong-term maintenance and repair of PAHO-owned buildings. A study of the Headquar-ters building, commissioned in 1988,evaluated the present condition and theremaining useful life expectancy of themechanical equipment and recommendedcriteria for a comprehensive equipmentrepair and replacement strategy.

PERSONNEL

At the end of 1989, PAHO/WHO had astaff strength of 1,055 (plus 71 temporaryemployees), which represents a 7% reductionfrom the end of 1985 when it was 1,134 (plus34 temporary employees). Of the total, morethan half were assigned to the field.

One of the most significant accomplish-ments of the personnel management pro-gram during the quadrennium was theimplementation of Resolution XIX, adoptedat the XXII Pan American Sanitary Confer-ence, which addresses the mobilization ofnational resources. Accordingly, the Depart-ment of Personnel diversified its functions,emphasizing the design of new methods forclassifying posts, administering salaries,recruiting staff, and monitoring and evaluat-ing staff performance.

The effort to build a national profes-sional system also constituted a significantchange in the orientation and priorities ofthe Organization's human resources man-agement. This effort was undertaken toaddress the need in some duty stations fornational professionals with a specific exper-

tise and an intimate knowledge of local con-ditions, including the social and economicsituation, who could complement the inter-national experience of non-national profes-sionals. By the end of 1989, 140 nationalprofessionals were on duty at four Centersand sixteen field offices.

In 1989, as in previous years, short-termconsultants and temporary advisers formedpart of the Organization's core work force.An analysis indicated that the 2,056 consul-tants and temporary advisers recruited in1989 contributed an equivalent of 60,874days of work and worked mainly in projectand program planning and, to a much lesserextent, in data processing, managementinformation systems, and general adminis-tration. This pattern generally holds for theperiod under review.

In order to comply with the GoverningBodies' directives concerning women,health, and development, efforts were pur-sued to increase the proportion of and topromote opportunities for women in theOrganization, particularly in decision-mak-ing positions. As part of its monitoring role,the Department collaborated with theWomen, Health, and Development Programto identify successes and shortcomings inattaining the goals set forth by the Govern-ing Bodies and, where appropriate, todevelop specific measures for makingimprovements. Moreover, the Departmentcooperated with the Office of InformationCoordination to gather extensive statisticaldata to monitor the status of women in theSecretariat. Female staff members occupied26% of the posts in the professional catego-ries as of December 1989, compared to 23%in 1985. The number of women assigned tograde P.4 and above increased from 38% ofthe female professional work force four yearsearlier to 45%.

As in previous quadrennia, high prioritywas given to staff development and training.The PAHO Human Resources System wasstrengthened in collaboration with theOffice of Information Coordination. By theend of the quadrennium, the system, which

77Administration


is linked to the financial management sys-tem, had been expanded to include data onshort-term consultants, temporary advisors,national professionals, and those hiredunder local conditions of employment. Fur-ther development and refinement of the sys-tem will continue in 1990.

PROCUREMENT

The Procurement Department is respon-sible for the cost-effective purchase andtimely delivery of goods and services to

PAHO/WHO Headquarters, field offices,and projects, as well as to Member Govern-ments under the Reimbursable ProcurementProgram, the Expanded Program on Immu-nization, and the Essential Drugs RevolvingFund for Central America. Total procure-ment during the quadrennium amounted to$US121,451,938. Acquisitions for MemberGovernments included $US27,886,663 forEPI and $US19,204,278 for other reimburs-able procurements. Purchases for goods andservices for PAHO/WHO-funded projectsand administrative and logistic supporttotaled $US74,360,997.

78

CHAPTER VI

PAHO/WHO TECHNICALCOOPERATION AT SUBREGIONAL AND

COUNTRY LEVELS

INTRODUCTION

The PAHO/WHO technical coopera-tion programs at the national level make upthe core of the Organization's proposed pro-gram and budget. The fundamental aim ofall the other PAHO/WHO technical cooper-ation activities is to support the country pro-grams through regional programs, sub-regional initiatives, and the mobilization ofother resources that advance achievement ofthe goals sought.

The programming for each country isbased on the identification of national prior-ities for technical cooperation through anongoing dialogue between the Organizationand national authorities. Priorities for thequadrennium covered by this report were setwithin the framework of the "Orientationand Program Priorities for PAHO during theQuadrennium 1987-1990," a collective man-date adopted by the XXII Pan AmericanSanitary Conference in September 1986.

Country programs are designed accord-

ing to an analysis carried out by nationalauthorities of the possible implications forthe health sector of the collective commit-ment to transform health systems by devel-oping their infrastructure; the need torespond to priority health needs of the mostvulnerable population groups; and the man-agement of knowledge required to makeheadway in these two major areas, in accor-dance with the "Managerial Strategy for theOptimal Use of PAHO/WHO Resources inDirect Support of Member Countries."

The subregional initiatives, meanwhile,are a key strategy of cooperation amonggroups of countries toward meeting thejointly identified priority health needs ineach subregion.

This chapter provides a brief overview ofthe main developments in the health sectorof each country between 1986 and 1989, aswell as activities carried out within theframework of the subregional initiatives.

79

I


CARIBBEAN AREA

CARIBBEAN COOPERATION IN HEALTH

In 1986, the Tenth Conference of Minis-ters Responsible for Health in the Caribbeanlaunched the Caribbean Cooperation inHealth initiative, a subregional approach forconducting joint health projects in theCaribbean. That same year, the XXII PanAmerican Sanitary Conference adopted aresolution endorsing the initiative. The ini-tiative rests on the premise that the healthservices can function better and more effi-ciently when national and subregional inter-ventions target priority areas.

The governments initially selected sixpriorities-environmental protection includ-ing vector control, human resource develop-ment, chronic disease control and accidentprevention, strengthening health systems,food and nutrition, and maternal and childhealth-and subsequently added AIDS as aseventh priority.

PAHO/WHO and the CARICOM Sec-retariat function as the joint secretariat forthe initiative, supporting the governments inthe twin strategies of promotion and projectpreparation. Countries such as Canada, theFederal Republic of Germany, France, andItaly; agencies including those of the UnitedNations System; and government bilateralaid agencies backed the Caribbean Coopera-tion in Health initiative. Projects were pre-pared at three levels-the Caribbeansubregion, the Eastern Caribbean states, andindividual national governments.

Initially, attention and funding focusedon subregional projects, partly becausedonor agencies considered the subregionalapproach to be a useful means of supportingthe countries and partly because the Carib-bean Ministers of Health themselves wishedto promote the initiative as a way to fosterintra-Caribbean collaboration. Toward theend of the quadrennium, more national

projects were designed. The Government ofTrinidad and Tobago, for example, prepareda portfolio of national projects addressingthe priority areas designated in the Carib-bean Cooperation in Health initiative andarranged a donor conference in November1989 which received substantial support.

To support the initiative, PAHO/WHOand CARICOM developed a range of docu-ments and presentations: printed and audio-visual promotional materials have beenprepared and distributed, and a regularnewsletter reporting on the initiative'sprogress has been circulated. An evaluationof the Caribbean Cooperation in Health ini-tiative was carried out in 1988 and presentedto the Ministers of Health that same year.The results demonstrated satisfactoryprogress in accomplishing the general objec-tives and showed the funding status for thevarious project areas.

As the CARICOM Ministers of Healthhave indicated repeatedly, securing externalfinancing is only one measure of the initia-tive's success, since several of the projectsoriginally developed at the national levelwere supported entirely with nationalresources. However, external support for theinitiative has been gratifying. Three yearsafter its inception, approximately $US32million had been committed and several ofthe projects were being executed. The bulkof the funding was for AIDS control, envi-ronmental protection, and maternal andchild health. Food and nutrition andchronic diseases attracted the least support.

Not all of the resources that were mobi-lized were financial. The Caribbean publichealth workers, for example, formed theCaribbean Public Health Association, andthere was greater information and staff inter-change between the French- and English-


PAHO/WHO Technical Cooperation at Subregional and Country Levels

speaking Caribbean nations. The latterdevelopment led the Government of Franceto lend considerable technical support, pre-dominantly to the Eastern Caribbean coun-tries. A Canadian-Caribbean partnershipalso developed, as a collaboration betweenthe University of Toronto and the Univer-sity of the West Indies and between theCaribbean and Canadian public health asso-ciations. PAHO/WHO developed formalcooperation agreements with the CaribbeanDevelopment Bank and the University ofthe West Indies. PAHO/WHO and CARI-COM collaborated with the CaribbeanDevelopment Bank in assisting the countriesto strengthen their capability to develop andmanage projects and in mobilizing Carib-bean nongovernmental organizationsinvolved in health, especially those whoseinterests are related to the seven priorityareas. These agreements are designed tomobilize internal national support and topromote links with non-Caribbean nongov-ernmental organizations, in order to facili-

tate the flow of additional resources to theCaribbean health sector.

PAHO/WHO, CARICOM, and theCaribbean health sector consider that theinitiative has succeeded in becoming theguiding framework for most of the PAHO/WHO technical cooperation projects, andhas provided a viable mechanism to facilitateinteragency and intergovernmental collabo-ration in health. These gains prove that thestrategies adopted for carrying forward theinitiative can be good vehicles to attract sup-port for health projects at the national andsubregional levels.

The ongoing progress of the initiativewill depend on the efficiency with which par-ticipating countries, assisted by PAHO/WHO, CARICOM, and Caribbean insti-tutions, execute the projects that have beendesigned and supported. The ultimate mea-sure of its success in the future will be aquantifiable improvement in the Caribbeanhealth systems and the consequent improve-ment of health indicators in priority areas.

ANTIGUA AND BARBUDA

During the 1986-1989 quadrennium,the government's national priorities for tech-nical cooperation in health focused on thedevelopment of the health infrastructure.Emphasis was placed on the development ofa national health information system, insti-tutionalization of the family services, thedevelopment of a national health plan, theintroduction of a drug supply system, andthe identification of health care financingalternatives. The technical cooperation lentby PAHO/WHO reflected these nationalpriorities. It concentrated upon establishingthe information base needed for effective

planning, monitoring, and evaluation, andmobilizing an intersectoral approach to thedelivery of health services.

A large intersectoral workshop on theprimary health care approach was held in1986, and Antigua and Barbuda participatedin related workshops in other countries ofthe Caribbean subregion. The Ministry ofHealth emphasized strengthening the healthinformation system at the community levelto improve the primary care approach. Agrant from WHO's Essential Drugs ActionProgram was used to upgrade the drug sup-ply systems and establish the basis for the

81


country's eventual participation in the East-ern Caribbean network.

In the area of environmental health, theministry drew up projects for funding underthe Caribbean Cooperation in Health initia-tive, and the Solid Waste ManagementCompany Limited of Trinidad and Tobagoassisted the Government of Antigua andBarbuda in improving the collection and dis-posal of solid waste. Basic sanitation in Bar-buda was improved with PAHO/WHO andUNICEF collaboration.

The government continued its campaignto reduce mortality and morbidity in chil-dren, focusing on vaccination and control ofdiarrheal diseases. Considerable success wasachieved, particularly through the Ex-panded Program on Immunization, forwhich coverage at the end of the periodexceeded 90%.

Given the changing age profile of thecountry, the government formulated pro-grams to control chronic diseases, in particu-lar diabetes and hypertension. It also revisedits mental health laws with PAHO/WHO'sassistance, and developed a medium-termplan for the control of AIDS with support

from CAREC. The plan was fully funded atthe donors' meetings organized by PAHO/WHO and the Global Program on AIDS.

The Pan Caribbean Disaster Prepared-ness and Prevention Project that is based inAntigua served as a primary focal point forthe coordination of relief efforts followingHurricane Hugo, which severely affected thenorthern Leeward Islands in 1989.

Antigua and Barbuda participated fullyin the formulation and promotion of theCaribbean Cooperation in Health initiative.The country's Minister of Health was amember of the PAHO/CARICOM teamthat promoted the initiative in Europe.Although not many of the projects fundedare specific to Antigua and Barbuda, thecountry will benefit from the subregionalprojects that are now being initiated in suchareas as maternal and child health and envi-ronmental health.

A highly successful country-PAHO/WHO joint evaluation of the Organization'stechnical cooperation was conducted in1989. This evaluation not only reviewed pre-vious efforts but provided guidelines forfuture cooperation.

BAHAMAS

The Commonwealth of the Bahamas isan archipelago of some 700 islands spreadover 100,000 square miles. Its 248,000 inhab-itants reside on 24 of these islands; about75% of the people live in urban settings ontwo islands and the remainder in scatteredrural communities. In addition to apprecia-ble logistical problems in the delivery ofhealth care and the provision of physicalfacilities, supplies, and manpower, this geo-graphic configuration has also given rise toeconomic and social pluralism. Thus, aggre-gate data must be interpreted with cautionin the determination of indicators.

In 1986, the Ministry of Health reviewedits existing Policy Document and prepared arevised document that specified 16 priorityareas to guide its program in the short andmedium terms. The revised Policy Docu-ment, which received Cabinet approval in1987, incorporated all areas covered in the"Orientation and Program Priorities forPAHO during the Quadrennium 1987-1990." In November 1989, the Prime Minis-ter committed the government to "thefurther democratization of the political man-agement of the country" in the 1990sthrough the establishment of local govern-

82


ment in the Family Islands. This policyshould imply significant strengthening oflocal health systems.

A concerted effort was made tostrengthen the organization and systems ofthe ministry headquarters, to complementthe decentralization of services in hospitalsand health centers and the strengthening oflocal health systems. External consultantswere funded by the IDB to assist in healthsystems development-a national priority.With considerable government funding, anumber of new health centers were built inNew Providence and the Family Islands andthe substantial upgrading of others wasstarted. A new nursing school was commis-sioned in 1987.

The Health Information and Coordinat-ing Services Unit (HICS), essential for plan-ning and decision making, received specialemphasis in the areas of improving data col-lection and analysis, computerizing hospitalinformation, and updating the cancer regis-try. The quality of primary health care datafor the Family Islands was improved. TheHICS also successfully completed a nationalnutrition survey, the preliminary results ofwhich are now being analyzed to determinetheir national food and nutrition policyimplications.

The government recognized the need toexamine alternative means of financinghealth services because of the escalatingcost of health care, which stands at ap-proximately 13% to 14% of the annual recur-rent national budget. A Working Partyappointed to study this matter submitted areport in late 1987. At the Cabinet's request,its principal recommendations were thenpresented in a form suitable for extensivepublic dialogue, which took place in 1989.

In the area of maternal and child health,the government maintained its campaign tovaccinate children under one year of age andformed national Coordinating Committeesfor the control of two chief causes of infantmortality, diarrheal diseases and acute respi-ratory infections. Vaccination coverage forDPT, polio, and measles vaccines surpassed

80% by the end of 1989. PAHO/WHO hasactively promoted activities related towomen in health and development.

Environmental health became a highnational priority. Environmental monitoringand risk assessment were improved throughthe training of local staff and the use of sig-nificant funding obtained from the local pri-vate sector. The problem of solid wastedisposal remained intractable, althoughinternational assistance contributed to itsmitigation. Vector control-particularly thecontrol of Aedes aegypti-was stepped up in1988 and 1989.

In response to a cocaine use epidemic, alarge number of educational activities tar-geted at vulnerable groups and "gate keeper"organizations were initiated. Prevalencestudies were conducted in schools, prisons,and colleges to provide sound informationfor use in formulating national prevention,treatment, and rehabilitation policies. Up to1989, these activities were principally fundedby UNFDAC.

The Bahamas has one of the highestincidence rates of AIDS in the Region, about54 per 100,000 population. To study theproblem and coordinate the health sector'sresponse, the government set up a multidis-ciplinary National Standing Committee. AnAIDS Secretariat was established as its oper-ating arm. The AIDS program addressedthree main areas-public education, surveil-lance, and laboratory support-and carriedout a knowledge, attitude, and practicestudy that was nearing completion at theend of 1989.

The government expanded efforts totrain health personnel, assigning a signifi-cant part of the health ministry's budget forstaff development in a variety of disciplines.PAHO/WHO provided assistance mainly byawarding fellowships and funding nationals'attendance at courses and seminars.

During the quadrennium the share ofthe national budget allocated directly tohealth remained consistently high at about13.5%. In addition, the government mobi-lized funding from external sources, includ-

83


ing its own private sector. Other sources of fited from a multidisciplinary and intersec-funds included service organizations, for toral approach. The Working Group on

mental health facilities; IDB, for infrastruc- National Health Insurance, the Committeeture; UNFDAC, for drug abuse prevention on Trauma Research, the AIDS Nationaland control; and PAHO/WHO, for AIDS Standing Committee, the National Drugprevention and control, health manpower Council, and the coordinating committeesplanning, solid waste management, and for the National Nutrition Survey and thehealth information. National Drug Use Survey were all intersec-

Many of the activities undertaken bene- toral in composition.

iica A Comparati ve Cns ttutal Scdy (Scientific Pubi ication No.: 50,

Coricdfhe edfor rigrus stud o the relationshp between health ala PA edad cniuio schlars from 29 of its Member C fn

tries contriute essaysanazing owtheir pliticaand leg systems treat the

kCoetoeaha arneda to give secialarttention to itelrationa dec iarains

on the subject. Th ~~ri>esult isa0 ascholar oti of cles that examines howaio ce h athbothas a hu gt d as an indiiual and c ev

Tw a tte inngo boo rvid a theoretical franework for itna btio c u iosnternainl -uranRih s La and lnstiutions" discusses

contemporary international efforts to promoteth0Xe ight to health, while "The Ríght toet a ti th soaeo ea scare as a legal right.

tohel bu t lo aie s pr:ovoaie si o h theoretical veru the0a a i to tor protection really mean

in a given societ it applto eryone oron to certain gu? Lsit rely anabstract( prinipI odoaseittoivitsbtneAdif are such ws, d

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

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BARBADOS

The new administration elected in May1986 established the national priorities forthe quadrennium. Health was affirmed as abasic human right, the establishment of ahealth planning committee to plan improve-ments in the health care delivery system wasproposed, and all Ministry of Health policiesand activities were reviewed. The govern-ment decided to postpone the developmentof a comprehensive National Health Servicesimilar to the United Kingdom's model, opt-ing instead for an expansion of the polyclin-ics system, including plans for theconstruction of three additional polyclinics.The government focused on developing pro-grams and services in polyclinics and hospi-tals to reduce morbidity and mortality fromchronic noncommunicable diseases. To sup-plement this effort, research to study riskbehaviors that influence diabetes and hyper-tension was designed and will be carried outin the early 1990s.

Polyclinics were reviewed and restruc-tured as necessary; they were provided withthe adequate quality and number of staff todeliver preventive and curative health ser-vices in a community setting. In line with thenational commitment to universal access tohealth services, the Barbados Drug Servicewas reviewed to ensure that high-qualityessential drugs were available either free or atmoderate cost. The Service, which contin-ued to function as a WHO CollaboratingCenter, set up a Drug Information Centerand automated its information system.

A Health Education Unit was estab-lished to promote healthy lifestyles. Somehealth services for elderly, indigent, handi-capped, or mentally ill patients were pro-vided at home rather than in institutions.

A government priority was a project toincrease the efficiency of the Queen Eliza-beth Hospital by integrating it within the

health system. Hospital services also wereextended through the acquisition of the St.Joseph's Hospital, which was formerlyadministered by the Roman CatholicChurch. The project, funded by the IDB andexecuted by PAHO/WHO, reviewed allaspects of the hospital's management,designed systems for bringing aboutimprovements, and provided training in theutilization of these systems.

In response to the increasing incidenceof AIDS, the government added a vigorouscampaign to control the disease to its prior-ity programs. To that end, a detailed strategyand plan of action were designed, and thepublic education program served as a modelfor several Eastern Caribbean countries.

New initiatives were undertaken in envi-ronmental health, including the conduct offeasibility studies on environmental protec-tion measures. New, comprehensiveenvironmental legislation was under consid-eration toward the close of the quadren-nium. The government evaluated its Envi-ronmental Health Services, and, with theassistance of the U.S. National Institute forOccupational Safety and Health, reviewedthe potential hazards from the use of asbes-tos in certain public buildings. The recom-mendations of the review are currently beingstudied. At the end of 1989, the governmentwas preparing a project to alleviate the asbes-tos problem.

CEPIS assisted the British GeologicalSurvey and the Government of Barbados inestablishing a system for monitoring thequality of the country's groundwater, whichis its main water supply source. CEPIS alsoprovided technical advice on submarine out-falls so that the new sewerage systems wouldnot contaminate the marine environmenton which Barbados so heavily depends.

A feasibility study on psychiatric and

85


geriatric care conducted during 1986 and1987 pointed to the need for closer linksbetween these services and the generalhealth services. The services of the main geri-atric hospital were modified accordingly, andcommunity mental health services weredeveloped.

In the last two years of the quadren-nium, the Ministry of Health increasinglyfocused on human resource development,which was regarded as a critical factor inimproving the quality of care and in permit-ting an expansion of the services. A review

of health manpower needs was undertakenin conjunction with the Queen ElizabethHospital Extension Project, and local train-ing took place in association with the Barba-dos Community College.

PAHO/WHO technical cooperationwas extended to facilitate technical coopera-tion between Barbados and the rest of theCaribbean. Barbados increasingly becamethe main reference center for the EasternCaribbean, and Barbadian expertise hasbeen made available to the other Caribbeancountries.

BERMUDA

During the period 1986-1989, thenational health priorities of Bermuda werein the areas of human resource development,primary health care, surveillance and evalua-tion for disease control, environmental qual-ity, dental health, and vector control.

Bermuda, along with two other north-ern Caribbean British territories (the Turksand Caicos and Cayman Islands), receivestechnical cooperation from PAHO/WHOthrough its Jamaica Country Office. PAHO/WHO supported the development of healthplans and health services delivery by offeringtraining in workshops and through fellow-ships, by providing short-term consultantsand staff visits, and by strengthening thehealth information systems. CAREC lenttechnical assistance to improve epidemio-logic surveillance and analysis.

Human resource development contin-ued to receive priority, but changes weremade in specific activities. For example, a

fellowship was provided to the health pro-motion coordinator to participate in a"Health City" seminar in Liverpool (UnitedKingdom), and the PAHO/WHO NursingAdviser participated in a visit to a CanadianNursing School and advised on the curricu-lum that would best enhance the training ofBermudan nurses. The limited availability ofhuman resources in the territory restrictedthe implementation of other proposed train-ing activities.

PAHO/WHO also provided assistancein the evaluation of the preventive dentalhealth program.

External resources were mobilizedthrough the Caribbean Cooperation inHealth initiative to support the vector con-trol program and the maternal and childhealth services. The mobilization of internalresources was limited, as it was in the otherNorthern Caribbean territories, by the smallnumber of trained professionals.



BRITISH WEST INDIES

Three British Dependent Territories inthe Eastern Caribbean-Anguilla, the Brit-ish Virgin Islands, and Montserrat-are con-sidered in this section under the rubricBritish West Indies. The problems character-istically encountered in small island Statesare emphasized by the small size of the popu-lations in these territories, ranging from7,000 to 14,000.

PAHO/WHO technical cooperationduring the quadrennium focused on helpingthe territories to implement the primaryhealth care approach to delivering services.In recognition of difficulties experienced byall the territories in obtaining trained per-sonnel and the lack of well-developed train-ing institutions, the fellowships program wasstrengthened through the provision of ongo-ing technical support to the fellows upontheir return to duty. Assistance was also pro-vided in improving information systems.

The maternal and child health servicesreceived continued support. The success ofefforts in this area was shown by decreases ininfant mortality and the expansion of immu-nization coverage to 100%. In the BritishVirgin Islands, a health and family life edu-

cation project was successfully concluded,and in Anguilla, local health programs weredeveloped with PAHO/WHO assistance.

Situational analyses were conducted inall the territories and a draft of a NationalHealth Plan was completed for Montserrat.However, the gains made in Montserrat werejeopardized by the devastation caused byHurricane Hugo. PAHO/WHO technicalcooperation was instrumental in establishingcommunications immediately after the hur-ricane and in coordinating internationalrelief efforts. The ongoing planning for thereconstruction and rehabilitation of thehealth services is being supported byPAHO/WHO.

The environmental health services of allterritories were evaluated by PAHO/WHO,and a Solid Waste Master Plan was devel-oped for Anguilla. Assistance was providedto Montserrat in the management of sani-tary landfills.

Medium-term AIDS prevention planswere prepared with CAREC's assistance.They were fully funded at a donors' meetingorganized by PAHO, CAREC, and theWHO Global Program on AIDS.

CAYMAN ISLANDS

The Cayman Islands is one of threenorthern Caribbean British territories (theothers being Turks and Caicos Islands andBermuda) that receive technical cooperationfrom PAHO/WHO through its JamaicaCountry Office.

Development of the National HealthPlan as an integral part of the National

Development Plan was a high priority duringthe quadrennium. The health plan empha-sized improving mental health and drugabuse prevention services, and reaffirmedthe policy of developing human resources tosupport the country's well-developed healthinfrastructure.

Within the area of health services deliv-

87


ery, priorities included child health, withspecific concern for the prevention and con-trol of genetic diseases; oral health, withemphasis on prevention; the control of sexu-ally transmitted diseases; family life educa-tion; and hospital maintenance. Increasingconcern about environmental health condi-tions led to planning and support for moreactivities in that area, which will become achief focus of technical cooperation in thefuture. AIDS prevention and control wasanother program that received specialattention.

PAHO/WHO cooperated in the devel-opment of the health services infrastructurethrough providing training, improving thehealth planning capacity, and developing ahealth information system. Training tookthe form of fellowships and the participationof nationals in local and overseas work-shops/conferences. PAHO/WHO supportedthe development of the health plan and thestrengthening of health services deliverymainly through provision of shart-term con-sultants and PAHO/WHO staff visits. Theacquisition of a computer improved the col-lection and consolidation of data for thehealth information system.

The school dental health education pro-gram was upgraded significantly. A nutritionworkshop was implemented with assistancefrom PAHO/WHO, including a visit from aCFNI staff member. A workshop was alsoheld on the management of drug-addictedpatients.

PAHO/WHO acted as- an executingagency for international projects in theNorthern Caribbean territories. Theseincluded the UNDP-funded "Developmentof Health Services" projects in both the Cay-man Islands and the Turks and CaicosIslands. External resources were also mobi-lized through the Caribbean Cooperation inHealth initiative in support of vector controland maternal and child health services.

The mobilization of internal resourceswas limited in the Northern Caribbean terri-tories, due to a lack of a sufficient number oftrained professionals. However, CaymanIslands nationals did collaborate in theimplementation of AIDS control programactivities.

As in Bermuda, some programmedtraining activities were not implemented.Registered nurse training was supported byboth the UNDP and government funds.

CUBA

Cuba continued to make markedimprovements in the health status of itspopulation. Life expectancy reached 74.2years in 1988, and infa'nt mortality wasreduced from 16.5 per 1,000 live births in1985 to 11.5 per 1,000 in 1988 -and 11.1 in1989. Simultaneously, the birth rate contin-ued to decline, due to the combined effectsof improved economic and educational lev-els, the ready availability of contraceptives,and couples' counseling.

The trend continued toward the sig-nificant reduction in morbidity and mortal-ity due to infectious diseases. In 1962 these

diseases accounted for 13% of deaths; by1988 and 1989, they caused 1.5% and 1.3%of deaths, respectively. Poliomyelitis, indig-enous malaria, diphtheria, and neonataltetanus have been eradicated. Other com-municable diseases have been broughtunder control.

While it made significant progress inthese traditional areas, Cuba witnessed anincrease in noninfectious diseases. As thepopulation lived longer, the morbidity andmortality profiles changed. The governmenthence gradually shifted its emphasis towarddeveloping facilities and retraining man-

88


power to care for chronic illnesses and topromote their prevention, and toward insti-tuting rehabilitation programs that facilitatethe full integration of elderly patients intothe community.

Teams consisting of a family doctor andfamily nurse have been the main providers ofmedical care in Cuba. This was especiallytrue in rural areas, where most of the publichealth programs revolved around commu-nity interaction with doctor/nurse teams.During the quadrennium, Cuba began toadd a public health worker to each of thesecore teams, with the aim that in 10 years theentire country will have a ratio of one doc-tor/nurse/public health worker team forevery 600 inhabitants.

One of Cuba's top national health prior-ities during the quadrennium was toimprove the quality of its medical carethrough, among other activities, assessingand acquiring new health technologies,training its manpower, and constructing orrefurbishing facilities. During the 1980s, thenumber of hospital beds in the city ofHavana increased from 17,605 to 23,730,with 3,990 of these beds being added duringthe 1986-1989 period. Pediatric hospitalfacilities were also extended and modernizedthroughout the country by constructingand inaugurating 31 pediatric intensive carewards, upgrading existing wards and poly-clinics, and modernizing equipment avail-able for pediatric care.

Ultrasound equipment was installed inthe country's entire hospital network, andspecialized facilities received magnetic reso-nance imaging and hyperbaric oxygen cham-bers. Cuba also invested in computerizedaxial tomography and extracorporeal litho-tripsy equipment as part of its national pro-gram to modernize diagnostic and treatmenttechniques.

Meanwhile, the Ministry of PublicHealth continued to carry out preventivehealth programs that centered on interven-ing in risk factors determined by epidemio-logic studies. To carry out its five-year healthplan, the health ministry worked closely

with the Council of State, Ministry of Plan-ning, State Council for External Coopera-tion, Ministry of Agriculture, Ministry ofIndustry, Academy of Sciences, Ministry ofLabor, and Ministry of Education. The Fed-eration of Cuban Women, the NationalAssociation of Small Farmers, and the Com-mittees for the Defense of the Revolutionparticipated in carrying out community-based health programs.

The public health and epidemiology sub-system, which employs the family doctor/family nurse/public health worker team,extended the scope of its work to includeprevention of chronic noncommunicablediseases. Preventive programs included spe-cial projects for pre- and postnatal care andfor the well-being of the elderly. Lifestylecampaigns were also important, especiallythose geared toward preventing smoking,alcoholism, obesity, and stress. Physical exer-cise and team sports were the primary pre-ventive behaviors promoted among families,workers, and students.

The epidemiologic surveillance systemand sanitary inspection services increasedtheir manpower and budgets to combat thechief communicable diseases and to improvesanitary conditions in neighborhoods and atwork sites. Local public health and epidemi-ology centers and units worked more closelywith polyclinics and the family doctor/fam-ily nurse/public health worker team. Thiscollaboration allowed the team's work vol-ume to be reduced, thereby improving thequality of its services while reducing theircosts.

As a complement to the Public HealthPlan, the ministry drafted a program todevelop the pharmaceutical industry. Thegoal is to raise the industry's technologicallevel and to speed up construction of newplants to produce antibiotics, blood deriva-tives, vaccines, reagents, and other biologi-cals. The country also made advances inthe realm of genetic engineering andbiotechnology.

The medical education subsystem had tobe adjusted to the changes noted above in

89


the health services system. Existing person-nel took courses to upgrade their expertise,and new health workers were trained to staffthe system. During the first phase of thishuman resources development, nurses weretrained in preventive work at the commu-nity level. The primary health care educa-tional curriculum focused especially ondeepening nurses' understanding of a com-prehensive epidemiologic approach-includ-ing hygiene and ethical and psychosocialfactors in health care-in addition to givingthem specific technical training. Epidemio-logic surveillance and determination of risk

factors were used as the primary means ofgauging the population's changing needs andthe resulting adjustments required in thehealth services. The curiculum for trainingmedical doctors-with the exception of sur-geons and those involved in basis research-underwent similar changes.

The ability of the science and technol-ogy subsystem to conduct research activitiesincreased substantially. Ways will be soughtin the future to create a scientific and techni-cal publication and information dissemina-tion system that will be accessible to healthworkers through the polyclinics.

DOMINICA

The priority of the Ministry of Health ofDominica during the first half of the qua-drennium was to continue efforts to extendaccess to primary health care services to theentire population. The measures startedunder the 1982-1987 five-year health planwere completed and a new plan was drawnup. The focus of the government shiftedtoward an emphasis on improving the qual-ity of care and, in particular, toward increas-ing the operating capacity of the mainhospital, the Princess Margaret Hospital,and integrating its services more closely withthe primary level of care.

PAHO/WHO technical cooperationreflected the national priorities. The Organi-zation conducted a complete situationalanalysis of the health sector and sponsored aseries of retreats at which performance underthe previous health plan was evaluated. Theretreats produced guidelines for the prepara-tion of the new health plan and for the cor-responding evaluation of PAHO/WHOtechnical cooperation in 1988.

Technical cooperation was extended inthe administrative reform of the Ministry ofHealth, the installation of automated finan-cial systems in the Princess Margaret Hospi-

tal, and the integration of primary andsecondary care. The capital costs entailedwere financed by the Government of France.

In the area of environmental health,PAHO/WHO executed a UNDP-fundedproject that studied the feasibility of install-ing sewerage systems in the city of Roseau.Technical cooperation was also extendedtoward improving the quality of the watersupply and upgrading basic sanitation inrural areas. The participation of communi-ties in vector control projects was examinedin a project funded by WHO and UNICEF.

Technical cooperation in maternal andchild health services promoted the achieve-ment of the subregional Plan of Action tar-gets set out within the CaribbeanCooperation in Health initiative. Consider-able progress was made in reducing infantmortality due to diarrheal diseases throughthe use of oral rehydration therapy and inincreasing coverage of the Expanded Pro-gram on Immunization, which reached arate of over 90% by the end of 1989.

The first case of AIDS was reported inDominica in 1986. CAREC assisted in thepreparation of a medium-term AIDS planwhich was fully funded at a donors' meeting



conducted by PAHO and the WHO GlobalProgram on AIDS.

Among chronic diseases prevalent in thecountry, diabetes received special attention.The health ministry designed control pro-grams with PAHO/WHO assistance, andcollaborated in their execution with a num-ber of nongovernmental organizations, mostnotably the Diabetes Association ofDominica.

PAHO/WHO, CFNI, and UNICEF col-laborated in the implementation of the JointNutrition Support Program in Dominica.This program aimed to augment the nutri-

tion services provided by the governmentand to develop nutrition education pro-grams for mothers and children, as well asthe general adult population.

Technical cooperation between countrieswas featured strongly in PAHO/WHO pro-grams in Dominica. The government hostedvisits from the French Departments, Haiti,and neighboring islands for the purpose ofobserving the experiences of Dominica.

A case study on Dominica, being pre-pared at the close of 1989, will enable infor-mation on its successes to be widelydisseminated.

DOMINICAN REPUBLIC

The sharp decline in gross domesticproduct (GDP), total public expenditures,and social expenditures in the DominicanRepublic from 1984 to 1985 leveled off at thebeginning of the 1986-1989 quadrennium.There was a boom in the construction indus-try in mid-1986 and a real increase in GDPfor the next two years. In 1988, however,GDP figures were again negative, and despitean increase in social expenditures and percapita outlays for health, many health indi-cators did not return to 1984 levels. The cri-sis in basic services (water, electricity, wastemanagement, fuels, and transportation) dra-matically affected the quality of life, whilethe health sector itself felt the impact ofstrikes and a shortage of materials.

The epidemiologic profile reflected thesituation. Maternal and infant mortalityrates remained high, with perinatal and neo-natal causes strongly predominant, as well aswater-borne communicable diseases (diar-rheas, typhoid fever, hepatitis), respiratoryconditions (acute respiratory infections,tuberculosis), vector-borne diseases (dengue,malaria), and sexually transmitted diseases(AIDS, syphilis, gonorrhea), aggravated in

the periurban area by overcrowding, envi-ronmental deterioration, and malnutrition.Accelerated urbanization and the introduc-tion of foreign behavioral mores contributedto problems such as drug addiction, vio-lence, alcoholism, the abuse and mistreat-ment of women and children, and trafficaccidents. The progressive aging of the popu-lation was reflected in an increase in chronicdiseases.

After the hospital crisis of 1985, themedical union, through strikes and longwalkouts, succeeded in obtaining sustainedincreases in posts and salaries. Attention toother demands-for more complex diagnos-tic and treatment facilities, new equipment,and remodeling of hospitals-caused thebudget to be concentrated on capital goodsand personnel costs. Toward the end of thequadrennium the hospital crisis reintensifiedas poor maintenance, scarcity of essentialdrugs, and increasing indebtedness to pri-vate providers caused a regression in thequantity and the quality of public sectorcare.

At the start of the new governmentalperiod in 1986, the Secretariat of State for

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Public Health and Social Welfare andPAHO/WHO carried out a joint review ofthe Organization's technical cooperation.The secretariat identified the followinghealth sector priorities: administrative reor-ganization, child survival, rehabilitation ofthe hospital infrastructure, supply of phar-maceuticals, and eradication of poliomyeli-tis. The main avenues it requested forPAHO/WHO cooperation were the mobili-zation of external financial resources, humanresources training, access to scientific andtechnical information, and direct technicalcooperation.

One of the ways in which PAHO/WHOaddressed the Dominican Republic's priori-ties was to include the country in the Planfor Priority Health Needs in Central Amer-ica. Admitted as a permanent observer atthe IV Meeting of the Health Sector of Cen-tral America (RESSCA), the DominicanRepublic reached several cooperation agree-ments with the seven Central Americancountries and, as a result, was included incertain projects undertaken as part of theCentral American initiative.

At the sectoral level, the health secretar-iat tried to coordinate activities with theDominican Social Security Institute (IDSS),the Social Security Institute of the ArmedForces and National Police (ISSFAPOL),and semiprivate public welfare institutes, soas to preclude duplication of efforts. To thisend, the secretariat, IDSS, and PAHO/WHO signed a cooperation agreement andIDSS took part in RESSCA. Relations werealso strengthened between the secretariatand water, sewerage, and sanitation agen-cies, especially in the areas of institutionaldevelopment, water quality and loss control,reduction of vulnerability to natural disas-ters, solid waste management, and rodentcontrol.

Efforts to better utilize and retainnational human resources were supported bypromoting continuing education and in-ser-vice training, as well as teaching-service inte-gration. Priority health problems wereemphasized in the undergraduate and post-

graduate curricula of health professionalsand in public health and occupationalhealth master's degree programs. The secre-tariat, IDSS, and ISSFAPOL signed severalagreements among themselves and with thecountry's universities regarding the develop-ment of their health personnel.

Local-level health activities were sup-ported by means of direct consultation,training, and information through jointworking agreements among the secretariat,IDSS, grassroots organizations (neighbor-hood, labor, youth, religious, and women'sgroups), nongovernmental organizationsconcerned with regional development, scien-tific societies, health workers' unions, andthe numerous local arms of foreign publicwelfare institutions.

Noteworthy accomplishments were theeradication of polio, the elimination ofhuman rabies and reduction in animalrabies, the introduction of the AIDS Con-trol Program, the successful National Scien-tific Meeting on Epidemiology, and progressin the Integrated Epidemiology Develop-ment Plan.

Significant advances have been made inthe field of information management, asreflected in the Program Budget for the firsttime with funding for two projects: one ondissemination of scientific and technicalinformation and another on information forthe general public. As part of the firstproject, the National Biomedical Informa-tion Network was organized. It consists ofthe PAHO/WHO and health secretariatdocumentation centers, university andteaching hospital libraries, the DominicanMedical Association, and the NetworkCoordinating Center at the AutonomousUniversity of Santo Domingo. Support wasgiven to the training of specialized personneland to direct access to the MEDLINE andLILACS data bases.

With PAHO/WHO collaboration, thesecretariat completed an infrastructureextension project with IDB and carried outactivities in the Plan of Action for the Eradi-cation of Polio by the end of 1990, supported



by IDB, PAHO/WHO, USAID, RotaryInternational, and UNICEF. The secretariatalso developed a joint program with theRegional Potable Water Committee, IDB,PAHO/WHO, and GTZ, and began severalprojects in the Plan for Priority HealthNeeds in Central America with funds fromSpanish Cooperation and UNDP. Its

medium-term AIDS control program culmi-nated with a donors' meeting, and fundswere obtained through WHO's Global Pro-gram on AIDS and the European EconomicCommunity. Family planning activities werecontinued with UNFPA funds, and a newfive-year project was drafted.

FRENCH ANTILLES AND FRENCH GUIANA

The Office of the PAHO/WHO Carib-bean Program Coordination, based in Bar-bados, assumed responsibility forcoordinating technical cooperation activitieswith the French Caribbean territories half-way through the quadrennium. The PAHO/WHO Representative Office in Surinamehad ably executed this task in previous years.

The health care system of the FrenchDepartments in the Americas is similar tothat of France. Hospitals and tertiary carefacilities and health technology and researchstandards are hence comparable to those inmetropolitan areas of France. It was there-fore unclear whether the Departments wereto be thought of as "donors" or "recipients"of assistance within the Caribbean. How-ever, closer examination and the exchange ofvisits with other parts of the Caribbeanmade it clear that they could both provideand benefit from technical cooperationarrangements in the subregion.

Tertiary care is highly developed andtends to be very expensive, based as it is onthe model of care in a metropolis. Theaccompanying support systems, such as labo-ratory and research facilities, are equallyexpensive and not necessarily correlatedwith local needs. The secondary care facili-ties are less developed, since most care is pro-vided at the primary level in the offices ofprivate physicians or through the publichealth promotion and preventive services.Development of health manpower and tech-

nology, with the exception of the training ofnurses, is largely dependent on institutionsin France.

The PAHO/WHO Office identified anumber of opportunities for technical coop-eration. Exchanges were promoted to enablethe French Departments to study the eco-nomic advantages of health services organi-zation and management in the English-speaking Caribbean countries, which, inturn, reviewed and learned from the state oftechnology-intensive medicine in theFrench-speaking Caribbean.

PAHO/WHO also identified other areasin which the French Departments couldbenefit and provided access to fellowships,research exchanges, seminars, and work-shops in Canada, Latin America, and theUnited States to various health personnelfrom Martinique, Guadeloupe, and FrenchGuiana.

Guadeloupe collaborated in a CFNIresearch project, and Martinique and Gua-deloupe were designated to be "first medicalresponders" in the event of disaster inDominica and Saint Lucia, respectively.

With the inception of the subregionalinitiative, Caribbean Cooperation inHealth, endeavors to link the English- andFrench-speaking Caribbean were intensified,culminating in the Agreement of Coopera-tion that emerged from the meeting held inSaint Lucia in April 1989. The Agreementprovides access to tertiary care facilities in

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the French Antilles to patients in theEnglish-speaking Caribbean and neighbor-ing countries and makes available technicalassistance for development of secondary carein neighboring countries. It also establishedthe joint execution of certain projects, suchas one on cancer of the cervix, greater partic-

ipation of the French Departments in subre-gional institutions, and technical assistanceby English-speaking Caribbean countriesthrough the sharing of their experience inthe development of primary health care/local health systems with the French-speak-ing Caribbean.

GRENADA

In the first half of the quadrennium,PAHO/WHO assisted the government incoordinating technical cooperation andassistance that was received from manysources. A joint country-PAHO/WHOreview of the Organization's technical coop-eration, conducted in 1987, pointed to theneed to strengthen the planning processthroughout the entire health system and toproceed with developing the humanresources critical to improving the healthservices infrastructure. PAHO/WHO tech-nical cooperation therefore focused on thesetwo areas. A National Health Plan was beingdrafted at the end of 1989 with the fullinvolvement of all portions of the healthsector.

During 1988 and 1989, increased atten-tion was paid to expanding the operatingcapacity and improving the efficiency of themain hospital and other hospital services. Afeasibility study on the construction of a newhospital was carried out by PAHO/WHO inconjunction with a team of consultants fromCanada. Recommendations for improvingthe management systems were made andincorporated into a project funded byPAHO/WHO under the Caribbean Cooper-ation in Health initiative.

PAHO/WHO assisted the governmentin improving aspects of environmentalhealth such as vector control, solid waste

disposal, and extension of the sewerage sys-tem of St. George's. Assistance in pollutionprevention was also provided in the GrandAnse area, the site of the main seweragedevelopment.

The focus of technical cooperation inmaternal and child health programs was tosupport the continuing efforts of the govern-ment to meet the subregional Plan of Actiontargets set out within the Caribbean Coop-eration in Health initiative. Some successwas achieved, as evidenced by a decrease ininfant mortality. Vaccination coverage wasextended to over 85% of children under oneyear of age, and hospital admission of infantsdue to diarrheal diseases decreased with theincreasing use of oral rehydration salts at theprimary care level.

Grenada was affected by the global pan-demic of AIDS and received advisory ser-vices to develop and carry out a short-termplan to address the disease's spread. CARECassisted national authorities in the develop-ment of a medium-term plan, which wasfully funded and was being implemented by1989.

PAHO/WHO also provided technicalcooperation to the government in formulat-ing programs for the control of diabetes andhypertension, and assisted in creating a dia-betic association which became active inpublic education activities.



GUYANA

Guyana faced severe economic problemsduring most of the quadrennium-serioustrade deficits, balance of payment problems,lack of foreign exchange, high inflation,inability to meet production levels in majorsectors of the economy, devaluation of thenational currency, and high levels of emigra-tion of skilled labor. The health sector con-fronted serious foreign exchange shortagesthat led to difficulties in replenishing sup-plies and equipment, including spare parts.The loss of skilled manpower added to thehealth sector's operational difficulties; how-ever, a newly created Agency for Health Sci-ences Education and the Environment andFood Policies gave new impetus to govern-ment health programs.

Another major government initiativewas the establishment of a medical school atthe Faculty of Health Sciences of the Univer-sity of Guyana, which offers innovative andcommunity-based teaching as a way to offsetthe brain drain of medical doctors. During1986-1989, the government also decentral-ized its health services, organizing their man-agement into 10 regional administrativeunits.

The PAHO/WHO technical coopera-tion programs that were given priority inGuyana during the period were humanresources development, development ofhealth services, maternal and child health,food and nutrition, control of communica-ble diseases, and environmental health. Thedental health and adult health programswere also active.

The Ministry of Health's efforts todevelop the country's health services infra-structure involved planning, programming,and budgeting strategies to institute a net-work of local health systems. To help createviable local health systems, intersectoralcooperation was pursued, government labo-

ratory services were supported through stafftraining, and the system for provision of sup-plies and aspects of the health informationsystem were updated. In addition, prelimi-nary studies were done on existing systems ofhealth financing (1987) and on the currenthealth manpower situation (1989).

In response to the country's vulnerabil-ity to floods, special training in disaster man-agement was provided locally, and Guyanesehealth professionals attended related semi-nars in the Region.

The maternal and child health programemphasized monitoring high-risk pregnan-cies and reducing infant mortality rates andthe incidence of low birth weight in new-borns. The system for prenatal and perinatalcare was assessed and the level of careupgraded. Family planning and family lifeeducation projects were designed and put 'into operation, and the use of Pap smeartesting was surveyed.

A four-year plan of action was devel-oped for the Expanded Program on Immuni-zation, and funding was obtained for itsexecution. PAHO/WHO provided vaccinesand trained national staff on technical andadministrative aspects of the immunizationprogram. The country's cold chain systemand transport/communication capabilitiesfor managing the vaccination programreceived special attention. Maternal andchild health personnel were trained in themanagement of acute respiratory infectionsand diarrheal disease control, and the sys-tem of collection, dissemination, and utiliza-tion of data on mothers and children wasupgraded. Drug use among schoolchildrenwas investigated.

Regarding food and nutrition, emphasiswas placed on monitoring the growth andimproving the nutritional status of children.The UNESCO School Feeding Program was

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evaluated and health workers received train-ing in community nutrition and food admin-istration. A food and nutrition situationanalysis was performed, which served as thebasis for initiating a national food and nutri-tion policy and plan; a computerized foodand nutrition surveillance system wasstarted.

In the area of communicable diseases,the management of malaria and other vec-tor-borne diseases, leprosy, tuberculosis, andHIV infection and other sexually transmit-ted diseases were the chief targets for controlprojects. A surveillance plan and a vectorcontrol project for Aedes albopictus were pre-pared. The technical and operating skills ofhealth teams working against malaria andother vector-borne diseases, leprosy, andtuberculosis were upgraded. Malaria labora-tory diagnostic services were developed andeducation materials on malaria preventionprepared. Short- and medium-term plans forAIDS control were drawn up, and the firstphase of the short-term plan, along with epi-demiologic surveillance to monitor thespread of the disease, was put into effect.PAHO/WHO provided laboratory supportfor the detection of AIDS cases and trainedrelevant personnel. Public education pro-grams also were conducted.

The Ministry of Health's main focus inenvironmental health was to improve thewater supply system, including the installa-tion of new wells in some rural communities,the upgrading of the skills of relevant per-sonnel, the conduct of a pilot project inwhich women participated in the provisionof potable water, and the implementation ofa program to fluoridate the overall watersupply. Training and technical advice insolid waste management also were providedby PAHO/WHO. During 1989, a proposalfor technical cooperation in solid waste dis-posal was developed with the Governmentof Trinidad and Tobago, and PAHO/WHOprovided collaboration in the area of envi-ronmental impact assessment.

The government set up an Environmen-tal Council and began to draft environmen-

tal health legislation. PAHO/WHO helpedtrain environmental health officers and par-ticipated in the Occupational Health andSafety Training Program. A Pesticide Unitwas established, training was provided in theepidemiologic surveillance of pesticides inhealth and agriculture, and a survey was ini-tiated to monitor this potential healthhazard.

The Dental Health Program providedsupplies for the national fluoride mouthrinseprogram and procured plastic sealants andtrained personnel in their use.

In the area of human resources develop-ment, PAHO/WHO assisted in the trainingof doctors, nurses, and allied health person-nel at the government's training institutions,and helped to develop and revise curriculafor that purpose. Efforts were made toimprove the management and supervisoryskills of health workers and to establish andevaluate a health manpower policy and plan.The Faculty of Health Sciences of the Uni-versity of Guyana was strengthened andlinks were established with the University ofGalveston (Texas, U.S.A.).

Assistance was given for the develop-ment of a center to provide health learningmaterials and for the development of tech-nology to prepare local materials for healtheducation and community participation.The use of fellowships remains an importanttool for improving the skills and knowledgeof national personnel; during 1986-1989, 30overseas fellowships were awarded. In addi-tion, several workshops/seminars were heldat the national level to upgrade the technicaland managerial competence of nationalhealth personnel.

An important aspect of PAHO/WHO'swork involved the mobilization of resourcesfrom international agencies. UNDP pro-vided funds for malaria control, veterinarypublic health, and the Regional Program forthe Training of Animal Health Assistants.Funds were obtained from CIDA for themalaria program and from the CanadianPublic Health Association, Rotary Interna-tional, and UNICEF for the Expanded Pro-



gram on Immunization. UNICEF providedassistance in nutrition and in improvementsof the water supply system. Technical assis-tance was obtained from UNFPA in the fam-ily life education and family life planningprojects.

The Government of Australia assisted inthe community water supplies project. Braziland Venezuela collaborated with Guyana inthe control of malaria along border areas.Cuba provided personnel through a techni-

cal cooperation arrangement among Guy-ana, Cuba, and PAHO/WHO for thedevelopment of the health services, healthmanpower development, and maternal andchild health programs. Through the Carib-bean Cooperation in Health initiative, thegovernments of Italy and the Federal Repub-lic of Germany supported subregionalprojects in maternal and child health and inenvironmental health that include develop-ment of these services in Guyana.

HAITI

The collapse of the government on7 February 1986 resulted in high expecta-tions among the public that democraticsocial institutions would be rapidly installedand the standard of living would improve.However, the subsequent years have seencontinuous political instability, marked bychanges of governments and successive mili-tary coups d'etat.

National health priorities remainedunchanged from those described in the 1982document "Nouvelles Orientations," whichoutlined the health policy. In 1986 AIDS wasadded to the list of priority health problems,and a national control program had beendeveloped by mid-1988. By the end of 1989,AIDS had become a major public healthissue with implications for all areas of healthcare, services, and programs. In general, thepriority health programs are to be carriedout through the application of a primaryhealth care strategy, utilizing decentralizedinstitutions.

The government's seven priority healthprograms and their activities during the qua-drennium are outlined below.

The Expanded Program on Immuniza-tion adopted the goal of eradicating polioand received ample financial support from aconsortium of agencies. It was successful in

more than doubling national coverage ofchildren one year of age, as well as substan-tially lowering childhood morbidity due tovaccine-preventable diseases.

The program to control diarrheal dis-eases and promote breast-feeding continuedits social marketing strategy, thereby increas-ing knowledge of oral rehydration tech-niques and making prepackaged oralrehydration salts available throughout thecountry. By the end of 1989 it was felt thatthe strategy, and the general program,needed to be reevaluated, mainly to ensurethe active involvement of health sectorinstitutions.

The program to improve nutrition wasbased on nutritional surveillance throughmaternal and child health clinics and foodsupplementation for malnourished children.By 1989 this program was still expandingand was attempting to establish intersectoralcoordination and a more global approach tonutrition in order to move beyond strictlyclinical surveillance and treatment.

The tuberculosis control program strug-gled with low case detection coverage andhigh default rates, which exacerbated theincreasing problem of drug resistance. AWorld Bank project was developed to intro-duce short-term treatment strategies, using a

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collaborative approach between the publicand nongovernmental sectors. Subunits ofthe program also addressed leprosy controland acute respiratory infections.

The maternal health and family plan-ning program suffered greatly from the cur-tailing of external financial support and thedisintegration of its coordinating institution.By the end of 1989, it was again receivingUNFPA financial support and was alsoassuming a coordinative role with nongov-ernmental organizations active in this area.

The program to control malaria andother vector-borne diseases also had itsexternal financial support curtailed, and itscoordinating institution, which had existedas a vertical program since the early 1960s,was disbanded. The government wasattempting to integrate these activities intoexisting health institutions and programs atthe close of 1989.

AIDS prevention and the control of sex-ually transmitted diseases was a programarea that grew rapidly. With PAHO/WHOsupport, the Ministry of Public Health andPopulation developed a medium-term planthat was presented to the internationaldonor community in April 1989 andreceived over $US10 million in pledges.

Unstable external financial supportaffected the priority programs and made pro-gramming very difficult. The collapse of ver-tical institutions produced a clear mandatefor priority programs to carry out theirprojects through existing health institutions,without creating parallel channels. In orderto diminish duplication and competitionamong the different programs, the ministryestablished a national coordinating unit,which combined the seven priority programsgeographically and programmatically for thefirst time.

A prominent feature of Haiti's healthpolicy, strengthened since mid-1989, hasbeen to coordinate with nongovernmentalorganizations and to prornote their actionsto complement the decentralization thrust.Nongovernmental organizations are alreadyresponsible for a significant share of the ser-

vices provided. Intersectoral linkages andcommunity participation remained areasthat needed strengthening in the struggleagainst the priority health problems.

At the beginning of the quadrennium,PAHO/WHO's cooperation focused on alarge project for the development of healthservices, smaller projects to support malariacontrol and maternal and child health/fam-ily planning, and support for the water andsanitation sector. As national policieschanged, cooperation was restructured alongthree programmatic lines: first, to develop anepidemiologic base for building the nationalcapacity to define and analyze priorityhealth problems and programs; second, toassist national authorities in coordinatingwith external agencies and the nongovern-mental sector toward decentralized adminis-tration and management of services; andthird, to ensure continuity in the water andsanitation sector, for which PAHO/WHOserved as catalyst and coordinator of themultiple national and international agenciesinvolved.

Each of these projects required its owntraining program, consisting of local semi-nars and fellowships abroad. A highlight ofthe training activities was the 10-monthfield epidemiology program, through whichfour regional epidemiologists were trained. Asecond round of training for eight additionalepidemiologists was in progress at the end of1989.

In resources mobilization, PAHO/WHOwas instrumental in facilitating the healthministry's dialogue with the World Bank,which committed itself to its first healthproject in Haiti, scheduled to commence inearly 1990. PAHO/WHO also providedtechnical cooperation and coordination withthe IDB in the preparation of follow-up stud-ies that led to a new loan for health servicesdevelopment in support of local health sys-tems. PAHO/WHO mobilized adequatefunds from a variety of sources to supportthe medium-term plan for AIDS control. Tosupport the maternal health and family plan-ning program, PAHO/WHO obtained



financial support from UNFPA and fromUNDP, the latter for training midwives.PAHO/WHO mobilized funds to aid Haiti'spolio eradication campaign from USAID,IDB, Rotary International, and CIDA,among others; USAID earmarked a grant insupport of the Expanded Program on Immu-nization. The malaria control program

received PAHO/WHO and UNDP assis-tance for carrying out the training needed tointegrate its services into primary health careprojects. PAHO/WHO regional funds madepossible a small pilot initiative in the preven-tion of blindness, and another in disasterpreparedness.

JAMAICA

The national health priorities of Jamaicaduring the 1986-1989 quadrennium, as setout in its policy document of 1984, were toreorganize the health care delivery systemfor greater cost effectiveness and to identifyalternative financing mechanisms; to reachthe national population policy target; and toraise the competence of management andsupport staff to the high level prevailingamong the technical personnel responsiblefor the direct delivery of health services. Thetechnical programs within the health servicedelivery system that were assigned prioritywere maternal and child health (especiallyimproved immunization coverage, neonatalcare, and adolescent health), family plan-ning, nutrition, communicable disease con-trol (emphasizing sexually transmitteddiseases), curative services, and environmen-tal health.

In early 1986 the Ministry of Health pro-posed restructuring several of its manage-ment systems, including that of the ministryitself and those responsible for the adminis-tration of the hospital network and themaintenance of health facilities. In 1988 thegovernment initiated a program to rational-ize hospital services, improve ambulatorycare, and link primary and secondary levelsof health care. Several hospitals were reor-ganized and reclassified as primary healthcare facilities. An IDB-funded hospital resto-ration project, for which PAHO/WHO wasan executing agency, upgraded a number ofkey facilities. Project HOPE and USAID,

meanwhile, provided support in the area ofimproving health care financing.

With technical cooperation fromPAHO/WHO, the ministry completed amap of health district boundaries in thecountry and upgraded its health informationsystem, including the epidemiologic surveil-lance system that tracks the spread of AIDS.PAHO/WHO also supported the AIDS pre-vention and control program and collabo-rated in the improvement of epidemiologyservices and the prevention and control ofdrug abuse.

The Organization aided the country'sefforts to develop human resources by pro-viding training in maternal and perinatalcare, as well as supplementary training fordental auxiliaries and hygienists. Preventiveoral health activities were furthered by thedevelopment of the salt fluoridation pro-gram. In the area of environmental protec-tion, advances were made in improvingwater quality and strengthening environ-mental health programs through provisionof staff support to the Environmental Con-trol Division.

In September 1988, the national healthsector was called upon to respond to the dev-astation caused by Hurricane Gilbert. Itsrole included providing relief services, estab-lishing emergency epidemiologic reportingsystems, and instituting special restorationmeasures for damaged environmental healthand hospital facilities.

The Organization cooperated in the

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mobilization of national resources, sup-ported national training institutions, andpromoted intersectoral collaboration andcommunity participation. It also mobilizedexternal support for the immunization pro-gram, leprosy and diarrheal diseases control,AIDS prevention and control, improvementof the immunology and family planning ser-vices, and disaster preparedness. The King-dom of the Netherlands funded a project totrain district health management teams as

part of the effort to develop local health sys-tems in the country. Under the CaribbeanCooperation in Health initiative, PAHO/WHO promoted interagency participationin the development of food protection andsafety projects.

With PAHO/WHO collaboration, thegovernment improved distribution of techni-cal information and introduced computerfacilities able to utilize CD-ROM technologyat the University of the West Indies.

NETHERLANDS ANTILLES AND ARUBA

The Netherlands Antilles and Aruba aredependencies of the Kingdom of the Nether-lands. In 1986, Aruba gained "separate sta-tus" within the Netherlands Antilles andappointed its own Minister of Public Health.Starting in 1987, the economy of the King-dom of the Netherlands underwent a con-traction that was reflected in the islands'policies of cost containment in the healthsector during the 1986-1989 quadrennium.Nonetheless, the delivery of health serviceswas not adversely affected. PAHO/WHOcontinued to provide technical cooperationto the islands in the areas covered below.

The health sector placed emphasis ondeveloping preventive health services; devel-oping environmental health programsincluding vector control, the regulation ofpesticide use, and the containment of air,soil, and water pollution; and expanding theactivities of its veterinary public health pro-grams, especially in the areas of controllingthe quality of imported food, safeguardinganimal health, and inspecting sanitation inslaughterhouses and retail food outlets.

In the area of reorganizing health ser-vices, emphasis was placed on psychiatricservices and drug abuse prevention, thedevelopment of health legislation, expansionof ambulatory and inpatient care, and disas-ter preparedness, with a focus on ambulanceservices. Oral health programs were

expanded, and an epidemiologic survey ofthe status of oral health among schoolchil-dren was conducted on Aruba.

The drug abuse prevention project wasgeared toward providing information at thecommunity level and obtaining communityparticipation. PAHO/WHO collaborated inan epidemiologic study of the use of psycho-tropic substances on Curaçáo.

Community participation was alsomobilized for the maternal and child health,AIDS prevention, and immunization pro-grams. Curaçao became a participant inPAHO/WHO's Revolving Fund for theExpanded Program on Immunization, andthe islands' laboratories received support inimproving their capability to diagnose sexu-ally transmitted diseases, including AIDS.

PAHO/WHO technical cooperationincluded promoting collaboration betweenthe health ministry and the Social SecurityBank and private agencies. The Organiza-tion also obtained an agreement wherebythe Government of Venezuela donated labo-ratory reagents and vaccines to the Nether-lands Antilles. As one of its major functionsin the Netherlands Antilles and Aruba,PAHO/WHO made technical informationavailable by providing advisory services, dis-seminating publications, and sponsoringworkshops, seminars, and fellowships.



SAINT KITTS AND NEVIS

The strategy followed in the delivery ofPAHO/WHO technical cooperation inSaint Kitts and Nevis during the quadren-nium was to mobilize resources from allPAHO/WHO programs that addressed thecountry's needs.

CAREC assisted in upgrading the AIDSsurveillance system and in preparing amedium-term AIDS plan, which was fullyfunded at a donors' conference sponsored bythe WHO Global Program on AIDS andPAHO. CFNI, UNICEF, and PAHO/WHOdeveloped a program aimed at combatingthe persistence of protein-energy malnutri-tion among some pockets of the population.This project was executed by CFNI. Toaddress problems associated with solid wastedisposal, a special grant provided by PAHO/WHO and technical advice obtained fromthe Office of the Caribbean Program Coor-dination were used to improve sanitary land-fills in Basseterre.

Assistance was also mobilized in supportof ongoing government programs to reduceinfant mortality. Oral rehydration therapy

was introduced, and the Expanded Programon Immunization supplied vaccines andadvisory services on program development.Infant mortality fell, and immunization cov-erage of children under one year of age roseto over 90%.

A joint country-PAHO/WHO evalua-tion of the Organization's technical coopera-tion was conducted in 1988, and one of therecommendations it produced was tostrengthen the national health sector plan-ning process. As a result, a Draft NationalPlan was prepared, with PAHO/WHO assis-tance; it will undergo review in a series ofseminars before being submitted to the Cabi-net for final approval.

Human resources development wasanother focus of PAHO/WHO technicalcooperation. Support was given for thetraining of family nurse practitioners, andfellowships were provided that the govern-ment used to upgrade the qualifications of itshealth personnel, including those working inthe area of nursing education.

SAINT LUCIA

The focus of the Ministry of Health,Housing, Labor, Information, and Broad-casting shifted from extending coverage ofprimary health care to improving the qualityof the services provided. This new focusstressed the importance of the hospital sys-tem in improving care. The governmentundertook the gradual refurbishment of theVictoria Hospital, as well as a project(funded by PAHO/WHO) to improve man-agement systems and coordinate hospital

services with the primary level of care. SaintLucia participated fully in Caribbean subre-gional workshops held to promote localhealth systems and was a signatory to theDeclaration of Tobago, which reaffirmedcommitment to the primary health careapproach and local health systemsdevelopment.

An effort to improve the health minis-try's information systems was begun. Itincluded the installation of automated data

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processing facilities with collaboration froma French Technical Mission and PAHO/WHO.

Another area on which the governmentconcentrated was increasing the quantityand quality of the water supply. With assis-tance from CIDA and the World Bank, con-struction began on a new dam on theRoseau River. PAHO/WHO technical coop-eration was extended to prevent the recru-descence of schistosomiasis. PAHO/WHOalso assisted the government in projectsaimed at preventing water-borne typhoidfever and improving the disposal of solidwaste.

The government obtained PAHO/WHO cooperation in formulating a popula-tion policy and establishing a populationunit. Through a UNFPA-funded project,family life education was vigorously pro-moted. Technical cooperation in the otherareas related to maternal and child healthprovided assistance to the government inmeeting the subregional Plan of Action tar-gets set out in the Caribbean Cooperation inHealth initiative, in eliminating polio, and

in eradicating measles. Immunization cover-age of polio vaccine exceeded 85% by theend of the quadrennium.

A medium-term plan to combat thespread of AIDS, formulated with CARECassistance, was fully funded at a donors'meeting organized by PAHO and the WHOGlobal Program on AIDS. Resources werealso provided by CFNI, UNICEF, andPAHO/WHO for development of a JointNutrition Support Program in Saint Luciathat addresses childhood malnutrition, adultnutritional problems, and diabetes andhypertension.

Technical cooperation with the govern-ment emphasized human resource develop-ment, including the establishment of aHealth Science Division in the Sir ArthurLewis Community College. Support wasprovided to the government in conducting acourse for community nutrition officers,improving the standards of nursing educa-tion, and providing training opportunitiesthrough the Fellowships Program to thosenationals who could not obtain training inthe country.

SAINT VINCENT AND THE GRENADINES

An evaluation of PAHO/WHO techni-cal cooperation over the quadrennium wasconducted jointly with the Government ofSaint Vincent and the Grenadines in 1989.This evaluation pointed to the need to moreclearly focus technical cooperation upon thefollowing priority areas: the development ofinfrastructure, including improvements inmanagement and information systems; theformulation of realistic and appropriatehealth manpower policies; and the strength-ening of public education programs to pro-mote healthier lifestyles with a view towardpreventing chronic disease.

Projects designed to improve the man-agement systems of the Ministry of Health,

both at the headquarters and in the districts,were prepared by the end of 1989. Man-power policy will be addressed in the techni-cal cooperation program of the nextbiennium.

PAHO/WHO's technical cooperationduring the quadrennium placed considerableemphasis on human resources development,and a large portion of its funding was used inoffering opportunities through the Fellow-ships Program. The highly successful familynurse practitioner program that had beenbased in Saint Vincent was terminated,since it was felt that it had satisfied the needfor this category of health worker in the par-ticipating territories.



In maternal and child health, coopera-tion was extended to the government inmeeting the Caribbean targets and, in par-ticular, in expanding immunization coverageand reducing infant mortality from diarrhealdisease. Infant mortality has fallen, andimmunization coverage is now in excess of90%.

A medium-term AIDS prevention plan,prepared with the assistance of CAREC, wasfunded and is now under way. PAHO/WHOalso provided assistance toward improvingthe blood transfusion services. In the area ofenvironmental health, technical cooperationaimed to improve the operation of sanitarylandfills and other services related to the dis-posal of solid waste.

CFNI, UNICEF, and PAHO/WHO col-

laborated in the implementation of the JointNutrition Support Program, which strength-ened the government's nutrition servicesand was effective in reducing the prevalenceof protein-energy malnutrition.

Saint Vincent and the Grenadines wasrepresented at the subregional workshops onlocal health systems development and socialparticipation. A project under the Carib-bean Cooperation in Health initiative tostrengthen the District Health Services wasdeveloped and funded. Saint Vincent andthe Grenadines participated fully in thedevelopment of the initiative and is expectedto benefit from the subregional projects thatare now being initiated in the fields of mater-nal and child health and environmentalhealth.

SURINAME

Suriname's health priorities over the lastfour years were dictated largely by an econ-omy that was in serious and continuing cri-sis. Health service delivery was profoundlyaffected by shortages of even the most basicsupplies and equipment.

Substantial emigration among their col-leagues forced many health professionalswho remained to fulfill multiple roles andfunctions, and compelled many others toprematurely enter levels of management forwhich they were not adequately prepared.Health priorities therefore centered on thefollowing activities: preventing further dete-rioration of health services caused by theeconomic crisis; using existing resourcesmore effectively and efficiently by strength-ening essential infrastructure and by pursu-ing more vigorous intersectoral cooperation;decentralizing the regional health services;completing and/or strengthening programsthat were already under way; improving theskills of existing manpower; establishing anational AIDS program; targeting specific

diseases for control; and mobilizingresources through project development.

Despite Suriname's immense difficultiesduring this period, major accomplishmentswere achieved in the health sector. Perhapsmost important, the entire health care deliv-ery system was maintained. In addition, theregional health service, which is responsiblefor primary health care in the coastal area ofSuriname, completed its decentralizationprocess. A national health plan was devel-oped as part of the five-year national devel-opment plan. Major effort went intoestablishing a primary health care informa-tion system, and an environmental healthdivision was also established. Other achieve-ments included provision of managementtraining at all levels of the health ministry,drafting of a national drug formulary, andcreation of a national AIDS program. Thegovernment also pursued a vigorous polioeradication campaign as part of the overallExpanded Program on Immunization.

Suriname's political and administrative

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system strongly promotes intersectoral link-ages at all levels of activity. Therefore, inter-sectoral cooperation was a daily reality incarrying out health programs. For example,the environmental health division of theMinistry of Health maintained daily contactwith the rural Water Supply Service of theMinistry of Natural Resources and Energy,with the Department of Environment of theMinistry of Education, Culture, and Envi-ronment, and with the Ministry of PublicWorks.

The major focus of PAHO/WHO's pro-gram of technical cooperation over the qua-drennium was to strengthen the healthservice infrastructure. Specifically, the gov-ernment sought PAHO/WHO technicalcooperation in the following areas: decen-tralization of local health systems, includingupgrading the various subsystems; compre-hensive studies and analyses of the healthsystem, including management, planningand programming, and financial evalua-tions; bed-needs analysis; studies of utiliza-tion and maintenance of health facilities,and drug supply profiles; development of epi-demiologic surveillance systems for diseasecontrol; establishment of a community-based primary care health information sys-tem; manpower development and training,including nursing and medical education;design and execution of environmentalhealth measures in the areas of water supply,sanitation, vector control, and malaria con-trol; and general maintenance of all ongoingprograms.

In addressing the needs of vulnerable

groups, the major challenge of PAHO/WHO's program of technical cooperationwas to prevent the deterioration of servicesand coverage. Other focuses were the mater-nal and child health program and its sixcomponents (Expanded Program on Immu-nization, control of diarrheal diseases andacute respiratory infections, nutrition,school health, perinatology, and day care),the establishment of a national AIDS pro-gram and reference laboratory, and leprosycontrol. Because of the economic conditions,the country was not able to expand ordevelop special programs for many vulnera-ble groups, such as the mentally ill, diabetics,hypertensives, the blind, and the elderly.

The national situation underlined theprimacy of sharing and spreading healthinformation as widely as possible. Work-shops were held to disseminate informationon a regular basis, and the PAHO/WHOCountry Office and the Regional HealthService arranged for all visiting consultantsto address national health personnel. A sig-nificant proportion of the ministry's budgetwent toward distributing technical informa-tion for the various program managers.Close ties were maintained with the printmedia and television, and press releases andclarifications on health matters were issuedfrequently.

During the years 1986-1989, PAHO/WHO sponsored 70 courses, workshops, andseminars on a wide variety of topics. It alsosupported 826 consultant days, 586 staffdays, and 164 fellowship months to trainnational health staff.

TRINIDAD AND TOBAGO

Health priorities for the Government ofTrinidad and Tobago in the 1986-1989period included improving the secondarycare infrastructure; identifying alternativemeans of financing the health sector;

strengthening management capacity, withspecial focus on information systems andplanning; and training health personnel andimproving their deployment. Priority wasalso given to health education, the role of

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women in health and development, mater-nal and child health, chronic disease con-trol, and environmental health. AIDSemerged as a major priority area.

A major policy document issued in1988-the Draft Medium-Term Macro Plan-ning Framework, 1989- 1995-designatedprimary health care as the main strategy toensure equity of access to basic services andprovide special attention to vulnerablegroups. Simultaneously, the governmentsought to increase the role of the private sec-tor in health care to reduce its cost to theState.

The program of the Ministry of Healthconsisted of three major initiatives: strength-ening the ministry's infrastructure whiledecentralizing health services; bolstering thesecondary and tertiary care infrastructure;and introducing a national health insurancescheme that addresses the growing issue ofhealth care financing. In this last area, aworking group was appointed by the Cabi-net and assisted by a task force.

The Ministry of Health requestedPAHO/WHO technical cooperation in thedevelopment of managerial capacity, second-ary and tertiary care infrastructure, hospitalinvestment projects, alternative financingmethods, training, health education andmobilization of resources at the communitylevel, the role of women in health and devel-opment, disaster preparedness, essentialpharmaceuticals supply management, andplant and equipment maintenance.

In the strengthening of secondary andtertiary care infrastructure, PAHO/WHOcollaboration focused on the commissioningof the Eric Williams Medical Sciences Com-plex, which was to open on a phased basis in1990, and support of feasibility studiesrequired for investment programs. IDBpledged assistance for subsequent phases ofthe Complex's development.

To aid in the development of alternativemethods to finance the health sector,PAHO/WHO provided a consultant towork with a Cabinet-appointed workinggroup to produce policy guidelines and a

funding proposal for a national health insur-ance scheme. The IDB will fund the start-upphase.

PAHO/WHO awarded 58 fellowshipsthat supported 258 person-months of studyin health-related fields. Major support wasalso given to the development of nursing ser-vices, including strengthening senior nursingadministration, dental nursing, midwiferytraining, and in-service training for commu-nity nurses. In-country training was found tobe the most cost-effective approach, giventhe high level of expertise available and thepresence of a campus of the University of theWest Indies as well as a national institutionof higher learning (NIHERST).

As an ancillary to training, PAHO/WHO collaborated in developing a docu-mentation center and a center newsletter("DOCINFO"), which was first issued in1989. PAHO/WHO carried out an assess-ment of the Health Education Unit of theMinistry of Health, and also funded a studyon predisposing and lifestyle factors thatinfluence chronic disease development.

Reflecting the priority given the roleof women in health and development bythe national government, PAHO/WHOincreased support in this area, and its effortsfocused on both the public sector and non-governmental organizations. A subregionalworkshop on this subject was held in 1988 inPort of Spain, and the government carriedout a situation analysis on the health statusof women in 1989.

The ministry also undertook nationaland local-level disaster preparedness plan-ning with PAHO/WHO cooperation,including mass casualty management in hos-pitals. A national disaster plan for healthwas developed and included in the overallplan of the National Emergency Manage-ment Agency, but it has yet to be tested andgeneralized.

Under the guidance of the PAHO/WHO Regional program, support was givento medical technology management. As afirst step, in 1988 a contract was awarded tothe national Hospital Management Com-

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pany to develop software for medical devicesinformation systems. In 1989, a subregionalworkshop produced guidelines for their usein the Caribbean, which led to developmentof a project proposal requesting IDRC fund-ing for their application in three countries,including Trinidad and Tobago.

At the 1989 joint country-PAHO/WHO review of the Organization's technicalcooperation, the government identifiedproperty, plant, and equipment managementand maintenance as a priority area, andPAHO/WHO pledged support for anexhaustive equipment and medical devicesinventory in hospitals and health centers.

In the area of health programs develop-ment for vulnerable groups, PAHO/WHOtechnical cooperation concentrated primar-ily on environmental health, maternal andchild health, nutrition, AIDS control,chronic diseases control, drug abuse preven-tion, and mental health.

In support of the environmental healthprogram in Trinidad and Tobago, PAHO/WHO gave assistance for improvement ofdrinking water quality and water supply leakdetection, eradication of Aedes aegypti, andmalaria surveillance. PAHO/WHO also sup-ported the national toxicity testing capabil-ity, the public health engineering trainingprogram, the development of preliminaryperformance indicators for national foodsafety programs, chemical safety measuresand the management of toxic and hazardousmaterials, and the training of health andagriculture personnel in the safe use ofpesticides.

In the maternal and child health area,assistance to the Expanded Program onImmunization was the most comprehensive,comprising program management training,planning of targets, supervision, reinforce-ment of cold chain logistics, and assurance ofvaccine supply continuity through thePAHO/WHO-administered revolving fundfor vaccine supplies. There was a markeddecrease in morbidity from vaccine-preven-table diseases, and poliomyelitis had beennearly eradicated by 1989. Coverage levels

for measles and rubella vaccination werelower than for the other EPI diseases, butthese programs were strengthened to meetthe subregional target of measles eradicationby 1995. The program to control diarrhealdiseases received support in program reviewand supervisory skills training. A researchproject on infant mortality and morbidity inCaroni, carried out in 1986-1987, was fol-lowed up by a national infant mortality andmorbidity study funded by PAHO/WHOand UNICEF within the framework of theCaribbean Cooperation in Health initiative.

With the assistance of CFNI, supportwas offered to the national nutrition servicesthrough community health services, includ-ing those of nongovernmental organizations;at institutional dietetic services; throughtraining, both in-service and at traininginstitutions; and finally through surveys,research, and direct provision of expertisefor policy formulation. The formulation of afood and nutrition policy, adopted by theCabinet in 1989, received technical inputfrom CFNI/PAHO.

Trinidad and Tobago has one of thehighest reported numbers of AIDS cases inthe subregion, with over 500 cases at the endof the period, and is experiencing increasesin cases among females and in perinataltransmission. A National AIDS Committeeadministers the program to address thespread of the disease. CAREC supportedlaboratory services and the screening pro-gram; collaborated in a knowledge, attitude,and practices study funded by the EuropeanEconomic Community; and assisted in apublic education campaign.

Chronic diseases were the most preva-lent causes of morbidity and mortalityamong adults. Prevention of cancer of thecervix, the most frequent cancer in women,was addressed through preparation of a jointproject with La Meynard Hospital of Marti-nique, which will provide training in Papsmear reading for cytotechnologists. A$US40,000 PAHO/WHO grant was used fora pilot cancer screening project in St. GeorgeCentral County.

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TURKS AND CAICOS ISLANDS

The Turks and Caicos Islands are one ofthree British territories in the northernCaribbean which receive PAHO/WHOtechnical cooperation through the Organiza-tion's Jamaica Country Office.

The government developed andapproved a National Health Plan. A healthmanpower development plan was preparedwith the assistance of the Office of PAHO/WHO Caribbean Program Coordination.General and clinical nursing, midwifery,operating room techniques, dental nursing,and basic sciences were the greatest trainingneeds; UNDP and PAHO/WHO sponsoredfellowships in these areas. Training alsofocused on strengthening management atthe local level.

The nutrition program emphasized ane-mia control and received support from theCaribbean Food and Nutrition Institute(CFNI). PAHO/WHO evaluated programsfor the control of both sexually transmitteddiseases and leprosy and supported vectorcontrol activities and services for the handi-capped. A UNFPA project contributed tostrengthen the family planning program,and included a family life workshop con-ducted by PAHO/WHO. UNDP provided

the services of a United Nations medicalvolunteer.

Attempts were made to promote inter-sectoral coordination for pre-health sciencesand nutrition programs. As part of theAIDS prevention and control program,national personnel collaborated in monitor-ing case detection and in carrying out publiceducation campaigns.

PAHO/WHO acted as an executingagency for international efforts, includingthe UNFPA-funded project, "StrengtheningMaternal and Child Health and FamilyPlanning," in the Turks and Caicos Islandsand the UNDP project, "Development ofHealth Services." External resources weremobilized through the Caribbean Coopera-tion in Health initiative to support vectorcontrol activities and to further strengthenmaternal and child health services. Mobiliza-tion of internal resources has been limiteddue to the shortage of trained professionals.

Under the Organization's auspices, theDental Officer received training in AIDSprevention and control, fellowships wereawarded for nursing courses in Barbados andJamaica, and considerable technical inputwas given to environmental health projects.

CENTRAL AMERICA

PLAN FOR PRIORITY HEALTH NEEDSIN CENTRAL AMERICA

The Pan American Health Organizationand the Ministers of Health of the CentralAmerican subregion founded the Plan forPriority Health Needs in Central America in1984. The purpose of the initiative was tounite the resources of and stimulate coopera-tion between the seven neighboring coun-

tries-Belize, Costa Rica, El Salvador,Guatemala, Honduras, Nicaragua, and Pan-ama-to address critical, shared health prob-lems. In so doing, it was hoped that theconsensus concerning health problems andthe progress in the health sector would serveas a catalyst for other cooperative efforts and

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thereby strengthen attempts to obtain peacein the war-torn area.

By 1989 the Central American initia-tive-the first of four such subregional effortsto be launched by PAHO/WHO-hadachieved notable progress in marshaling theresources of the participating countriestoward addressing a number of commonhealth problems and, in some cases, hadobtained clear results. The governments ofthe countries of the Central American Isth-mus-representing widely varied politicalsystems-engaged with resolve in sustainedcooperation that involved discussing, plan-ning, and executing key preventive healthprojects.

Within each country, the health minis-ters and directors of the social security insti-tutions pledged greater coordinationbetween sectoral institutions and agreed toincrease coverage and provide services forhigh-risk groups. Together, they initiated theSpecial Meeting of the Health Sector of Cen-tral America, held yearly since 1985, whichreplaces the former meetings held exclusivelyfor the Ministers of Health.

The Central American nations and thePan American Health Organization alsoaccomplished another chief objective of thehealth priorities plan: to mobilize financialsupport from outside the Region to makepossible critical projects for which nationalfunds were lacking. By the end of the qua-drennium, more than 25 agencies and orga-nizations had lent their technical andfinancial support to the initiative. Includedamong them are the European EconomicCommunity (EEC); the governments of Bel-gium, Denmark, the Federal Republic ofGermany, Finland, France, Italy, Japan, theKingdom of the Netherlands, Norway,Spain, Sweden, Switzerland, and the UnitedStates of America; and agencies such asUNICEF, IDB, the World Bank, OAS,UNFPA, and UNDP.

The Government of Spain, which hasbacked the subregional initiative since itsinception and held a conference in 1985 toinaugurate it, sponsored a second "Health, a

Bridge for Peace" conference three yearslater in Madrid. At the 1988 conference, thehealth ministers of Central America andPAHO/WHO technical advisers presentedprogress reports and proposals for medium-term health projects to officials from theinternational community.

With the collaboration of PAHO/WHO, the Central American countriesreviewed the status of the priority projectsand presented an analysis of progress to theV Special Meeting of the Health Sector ofCentral America, held in August 1989.Coordinating the review of a priority areawas the responsibility of a given country:Costa Rica, strengthening of health services;El Salvador, food and nutrition; Guatemala,human resource development; Honduras,essential drugs; Nicaragua, tropical diseasecontrol; and Panama, child survival. TheRegional Potable Water Committee(CAPRE) assisted in preparing the water andsanitation report.

In the area of strengthening health ser-vices, the review found that importantprogress had been made in extending ser-vices to groups lacking access, by beginningto develop local health systems. Althoughservices have improved for refugees and dis-placed persons, those groups still do nothave full coverage.

The review found that operationalcapacity had been improved and resourceuse made more efficient by coordination ofprojects undertaken by the ministries ofhealth and social security systems. Chiefachievements in this area were joint projectsto set up local health systems and to supportepidemiologic, nutritional, child survival,and essential drugs monitoring networks.However, the insufficiency of the infrastruc-ture and the great need to provide coverageto the population, principally the groups athighest risk, were recognized.

The national health sectors made head-way in reforming the procurement and dis-tribution of critical supplies in accordancewith the administrative decentralizationstrategy. The respective ministries prepared

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lists of long-term critical equipment needsand drafted procedures for systematic inven-tory and maintenance of equipment andspare parts. A special project to supportthese activities was initiated with funds fromthe Kingdom of the Netherlands.

Progress was made in establishing subre-gional norms for delivering primary care ser-vices to women, children, and the elderly.The countries also worked on devising stan-dard procedures for AIDS surveillance, casedetection, blood screening, and treatment.Costa Rica and Honduras established bilat-eral agreements with Nicaragua to controlthe spread of malaria in those countries' bor-der areas.

In order to train the personnel requiredfor their execution, projects such as tropicaldisease control, child survival, equipmentmaintenance, and essential drugs included amanpower development component. How-ever, the review found gaps and the need forfurther work to achieve the subregionalplan's main objective in that field, namely, totrain health professionals in all the disci-plines needed to ensure the delivery of com-prehensive primary care services to prioritypopulation groups. At the end of the qua-drennium, resources were obtained from theGovernment of Denmark in support ofhuman resources development andPASCAP.

National essential drugs programs haveconstituted an area of continuing concern inCentral America, one which has repeatedlybeen assigned priority, since large numbersof people continue to lack access to basicdrugs. In a meeting in Panama in 1989, rep-resentatives of the health sectors passed aresolution calling for the rapid developmentof policies and legislation to remedy the situ-ation. They also recognized that the limitedcoverage of health services, their deficientorganization, and the lack of trained staffwere underlying conditions that wouldrestrict drug availability even if national pro-duction capacity were increased. The gov-ernments of Denmark, Finland, Norway,Sweden, and the United States of America

are sponsoring subregional projects that willprovide Central American governmentswith technical cooperation toward buildingthe organizational and human resources torespond to needs singled out by the review.The projects will aim at establishing nationalintersectoral committees on drug policiesand pharmaceutical production; developingmodern pharmaceutical services in hospitalsand health centers; improving the physicalinfrastructure of pharmacies and storagefacilities in selected sites; strengthening drugregulation and quality control; producingessential drugs in the subregion when possi-ble; ensuring WHO drug manufacturingstandards; and providing up-to-date infor-mation on drugs.

In the area of food and nutrition, thehealth sector progress review noted that thegovernments must be urged to step upactions aimed at increasing the availabilityof food for low-income groups, such as allo-cating greater agricultural production fordomestic use. Simultaneously, the health sec-tors resolved to expand their own programsto monitor nutritional deficiencies due toinsufficient intake of vitamin A, iodine,iron, and fluoride. The Institute of Nutritionof Central America and Panama (INCAP)continued to lend its collaboration in theseactivities in the subregion.

Malaria is the tropical disease of greatestconcern to the Central American countries.Although malaria transmission declined inthe first part of the quadrennium, in 1988 itwas on the rise again. The disease was diffi-cult to control for a number of reasons.Chief among them were the danger to vectorcontrol personnel in some border areas occu-pied by contending forces in the periodunder review, the cross-border displacementof people infected by the disease and ofhealthy people who entered malaria-infestedregions, the development of insecticide resis-tance among the anopheline mosquitoes,and faulty epidemiologic surveillance capa-bilities. At the end the quadrennium, feasi-bility studies were under way for specificprojects for which the countries had

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requested support from the Inter-AmericanDevelopment Bank.

The governments of Central Americacontinued to place special emphasis onimproving the protection of mothers andchildren and reducing infant mortality. Keyinterventions included expanding immuniza-tion coverage against vaccine-preventablediseases and ensuring the practice of oralrehydration therapy for children sufferingfrom diarrheal diseases.

During the quadrennium, PAHO/WHO and UNICEF, with financial supportfrom the EEC and the governments of Italyand the United States, succeeded in estab-lishing all of the educational centers origi-nally planned in this area and in developingthe proposed program. In addition, theTreatment Modules and Pediatric CareNorms produced during the quadrenniumwere being used in all of the countriesinvolved.

In the area of water and sanitation, theRegional Potable Water Committee(CAPRE) and the PAHO/WHO office staff

in Honduras reported that coverage of pota-ble water and sanitation services increasedbetween 1984 and 1988, although popula-tion growth offset some of the gains. Thereview of water quality pointed out thatwater tends to be treated in urban areas of100,000 inhabitants or more, and is gener-ally not treated in rural areas. An additionalconcern is the unchecked contamination ofwater by fertilizers, pesticides, and industrialwaste, as well as the unsanitary disposal ofsewage and solid waste.

Overall, the Plan for Priority HealthNeeds in Central America was considered asuccess in demonstrating the vast potentialfor subregional cooperation on areas of com-mon concern. The concerted work of thehealth authorities of these seven countriesdemonstrated that health can indeed serveas a "bridge" for peace and subregionaldevelopment. The health sector's effortshave contributed to advances in otherspheres, particularly at the political level,leading to greater understanding and soli-darity in the area.

BELIZE

During the 1986-1989 period, the Gov-ernment of Belize, which became indepen-dent in 1981, was consolidating the transitionto public administration by nationals. In thehealth sector, this process involved studyingthe status of the country's health services' sys-tem and taking charge of the planningprocess. The five-year health plan covering1989-1994 was developed as part of the over-all national development plan.

The major problem that concernedhealth authorities and limited the sector'seffectiveness was the continued scarcity oftrained public health professionals and clini-cians to staff projects and treatment units.Many of these professionals-especially

nurses-emigrated to work elsewhere oncethey received their training.

Personnel shortages notwithstanding,Belize's health indicators remained good. Atthe end of the quadrennium, infant mortal-ity was around 20 per 1,000 live births,immunization coverage against vaccine-pre-ventable childhood diseases reached 80%,and malnutrition was rare. In large part, thefavorable health profile can be attributed tothe small size of the population (under200,000) and the fact that rapid urbaniza-tion, with its attendant burden on services,has not taken place. Most of Belize's inhabit-ants live in rural farming communities.Malaria, tuberculosis, and sexually transmit-

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ted diseases were the key health problemstargeted by treatment and preventive ser-vices among low-income groups. Due to alack of qualified staff at the local level, themalaria control program was less successfulthan anticipated.

Training health manpower was the Min-istry of Health's priority, and PAHO/WHOlent its support by providing the opportunityfor fellowships abroad and developing andimplementing intensive, short-term trainingprograms in the country. A number of pub-lic health inspectors received trainingthrough the fellowships program.

Epidemiologic research on the mosturgent health problems and the interven-tions they require was given special attentionby the government. Such research will be amajor focus of activity during the next qua-drennium, once a sufficient cadre of investi-gators has been trained.

The Ministry of Health made headwayin its efforts to monitor and prevent thetransmission of AIDS; there is no evidenceso far of indigenous spread. It also plannedand obtained funding for the construction ofa new hospital in the capital city.

The government transferred responsibil-ity in the area of environmental health tothe Ministry of Natural Resources at thebeginning of the quadrennium. As a result,projects in that area were coordinatedjointly with the health ministry.

Belize is the only English-speaking coun-try that is a member of the Plan for PriorityHealth Needs in Central America. TheEuropean Economic Community, CAREC,CFNI, INCAP, PASCAP, UNICEF,USAID, and other agencies lent technicaland financial support to health projects thatBelize carried out with its neighbors in Cen-tral America.

COSTA RICA

Costa Rica's stable economic and politi-cal climate has permitted the steady evolu-tion and institutionalization of health policyover the last 40 years. That policy-focusedon achieving universal access to health ser-vices-has been consistent with the orienta-tion of the country toward social develop-ment and economic growth.

Costa Rica was able to implementimportant new strategies effectively duringthe last quadrennium by building strong ser-vices systems for communities and families.Its efforts to deploy resources toward prioritygroups and problems produced markedimprovements in key health indicators, atrend that accelerated in the 1970s and thatcontinues to the present time. From 1986 to1988, infant mortality declined from 17.76 to14.67 per 1,000 live births. In 1988, thedeath rate for children aged 1 to 4 years was8.48 per 10,000, and general mortality was

3.8 per 1,000 population. Life expectancy atbirth in that same year was 74.7 years.

Coverage against diseases preventableby vaccination reached high levels. Provi-sional data from 1988 indicated that it was86% for oral polio vaccine, 87% for DPT,97% for measles vaccine, and 87% for BCG.

The incidences of undernutrition, dis-eases preventable by vaccination, dehydra-tion from acute diarrheal disease, acuterespiratory infections, and serious parasi-toses decreased notably.

The low general mortality and theincrease in life expectancy resulted in a grad-ual aging of the population, with an atten-dant increase in chronic and degenerativediseases as well as other disorders of old age.The almost complete disappearance of seri-ous undernutrition has been accompaniedby problems caused by bad eating habits,leading the health authorities now to con-

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sider preventive nutrition programs anational priority.

Environmental sanitation is also a topicof concern and it has been given specialattention. Coverage of the population hasreached 93% for potable water and 94.8%for the sanitary disposal of excreta. However,problems caused by pollution, solid wastes,and the assault on the natural environmentare becoming increasingly frequent, andhence environmental health will be affordedvery high priority.

Costa Rica established the frameworkfor its health policy during the quadrenniumin the National Economic and Social Devel-opment Plan for 1986-1990, which treats theimprovement of health conditions as anintegral part of overall development. Duringthe Meeting for Analysis of PAHO/WHOCooperation to Costa Rica, the validity ofthis policy, the adherence of the nationalprograms to it, and the relevance of theOrganization's support of those programswere analyzed. This exercise and the FirstForum on Health and Development consti-tuted important milestones in the consider-ation and analysis of the evolution of healthin the country.

The health policy for the 1986-1990period was oriented toward guaranteeingaccess to health services for all individuals,without restrictions and with equity. It seeksto narrow the social gap and achieve themaximum possible physical and mental well-being for all inhabitants through reductionof infant mortality, eradication of predispos-ing risk factors, reduction of avoidable pre-mature deaths, and recovery and rehabilita-tion of the ill and disabled.

The National Health System (SNS) andthe functions of each of its agencies weredefined with the aim of fulfilling the goalsnoted above. The SNS includes all thehealth programs in the country within a sin-gle political orientation and emphasizesprojects selected in accordance with develop-ment goals. Specifically, it strives to increaseaccess to services and preventive health pro-grams in the less-developed regions of the

country and to decentralize resources, grant-ing greater administrative autonomy to thelocal services.

As a result, consolidation of the SNSwas set as a medium-term objective, and forthat purpose joint programming was pro-moted at the local and regional levels amongthe Ministry of Health, the Costa RicanSocial Security Fund (CCSS), and commu-nities. This process has already beenextended to the entire country and is accom-panied by measures aimed at the technical-administrative decentralization of boththose institutions.

The development of new models ofhealth care, such as medical cooperativesand family medicine, was encouraged in asearch for greater efficiency, effectiveness,and social participation in outpatient care.Through joint local programming amongsector institutions and the community, suchmodels are being articulated and improvedover the entire country and, when fullyestablished, will comprise 56 local health sys-tems. Development of institutions, humanresources, social participation, and physicalinfrastructure will require external funds forwhich negotiations with IDB are under way,with the support of PAHO/WHO.

Substantial effort has been devoted toreviewing the information system for deci-sion-making in the local health systems,developing human resources, and using andevaluating technology aimed at resolving pri-ority problems.

The Ministry of Health and the CCSShave united their resources to give specialattention to the least protected cantons, bymeans of programs oriented toward revers-ing their current marginalized status.

In an attempt to identify the risk factorsthat predispose to priority health problems,with a view toward adopting preventivemeasures, the health ministry collaboratedwith other sectors whose services have animpact on health. Thus, it joined with otherministries, universities, specialized agencies,and private groups in conducting a compre-hensive review of the potable water supply,

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sanitary services, pollution control, foodprotection, occupational health, zoonosescontrol, and environmental impact assess-ments of major development projects.

The consolidation of local health sys-tems calls for massive and intensive trainingprograms. For that purpose, the Universityof Costa Rica, together with the health sec-tor and with the collaboration of PASCAP,has established a continuing education pro-gram that makes use of self-instruction mod-ules. A first step centered on the training ofadministrators for local health systems andtraining of the Technical Councils, in orderto guarantee community participation in thepreparation and evaluation of localprogramming.

The Costa Rican training program inequipment maintenance and energy conser-vation attracted students from other coun-tries in the Central American subregion.

The program for maternal and childhealth has had high priority. Its activitieshave centered on normative updating andthe development of perinatology. The pro-gram dealing with adult health and chronic

diseases has adopted the multisectoral riskapproach as its principal strategy.

The nutrition of specific populationgroups continues to be a major focus of theministry's activity. With support of INCAP,work related to preventing poor nutritionwas intensified.

In 1989, the disaster preparedness pro-gram developed significantly. It trained pub-lic health personnel throughout the countryand developed emergency plans for desig-nated hospitals that were evaluated anddeemed essential for responding to majordisasters. Collaboration with the CCSS, theNational Emergency Commission, the min-istries of education, government, and foreignaffairs, the Red Cross, the School of Journal-ism, the University of Costa Rica, and theNational University for Distance Educationwas fundamental for the institutionalizationof that type of national planning.

Costa Rica participated actively in thesubregional initiative, the Plan for PriorityHealth Needs in Central America, the politi-cal and technical objectives of which areconsistent with those of the country.

EL SALVADOR

Because of persistent violence, whichbecame acute during the last quarter of 1989,El Salvador experienced economic and socialdeterioration that hampered public sectorprograms. Cooperation activities in thehealth sector also were hindered by theuncertainty preceding and surrounding thepresidential election of March 1989. Thechange in national authorities that occurredon 1 June 1989 entailed a fundamentalchange in health policies and priorities.

The areas on which the Ministry of Pub-lic Health and Social Welfare had concen-trated earlier-including local health systemsdevelopment, integrated health programs,intersectoral coordination, and community

participation-were revised. The ministryalso replaced division and department chiefsat the central level, regional directors, andheads of health facilities.

Because of the instability, progress in thedesignated priority areas of work was onlypartial. Health indicators did not evolve asfavorably as had been hoped, despite thehealth ministry's efforts and substantial for-eign support. Nonetheless, malaria morbid-ity continued to decline, as it has since 1983,as a result of the combined interventionstrategy of vector control and chemopro-phylaxis. The increase in vaccination cover-age, despite the risks to health personnelworking in war zones, was also a significant

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achievement. Poliomyelitis decreased in inci-dence, and by the end of 1989 no casescaused by the wild poliovirus were detected.

During the second half of 1989, PAHO/WHO supported health ministry authoritiesby helping to define the national prioritiesthat were issued as "Health Policies, 1990-1994." These priorities were based on theguidelines set out in the National Economicand Social Development Plan.

An 18-month senior health administra-tion course, offered as part of the manage-ment capacity development project, wasconcluded in May 1989. Meanwhile, thestrategy to integrate health sciences educa-tion with service in related fields was carriedout through agreements between the healthministry and the University of El Salvador,which collaborated in modifying the stan-dard curriculum.

Relations between the Ministry of PublicHealth and Social Welfare and the Salva-doran Social Security Institute were consoli-

dated in 1989, and PAHO/WHO supportedtheir joint programs in such areas as drugpurchasing, human resources training, andfacilities' maintenance.

The project to restructure the delivery ofprimary care services, financed by a grantfrom the Kingdom of the Netherlands, wasimplemented and continues to be carriedout. The Government of Italy, the Kingdomof the Netherlands, UNDP, ILO, UNHCR,UNFPA, USAID, INCAP, and PASCAP alllent cooperation to social developmentprojects in El Salvador. The Ministry of Pub-lic Health and Social Welfare continued itsefforts to integrate external cooperation inthe health sector and determined thatPAHO/WHO should be the coordinatingagency.

Because of the state of emergency in thecountry in late 1989, all officials of UnitedNations system agencies, including those ofPAHO/WHO, were evacuated by order ofthe Secretary-General.

GUATEMALA

Guatemala's economy remained rela-tively stable over the quadrennium, butgrowth was slow. A large portion of the peo-ple-including over half of the rural resi-dents, who constitute the majority of thepopulation-did not earn enough to coverbasic food costs. Undernutrition and diar-rheal, infectious, and parasitic diseasesranked among the main causes of morbidityand mortality.

The 1987-1988 National ReorganizationProgram provided the framework for Guate-mala's health policy during the quadren-nium. Based on the goal of equity in accessto health services, the program expressed thegovernment's commitment to pay its accu-mulated "social debt" by investing in educa-tion, health, and housing. The government'shealth program was shaped by a series of

changes in national policies, including theapproval of a new constitution in 1985 andthe change in government in 1986.

The new government's political planfocused on consolidating democracy in Gua-temala by establishing a pluralist systembased on the decentralization of government,as called for in the new constitution. Attend-ant legislation created a region-based eco-nomic development plan that wouldstrengthen local health systems and fostersocial participation. Health directors weredesignated for each region and wereappointed to the regional development coun-cils. These measures bolstered the health sec-tor's attempt to transform the national healthsystem into a community-based, primaryhealth care service that reaches even the mostunderserved rural areas.



In shifting from a curative to a preven-tive model, the primary goals established bythe Ministry of Public Health and SocialAssistance were to reduce childhood andmaternal mortality, eradicate the transmis-sion of wild poliovirus, reduce the incidenceof vaccine-preventable diseases, and increaserural access to potable water and essentialpharmaceuticals.

Coverage of the Expanded Program onImmunization increased notably by 1989,not long after national vaccination dayswere introduced as a strategy. Currently,coverage has reached 60%. However, as aconsequence of the low measles vaccinationcoverage throughout the decade, an out-break of measles peaked toward the end of1989. PAHO/WHO's cooperation was cru-cial in the epidemiologic analysis that led tostrategies to control the outbreak, and in thedelivery of vaccine within two days of thegovernment's request.

In general, the period was characterizedby slow and gradual progress as primary carecriteria were applied in formulating, carryingout, and evaluating the priority health pro-grams. Emphasis was placed on traininghealth personnel in primary care methods inlieu of the traditional hospital-basedapproach.

The development of the health infra-structure was based on the constitutionalmandate to decentralize government admin-istrative procedures. The corresponding planfor institutional development reorganizedthe health ministry and emphasizedstrengthening local services.

In order to create strong local services,the ministry brought community workersand volunteers into health projects, pro-moted preventive health campaigns, andforged links with "informal" health workerssuch as midwives, whom it trained in mod-ern, safer birthing practices.

The ministry signed an agreement withthe Guatemalan Social Security Institute tocooperate in the primary care strategy. Theinstitute extended coverage of its health pro-

grams, including preventive activities, tolarger groups of the population. The Minis-try of Education collaborated with thehealth ministry in designing and carryingout community education projects in pre-ventive health. A number of nongovern-mental organizations active in health carealso carried out joint training activities withthe ministry at the local level.

The Ministry of Agriculture signed anagreement with the Ministry of Health in1986 establishing collaboration in the area ofveterinary health. Urban rabies control andimprovement of meat inspection practiceswere among their main joint projects. Therabies control project was supported by apublic information campaign spearheadedby the Ministry of Education and theNational University of San Carlos, both ofwhich were members of a commissionformed by the agriculture and health minis-tries. The incidence of rabies started todecline as a result of the joint effort and theincreased availability of vaccines thatresulted from improved national productioncapacity. The Ministries of Health and Agri-culture also collaborated on reducinganother important health hazard in thecountry: the improper use and disposal ofpesticides.

All national agencies involved in healthactivities were participants in the NationalAIDS Commission. Although relatively fewcases have been confirmed in Guatemala todate, the commission's purpose is to addressareas of common interest to all health careagencies. Chief among these are guarantee-ing the safety of blood bank supplies throughprovision of adequate laboratory services,and establishing protocols for the treatmentof AIDS patients.

In the area of public health research anddocumentation, the government took stepsto establish a national Institute of Health. Itspurpose will be to promote and facilitatenational capability for health problem analy-sis, research, and the formation of high-leveltechnical resources.

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HONDURAS

Honduras' political and economic cli-mate during the quadrennium was markedby uncertainty stemming in large part fromthe conflicts in its neighboring countries,Nicaragua and El Salvador. Nationalresources in the corresponding border areaswere taxed by the influx of displaced personsand refugees.

In 1987, the Ministry of Public Healthand Social Welfare called on all internal andexternal agencies and organizations support-ing the health projects of Honduras to joinforces in helping to define a basic policy anddesigning a comprehensive health plan. In aconsultation meeting, the agencies-includ-ing PAHO/WHO, UNICEF, USAID,UNDP, the Government of Spain, andProject HOPE-cooperated with the countryin identifying its main health problems andranking them according to their frequencyof occurrence in each of the eight healthregions. The government then outlinedstrategies for tackling the priority problems(maternal and child health risks, inadequateimmunization coverage, diarrheal diseases,acute respiratory infections, tuberculosis,vector-borne diseases, malnutrition, sexuallytransmitted diseases, rabies, epilepsy, alco-holism, and drug addiction) at the national,regional, and local levels.

The government decided that theNational Health Plan should be revised togear services toward the groups at highesthealth risk: the rural and urban poor whohave limited access to health care. To thatend, the Ministry of Public Health andSocial Welfare focused on upgrading its oper-ations and management systems and rehabil-itating critical facilities in the nationalnetwork according to the priority needsdetected in each catchment area.

In four of the eight regions, the newcomprehensive approach produced marked

results, especially in increased efficiency andequity of services. In Villanueva, for exam-ple, the health ministry, Honduran SocialSecurity Institute (IHSS), and local govern-ment attained the full functional integrationof their respective health services for the firsttime in the country's history. The success oftheir efforts led other regions to adopt simi-lar models.

While these reforms were being testedand instituted, routine preventive healthprograms continued. The campaign tostrengthen the Expanded Program on Immu-nization and to eradicate wild poliovirustransmission succeeded in obtaining thehighest vaccination coverage in the coun-try's history. In addition to PAHO/WHOsupport, the ministry's campaign was backedby USAID, UNICEF, Rotary International,and the IDB.

Record vaccination coverage rates werealso achieved in the campaign against urbanrabies, a project that was directed by PAHOand received funding and material supportfrom the European Economic Communityand the French agencies BIOFORCE andthe Mérieux Foundation.

Excellent results were also obtained inthe effort to create a core of health profes-sionals trained in management who in turntrained local health workers in the methodsand technical requirements for reformingthe delivery of services. With strong backingfrom PAHO/WHO, many of the staff of thehealth ministry and the IHSS were trainedin this fashion.

The AIDS control project focused ontraining medical and health personnel incase recognition and management, and insetting up laboratory facilities and trainingtheir staff in diagnostic techniques andblood screening processes. The ministry alsodesigned a medium-term AIDS prevention



plan that has been submitted for consider-ation to and has gained support from fund-ing agencies.

The Institute of Nutrition of CentralAmerica and Panama (INCAP) lent its tech-nical assistance to a national survey to deter-mine the incidence of malnutrition and toevaluate the effectiveness of the food assis-tance program. The ministry then took mea-sures to improve the program's impact onthe nutritional status of mothers and chil-dren. The drive to improve the overallhealth conditions of women received sup-port from the National Planning Secretariatand the Economic and Social Office, whichapproved a National Policy for Womenintended to increase their well-being andparticipation in the economy.

Honduras continued to experiencechronic shortages of essential pharmaceuti-cals due to their high import costs. The gov-ernment took steps to revive the idlecapacity of its national production facilities,and reorganized its existing distribution sys-

tem to ensure a regular supply of key drugsin underserved areas. In support of thehealth ministry's efforts to boost nationalpharmaceutical production capacity, theCentral American Economic IntegrationBank (BCIE) engaged in formulating mecha-nisms for the joint purchase of necessary rawmaterials.

During 1988 a joint PAHO/WHO-country evaluation of the Organization'stechnical cooperation was conducted withthe extensive participation of experts fromall health sector agencies (Ministry of PublicHealth and Social Welfare, IHSS, NationalAutonomous Water and Sewerage Service,Faculty of Medical Sciences, and profes-sional associations). The pertinence, effi-ciency, and impact of PAHO/WHOcooperation to the country were analyzed.The review served to adjust programming forthe 1990-1991 biennium, chiefly along thelines of increasing cooperation activitiesaimed at managerial reform throughout thenational health network.

NICARAGUA

Nicaragua's economy deteriorated mark-edly between 1986 and 1989. Its productivecapacity was diminished by the decade-longstate of war, and goods and services-boththose produced domestically and thoseobtained from abroad-were curtailed.

At the end of the quadrennium, realper-capita consumption was 21% lower thanin 1980. In 1988, the gross domestic productfell by 8.0% and the balance of paymentsshowed a $US353.9 million deficit. Reper-cussions of the war economy were felt in thesocial sector, as budgets had to be cut despiteworsening living conditions.

Migration related to the armed conflictwas extensive; rural migrants fleeing warzones settled in new slums around the main

cities, creating a need to reallocate Stateresources. Scarce funds were also depleted bynatural disasters, as the country tried torecover from droughts, floods, and Hurri-cane Joan, which struck Nicaragua in 1988and affected 2.8 million people.

The Government of Nicaragua mademajor efforts to improve the well-being of itspeople despite these conditions. Social assis-tance programs increased their coverage dur-ing the last four years, and morbidity andmortality indicators stabilized even thougheconomic indicators deteriorated.

National health priorities were estab-lished by analyzing the general structure ofmorbidity and mortality and the nationalhealth system's capacity to deal efficiently

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with the main problems that were identified.These are as follows: childhood morbidityand mortality; injuries caused by firearms,and deaths from other violent causes andaccidents; morbidity and mortality affectingcombatants and workers; communicable dis-eases, including potentially epidemic onessuch as malaria; and noncommunicable dis-eases. The chief specific causes of childhoodmorbidity and mortality were diarrheal dis-eases, neonatal complications, acute respira-tory illnesses, septicemia and meningitis,malnutrition, and vaccine-preventablediseases.

Injuries from war and other violentcauses resulted in a substantial increase inthe number of handicapped persons. TheNational Health System did not have themeans to reduce the number of deaths andincapacities caused by war injuries, but itplaced emphasis on rehabilitation and theproduction of prosthetics for handicappedsurvivors.

The communicable diseases of greatestconcern are malaria, parasitoses, and tuber-culosis. Their increase was favored by theprogressive deterioration in sanitation andin the overall standard of living; rapid migra-tion and unsanitary, overcrowded new set-tlements were intractable risk factors fortheir transmission. Furthermore, the hazardsencountered by workers in war-torn areasmeant that some critical vector control pro-grams were interrupted.

All of these factors created precariousconditions that could also promote increasesin dengue and sexually transmitted diseases.The Ministry of Health issued a warningthat these diseases may reach epidemicproportions.

One of the principal initiatives under-taken by the Ministry of Health was thedesign and implementation of a new modelof health services organization. The model isbased on the development and strengthen-ing of local health systems, as part of theMaster Plan for Developing the UnifiedNational Health System. In this endeavor,"Situational Planning" is being tested as a

programming method for local health sys-tems and political and administrative decen-tralization. It is hoped that this techniquewill enable the political, social, and militarysituation of each municipal catchment areato be taken into account in health planning.

In addition, since hospitals have a piv-otal role in local health systems in Nicara-gua, the improvement of facilities andsupplies was given special attention.

One of the country's principal initiativesduring the quadrennium was the NationalCampaign to Protect Children's Lives,which focused on reducing mortality and themain causes of illness in children one to fiveyears old. The campaign was headed by theMinistry of Health and pooled resourcesfrom all sectors in the country.

PAHO/WHO focused its technicalcooperation on several key areas, includingthe development of health infrastructure toimprove institutional response capacity andthe design of a legal framework for the newsystem's implementation. Within that basicframework, special attention was given toimproving financial analysis capabilities andto reforming health financing methods.

In addition, PAHO/WHO cooperatedin improving engineering and maintenance,training personnel, and developing adminis-trative methodologies and instruments. Aspart of the Regional Emergency Prepared-ness and Disaster Relief Coordination Pro-gram, PAHO/WHO supported nationalprojects that organized emergency servicesand personnel training and that promotedintersectoral coordination for emergencies.

In the area of pharmaceuticals, PAHO/WHO cooperated toward improving thesupply system, training distribution person-nel (especially at the local level), and increas-ing quality control. Progress was made ininstituting a standardized national drug pol-icy, which included efforts to revitalize thepharmaceutical industry. To this end, meth-ods were sought to coordinate State and pri-vate production capabilities.

In the area of priority health needs,projects were carried out regarding food and

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nutrition; water supply and environmentalsanitation services; human growth, develop-ment, and reproduction; prevention andcontrol of communicable diseases; tropicaldisease research; malaria; rehabilitation ofthe handicapped; ophthalmology; andzoonoses. UNICEF, UNFPA, UNDP, theWorld Food Program (WFP), the NorwegianAgency for International Development(NORAD), the Finnish International Devel-opment Agency (FINNIDA), and the Swed-ish International Development Authority

(SIDA) collaborated with PAHO/WHO onmany of these projects.

The health ministry and PAHO/WHOcooperated in developing a model for anationwide scientific and technical informa-tion system. Special support was given tohealth research and to a five-year humanresources plan. The latter seeks to redefinekey health personnel functions, improvetraining programs, and reshape continuingeducation projects to lend support to thelocal health systems.

PANAMA

Panama, which had a population of1,831,400 and an annual growth rate of1.9% in 1980, was estimated to have2,300,000 people in 1989. The population isyoung-45% of the people are under 20 yearsold-and is approximately 48% rural and52% urban. Population density is variable,with people highly concentrated in metro-politan areas and dispersed in rural areas. Itis estimated that around 20% of the popula-tion is critically poor; most of the poor livein isolated rural communities and on theperiphery of large cities.

After a brief economic recovery, thegross domestic product declined by 15% inmid-1987 compared to 1986, and in 1988and 1989 it decreased an estimated 17% eachyear. Overt unemployment remained atbetween 17% and 21% during the entirequadrennium, and consumption of goodsand services declined, as did public and pri-vate capital investment. The worsening eco-nomic situation was felt by health sectorinstitutions as shortages occurred in phar-maceuticals, supplies, and equipment.

During the 1986-1989 period, the popu-lation's health conditions were good,although no major improvements wereobserved. Infant mortality remained stable

at about 20 per 1,000 live births, and lifeexpectancy at birth was between 70 and 72years. The chief causes of death in childrenunder 15 years of age continued to be acuterespiratory infections and causes associatedwith malnutrition, especially in deprivedareas. The main causes of general mortalitywere those related to old age and urban liv-ing conditions. Drinking water servicesimproved, reaching 95% urban and80% rural coverage by the end of thequadrennium.

In 1986 health authorities placed prior-ity on the development of service infrastruc-ture and management capacity and oninterventions to control the diseases affect-ing vulnerable, socioeconomically deprivedgroups. To these ends, a Strategic Develop-ment Plan for health services was conceived,to commence in 1986 and end in 1990. Itsconcrete goals were to extend health ser-vices, drinking water, and basic sanitationcoverage to 90% of the population. It alsoaimed to improve efficiency, reduce costs,and achieve a balanced distribution ofresources.

The strategic plan comprised seven pro-grams: (1) the strengthening of health ser-vices, with projects to mobilize external

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resources for the development of manage-ment capacity in the sector, to involve othersectors of the economy in health activities,and to extend and modernize infrastructure;(2) the pharmaceuticals program, aimed atmodernizing existing quality assurance,inventory and control, supply, and logisticssystems; (3) the human resources program,which included designing new care models,modernizing the work force, and redefiningmanpower requirements; (4) the nutritionprogram, aimed at improving general nutri-tional status, but emphasizing those at highrisk; (5) the epidemiology program, focusingon the control of vaccine-preventable dis-eases, malaria, dengue, yellow fever, sexuallytransmitted diseases (including AIDS), andother health problems; (6) the childhoodsurvival program, with components thatincluded improved access to services in themost deprived districts, prevention andtreatment of acute respiratory infections,oral rehydration, perinatal care, promotionof breast-feeding, and pre- and postnatalcare; and (7) the potable water program,which emphasized a project to build 400aqueducts and improve 300 existingsystems.

A study of the services' network wascompleted in 1986 and the strategic plan tomobilize external resources was begun thefollowing year. It sought to obtain funds toextend, rehabilitate, and modernize theentire network, and included projects toconstruct water mains and latrines in ruralareas and to build and remodel a number ofhospitals and health centers.

The strategy of emphasizing preventionactivities, particularly with respect to high-risk groups, was maintained throughout thequadrennium, as was the policy of promot-ing community participation in healthprojects. However, the extent to which pro-grams were carried out was affected byrepeated changes in leadership and staffingof the Ministry of Health. A number ofprojects, including the Expanded Programon Immunization, could not be evaluated asa result.

Despite the above-mentioned con-straints, PAHO/WHO provided technicalcooperation in the strategic plan to developservices, including the selection of programpriorities. The Ministry of Health especiallyasked for PAHO/WHO cooperation in thearea of pharmaceuticals, human resources,and equipment maintenance. The Organiza-tion helped analyze and reestablish thenational pharmaceuticals system and lentassistance in improving its administrativeand technical management. Through theEssential Drugs Revolving Fund for CentralAmerica and Panama, $US500,000 wasspent to acquire pharmaceuticals fornational institutions.

With IDB support, PAHO/WHOassisted in developing the National Mainte-nance System. Starting in September 1988,the system received backing from the Subre-gional Maintenance Project financed by theKingdom of the Netherlands. The projectsupported manpower training programs, theacquisition of tools, and the purchase of crit-ical spare parts.

PAHO/WHO also cooperated in thedevelopment of special programs for vulnera-ble groups living in rural and peripheralurban areas. These groups lack access to san-itary services and have high morbidity andmortality rates from poverty-related causes.Major protein-energy malnutrition, anemia,and infectious diseases are endemic amongthem. As a result, maternal and child healthand immunization projects, the promotionof better nutrition, and studies to determinesocial factors influencing health were pri-mary interventions. Health workers andcommunity groups in these areas were tar-geted for health education projects.

In addition to its routine projects, theinfectious disease control program launchedan intensive drive to reduce the populationof Aedes aegypti, the dengue-carrying mos-quito that reinfested Panama City.

The University of Panama revised thenutrition curriculum for student physicians,nurses, and teachers, and the TechnologicUniversity of Panama introduced training in

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disaster response administration in the engi-neering curriculum. In-service health minis-try personnel were trained to manage theExpenses, Production, and Costs System,which was created as a management infor-mation tool to assess cost components,trends, and determinants. In support of thedevelopment of local health systems,national technicians took courses in infor-mation systems, local programming, person-

nel administration, and management of thecritical inputs supply system, including phar-maceuticals, biologicals, and spare parts. Allof these manpower training activities werecarried out with PAHO/WHO technicalcooperation. The UNDP was a primary fun-der of the pilot programs to train health per-sonnel in management and local program-ming techniques.

SOUTH AMERICA

ANDEAN COOPERATION IN HEALTH

The beginning of the Andean Coopera-tion in Health initiative coincides with thestart of the 1986-1989 quadrennium.Encouraged by the experiences of the Cen-tral American and Caribbean initiatives,which demonstrated the merits of a subre-gional approach in dealing with selectedcommon problems, the Ministers of Healthof Bolivia, Colombia, Ecuador, Peru, andVenezuela embarked on the Andean Coop-eration in Health effort in 1986.

The five areas originally selected for con-certed action were the development ofhealth services systems, maternal and childhealth, malaria and other vector-borne dis-eases, drug dependency, and essential drugsand biologicals. In 1987, the Ministers addeddisaster preparedness as the sixth priorityarea for joint action.

The basic approach has been to identifykey activities for each of the six priority areasthat are of interest to two or more countriesand that would have a significant impact, bewithin the capabilities of the governments tocarry out, lead to short- and medium-termpositive results, and strengthen nationalcapacity in the chosen field of action.

In their approval of the Andean Cooper-ation in Health initiative, the Ministers of

Health of the subregion stipulated thatPAHO/WHO and the Secretariat of theHipólito Unanue Agreement (their Secretar-iat) should work closely together to promoteand implement the initiative. As a result, theactions of both entities were closely coordi-nated and joint programs of work weredeveloped in the last two years.

Groups of national experts, withPAHO/WHO and Hipólito Unanue Agree-ment support, met on several occasions todetail areas of cooperation. Focal points foreach priority area were established in eachcountry to promote and coordinate theefforts in their respective areas of expertise,and the Director General of Health of eachcountry was designated as the coordinator ofthe initiative.

Within the subregion, the Director ofPASB assigned specialized staff to workalmost exclusively on malaria and vector-borne diseases, essential drugs, maternal andchild health, and disaster preparedness. As aresult, several subregional and nationalproject proposals were drafted and submit-ted to potential donors. A number of themhave already been approved and others arebeing reviewed.

At the international level, the existence

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of the Andean Cooperation in Healthinitiative was made known through thepublication of a basic document that was dis-tributed to more than 60 governments,international organizations, and institutionsthat might support its efforts. In several casesthis initial step was followed by visits anddiscussions with representatives of theseentities. The document was also presented toWHO in Geneva, to the Andean Parlia-ment, and to the Cartagena Accord for theirformal endorsement. A video on the initia-tive also was prepared and distributed. Insome of the priority areas, PAHO/WHO isworking closely with other institutions, suchas UNICEF and UNDP. In addition, there isnow a need for very close coordination with

the Amazon Cooperation Treaty, which hasestablished its own Health Secretariat andaddresses the same countries and priorityareas, but does so through thee Ministries ofForeign Affairs rather than the Ministries ofHealth.

While the Andean Cooperation inHealth initiative is not yet in full operation,positive results are already being noted. Thisis most evident in the area of maternal andchild health, in which each government hasprepared a national plan of action along sim-ilar lines. The same approach has been usedto define the problems involved in mainte-nance of infrastructure and equipment, anda detailed analysis of needs, by country andby institution, has resulted.

BOLIVIA

Health conditions in Bolivia are amongthe most precarious in the hemisphere. Pub-lic health problems are caused predomi-nantly by poverty, inadequate housing, andlack of basic services in a geographic areawith many serious endemic diseases.

Although inflation was brought downfrom almost 300% in 1986 to around 16% atthe end of the quadrennium, unemploymentwas still over 20% and resources for the pub-lic sector were sorely lacking. Economichardship notwithstanding, the stable politi-cal climate made it possible to carry outhealth programs without interruption and toobtain external financing for several priorityprojects.

One of the key reasons that health pro-grams were carried out successfully was col-laboration between the national Ministry ofSocial Welfare and Public Health and thePeople's Health Committees. Organized atthe local level throughout the country andmade up of community leaders, the commit-tees determine needs, implement programs,negotiate resource requirements with thecentral government, and ensure that the

people in their jurisdiction receive compre-hensive services rather than isolated, verticalprograms.

This community-based, comprehensiveapproach is in full consonance with PAHO/WHO's own principle of building a networkof local health systems that serve as the basicfunctional units of the national health struc-ture. PAHO/WHO's technical cooperationwas hence delivered with an emphasis onsupporting and strengthening the localunits.

The Ministry of Social Welfare and Pub-lic Health set out its priorities for the qua-drennium in the 1985-1989 Global HealthPlan. The plan was established to addressthe needs of particularly vulnerable groupsand to tackle tropical diseases, which are stilla major cause of morbidity and mortality.

The most important groups targeted forspecial projects are women of childbearingage, children, and periurban and rural popu-lations that traditionally have lacked accessto the health care delivery system.

Malnutrition, endemic goiter, vaccine-preventable childhood diseases, gastrointes-



tinal illnesses, yellow fever, malaria, dengue,and Chagas' disease are the most stubbornhealth problems that affect large numbers ofthe population, whose 51-year life expect-ancy is the lowest in the Americas. Environ-mental health-especially the extension ofaccess to potable water supplies and sewerageand sanitation services-was a priority inrural areas, in which 52% of the country'spopulation lives.

PAHO/WHO collaborated with theBolivian health ministry in designing thenational health policy and in carrying outthe specific projects called for in the 1987-1989 three-year plan. The plan was based onthe twofold strategy of training physiciansand other health workers to join local Peo-ple's Health Committees and obtaining theeducational materials and primary healthequipment necessary for them to deliver pri-mary health care services.

The recently elected President of theRepublic launched a plan for childhood sur-vival and growth and maternal health.PAHO/WHO is the Secretariat for theplan's executing committee. Given that themain illnesses involved in infant mortality-which is over 169 per 1,000 live births byconservative estimates-are respiratory anddiarrheal diseases, the plan stressed theiremergency treatment. To this end, antibiot-ics and oral rehydration salts were distrib-uted widely, at no cost to the recipients, andnutritional monitoring systems and supple-mentary feeding programs were strength-ened throughout the country.

The national health strategy also singledout a nutrition-related disease-endemic goi-ter-which affects up to 65% of the popula-tion. The ministry's control measuresincluded facilitating the marketing and dis-tribution of iodized salt, educating the publicto use it, and providing oral supplements ofiodized oil to pregnant women and ruralpopulation groups at high risk of developinggoiter.

In the area of infectious disease control,surveillance and reporting systems detectedan increase in malaria, over 24,000 cases of

which were reported in 1987. Studies alsoshowed a troublesome rise in drug-resistantstrains of Plasmodium falciparum. Simultane-ously, Chagas' disease is widespread through-out the country, and yellow fever anddengue outbreaks occurred over the last twoyears. The dengue epidemic-affecting over200,000 people-was quickly arrested withan intensive mosquito control campaignthat lowered the household index to 6.5%.However, given the constant surveillanceand difficult control measures required toprevent a new outbreak, authorities are con-cerned about not being able to guarantee theavailability of material and personnel forsuch an undertaking.

Access to potable water increased mark-edly in cities over the last decade, and alsowas extended in the countryside. Extensionof coverage of sewerage and sanitation ser-vices was less dramatic, but also showedimprovement. Given the critical nature ofthese services, a number of agencies, includ-ing IDB, World Bank, CARE and othernongovernmental organizations, USAID,the International Bank for Reconstructionand Development, the German Develop-ment Bank (KfW), and the Agency for Tech-nical Cooperation of the Federal Republic ofGermany (GTZ), collaborated on projects toextend their coverage. These services, whoselack is at the root of many health problems,will receive the ministry's priority attentionand PAHO/WHO's intensive technicalcooperation in the future.

With limited capital and manpoweravailable, the health ministry focused on car-rying out its projects by eliciting the supportand collaboration of other national sectorsand updating the training of its own person-nel. It sought to involve the social securitysystem in preventive health projects, forexample, and worked closely with the Minis-try of Agriculture in a campaign to eradicatefoot-and-mouth disease.

Meanwhile, PAHO/WHO participatedregularly in meetings of international donorsand, together with USAID, UNICEF,UNFPA, WFP, UNDP, and nongovernmen-

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tal organizations, carried out a systematicreview of external cooperation in order toensure that supplementary funds wereobtained.

The health sector obtained funding frominternational agencies for several projectsdeveloped with PAHO/WHO's technicalcooperation. The nutrition and supplemen-tary feeding program, for example, was ajoint UNICEF-PAHO/WHO-governmentproject. UNICEF, PAHO/WHO, RotaryInternational, and USAID joined forcestoward increased coverage of the ExpandedProgram on Immunization, while the IDBfinanced several rural water and sanitationprojects. UNFPA funded a reproductivehealth project administered by PAHO/WHO, the Government of Italy underwrotethe endemic goiter control project, and theWorld Bank developed and funded a projectto strengthen the health infrastructure.

PAHO/WHO also lent its technicalcooperation to the government for activitiesin several key areas that were intended toreduce unnecessary expenses and improveproject management. These endeavors were

to design and promote the generalized use ofa standardized list of essential pharmaceuti-cals, train health professionals in modernmanagement methods, review curriculumrequirements and future deployment pros-pects of RN and MPH graduates, supporthealth services research, publish and widelydisseminate technical information neededfor priority projects, and coordinate zoono-sis control and other border projects withneighboring members of the Andean Coop-eration in Health and Southern Cone healthinitiatives.

One of the most significant accomplish-ments of the quadrennium in the area ofinformation management was the comple-tion of a national health profile and trendsassessment. Developed by the health minis-try and PAHO/WHO, the profile has beenused as the basis for several of the projectsfor which outside funding was obtained. Aconcomitant effort to train health personnelin research methods is progressing withPAHO/WHO's support and will bestrengthened in coming years.

COLOMBIA

Colombia's economy was more stablethan those of most of its South Americanneighbors, with a manageable inflation rateand slow but steady economic growth. Itsgood prospects for development were ham-pered, however, by the powerful drug trade.The country's crackdown on drug traffick-ers, and their violent attacks on governmentofficials and institutions, called for theexpensive mobilization of special resources.

This necessary expenditure diverted partof the national budget from developmentprojects that might have otherwise countedon greater funding. There is concern thatthe national war on drugs may further sapresources for social programs in the comingyears.

Having to accommodate to more meagerfunds than needed, the health sector none-theless vigorously pursued its campaign toreach the goal of universal access to primaryhealth care services. This longstandingobjective of the health sector was bolsteredby the national executive and legislativecommitment to spreading economic andsocial development beyond major metropoli-tan areas by decentralizing social servicesand democratizing their planning and execu-tion. Toward the end of the quadrennium,the National Congress passed a reform of theNational Health System proposed by theMinistry of Health. The reform transfers alarge measure of control of the country'shealth policy to the municipalities. The aim



of this political, administrative, and fiscaldecentralization is to strengthen the munici-pal level and to decentralize services, therebyensuring primary care services for the entirepopulation.

Further certifying the government's gen-eral commitment to decentralizing anddemocratizing all development projects, thecreation of 3,500 Community ParticipationCommittees nationwide was mandated bydecree. Meanwhile, Bill 120-expected topass in early 1990-spells out the relation-ship between these committees and nationalhealth, family welfare, and social securitysystems.

The community-based social action pro-grams, such as the National Plan for Sur-vival and Development, the NationalRehabilitation Program, and the Plan ofAttack against Absolute Poverty, as well asprograms to generate employment, requireboth educated civic involvement and link-ages between different government sectorsresponsible for rural development projects,water and sanitation coverage, nutrition andhealth, infrastructure, and education. In sev-eral municipalities covered by the nationalreform plan, for example, the Ministry ofHealth has awarded management responsi-bilities to community organizations for con-tracting the construction and expansion ofhealth facilities. Already, municipalities havebuilt or remodeled 422 facilities, constructedor improved 313 water supply systems, built1,346 school health units, trained 132 newstaff members, provided refresher courses for18,382 other staff and 5,500 communityleaders, financed 173 community pharma-cies, and supplied 2,162 health and sanita-tion promoters and nursing auxiliaries withvehicles for transportation. Communityaction was evidenced in projects such as theCommunity Rehydration Units (URDC),which combated infant mortality due todiarrhea by teaching mothers how to pre-pare and use oral rehydration solutions.

To make decentralized management andoperations of the sector more dynamic andefficient, the Ministry of Health coordinated

with different social, economic, political,and technical sectors of the country in devel-oping norms to regulate the organizationand financing of the health institutions atthe municipal, departmental, and nationallevels. However, the reorganization has stillnot been carried out at some of these levels.

The national health sector and PAHO/WHO collaborated on designing an innova-tive methodology for organizing the deliveryof services, based on epidemiologic surveil-lance to detect priority problems and theirrisk factors. The approach seeks to deliverservices that not only treat but prevent thecauses of morbidity in given geographicareas, in keeping with the decentralizationprocess. By defining geographically distincthealth "ecosystems," it enables local authori-ties to design projects in which governmentand other agencies can coordinate theirefforts toward the precise needs of a specificpopulation group.

The technical cooperation provided byPAHO/WHO during 1986-1989 thusstressed supporting national and departmen-tal decentralization of health services, train-ing personnel to run them, developinginfrastructure, reforming hospital care,encouraging community participation, pro-moting intersectoral coordination, anddesigning projects to address the most press-ing communicable diseases and other healthconcerns of vulnerable groups. These prob-lems include malaria and dengue, vaccine-preventable childhood illnesses, zoonosessuch as urban rabies as well as foot-and-mouth disease, AIDS, cancer and otherchronic diseases, and maternal health, fam-ily planning, and occupational health.

In its effort to limit the spread of AIDS,the ministry reorganized the responsiblecommittee. PAHO/WHO assisted in devel-oping legal/ethical guidelines for the controlprogram, set up a network of eight bloodscreening laboratories, and prepared instruc-tions and facilities for the treatment of AIDSpatients.

The maternal and child health projectwas backed by UNICEF, which, together

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with the Ministry of Health and PAHO/WHO, formed a tripartite Child HealthCommittee. National vaccination days,started in 1984 to improve coverage, weresuccessful. By 1989, provisional data showedvaccination coverage of children under oneyear of age as follows: trivalent oral poliovaccine, 89%; DPT, 78%; measles, 74%; andBCG, 94%. In addition, the government haspledged its commitment to the eradication ofwild poliovirus transmission by 1990, elimi-nation of neonatal tetanus, and 90% reduc-tion of measles by 1995. Epidemiologicsurveillance of vaccine-preventable diseaseswas strengthened, especially with respect tosuspected cases of poliomyelitis.

PAHO/WHO technical cooperationalso included advice in the production, con-trol, and purchase of vaccines, and thedesign of a national pharmaceutical policy.The purpose of the policy is to correct theexisting situation in which the countryimports a wide range of pharmaceuticals,many of which are redundant and costly and

some of which are of dubious quality.Colombia has also determined that it couldsave in import expenses by promoting thenational production of essential vaccinesand laboratory reagents.

The Pan American Health and Educa-tion Foundation collaborated on projects totrain medical and nursing professionals inareas that are suited to the decentralizedapproach.

The PAHO/WHO Emergency Prepared-ness and Disaster Relief Program activelyassisted the government in imparting emer-gency management skills to health profes-sionals through courses offered in thefaculties of medicine, schools of publichealth, and the Ministry of Health.

The World Bank, Rotary International,USAID, UNICEF, UNFPA, UNFDAC, andthe governments of the Federal Republic ofGermany, Italy, Japan, the Kingdom of theNetherlands, and Spain were major partnersin funding support for national priorityprograms.

ECUADOR

The regional economic crisis was feltsharply in Ecuador, where it was aggravatedby the drop in international oil prices. Thepetroleum-rich country had an economicboom during the 1970s, and public develop-ment policies during those years weredesigned around plentiful resources. Thegovernment undertook costly developmentprojects with long-term completion sched-ules, including construction of modern,high-technology hospitals.

When petroleum prices plummeted inthe 1980s, Ecuador lost its main source offoreign earnings. The 1987 earthquake com-pounded difficulties when it ruptured pipe-lines, delaying explorations and exports forsix months, during which time the countryhad to import oil. The earthquake also dam-aged roads, bridges, other basic infrastruc-

ture, and health facilities, setting back manycostly development projects.

As a result of the crisis, the rapid,import-dependent development to which thecountry had been geared underwent a sud-den contraction. Increased unemploymentand underemployment (affecting 63% of thepopulation in 1988), a drop in real wages, alowered standard of living, and the weaken-ing of social development programs ensued.In the public sector the impact was felt in theextension of project completion dates, theincrease in their cost, legal problems withcontractors, and delays in supplying and fur-nishing installations.

Programs already in operation also feltcutbacks in real budgets. Buildings, equip-ment, and installations deteriorated becauseof delayed maintenance. There were short-



ages of pharmaceuticals, medical and publichealth supplies, and critical raw materialswhose rising costs became prohibitive. Thequality of the delivery of services to thepopulation further declined when healthworkers-demoralized by low pay and poorworking conditions-often went on strike orworked inefficiently.

The 1988 elections brought in a govern-ment with a social democratic philosophy toreplace its neoliberal predecessor. The newgovernment set aside 7% of the nationalbudget as a Social Fund and formed theSocial Front, made up of the Ministries ofHealth, Education and Culture, Labor andHuman Resources, and Social Welfare. TheFront is responsible for coordinating socialprograms at the executive level and reflectsthe social base and participative organiza-tion of the ruling party.

The health program priorities defined bythe new government were provision of inte-grated family health care, the fight againstmalnutrition, and expansion of coverage ofpotable water supply and sanitary services.

The creation of the Social Front waspart of a dramatic shift in the concept ofdelivering public health services. The Minis-try of Health focused on projects aimed pri-marily at strengthening the operationalcapacity of services, especially those locatedin rural and marginal urban areas. This wasdone by constructing, equipping, and sup-plying smaller, less technologically complexhealth care units in underserved areas.

These local health units are part of thelocal health systems on which the newnational health policy is based. The mainstrategy consists of building a stepwise net-work of preventive and curative servicesorganized according to level of complexity.Simultaneously, other development effortsthat have a bearing on health are included inprogram planning to maximize the joint useof resources. Because of the restrictednational budget, provincial and municipalgovernments must assume greater respon-sibility in financing and staffing theprograms.

In addition to promoting the delivery ofintegrated health services, the local systemsactively seek out underserved populationgroups in a campaign to ensure universalaccess. During a childhood vaccinationdrive, for example, mothers, fathers, and sib-lings are also provided with primary care.

PAHO/WHO has responded to thechange in the national government by reor-ganizing its technical cooperation accord-ingly. Program support is provided throughinterproject coordination that is based onrisk assessments developed through epidemi-ologic surveillance. The Director, PASB, haspledged special attention to the Ecuadorianreform experiment, the results of which mayprove useful for other countries.

Within the three broad priority areas,national attention and PAHO/WHO tech-nical cooperation focused on a number ofspecific projects; The program of free distri-bution of prescription generic drugs forminors was expanded to cover children up tothe age of 14, and the Center for Pharmaceu-ticals and Medical Inputs was formed. TheNational Committee on AIDS was also cre-ated to determine the incidence of the dis-ease and devise measures to halt its spread.

PAHO/WHO technical cooperation inthe development of health services infra-structure was aimed primarily at the follow-ing: general planning to enlarge the areasreceiving services; development of andexperimentation with plans for the regional-ization and decentralization of services;design and testing of new models of inte-grated family health care; development oflocal services networks; projects for increas-ing the efficiency with which essential phar-maceuticals and vaccines are procured,stored, and distributed; institutional devel-opment; social participation, including thatof women; promotion of the subregional ini-tiative and border health projects; and mobi-lization, coordination, and evaluation ofexternal aid.

The priority health problems of vulnera-ble groups received special attention. Theseincluded growth, development, and repro-

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duction; diarrheal and respiratory diseases;tuberculosis; food and nutrition; oral health;water quality, domestic hygiene, and wastedisposal; environmental risks to health;malaria and leprosy; endemic sexually trans-mitted diseases and AIDS; foot-and-mouthdisease and urban rabies; cervical and uter-ine cancer; and smoking, alcoholism, anddrug abuse.

The search for and compilation and dis-semination of technical and scientific docu-mentation analyzing national health trends

was critical in the determination of specificneeds. The importance of this informationwas brought to light particularly during theeconomic crisis, when it became clear thatmany large development projects had beenbased on only a generic notion of what wasrequired. PAHO/WHO built an analyticdata bank to serve as the basis for draftingprojects that address specific national prob-lems, and its documentation center is linkedto a network of national informationcenters.

PERU

During the quadrennium, Peru under-went the most serious and prolonged eco-nomic crisis in its history. Unemploymentand the cost of living rose, and at the sametime food production dropped, partly as aresult of arrested agricultural production inwar-torn rural areas. These conditionsincreased the serious nutritional problemsfaced by low-income rural and periurbanfamilies, who are the groups already at great-est health risk.

The National Health Policy, developedduring the second half of 1985, has been theframework guiding the conduct of healthactivities. It delineates the following broadcategories for program emphasis: strengthen-ing local health systems through decentral-ization; improving collaborative efforts withother development sectors; developing newapproaches to carrying out programs inmaternal and child health, communicabledisease prevention, food and nutrition, envi-ronmental health, emergency preparedness,mental health, and control of some chronicdiseases; reorganizing the health servicesdelivery structure by the functional integra-tion of the Peruvian Social Security Institute(IPSS) and the Ministry of Health; reestab-lishing the leadership role of the health min-istry; mobilizing community participation;and reaffirming the national commitment to

achieving the goals set out in the strategy ofhealth for all by the year 2000.

Rural workers and periurban dwellers,other economically and socially deprivedgroups, pregnant and lactating women, andchildren under one year of age received pri-ority attention as high-risk groups. Becauseof financial and staffing limitations, the min-istry tackled these front-line areas by chan-neling its resources into a few criticalpreventive projects: the Expanded Programon Immunization, control of acute respira-tory and diarrheal diseases, food and nutri-tion, family planning, child growth anddevelopment, tuberculosis prevention, envi-ronmental health, and malaria control.Meanwhile, it gave attention to refurbishinghealth centers, installing and supplying pri-mary health services in outlying areas,remodeling and stocking key hospitals, andcompleting major infrastructure works thathad been started earlier.

As noted above, efforts were made toimprove the efficiency of the care deliverysystem by functionally integrating the ser-vices provided by the health ministry andthose of the IPSS, decentralizing them alongregional lines. Coordination of resourceswith other social services and ministriesinvolved in development projects was alsostrengthened. The strategy to reform the



organization of services was coupled withattempts to mobilize community participa-tion at the local level.

The National Health Policy draftedearly in the quadrennium aims to treathealth problems in an integral fashion withthe participation of other sectors, and theministry achieved positive results in thisendeavor. In a joint project with the housingsector, it obtained substantive increases ininvestments for potable water supply andsanitation works. In collaboration with theeducation sector, the ministry designed newuniversity-level curricula and graduate pro-grams, such as one in occupational healthand toxicology. By 1989 five dissertationshad already been completed in this newarea. Improving food safety was the object ofa major campaign undertaken together withthe Ministries of Education, Agriculture,and Municipalities.

The national attempt to improve inter-sectoral coordination was spelled out in theTriennial Plan-a multisectoral project forchild survival-that was designed withPAHO/WHO cooperation. The plan coor-dinates actions in the areas of the ExpandedProgram on Immunization, diarrheal disease,acute respiratory infections, nutrition, peri-natal care, child growth and development,and environmental health during the period1988-1991. Together with the National Vac-cination Plan for 1987-1991, this joint effortof several agencies and national sectorsachieved higher immunization coveragethan in the past few years. By 1988, provi-sional evaluation results showed vaccinationcoverages as follows: OPV3, 68%; DPT3,51%; measles, 49%; and BCG, 78%.

PAHO/WHO supported national effortsthrough cooperation in all of the priorityprogram areas, providing technical expertiseand funding, assisting in the purchase of sup-plies and equipment, offering courses andseminars, and acting as an adviser and thirdparty in negotiations with other sectors andagencies.

Despite the state of insolvency andshortages in the sector, technical coopera-

tion succeeded in beginning the decentraliza-tion of services and health programs and inobtaining the functional integration of theMinistry of Health and the IPSS in some ofthe most vulnerable regions of the country.PAHO/WHO also collaborated with theministry in developing a four-year, $US70million project to rehabilitate, expand, andequip hospitals (including laboratories,blood banks, and radiology units); the pro-posal will be presented to the IDB forfinancing.

In conjunction with projects to reducemorbidity and mortality among infants andyoung children, the government initiated afamily planning program with $US4.2 mil-lion in funds from the UNFPA to be spentover four years. Likewise, with financingfrom the Government of Italy, the five-yearprogram PROCAN was established, with aview toward improving nutrition in eightseverely deprived microregions of Puno,Tacna, and Moquegua, areas in which thefood and nutrition surveillance system wasfirst established. PAHO/WHO formed anExecutive Secretariat with UNICEF andUSAID to coordinate this and other nutri-tion programs under the Joint NutritionSupport Program, including one aimed ateliminating endemic goiter. Moreover, nutri-tion surveillance was introduced as a stan-dard planning and evaluation criterion forcommunity health programs.

Progress also continued on projectsmotivated by the International DrinkingWater Supply and Sanitation Decade, andCanada provided financial support for thedevelopment of a national information net-work on the subject.

PAHO/WHO gave strong support tothe development and strengthening of localhealth systems through research, meetings,and collaboration in the drafting of legalinstruments and regulations for the estab-lishment of local health systems in Lima,Trujillo, Iquitos, Arequipa, and Piura-Tumbes. The ministry is now consideringexpanding the use of local health systems asthe basic organizational units of the health

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130 Reporr of the Director

care system throughout the country, aspart of the process of strengtheningregionalization.

PAHO/WHO was also instrumental in astudy of the Lima-Callao area and proposalof an improved emergency response system,which was adopted by a permanent commis-sion made up of the IPSS, Armed Forces,Police, and Ministry of Health. Each Depart-

mental Health Unit now has a focal pointfor emergencies and disasters.

At the end of the period, cooperationwas being directed toward the process ofpolitical-administrative regionalization,begun by the government in November 1989when representatives were elected and thefirst 5 of 12 regions into which the countrywas divided began to operate.

VENEZUELA

The beginning of the quadrennium wasrelatively auspicious for Venezuela, but by1989 the drop in revenues from oil exportsand the increase in the cost of importscaused concern. Inflation more than dou-bled between 1988 (35.5%) and 1989(77.9%), reaching an alarming rate whencompared to the 1986 level (11.5%). In 1989,purchasing power fell 60%. The economiccontraction and inflation sparked laborunrest and concern about the future ofinvestment and development projects.Hence, the next quadrennium may be char-acterized by austerity measures in the publicsector, including health programs.

During the last four years, the VIINational Plan for Social and EconomicDevelopment for 1985-1989 set the contextfor the major developments in the Venezue-lan health sector. The Ministry of Healthand Social Welfare was charged with design-ing and putting into effect a national healthsystem that would bring the 72 separate enti-ties that provided health care services in thecountry under unitary and cohesiveleadership.

In 1985 and 1986 the ministry draftedthe foundations of an historic new healthsystem and introduced the bill to theNational Congress. The Congress passedthis bill, the Organic Law for the NationalHealth System, in 1987. It places all public-sector services devoted to the protection of

health under the management and adminis-tration of the health ministry. These servicesinclude all medical care and related activitiesprovided by various state agencies andautonomous institutions, with the exceptionof those of the National Armed Forces.

The law also nationalizes services pro-vided by federal institutions and agencies,municipalities, and civil and commercialcompanies in which the national govern-ment holds a controlling share, capitalinvestment, or interest. This reform processreorganized the health system so that itsbasic administrative units are now centeredin "health subregions" based in each state.

In addition to medical care services, thenew National Health System is made up ofother subsystems, including environmentalprotection and environmental health hazardcontrol and social welfare programs.

The government also created the Stand-ing Commission on Primary Health Care tooversee the delivery of preventive servicesthroughout the country. Based on a recentlystrengthened epidemiologic surveillance sys-tem, the preventive services are aimed ataddressing the most pressing problems in acommunity-such as maternal and childhealth, nutrition, and environmental sanita-tion-through controlling key risk factors.

In adopting this approach to the deliv-ery of primary care services, the ministry alsoplaced emphasis on training personnel in



epidemiology and its main analytic tools. Asa result, effort was put into strengthen-ing the National Commission for Develop-ment of the Teaching and Practice ofEpidemiology.

In regard to priority health projects, theministry executed a medium-term programto arrest the spread of AIDS, developed pro-tocols and carried out in-service research onoccupational health, continued its campaignto extend the coverage of the Expanded Pro-gram on Immunization (including the polioeradication campaign), evaluated and stand-ardized food safety projects, and promotedfamily involvement in nutrition education.In the area of tropical diseases, specialemphasis was placed on control of malaria,leprosy, and leishmaniasis. The Pan Ameri-can Center for Research and Training inLeprosy and Tropical Diseases served as theepidemiologic intelligence center for theseprojects. The AMERICARE Foundationprovided financial support for the nationalleprosy control program.

The UNDP, meanwhile, financed aresearch project on tropical diseases endemicto the Amazonas Federal Territory. Theproject benefited from advice by PAHO/WHO technical staff and also received fundsfrom the World Bank/UNDP/WHO SpecialProgram for Research and Training in Tropi-cal Diseases.

Urban rabies and foot-and-mouth dis-ease were not completely eradicated,although progress was made toward thatgoal for both diseases. In a project under-written by the IDB, the Agricultural Invest-ment Fund and the Ministry of Agricultureand Livestock collaborated with PANAF-TOSA toward creating a national foot-and-mouth disease vaccine production capabilitythat will eventually provide enough immu-nobiologicals for export to the rest of theAndean Subregion. The University of Zuliawas selected as the School of Animal Healthfor Latin America, and it established a mas-

ter's degree in preventive medicine in theVeterinary School. Venezuela has alreadydonated yellow fever vaccine to the Carib-bean Epidemiology Center (CAREC) and,through PAHO/WHO, to several Carib-bean countries.

In the area of physical infrastructure, thehealth sector completed a three-year plan toreconstruct and remodel existing hospitalsand 1,000 ambulatory care facilities, serving20,000 people each. The Infrastructure andEquipment Foundation was established as ameans of ensuring the maintenance of thefacilities and their expansion when neces-sary. PAHO/WHO carried out a detailedsurvey of needs in this area and has proposeda subregional project for consideration byoutside funding sources.

In addition to lending technical coopera-tion on the above projects, PAHO/WHOwas particularly active in efforts toward thetraining of highly qualified health personneland creation of a first-rate information base.To that end, special emphasis was placed onredesigning the Central University of Vene-zuela's curriculum for health professionalsand establishing a master's program in theepidemiology of metoxenous diseases at theSchool of Malariology, which trains peoplefrom all over the Americas. Attention wasalso paid to training health promoters andnurses, working with the National Commis-sion for Development of the Teaching andPractice of Epidemiology, and collaboratingwith the National Council on Scientific andTechnological Research and other nationalagencies to set up a documentation base andinformation network.

The Sanitary Works Institute madeheadway in a joint project with the IDB andPAHO/WHO to improve the quality ofdrinking water in the central region of thecountry. It also assigned priority resources tothe environmental sanitation and recoveryproject in the Tuy River Basin that wasundertaken with UNDP and UNEP support.

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SOUTHERN CONE HEALTH INITIATIVE

In August 1986 the Ministers of Healthof Argentina, Brazil, Chile, Paraguay, andUruguay began the Southern Cone HealthInitiative. Meeting in Montevideo with tech-nical teams and the PAHO/WHO Represen-tatives from those countries, as well as theDirector, PASB, and technical staff, theMinisters examined common problems andplanned joint actions to address them.

The Ministers decided to update existingagreements on border health problems andto meet every two years. They also agreedthat annual technical discussions should beheld to foster the exchange of informationand experiences on priority health problems,decide on subregional or bilateral actionsthat promote better use of resources, andassess the extent to which each country com-plies with the recommendations of the jointtechnical and ministerial meetings.

At the Southern Cone Ministers' Meet-ing held in Buenos Aires in November 1988,Bolivia was incorporated as a full member ofthe initiative.

The October 1989 technical workinggroup meeting that took place in Santiago,Chile, selected four common priority areas,reviewed work done so far, and programmedactivities in detail. The four priority areasare disaster preparedness, border health,AIDS virus transmission control, and essen-tial pharmaceuticals and biological products.The following were some of the key recom-mendations of the meeting:

Disaster preparedness. To make prepared-ness a permanent priority for discussion atthe Ministers' meetings throughout theInternational Decade for Natural DisasterReduction; to include manmade hazardssuch as chemical and radiation accidents inthe definition of "disasters"; to form a subre-gional Operational Committee of the South-ern Cone for Health Emergencies, made upof the technical officers of the ministriesresponsible for disaster relief coordination

and preparedness; to assign countries asfocal points, on a rotating basis, to monitorthe technical and educational activities car-ried out (Argentina is to be the first site); torequest that PAHO/WHO find extrabudge-tary funds to finance a full-time technicalofficer to support the subregional effort; tomodernize direct communications betweenthe national disaster programs; and to stepup emergency training programs.

Border health. To draw up legal instru-ments to facilitate joint health projects alongborders; to develop an epidemiologic controlproject focused on malaria, dengue, yellowfever, and American trypanosomiasis (Cha-gas' disease); to train staff in control methodsfor infectious diseases prevalent in borderzones; and to design and test a common epi-demiologic intelligence system.

AIDS. To rank risk factors in patientspresenting with several; to study the possibil-ity of adopting subcategories for classifyingheterosexual transmission; to adopt the casedefinition used by PAHO; to provide thematerial, technical, and administrativerequirements to study and manage infectedcases; to ensure 100% screening of bloodsupplies; to take into account existing regula-tions related to infectious diseases before cre-ating new legislation regarding AIDS; and toconsider the ethical principles established inthe UN Declaration of Human Rights, inorder to avoid social segregation and stigma-tization of infected persons and theirfamilies.

Pharmaceuticals, vaccines, and blood prod-ucts. In continuation of the areas of workagreed upon in the technical meeting held inApril 1988, to stimulate bilateral and multi-lateral activities in production and commer-cial exchange of essential pharmaceuticals;to study and resolve the classification andcertification of pharmaceuticals and biologi-cal products; to exchange informationregarding procurement and purchase; to

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carry out public information programs onthe proper use of drugs; and to coordinateinformation regarding ethical norms fordrug advertising, quality control to ensuretheir safety and effectiveness, and storageand distribution. The group furthermorecalled for the establishment of a data bankon pharmaceuticals, equipment, services,manpower, and analytic capability; a com-parative analysis of health legislation; astudy of supply and demand of vaccine prod-

ucts; and joint subregional studies on the useand consumption of medicines.

The selection of these concrete areas forjoint subregional action represents signifi-cant headway in coordinating resources tosolve critical problems in the area. Since thedifficult financial situation of the countriesinvolved may jeopardize the full execution ofthe projects, PAHO/WHO has presentedseveral of them to interested fundingsources.

ARGENTINA

Argentina's public health sector hascome under serious scrutiny since civilianrule was reinstated in 1983. Two distinctphases marked the last quadrennium: 1986through 1988, and 1989. The first period wascharacterized by relative political stability,the second by an early change in govern-ment as the long-brewing economic crisiscame to a head. The political climate had adecisive impact on health policies.

Up to 1989, the Ministry of Health andSocial Action worked steadily to ensure thatthe country's health care delivery systemwould increase coverage as well as equity inthe quality of care. "Federalization" withrespect to health measures was at the core ofthe new planning approach.

In undertaking this initiative to revampand modernize the health services deliverysystem, the health ministry made use ofexpertise in the fields of health financing,strategic analysis, and planning, and carriedout extensive staff training programs. It alsorequested that PAHO/WHO provide assis-tance by evaluating the status of health careand by organizing its technical cooperationin accordance with the modern managementtechniques called for by structural reform.

After an extensive evaluation of the sta-tus of the national health care delivery sys-tem, seven program categories emerged aspriorities: managerial reform for national

health development, health policy coordina-tion, program and service development,institutional development, financial coordi-nation, federalization of the health sector,and health and welfare intersectoralcoordination.

The analysis phase, which concentratedlargely on the distribution and coverage ofcurative services based in hospitals andhealth centers, showed that funding for thepublic health sector had eroded over theyears as more and more of these serviceswere taken over by the private sector. As oflate 1988, for example, 66% of hospital bedswere in the public sector, but they accountedfor only 40% of total hospital discharges.The loss of revenues exacerbated the inequi-ties inherent in a two-tiered health care sys-tem, in which those who could afford privatecare paid for it, while those who could notwere treated in increasingly deficient publicfacilities. As a result, the ministry's planningstrategy emphasized finding new means offinancing public care.

Another problem that emerged fromstudy of the configuration of the nationalhealth services was the skewed manpowerprofile. Medical doctors were graduating at arate of 5,000 yearly. This meant that Argen-tina had a ratio of one doctor for every 355people, although most of them practiced inthe Buenos Aires metropolitan area. Mean-

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while, there was a critical shortage of ade-quately trained public health personnel,including nurses. The ministry thereforeconcentrated its efforts-and the technicalcooperation it requested from PAHO/WHO-on bolstering the federalization pol-icy through diversified manpower training inthe provinces.

Simultaneously, the newly reinstatedEnvironmental Health Project developed aNational Environmental Plan to address sev-eral key areas: expansion of the water andsewerage network, occupational health, andtoxicology and hazardous substancescontrol.

By 1988, most of these reform initiativeswere in place. The process culminatedtoward the end of the year when new legisla-tion-the National Health Insurance Law-was enacted to create a single health systemguaranteeing universal coverage. However,the new policy impetus was thwarted by theexplosion of the economic crisis.

Spiraling inflation, unemployment, andthe first food riots in the country's historybrought public programs to a standstill. Pres-idential elections resulted in a new govern-ment headed by the main opposition party,which took over earlier than scheduledbecause of the escalating social emergency.Faced with public demands for urgent mea-sures, the new government's health ministryallotted its resources to emergency distribu-tion of food and medicine, nutritional sur-veillance, supplementary feeding programsfor children, and preventive health care forpregnant women and infants.

The changes taking place in nationalhealth policies are reflected in the technicalcooperation that PAHO/WHO will be offer-ing over the next quadrennium. In additionto placing continued emphasis on maternal

and child health, environmental health, andnutrition programs, the new governmenthas singled out AIDS and vector-borne dis-eases as targets for special control measuresover the coming period. Likewise, healthinformation and statistics are being reap-praised and given priority at the level of theHealth Status Secretariat, as these areas weresubstantially affected in recent years by per-sonnel and funding reductions.

PAHO/WHO has strong regional pro-grams in each of the above technical areasand will also assist the ministry in obtainingexternal financing and arranging collabora-tive projects with other agencies. In themeantime, the Organization has acted as asource of program continuity. While reor-ganization was taking place at the centrallevel of the ministry, PAHO/WHO pro-ceeded with manpower training in the prov-inces and provided extensive technicalcooperation in water supply and sanitation,preparedness for radiological accidents andhandling of hazardous substances, environ-mental pollution control, occupationalhealth, and hospital infection control. Atthe ministry's request, PAHO/WHO dedi-cated a large amount of its resources to thisenvironmental health component. A projectand a protocol that are ready for signatureestablish a subcenter of the Pan AmericanCenter for Human Ecology and Health inthe province of Misiones.

With PAHO/WHO technical coopera-tion, the government has obtained supportfrom two major lending institutions. TheIDB is providing $US124 million for devel-opment of provincial hospital infrastructure,and the IBRD approved US$12 million formanpower training, health information,national health insurance, and decentraliza-tion plans.



BRAZIL

In 1986 the VIII National Health Con-ference of Brazil launched a reform move-ment founded on the principle that health isa right of all citizens and, as such, its protec-tion should be guaranteed through aUnified National Health System that is or-ganized democratically. Moreover, accordingto the Health Reform Statement, healthstatus should be considered "the result ofnutritional conditions, habitat, education,adequate income, environment, work, trans-port, freedom, leisure time, access to land,and access to health services." The UnifiedNational Health System would consequentlybe based on a comprehensive epidemiologicunderstanding of health interventions thatare broader than medical-hospital care.

In October 1988, the national constitu-tion incorporated this groundbreaking con-cept in its articles, thereby expresslyasserting the State's responsibility to safe-guard the health of all of its citizens andestablishing the juridical basis for the Uni-fied National Health System. Specifically,Article 196 states that "Health is the right ofall [citizens] and the duty of the State toguarantee, through social and economic pol-icies that aim to lessen the risk of sicknessand other ills and to [ensure] universal andequal access to actions and services for itspromotion, protection, and rehabilitation."

The main directives set out in the 1988constitution are to decentralize services tothe states and municipalities, provide inte-grated services with emphasis on preventivehealth, and democratize the delivery of ser-vices by promoting community participa-tion. The following priority functions areassigned by law (Article 200) to the healthsector: controlling and supervising healthprocedures, products, and substances andparticipating in the production of drugs,equipment, immunologic antibodies, bloodproducts, and other inputs; carrying outhealth and epidemiologic surveillance activi-

ties, as well as activities concerning worker'shealth; directing the training of humanresources in the health sector; participatingin the drafting and implementation of basicsanitation measures; promoting scientificand technological development within thehealth area; supervising food processing andinspecting foodstuffs (including monitoringtheir nutritional content) and beverages andwater for human consumption; helping tocontrol and supervise the production, trans-portation, storage, and utilization of psycho-tropic, toxic, and radioactive substances andproducts; and collaborating in protection ofthe environment, including the workplaceenvironment.

The transition to full reorganization ofthe health services started prior to itspromulgation in the constitution and willcontinue until it succeeds in replacing themarket-based system of the past. Nationalhealth authorities and PAHO/WHO staffhence spent a major part of the quadren-nium designing the Health Reform proposal,models for delivery systems, managerialchanges, and continuing education pro-grams for health professionals.

A second major focus of action was theproduction and quality control of essentialpharmaceuticals and vaccines. The aim ofthe program is for Brazil to supply its ownoral polio, measles, yellow fever, rabies, DPT,DT, tetanus toxoid, and diphtheria vaccines,as well as snake antivenin, by 1992. Soonthereafter, Brazil hopes to produce enough ofthese biologicals for export to other coun-tries in Latin America and Africa.

PAHO/WHO and the Institute of Qual-ity Control in Health collaborated on qual-ity control and trained technicians in liquidchromatography, toxicology, and researchmethods for the medicinal use of native flora(a joint project with Cuba and China). Insupport of the research and productionaspects of vaccine and pharmaceutical self-

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sufficiency, work toward supplying the nec-essary infrastructure continued throughoutthe quadrennium.

Maternal and child health was a priorityamong national preventive health programs,and PAHO/WHO and UNICEF were activein this area. Brazil sponsored two interna-tional WHO meetings on the subject and setup its own national, state, and municipalcommittees to monitor and analyze data onmaternal and infant morbidity and mortalitypatterns. Childhood survival measures thatwere undertaken included controlling diar-rheal and respiratory diseases, developingcommunity health education projects, andplanning a data reporting system on mater-nal and child health. As a complementaryactivity, the National Food and NutritionInstitute carried out research projects andmanpower training in coordination withother agencies.

In environmental health, the State BasicSanitation Technology Company played aleading role in training engineers throughvarious courses, including one on watertreatment plant design and water qualitymonitoring.

In December 1988 Brazil was the site ofthe II Pan American Teleconference onAIDS. The national program to control andprevent AIDS invests a large part of itsresources in measures to prevent humanimmunodeficiency virus contamination ofblood bank supplies, as well as in health edu-cation and promotion of behavior change.

In addition to the AIDS program, con-tinued surveillance and control were neces-sary for yellow fever, schistosomiasis,malaria, and other endemic diseases in thenortheast and the Amazon Basin. TheWorld Bank provided financial support tothese efforts and, along with the UnitedNations Development Program, sponsoredspecial training to qualify people to carry outoperational research in tropical diseases.

The food control program also focusedon training and on coordinating the exportand import of food with other countries andinternational agencies. The MonitoringCommission maintained surveillance ofmeat commerce with the countries in theRio de la Plata Basin.

Regarding zoonoses, urban rabies isresponding to control measures and isdeclining steadily, especially in the south ofthe country. The control program empha-sized training personnel in the use of rabiesvaccine and diagnostic supplies. The Secre-tary of Health of Paraná State drew up aproject to control taeniasis and cysticercosis,which includes environmental engineeringand sanitation as well as nutrition and vac-cine components.

Technical cooperation between Braziland other countries took the form of infor-mation sharing and collaboration with its 10bordering neighbors, especially in the con-trol of infectious diseases, the exchange ofconsultants, and the training of personnel.Joint projects were discussed with Argen-tina, Bolivia, Chile, Paraguay, and Uruguayregarding infectious diseases, AIDS, pharma-ceuticals and vaccines, disaster preparedness,and women in health and development.

Brazil signed pacts with Paraguay to con-trol rabies; with Mexico to cooperate inenvironmental health; with Colombia tocollaborate in health education; with theAmazonian countries to control malaria,leprosy, and dengue; with Bolivia to supplyhealth inputs and control diseases in theborder zones; and also with Argentina, Guy-ana, and Uruguay to control border-areadiseases. Technical cooperation with thePortuguese-speaking African countries hasbeen increasing in recent years through pro-vision of equipment, materials, reagents, anddrugs and biologicals, and through the train-ing of human resources in nursing and medi-cal schools in Brazil.

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CHILE

As was the case with most of its South-ern Cone neighbors, Chile underwent amajor political change during the quadren-nium, holding democratic presidential elec-tions for the first time since 1970. Since theelections took place in December 1989 andthe transition to the new government isscheduled for March 1990, public policychanges will not be felt until the next period.The Chilean economy showed a modestgrowth rate throughout the quadrennium,real wages stayed steady, and the increase incopper prices meant that foreign exchangeearnings rose.

The nation's health care delivery systemhas been administered on a decentralizedbasis for many years. The National HealthServices System (SNSS) comprises the Min-istry of Health, 13 regions and 27 geographi-cally decentralized health services, aNational Health Fund, and the NationalInstitute of Health. There is also a privateprepayment system that covers about 10% ofthe population. A large part of the ministry'sattention was focused on improving themanagement efficiency of the regional ser-vices by ensuring that critical supplies andequipment were available in the most eco-nomically deprived zones and by carryingout training courses for key personnel. Anumber of health care professionals workingat the municipal level received grants forintensive course work in modern manage-ment methods. Sponsored by the Universityof Chile, the courses were partially fundedby the W. K. Kellogg Foundation.

Technical cooperation provided byinternational organizations and agencies,including PAHO/WHO, has contributed tothe development of health services in Chile.Of special value has been the training of per-sonnel in the implementation of the primaryhealth care strategy, which is the basis of theNational Health Services System. In otherareas of human resources development,

PAHO/WHO technical cooperation hassupported the development of a medicalinformation system for personnel, continu-ing education for health professionals in alldisciplines of the health sector, andresearch.

Notwithstanding the stable economicand political environment, an estimated45% of Chilean families lived in poverty.Therefore, the maternal and child healthprogram, including supplementary feedingand intensive control of diarrheal and respi-ratory diseases, continued to be one of thehealth ministry's priorities. Given the lowrates already achieved, progress in reducingmaternal and infant mortality was lessmarked than in the past, but by 1987 infantmortality reached the lowest rate in thecountry's history, at 18.5 per 1,000 livebirths, down from 120.3 per 1,000 in 1960.

Simultaneously, life expectancy rose to71.5 years, and the burden of health prob-lems typical of older, heavily urban societies(such as cancer and cardiovascular diseases)rose with it. Aware of the changing healthprofile of its population, the governmentestablished programs in adult and adolescenthealth. In addition to the problems of aging,urban concentration has caused seriousenvironmental pollution that now reachesalarming levels in the Santiago metropolitanarea, especially during summer months.Health authorities consider pollution a pri-mary health hazard, and it is proposed thatsubstantial funding be obtained to get con-trol measures under way.

In the area of endemic infectious dis-eases, ongoing surveillance and control pro-grams remained successful, except in regardto tuberculosis, which has not declined asrapidly as expected. Sexually transmitteddiseases have responded well to preventionand treatment measures, and the ministryhas set up a surveillance project and publiceducation campaign for AIDS.

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Lastly, the newly established NationalHealth Sciences Information System (Sis-tema Nacional de Información en Cienciasde la Salud) linked its bibliographic servicesto key health service institutions and univer-

sities. PAHO/WHO has played an instru-mental role in the development andimplementation of this system, providingtechnical and administrative support.

PARAGUAY

In February 1989 Paraguay underwentthe most significant political change in itspostwar history: the government that hadruled for 35 years was transformed into ademocratic government through the elec-toral process. This change in national gov-ernment set into motion a process to reformthe policy and management structure of thepublic sector. Thus, health activities during1989 were characterized by emphasis on theplanning of health sector services.

In the three years preceding 1989 thenational health strategy focused on severalmajor fronts: to extend coverage by increas-ing the number of care facilities and theircapacity (including the building and equip-ping of the Grand National Hospital), totrain public health professionals, and to pro-ceed with regular baseline projects such asmaternal and child health, tropical diseasecontrol, and environmental health.

Meanwhile, health authorities contin-ued the manpower training programplanned for five years, by the end of whichtime the country would have a sufficientnumber of qualified public health profession-als to staff national programs. This approachwas taken to correct the lack of physicians,dentists, pharmacists, and public health per-sonnel that existed in the country. The Min-istry of Public Health and Social Welfare andPAHO/WHO designed several new curric-ula for advanced training that included, forexample, a graduate program in environ-mental health. The W. K. Kellogg Founda-tion and UNFPA also supported thematernal and child health program, and the

former organization provided support forthe in-service training program.

As part of its work to promote the well-being of mothers and children, the health min-istry concentrated on reducing perinatalmortality and extending coverage of theExpanded Program on Immunization, includ-ing the campaign to eradicate polio. A largenumber of resources were required to maintainvaccine supplies and cold chain equipmentand to mobilize the population on special vac-cination days. The vaccination days approachwas problematic, and health authoritiesdecided that better coverage would beachieved if vaccination is done as a regularlyscheduled activity throughout the year.

Although chronic illnesses are graduallybecoming the main causes of morbidity andmortality among adults, infectious diseasesstill take a significant toll in lives and well-being. Surveillance and control of malariaand dengue received priority. Both thesemosquito-borne illnesses are major causes ofmortality and morbidity and are difficult tocontrol. Dengue control measures includedattempts at systematically cleaning up mos-quito breeding sites in population centers,such as those found in refuse areas. Urbanrabies, tuberculosis, food contamination,Chagas' disease, and leishmaniasis are stillimportant public health risks in Paraguay,and ongoing programs for their control weremaintained. It is hoped that foot-and-mouthdisease will soon be eradicated in the easternzone of the country.

Notwithstanding the fact that few con-firmed cases of AIDS have been reported so



far, the ministry established an AIDS sur-veillance system and the beginnings of a lab-oratory research project in the hope of beingable to detect and stem the spread of thisdeadly disease before it affects large segmentsof the population.

The extension of potable water suppliesto rural and periurban dwellers progressedslowly but steadily throughout the quadren-nium. While that infrastructure project con-tinued, city-based water treatment facilitieswere studied to determine the most efficientmeans of improving their capacity. In relatedwork, PAHO/WHO and the ministry ofhealth also undertook a study of the contam-ination of the Paraguay River.

When the change in governmentoccurred in 1989, a National Health Councilwas created with advice from PAHO/WHO.Made up of all the institutions that areactive in health care delivery, the councilnow serves a national advisory function.

The new government's health prioritieswere set out in the Plan for ImmediateHealth Actions. This interim plan served toensure the continuity of projects during1989, while the medium-term health strate-gies were written up in a National HealthPlan. Published in early 1990, the NationalHealth Plan includes an organic charter andorganization manual for the health ministry.It also outlines steps to make better use ofthe existing infrastructure and idle capacity,enhance resource use by collaborating withother public sectors, and convert the statis-tics division into an integrated health infor-mation system.

PAHO/WHO lent its technical coopera-tion to all of the above projects in the formof personnel, supplies and equipment, spe-cial training programs and grants, and epide-miologic surveillance and informationdissemination, as well as in an advisorycapacity during the planning phases.

URUGUAY

By virtue of its demographic and epide-miologic situation, Uruguay presented fewchanges in mortality indicators during thequadrennium, with the exception of a signifi-cant decline in infant mortality (from 29.4per 1,000 live births in 1985 to 20.9 in 1988,a 28.9% reduction).

A proposed law sent by the executivebranch to the Parliament summarized thehealth services situation in the country asfollows: The National Health Organizationwas described as a complex and poorly orga-nized mosaic made up of a variety of hetero-geneous and uncoordinated institutions. Inrecent years, both public and private institu-tions were unable to spend the funds neces-sary to ensure their proper functioning,owing to the socioeconomic crisis in thecountry. Mutualism, a voluntary form of

insurance featuring monthly prepaymentsand equal quotas for all affiliates indepen-dent of their income, had perpetuated socialinequities. Finally, the health system modeloperating in the country did not satisfy theneeds of the population.

The government that was installedshortly after the beginning of the quadren-nium carried out a democratic transitionand developed its management policies inthe middle of an economic crisis similar tothe one faced by the majority of the Region'scountries. In spite of the government'sefforts to increase the proportion of publicspending allocated for health, the resourcesavailable did not allow reversal of the deteri-oration of many public establishments norrestoration of acceptable levels ofinvestment.

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A funding proposal was submitted toIDB for the replacement of a large hospital inMontevideo, as well as the strengthening ofprograms aimed at improving adult health.The Ministry of Public Health fostered andobtained the institutional decentralization ofthe State Health Services Administration,an action that reinforced the ministry'sresponsibility.

A family physician program was insti-tuted and now includes a corps of more than100 professionals, remunerated by means ofa head tax, that provide coverage for morethan 150,000 persons. Vaccination coverageis close to 100%, and both cold chain opera-tion and vaccine availability are adequate.Thorough surveillance has not detected anycases of wild virus poliomyelitis.

Health authorities emphasized environ-mental sanitation, especially urban wastedisposal (at sanitary landfills and the Monte-video biogas production plant, for example)and treatment of wastewater discharged incoastal areas. A project is under study at theIBRD to develop an Environmental Health

Master Plan, a major part of which is exten-sion of water supply coverage in rural areas.

Regional concern about the spread ofAIDS, and the fact that 29 deaths hadoccurred out of 50 diagnosed cases and 309known HIV-positives as of early 1989, ledthe National AIDS Program to strengthenits public education campaign and to importreagents and testing equipment needed toguarantee the safety of the national bloodsupply.

In the rural interior of the country,health personnel worked with the Ministryof Stockraising, Agriculture, and Fisheries toeradicate foot-and-mouth disease, which stilltakes a toll on the economy. Funds for theproject were provided by the IDB.

Another subregional program thatgained momentum was the disaster pre-paredness project. Special attention will begiven to the threat of technological disastersin countries of the Southern Cone. Severalworkshops on norms and procedures arescheduled to take place in Montevideo in1990.

NORTH AMERICA

CANADA

Throughout the 1986-1989 period, Can-ada experienced a deepening social aware-ness of the importance of responsible healthbehavior, of a safer environment, and of theinvolvement of patients in health matters inorder to maintain and increase its presentgood levels of health care.

Canada's high life expectancy attests, ata minimum, to the successes achieved in itsbattle against infectious diseases, which wereprimarily a threat during infancy. Accordingto preliminary life tables prepared for the1983-1985 period, average life expectancyincreased by approximately one year for

both males and females, reaching 72.9 yearsfor males and 79.8 years for females. More-over, the primary change since 1931 was notso much the lengthening of old age as anincrease in the proportion of the populationreaching an advanced age. In 1931, 66% ofthe male population could expect to reachthe age of 60; by 1981 the proportion hadincreased to 83%. The corresponding figuresfor females were 68% and 90%.

The present Canadian policies andapproaches toward health issues began toemerge in the late 1950s. In 1957, federallegislation provided the basis for universal

.



prepaid hospital insurance. A decade later,comprehensive complementary medicalinsurance legislation provided a broad rangeof medical and hospital benefits to the peo-ple of Canada. Services were provided by theprovinces in accordance with national stan-dards. Provincial governments added a widearray of other benefits beyond those coveredby the national insurance program, rangingfrom dental services for children and freeprescription drugs for senior citizens toorthodontic and prosthetic aids.

Five basic principles guide the currentCanadian approach to health care: univer-sality (all Canadians have access to the sys-tem regardless of income); portability(moving from one province to another doesnot change a person's type of coverage);comprehensiveness (all services provided byhospitals-drugs, dressings, rooms, surgery-are covered, and all physician visits are paidfor by the government); accessibility (healthfacilities are reasonably accessible to every-one); and public administration (the systemis directed by the government, not the pri-vate health sector, although the provision ofservices rests with the private sector). Thefederal government refunds the provincesabout 50% of the cost of care. The provincialgovernments pay the remainder throughvarious methods, including taxation, indi-vidual premiums, or premiums shared byemployer and employee.

The present federal-provincial healthinsurance program covers about 97% of theCanadian population. National health poli-cies are in accord with provincial and territo-rial policies, since they are developed withfederal, provincial, and territorial represen-tation. Professional medical and voluntaryhealth agencies contribute substantially tothe formulation and design of health policy.Attention is targeted to groups with specialneeds, such as the elderly and handicapped.Heart diseases, cancer, accidents, mental ill-ness, and chronic diseases are priority issues.There are three levels of service: primarycare is available and accessible to all throughlocal family practitioners (in sparsely popu-lated areas, public health nurses provide this

service); secondary care is available in areahospitals; tertiary care is available inregional hospitals.

Provincial, regional, and municipalhealth authorities manage primary healthcare services, such as the provision of safewater and sewage treatment; operate publichealth programs, such as communicable dis-ease surveillance and control and healtheducation; provide inspection of food ser-vices; offer home and hospital care to moth-ers and newborns; and provide healthservices in schools, such as immunizationclinics and preventive care dental clinics. Inthe province of Québec, for example, localcommunity health centers are involved insuch activities as providing referrals to hospi-tals and social service agencies and assistingin the development of support groups. Reha-bilitation and home care services often aresupplied by the health authorities and vol-untary agencies.

Awareness of the importance of healthpromotion and disease prevention throughhealthful behavior, a safer environment, andpatient involvement paved the way for areorientation of health initiatives and thedevelopment of new promotion and preven-tion programs. National health concernsalso included health care cost increases, anissue common to North America and otherdeveloped countries; provincial differencesin financing long-term and home care; excesshospital capacity; and oversupply of physi-cians. The number of active civilian physi-cians, including interns and residents,increased almost 33% from 1975 to 1985,while the population grew only 11.4%.Nonetheless, the geographic and functionaldistribution of physicians remains uneven.To stimulate interest in practicing in nonur-ban areas, many of the provinces have estab-lished incentive programs in collaborationwith the federal government and profes-sional associations to support undergraduateand postgraduate medical students in termsof guaranteed incomes, location grants, andon-the-job training in rural areas.

Canada developed a set of health poli-cies and orientations, which it released in a

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strategy document, "Achieving Health forAll: A Framework for Health Promotion," atthe first International Conference on HealthPromotion held in Ottawa in 1986. The doc-ument defines the country's three majorhealth challenges: reducing inequities inhealth, increasing disease prevention, andenhancing abilities to cope with chronicillness and disability. Public participation,strengthened community health services,and coordinated public health policy wereseen as essential elements in achieving theself care, mutual aid, and healthy environ-ments needed to meet these challenges.

Collaboration among federal, provin-cial, territorial, regional, and municipal gov-ernments, together with the efforts ofprivate, professional, and voluntary agen-cies, has also produced several health poli-cies and initiatives. These include thenational program to prevent driving underthe influence of alcohol, the national AIDSstrategy, the senior citizens initiative, thenational program to strengthen communityhealth, and guidelines to develop mentalhealth policies and programs. These andother initiatives are evidence of the strongintersectoral collaboration for achievinghealth goals that occurred in Canada overthe period. As further examples, the federaldepartments of health and labor and theTreasury Board announced a policy tostrengthen the existing tobacco control pro-gram and include smoking cessation as agoal; the Action on Drug Abuse Programwas coordinated by 10 federal departments;the Canadian Environmental ProtectionAct resulted from wide consultation withenvironmental groups, industry, labor, and

provincial governments, and is designed toprotect the public and the environmentfrom industrial chemicals; and the healthycities project involved creating a networkthat includes the Federation of CanadianMunicipalities, the Canadian Institute ofPlanners, and the Canadian Public HealthAssociation, as well as founding a nationalcoordinating office supported by the Depart-ment of National Health and Welfare.

Canada's international health develop-ment and assistance policies are imple-mented through various governmentalagencies and, increasingly, with the collabo-ration of nongovernmental organizations.The priorities and resources for Canadiandevelopment assistance are determined bythe Cabinet, and funds are channeled pri-marily through the Canadian InternationalDevelopment Agency (CIDA). Officialdevelopment assistance is currently 0.5% ofthe Canadian gross national product (1988figures). The Department of National Healthand Welfare provides technical advice andcarries out a well-established program ofinformation and personnel exchange withdeveloped and developing countries.

PAHO/WHO contributed to develop-ing and mobilizing Canadian resources tohelp make Canadian expertise available toPAHO/WHO and the other Member Coun-tries. It also supports training of Canadianprofessionals by providing short-term fellow-ships. Some competitively selected Canadi-ans were provided fellowships for studies toincrease their understanding of state-of-the-art approaches in fields such as multilateraldevelopment, public health, and the bio-medical sciences.

MEXICO

Despite severe resource limitations,Mexico made advances in bettering thehealth of the population. The majority ofMexicans have access to health service facili-

ties, and regulated population growth hasbeen achieved. However, coverage by healthservices of adequate quality is still insuffi-cient in marginal urban and rural areas, and



in general there continue to be shortages ofmedical materials, equipment, instruments,and pharmaceuticals, as well as inadequatefunds for their maintenance. Notwithstand-ing the country's accelerated urbanization,the population continues to settle in ruralareas, making the improvement of servicesmore difficult. In accordance with the broadgoal of its health, social welfare, and socialsecurity policy, the government continued topromote universal access to preventivehealth care.

The specific national health prioritiesduring the 1986-1989 quadrennium were toincrease the quality of health services;redress inequalities in access; modernize anddecentralize the management of the healthsystem; ensure adequate availability ofdrinking water, sewerage, and sanitation ser-vices; and undertake measures to controlenvironmental pollution.

PAHO/WHO technical cooperation inMexico was oriented toward developinglocal health systems and was focused onseven national programs: the developmentof health services, disease control, healthpromotion, environmental sanitation, fam-ily planning, social welfare, and supportprograms.

PAHO/WHO cooperated in the imple-mentation of the 1984-1988 NationalHealth Program and the decentralization ofhealth services in order to improve theircoordination. Other activities involvedupdating the juridical framework withinwhich the health sector operates and estab-lishing planning and coordination mecha-nisms to avoid duplications and waste ofresources. Support also was provided forconsolidation of the national informationsystem on health services infrastructure, pro-grams, productivity, control, and impact.

Emphasis was placed on strengtheninglocal health systems by increasing manage-ment and decision-making skills at key levels

of the health sector. Agreements and proce-dures were established to overcome prob-lems in training personnel, maintainingsupplies of basic inputs, and conserving andmaintaining logistical support requirements.

The Secretariat of Health began rehabil-itating 1,550 health centers and 950 otherhealth service units, representing 70% of itsfacilities. It also added 118 new rural healthcenters to its services, as well as 94 familytreatment units that were transferred fromthe Mexican Social Security Institute. Theseadditional facilities extend coverage to 2,385localities with a combined population of onemillion.

Among the most' important achieve-ments of PAHO/WHO technical coopera-tion were the improved administrative andtechnical capacity of health services opera-tion in the states that were decentralized, theServices Reconstruction Project in the met-ropolitan area, the project to extend primaryand secondary health care infrastructures,the reorientation of epidemiologic surveil-lance and control toward clustering preven-tive health measures designed to reducerisks, coordination with the Mexico-IDBmanagement improvement project, and sup-port for the environmental health programin the prevention and control of air, water,and soil pollution. PAHO/WHO also lenttechnical cooperation for a project to pro-mote efficient water use and control waterloss in Cuernavaca and for the institutionaldevelopment of the State Commission onTijuana-Tecate Public Services.

The new government administrationthat was installed on 1 December 1988 forthe period 1988-1994 ratified the politicaldecision to decentralize the health services,emphasizing the strengthening of their oper-ative structure, and intensified actions of sol-idarity as means of extending coverage andimproving the quality of life of the popula-tion served.

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PAHO/WHO FIELD OFFICE, EL PASO, TEXAS

The 2,000-mile long United States/Mexico border is shared by 10 states that-despite socio-cultural, economic, andpolitical differences-also share public healthconcerns. During the 1986-1989 quadren-nium chief concerns included providing con-tinuing education for public healthprofessionals, building information systemsin support of technical projects, and stan-dardizing reporting procedures for epidemio-logic surveillance of diseases in the borderarea.

The PAHO/WHO Field Office in ElPaso, Texas, acted primarily as an informa-tion coordination center to facilitate theidentification of border health projects andassist in their execution. The projects inwhich it participated increased in numberduring the quadrennium from 26 to 36 andaddressed key areas of binational concern:maternal and child health, AIDS preventionand control, substance abuse prevention,tuberculosis control, hospital administra-tion, and rabies control.

The Field Office carried out its coopera-tion activities principally by supportingefforts to obtain and transfer informationthrough such means as surveys, researchprojects, workshops, seminars, publications,and coordination with the mass media. Italso contracted specialists for short-termassignments in direct technical cooperation.

Information systems were established forborder maternal and child health projects(including the Perinatal Information Sys-tem), AIDS public education materials, aborder laboratory network, the UniversityNetwork for 'information exchange, andother binational technical projects. A surveyon drug abuse reviewed the nature and

extent of that problem along the border andidentified opportunities for future epidemio-logic research and prevention initiatives, aswell as barriers to those activities.

The U.S./Mexico Border Health Associ-ation's maternal and infant risk assessmentand training improvement project (ProjectMIRAR), funded by the United States Gov-ernment, sponsored workshops on high-riskpregnancy assessment for lay midwives, aux-iliary health workers, and nurses on bothsides of the border.

The Carnegie Corporation of New Yorkand Pew Charitable Trust awarded the FieldOffice a two-year grant for a project on pri-mary health care and maternal and childhealth technologies for women, adolescents,and children. The project is scheduled forcompletion in 1990.

In July 1988 testing of a counseling out-reach program began in Ciudad Juárez, Chi-huahua. The program collects data andcarries out health education and promotionprograms among women who engage inprostitution, use drugs intravenously, or arethe sexual partners of I.V. drug users.

The Field Office issued six bimonthly,quarterly, or annual health publications andestablished a system to routinely forwardinformation on its activities to newspapers,radio stations, and state and local publichealth agencies. By 1989 the Field Office wasoffering 80 courses and seminars yearly, andhad sponsored or supported another 70binational technical meetings over the qua-drennium. It also provided support to borderhealth programs by reviewing or developingproject proposals and submitting them tofunding sources.

144


UNITED STATES OF AMERICA

The approach toward health issues inthe United States of America reflects someof the most basic assumptions of the society:individual rights, individual responsibility,and an emphasis on private, nongovernmen-tal production and distribution of goods andservices. Thus, about 60% of health carecosts are paid by private insurers or thepatients themselves, while federal, state, orlocal governments finance most of the rest.The provision of health services is over-whelmingly in the hands of the privatesector.

Decision making and resources are notcontrolled at one single point in the healthsystem. Decisions regarding a provider aregenerally made by the patient, althoughsome newer organizational approaches, suchas health maintenance organizations, limitchoices to some degree.

Health planning and management arehighly dispersed among federal, state, andlocal entities-both governmental and non-governmental. The states are the principalgovernmental units responsible for publichealth activities and have in turn delegatedresponsibility for some health-relatedefforts-particularly the direct delivery ofhealth services-to local entities. All statesare involved in planning and policy develop-ment, and data collection occurs at federal,state, and local levels.

The federal government directly sup-ports activities such as assessment, policymaking, resources development, knowledgetransfer, financing, and some delivery of per-sonal health care. Its role includes establish-ment of national health goals and objectives;management of surveys regarding the pub-lic's health status and health needs; conductof biomedical, clinical, and health servicesresearch; regulation and inspection of foodsand drugs; and provision of technical assis-tance to states and local health systems. It

also indirectly supports most service pro-grams through contracts with states, locali-ties, and private organizations.

Most of the federal resources available tothe states are in the form of block grants thatthe states use to support their own priorityactivities. State health agencies, which havemajor responsibility for administering thesehealth activities, vary in the breadth of theirmandate and their placement within thestate government. With guidance from thefederal government, state legislature, andoutside groups, these agencies set healthpolicy.

The nearly 3,000 local health agenciesalso vary in size and responsibility, butmainly provide preventive health servicessuch as communicable disease control, res-taurant inspections, and food- and water-borne disease investigation. Their fundingprimarily originates from state and federalprogram grants.

Other entities involved in health plan-ning, research, and policy developmentinclude professional organizations, nonprofitorganizations formed around specific healthissues or diseases, organizations that repre-sent specific citizen groups, and foundationsthat support health research and programs.These groups seek to influence or supportspecific health issues through encouragingpolitical action, focusing public attention,and financing health projects.

A major planning effort that has drawnthese various entities together has been theestablishment of Objectives for the Nation-1990 and the current development of theYear 2000 National Health Objectives, whichidentify achievable goals for the nation inspecific priority areas. In developing andmonitoring these objectives, the federal gov-ernment has worked and continues to workwith health-field entities at all levels withinand outside of government. The objectives

145


have provided a planning tool at thenational level and have guided state healthagencies in setting priorities.

The 1990 objectives address reductionsin mortality and morbidity among U.S. citi-zens in five major age groups, focusing onspecial problems in each group. For healthyinfants (below one year of age) the goal is toreduce mortality by 35%, with special focuson low birth weight and birth defects. Forhealthy children the goal is 20% fewerdeaths, with special focus on growth anddevelopment. The goal for healthy adoles-cents and young adults (ages 15-24) is 20%fewer deaths, with emphasis on preventingmotor vehicle injuries and alcohol and drugabuse. For healthy adults (ages 25-64), thetarget is 25% fewer deaths, with a focus onheart attacks, stroke, and cancer. Lastly, thegoal for healthy older adults (age 65 andover) is to achieve 20% fewer sick days, byfocusing on functional independence andprevention of influenza/pneumonia. Thesegoals are supported by 226 measurable objec-tives-set in 1980 to be achieved by 1990-that emphasize many aspects of primarycare.

Federal-level programs exist to helpassure that primary care services are pro-vided to persons living in medically under-served areas and to persons with specialneeds. The Public Health Service, within thefederal Department of Health and HumanServices (HHS), is responsible for providingprimary health care services in underservedareas and for the redistribution of healthcare professionals to areas with shortages.Although only about 0.2% of the populationlacks access to a practicing physician and98% of the population resides within 25miles of a general or family practitioner,some 35 million persons reside in under-served areas, evenly divided between urbanand rural locations.

In an effort to close this gap, the federalgovernment provides health care to specificpopulations. HHS is directly responsible forthe health care of almost one million Ameri-can Indians and Alaska Natives, through a

network of hospitals and clinics, and otherpopulation groups. Federal block grants pro-vide funds to states for maternal and childhealth and preventive health programs, aswell as alcohol and drug abuse preventionand mental health activities. A federal grantprogram furnishes limited support for com-munity health centers for the underservedpopulation.

The federal government sponsors pro-grams for graduate education of physiciansin primary care, concentrating on familymedicine, general internal medicine, andgeneral pediatrics. In implementing healthmanpower plans, two particularly trouble-some problems are providing sufficienthealth personnel in geographic areas that areunattractive practice settings due to insuffi-cient or marginal economic support, profes-sional isolation, or other factors, andfinancing additional training for health pro-fessionals in a time of increasing competitionfor funds. The current supply of nurses maybe insufficient and a shortfall in the supplyof dentists is projected. Rehabilitation spe-cialists and certain types of public healthworkers are in demand. The approach tosolving the complex problems of the U.S.market for health personnel is to achieve ahigher degree of coordination in efforts ofthe federal government, the states, and theprivate sector to remove manpower con-straints on the delivery of necessary healthservices.

It is expected that by 1990, 35% of thenational objectives for the year 2000 willhave been met. Revision of the nationalhealth objectives for the year 2000 started in1987, and the final document is expected tobe published in September 1990. The revi-sions were necessary because of changinghealth conditions during the recent qua-drennium. AIDS, for example, has become amatter for serious public health and sociopo-litical concern.

Projections made in the fall of 1989 sug-gest that approximately 390,000 to 480,000AIDS cases will have been diagnosed in theUnited States by the end of 1993, causing

146


between 285,000 and 340,000 cumulativedeaths. The number of diagnosed andreported cases is expected to increase eachyear. Current estimates put the average costof care at $US75,000 per AIDS patientthroughout the course of the disease, butcost projections are difficult due to the avail-ability of drugs such as AZT and betterpatient care.

Health care financing emerged as animportant public concern. While the UnitedStates spends a larger share of its grossnational product on health than any otherindustrial nation, the system still leavesmany gaps in meeting the needs of the poor,the elderly, the unemployed, and those whorequire long-term care. Approximately 52million of the nation's citizens had theirhealth care needs partially met in 1988through Medicare (for the elderly) and Medi-caid (for the poor)-an increase of five mil-lion people, or 11%, above 1980 levels.These programs have been assisting approxi-mately one in every five U.S. citizens.

PAHO/WHO provides technical coop-eration to the United States in the form offellowships for U.S. health professionals,and arranges for U.S. nationals who areexperts in specialized fields to serve as con-sultants in other countries, upon request.Public Health Service bilateral programs his-torically have been the main mechanism ofHHS cooperation with other PAHO/WHOMember Countries. Within the PublicHealth Service, the National Institutes ofHealth (NIH) is particularly active in inter-national cooperation activities, having

devoted close to $US100 million per year tosuch projects in recent years. This amountincludes grants and contracts to foreign sci-entists and institutions to carry out researchas a part of the NIH extramural researchprogram, and funding for over 1,500 foreignscientists who work in NIH laboratories.

The regulatory role of the Food andDrug Administration (FDA) also requires itto interact with a number of foreign govern-ments. It provides technical assistance andguidance to other governments regardingU.S. import regulations and restrictionsapplied to food, drugs, medical deliveries,and cosmetics.

The U.S. Agency for InternationalDevelopment (USAID) functions as thecountry's main channel for internationalfinancial contributions in health and health-related areas. In fiscal year 1990, funding forUSAID's programs in health, family plan-ning, child survival, and AIDS preventionin the Americas totals $US85.7 million. TheUSAID health policy continues to stressincreasing life expectancy in developingcountries through reduction of infant andchild mortality and morbidity, as well asmaternal mortality and morbidity, and useof child survival interventions, includingbroadened coverage of new, basic, and effec-tive technologies and improved systems fordelivery of child survival services. Other pri-orities include primary health care, waterand sanitation, vector control, AIDS pre-vention and control, health care financing,and research.

147

INDEX

Accidents, 11, 67, 68, 80Acquired immunodeficiency syndrome (AIDS), xiv, 3,

7, 39, 43, 44-45, 47, 63-67, 80, 82, 83, 87, 90, 93,94, 96, 97, 98, 99, 100, 101, 102, 103, 106, 107, 109,111, 115, 116, 131, 132, 134, 136, 137, 139, 140,143, 144, 146-147

Acute respiratory infections, 26, 55, 58, 60, 61, 119Administration, 38, 75-78Adolescents, health of, 31, 55, 58, 59Adults, health of, 16, 29, 48, 67-69Advisory Committee on Health Research (PAHO/

WHO), 45, 47Aedes aegypti, 3, 83, 106, 120Aedes albopictus, 3, 96Agency for International Development (see United

States Agency for International Development)Agency for Technical Cooperation of the Federal

Republic of Germany (GTZ), 52, 53, 54, 93, 123AIDS (see Acquired immunodeficiency syndrome)AIDS Information Exchange Centers, 66AIDS: Profile of an Epidemic, 10Alcoholism, 67, 68Amazon Cooperation Treaty, 122American Association of Retired Persons (AARP), 31,

39American Hospital Association, 18American Medical Association (U.S.A.), 18, 39American Public Health Association (U.S.A.), 29, 37,

39American Region Planning, Programming, Monitoring,

and Evaluation System (AMPES), 6AMERICARE Foundation, 131Andean Cooperation in Health, xiv, 2-3, 7, 11, 121-

122Andean Parliament, 122Andean Subregion, 22, 31, 54, 67, 70, 71, 121-131Anguilla, 87Animal health (see Veterinary public health; Zoonoses;

individual diseases)Annual Operating Program Budget (APB), 6Anopheles, 62Antigua and Barbuda, 81-82Arab Gulf Program for United Nations Development

Organizations (AGFUND), 68, 70, 72Argentina, xii, 7, 12, 15, 16, 18, 23, 25, 26, 27, 37, 39,

70, 71, 132, 133-134, 136Argentine hemorrhagic fever, 61, 62Aruba, 100Association of Schools of Public Health (ASPH,

U.S.A.), 13Australia, 59, 97

Bahamas, 29, 82-84Barbados, 50, 67, 85-86Basic Radiology System (WHO), 27Belgium, 59, 108Belize, 11, 20, 27, 110-111Bermuda, 24, 86Bibliographic Exchange Service, 42BIOFORCE (France), 70, 116Biologicals (see Vaccines and biological products)Biosafety, 26-27Biotechnology, 47BIREME (see Latin American and Caribbean Center

on Health Sciences Information)BITNET, 10, 42Blindness prevention, 67, 68Blood and blood products, 22, 65Boletln de la Oficina Sanitaria Panamericana, 39Bolivia, 22, 27, 31, 37, 45, 49, 54, 70, 74, 122-124, 136Brazil, xii, 12, 15, 16, 18, 20, 23, 25, 26, 27, 37, 39, 45,

54, 56, 63, 66, 67, 70, 71, 72, 74, 97, 135-136British Virgin Islands, 87British West Indies, 87Brucellosis, 70Budget and finance, viii, 1, 2, 5, 6, 7-8, 10-11, 75-76Building fund, 4, 76, 77Bulletin of the Pan American Health Organization, 39

Cajanus, 49Canada, xiv, 7, 29, 39, 70, 80, 93, 94, 129, 140-142Canadian International Development Agency (CIDA),

29, 35, 53, 54, 96, 99, 102, 142Canadian Public Health Association (CPHA), 29, 56,

58,60,80,96, 142Cancer, 23, 67-68Cardiovascular diseases, 67CARE, 123Caribbean Area (see also under each country), xiv, 16,

18, 24, 29, 31, 34, 35, 49, 50, 52, 53, 55, 63, 66, 67,70, 80-107

Caribbean Community (CARICOM), 1, 80, 81, 82Caribbean Cooperation in Health, xiv, 1, 2, 7, 11, 80-

81,82, 86, 93, 94, 97, 100, 102, 103, 106,107Caribbean Development Bank, 52, 53, 81Caribbean Epidemiology Center (CAREC), 12, 63, 66,

75-76, 82, 86, 87, 90, 94, 101, 102, 103, 106, 111,131

Caribbean Food and Nutrition Institute (CFNI), 49-51,76,88,91, 101,102, 103, 106, 107, 111

Caribbean Program Coordination, 35, 93, 101, 107Caribbean Public Health Association, 80

148

índex 149

Caries, dental (see Oral health)Carnegie Corporation, 7, 29, 60, 144Cartagena Accord, 122Cayman Islands, 87-88CD-ROM, 7, 10, 42, 100Center for Biologics Evaluation and Review (U.S.A.),

22Centers for Disease Control (CDC, U.S.A.), 13, 25, 29,

54, 59, 70, 72Central America, 15, 20, 21-22, 30, 31, 37, 49, 54, 66,

67, 70, 107-121Plan for Priority Health Needs in, xv, 7, 11, 21, 37,

92, 93, 107-110, 111 (see also under each coun-try)

Central American Economic Integration Bank, 22, 117Central American Industrial Technology Research

Institute, 69Central American Information System on Women,

Health, and Development (SIMUS), 31Central American Institute for Business Administra-

tion (INCAE), 18, 50CEPANZO (see Pan American Zoonoses Center)CEPIS (see Pan American Center for Sanitary Engi-

neering and Environmental Sciences)Chagas' disease, 61Challenge of Epidemiology, The; Issues and Selected Read-

ings, 10, 13Chibret International, 68Children, health of (see Maternal and child health,

including family planning)Children of the Caribbean, 50Chile, 20, 24, 26, 27, 37, 39, 42, 50, 54, 60, 63, 66, 67,

70, 71, 136, 137-138China, 135Chronic diseases, xiii, 67, 80CLAP (see Latin American Center for Perinatology and

Human Development)Clinical technology, 26-28Colombia, 15, 18, 20, 22, 24, 26, 27, 29, 31, 50, 54, 60,

63, 67, 70, 72, 74, 124-126, 136Communicable diseases, 48, 61-63, 66, 96, 131, 132Community participation, 28-30, 72Computer systems, 7-8, 10, 35, 42, 43, 75, 100Conference and general services, 76Conference of Ministers Responsible for Health in the

Caribbean, 1, 80Consultants, technical, 48, 59, 63, 77Costa Rica, xiv, 18, 21, 23-24, 25, 26, 27, 29, 39, 42, 50,

66,67,70,71,108, 109, 111-113Country Representations, PAHO/WHO, 6, 10-11, 30,

43, 75Cuba, xiv, 18, 24, 26, 27, 39, 42, 54, 60, 67, 69, 70, 88-

90, 97, 135Cysticercosis, 61, 71

Decentralization (see Local health systems)Democratization, xi, xiv, 9, 15Dengue, 61, 62Denmark, 7, 108, 109Dental health (see Oral health)Diabetes, 67Diarrheal diseases, xiii, 29, 51, 55, 58, 59, 60, 61Directing Council, PAHO, viii, 1, 2-4, 30, 32, 49, 56,

62, 76

Disabled, health of, 67, 68, 118Disasters (see Emergency preparedness and disaster

relief coordination; Hurricanes)Diseases (see specific diseases)Documentation and information centers, 11, 42-43Dominica, 49, 90-91, 93Dominican Republic, 22, 26, 27, 45, 54, 66, 69, 70, 72,

91-93Drug abuse, xiv, 3, 39, 48, 67, 68, 121Drug policy, 20Drugs, essential, and vaccines, 18, 21-23, 29, 37, 109,

118, 121, 132-133, 135 (see also Vaccines and bio-logical products)

ECO (see Pan American Center for Human Ecologyand Health)

Economic Commission for Latin America and theCaribbean (ECLAC), xii, xiii, 16, 18, 30

Economic crisis, effect on health, xi-xvi, 3, 9, 11, 16, 36Ecuador, 16, 20, 22, 25, 26, 31, 49, 63, 126-128Editorial service, 39Educación médica y salud, 37, 39Education (see Health education and community par-

ticipation; Human resources development; Train-ing of personnel)

Egypt, 59Elderly, health of, 11, 67, 68El Salvador, 25, 26, 27, 29, 70, 72, 108, 113-114Emergency preparedness and disaster relief coordina-

tion, 3, 31, 34-36, 51, 118, 121, 126, 132Environmental health, xv, 15, 29, 48, 51-55, 80, 85, 96,

112 (see also Pollution, environmental)Environmental Protection Agency (U.S.A.), 54Epidemiological Bulletin (PAHO), 13Epidemiology, 11-14,30, 68

surveillance, 55, 57, 63, 64, 68, 69-70, 71, 73training in, 13, 38, 63, 68

Essential drugs (see Drugs, essential, and vaccines)Essential Drugs Action Program (WHO), 22, 81Essential Drugs Revolving Fund for Central America

(FORMED, PAHO), 21-22, 78, 120European Economic Community (EEC), 7, 60, 70, 71,

72,93, 106, 108, 110, 111,116Excreta disposal, 51-53Executive Committee, PAHO, viii, 1, 4, 76Expanded Program on Immunization (EPI), xiv, 22, 56,

57, 58, 74, 78, 82, 90, 95, 97, 103, 106, 115, 116,126, 128, 129, 131, 138

Revolving Fund, 22, 75, 100, 101Expanded Textbook and Instructional Materials Pro-

gram, 38, 58

Family planning (see Maternal and child health,including family planning)

Fellowships program, 4, 38, 102Field Office, PAHO/WHO, El Paso (Texas), 144Filariases, 61, 62Finance (see Budget and finance)Financial management, 5, 7-8, 11, 75Finland, 7, 108, 109Finnish International Development Agency, 119Fluoridation of water and salt, 23-24

Index 149


Food and Agriculture Organization of the UnitedNations (FAO), 69

Food and Drug Administration (FDA, U.S.A.), 23, 147Food and nutrition, xv, 4, 37, 48, 49-51, 60, 80, 96,

109, 129Food protection, 69-70Foot-and-mouth disease, 48, 69, 71, 72France, 7, 49, 80, 81, 90, 93, 102, 108French Antilles, 91, 93-94French Guiana, 91, 93-94

General services, 76-77German Development Bank, 123Germany, Federal Republic of, 7, 70, 80, 97, 108, 126Global Program on AIDS (WHO), 63, 64, 66, 82, 87,

91, 93, 101, 102Goiter, endemic, xv, 24, 50, 123Governing Bodies, vii-viii, 1-4, 5, 6, 32, 39, 47, 55, 67,

76Grenada, 26, 94Guadeloupe, 93-94Guatemala, 15, 20, 23, 26, 29, 63, 69, 70, 108, 114-115Guyana, 7, 24, 95-97, 136

Haiti, 27, 49, 63, 70, 91, 97-99Headquarters, 76-77Health communications, 43, 44-45, 63Health Conditions in the Americas, 14, 30, 61Health economics, 39, 141, 147Health education and community participation, 18,

28-30Health information, xiv, 12-14, 49-50, 63, 66Health legislation, 15, 17, 21, 30-31, 54, 69, 84Health personnel (see Human resources development)Health planning, 14-17, 48, 58, 68Health policies development, 9, 14-17, 30, 48Health programs development, 48-74Health promotion, 18, 28, 48, 63, 67, 68Health services

development, 9, 16, 17-21, 24, 30, 47, 48-74, 121organization of, 141, 145research, 21, 47, 48

Health Services Research Bulletin, 21Health Services Research Foundation (U.S.A.), 21Health situation and trend assessment, 9, 11-14, 60, 63Health systems infrastructure, 9-47Health Training Program for Central America and Pan-

ama (PASCAP), 37-38, 60, 109, 111, 113, 114Helminthiases, 61Hemispheric Foot-and-Mouth Disease Eradication

Committee, 71Hepatitis, viral, 61, 62Hipólito Unanue Agreement, 2, 121Honduras, 15, 16, 29, 69, 108, 109, 116-117Hospitals, xv, 18, 20, 22, 34Human growth, development, and reproduction, 55,

59, 60Human immunodeficiency virus (HIV), 23, 25, 26, 64,

65, 66Human resources development, 9, 13, 15, 23, 24, 25, 34,

36-39, 59-60, 80, 101, 108, 109Human resources system, 8, 77-78

HurricanesGilbert, 5, 31, 35, 51, 99Hugo, 3, 31, 35, 82, 87Joan, 5, 31, 71,117

Hydatidosis, 71Hygiene, household, 51, 53

Immunization (see Expanded Program on Immuniza-tion)

India, 59Infants, health of (see Maternal and child health,

including family planning)Information and public affairs, 35, 43-45, 66

centers (see Documentation and information centers)coordination, 7-8, 77management and dissemination, 27, 30, 39-43, 48,

53, 58, 62systems, 6, 10, 15, 24-25, 31, 39, 41-43, 50

Institute of Nutrition of Central America and Panama(INCAP), 49-51, 60, 76, 109, 111, 113, 114, 116

Institute of Women (Spain), 30, 31Instructional materials, 16, 17, 20, 22, 29, 31, 34-35, 38,

44,51,54,58,59,60,68,70Inter-Agency (PAHO/WHO-FAO-UNICEF) Food and

Nutrition Surveillance Program, 49Inter-American Association of Sanitary and Environ-

mental Engineering (AIDIS), 51Inter-American Development Bank (IDB), 6, 7, 14, 16,

20, 21, 49, 52, 53, 54, 56, 58, 60, 62, 70, 71, 83, 84,85, 92,93,98, 99, 105, 108, 110, 112, 116, 120, 123,124, 129, 131,134, 140, 143

Inter-American Institute for Cooperation on Agricul-ture (IICA), 30

Inter-American Meetings, at the Ministerial Level, onAnimal Health, 69, 76

International Agency for Research on Cancer (IARC),67-68

International Atomic Energy Agency (IAEA), 27International Bank for Reconstruction and Develop-

ment (IBRD), 123, 134, 140International Center for Research on Women, 49International Classification of Diseases (ICD), 14International Decade for Natural Disaster Reduction,

35-36, 132International Dental Federation, 25International Development Research Center (IDRC,

Canada), 21, 29, 52, 54, 106International Drinking Water Supply and Sanitation

Decade, 52, 129International Red Cross, 66International Union for Health Education, 28, 29Intersectoral and interinstitutional coordination, 34,

37, 55 (see also Social security institutions, coordi-nation with health sector)

Iodine deficiency disorders, 49, 50 (see also Goiter,endemic)

lodization of salt, 24Italy, 7, 35, 59, 60, 80, 97, 108, 110, 114, 124, 126

Jamaica, 15, 20, 23-24, 29, 35, 50, 51, 63, 99-100Japan, 7, 34, 35, 59, 70, 108, 126Japanese International Cooperation Agency, 34, 54


índex 151

Joint Commission on Health Services Accreditation, 18Joint (PAHO/WHO-UNICEF) Nutrition Support Pro-

gram, 49, 102, 103, 129

Kellogg Foundation, W. K., 7, 20, 24, 60, 137, 138Kingdom of the Netherlands (see Netherlands, King-

dom of the)

Laboratory animal science, 69, 71, 74Laboratory services, 22-23, 26-27, 62, 69, 72-73Latin American Association of Faculties and Schools of

Medicine (ALAFEM), 37Latin American Association of Faculties and Schools of

Nursing (ALADEFE), 37Latin American Association of Social Medicine, 37Latin American Cancer Research Information Project

(LACRIP), 67Latin American and Caribbean Association for Educa-

tion in Public Health (ALAESP), 13, 37Latin American and Caribbean Center on Health Sci-

ences Information (BIREME), 7, 15, 25, 39, 42, 60Latin American and Caribbean Health Sciences Infor-

mation Network, 39Latin American and Caribbean Institute for Economic

and Social Planning (ILPES), 18Latin American Center for Perinatology and Human

Development (CLAP), 58, 59, 60Latin American Center on Demography (CELADE),

14Latin American Development Administration Center,

16Latin American Economic System (SELA), 11Latin American Health Sciences Literature Data Base

(LILACS), 10, 15, 39, 92Latin American Network for Epidemiologic Surveil-

lance of Food-borne Diseases, 69Latin American Network of Drug Quality Control

Laboratories, 22Leishmaniasis, 61, 62Leprosy, 61, 62Leptospirosis, 61, 71LEYES data base, 15Library (PAHO), 42-43Library of Congress (U.S.A.), 15LILACS (see Latin American Health Sciences Litera-

ture Data Base)Lions Club International, 66Local health systems

development of, xiv, 2, 9, 10, 17-21, 24, 26, 28, 47,56, 108, 127, 129

research on, 20

Madrid Conference, II, 7, 108Malaria, 3, 29, 37, 61, 62, 109, 121, 123Malnutrition, 49 (see also Food and nutrition)Management

executive, 5general program development and, 5-8

Managerial process for national health development,10-11

"Managerial Strategy for the Optimal Use of PAHO/

WHO Resources in Direct Support of MemberCountries," 79

Martinique, 93-94Maternal and child health, including family planning,

xiv, xv, 24, 29, 32, 37, 48, 49, 50, 55-61, 80, 95, 97,98, 102, 103, 110, 121, 123, 129, 137, 144

Measles, xiv, 55Medicine, traditional, 25, 135MEDLARS, 42MEDLINE, 50, 63, 92Mental health, 31, 39, 67, 68Mérieux Foundation, 70, 72, 116Mexico, 11, 15, 16, 18, 20, 24, 25, 26, 27, 31, 37, 39, 42,

49, 56, 63, 66, 69, 70, 136, 142-143, 144Midlife and Older Women in Latin America and the Carib-

bean, 31Mobilization of external resources, xiv, xv, 6-7, 48, 56,

60Montserrat, 35, 87Mortality

infant, xv, 59, 61maternal, 3, 32, 55, 59, 61

National Institute of Allergy and Infectious Diseases(U.S.A.), 66

National Institute of Occupational Safety and Health(U.S.A.), 85

National Institute of Virology (Mexico), 22National Institutes of Health (U.S.A.), 25, 39, 66, 74,

147National Library of Medicine (U.S.A.), 42National Organization of Blind Spaniards (ONCE), 68Netherlands Antilles, 27, 100Netherlands, Kingdom of the, 7, 59, 100, 108, 109, 114,

120, 126Nicaragua, xii, 20, 39, 49, 67, 108, 109, 117-119Noncommunicable diseases, 67-68North America, 140-147Norway, 7, 30, 108, 109Norwegian Agency for International Development, 119Nursing, 20"Nutrient-cost tables," 50Nutrition (see Food and nutrition)Nyam News, 49

Occupational health, 15, 48, 51, 54-55Onchocerciasis, 61, 62Oral health, 23-26Oral rehydration therapy, 50, 55, 59, 61Organization of American States (OAS), 16, 29, 108Organization of Faculties, Schools, and Departments of

Dentistry of the Union of Latin American Univer-sities (OFEDO/UDUAL), 25, 37

"Orientation and Program Priorities for PAHO duringthe Quadrennium 1987-1990," vii, xiv, xv, 1, 6, 36,79, 82

Oswaldo Cruz Foundation (Brazil), 62, 63Ottawa Charter for Health Promotion, 28Overseas Development Agency (U.K.), 22

PALTEX (see Expanded Textbook and InstructionalMaterials Program)

Index 151


Panama, 29, 63, 70, 108, 119-121Pan American Center for Human Ecology and Health

(ECO), 51, 53-54, 134Pan American Center for Research and Training in

Leprosy and Tropical Diseases, 131Pan American Center for Sanitary Engineering and

Environmental Sciences (CEPIS), 51-54, 85Pan American Federation of Associations of Faculties

and Schools of Medicine (FEPAFEM), 37Pan American Federation of Nursing Professionals

(FEPPEN), 20, 37Pan American Foot-and-Mouth Disease Center

(PANAFTOSA), 69, 71, 131Pan American Health and Education Foundation

(PAHEF), 126Pan American Sanitary Bureau, vii, viiiPan American Sanitary Conference, vii, 1-2, 30, 36, 54,

69, 76, 77, 79, 80Pan American Technical Standards Commission, 69Pan American Teleconferences on AIDS (I and II), 43,

44-45, 64-65, 66, 76, 136Pan American Zoonoses Center (CEPANZO), 22, 60,

69,70,71Paraguay, 15, 49, 63, 70, 136, 138-139Parasitic diseases, 61-63 (see also individual diseases)Participation, social (see Health education and commu-

nity participation)PASCAP (see Health Training Program for Central

America and Panama)Perinatal health, 32, 58, 61 (see also Maternal and child

health, including family planning)Personnel, PAHO/WHO, 77-78 (see also Staff develop-

ment and training)Peru, xii, 15, 16, 18, 24, 25, 26, 27, 31, 34, 39, 42, 49, 52,

54, 70, 74, 128-130Peruvian Primatology Project, 74Pew Charitable Trust, 60, 144Pharmaceuticals (see Drugs, essential, and vaccines)Plague, 61Plan for Priority Health Needs in Central America (see

Central America, Plan for Priority Health Needs inCentral America)

Poliomyelitis, eradication campaign, xiv, 3, 7, 44, 48,55, 56-57,60,61

Pollution, environmental, 11, 48, 51, 53-54, 110Population Council, 59Portugal, 42Primary health care, 17, 18, 24, 28, 31, 55, 62, 67, 68Primary Health Care and Local Health Systems in the

Caribbean, 18Primates, nonhuman, 71, 74Procurement services, 78Program budget, 2, 6Program development, general, 5-8Project Hope, 99, 116Publications, distribution and sales, 39Publications, official and technical, 10, 31, 39, 40-41Puerto Rico, 25

Quota contributions, 2, 75

Rabies, xv, 48, 69, 70, 72-73, 115Radiological technology, 27-28

Reagents, laboratory, 26, 47Recomendaciones de la Comisión Internacional de Protec-

ción Radiológica, 10, 27Regional Director's Development Program, 5Regional Operative Network of Food and Nutrition

Institutions (RORIAN), 50Regional Potable Water Committee (CAPRE), 93, 108,

110Regional Training Program in Food and Nutrition Sur-

veillance (PAHO), 50Rehabilitation, 67, 68Renal insufficiency, chronic, 16, 67Research

grants program, 16, 31, 46promotion and development, 30, 45-47, 48, 59

Residents program, 38-39Resources Development Institute, 59Rickettsioses, 61Right to Health in the Americas, The: A Comparative Con-

stitutional Study, 84Rockefeller Foundation, 21, 70, 72Rotary International, 7, 56, 58, 60, 96, 99, 116, 124, 126Royal Commonwealth Society for the Blind, 68

Saint Kitts and Nevis, 4, 49, 101Saint Lucia, 7, 49, 93, 101-102Saint Vincent and the Grenadines, 49, 102-103"Salud para Todos," 43, 44Sanitation, xv, 29, 51-53, 110Schistosomiasis, 61Scientific and technical information, 9, 39-43Sewerage (see Sanitation)Sexually transmitted diseases, 63Smoking (see Tobacco use)Social security institutions, coordination with health

sector, xv, 10, 15, 17, 55Solid waste management, 51, 53, 110South America, 121-140South American Foot-and-Mouth Disease Control

Commission (COSALFA), 71Southern Cone, 31, 67, 70, 71Southern Cone Health Initiative, xiv, 11, 22, 124, 132-

133Sovereign Order of Malta, 70, 72Spain, 7, 13, 18, 26, 30, 31, 39, 42, 51, 69, 70, 108, 116,

126Spanish Cooperation, 93Special Meeting of the Health Sector of Central Amer-

ica (RESSCA), 54-55, 92, 108Special Program for Research and Training in Tropical

Diseases (UNDP/World Bank/WHO), 62, 131Staff development and training, 6Staff Rules, 4Standing Subcommittee on Inter-American Nongov-

ernmental Organizations in Official Relations withPAHO, 4

Subcommittee on Planning and Programming, viii, 4,76

Subcommittee on Women, Health, and Development,4, 76

Subregional initiatives, xiv, xv, 2-3, 79 (see also undereach initiative)

Suriname, 24, 103-104Sweden, 7, 30, 49, 60, 108, 109


mdcx 153

Swedish International Development Authority, 62, 119Switzerland, 49, 108

Taeniasis, 61, 71Technical cooperation, PAHO/WHO, at subregional

and country levels, 79-141Technical cooperation among countries, 11Technology

development, 16, 17, 25evaluation, 16rationalization, 67research, 45-47

Telecommunications, 35, 43, 44-45, 64-65, 66 (see alsoPan American Teleconferences on AIDS)

Tetanus neonatal, 55-58Tobacco use, 3, 67Training of personnel, xv, 13, 16, 20, 23, 25, 26, 29, 34,

36-37, 38-39, 48, 50, 51, 53, 55, 59-60, 62, 63, 66,71 (see also Human resources development)

Translation and interpretation, 75, 76Trinidad and Tobago, 7, 24, 25, 27, 63, 80, 82, 96, 104-

106Tuberculosis, 61

bovine, 70-71Turks and Caicos Islands, 107

UNICEF (see United Nations Children's Fund)Union of Latin American Universities (UDUAL), 9,

25, 37United Kingdom, 7, 59, 85United Nations, vii, 35, 114

Subcommittee on Nutrition, 50United Nations Center for Human Settlements, 18United Nations Children's Fund (UNICEF), 6, 7, 29,

30, 38, 44, 56, 58, 60, 82, 90, 91, 93, 96, 97, 101,102, 103, 106, 108, 110, 111, 116, 119, 123, 124,125, 126, 129, 136

United Nations Development Program (UNDP), 6, 7,18, 20, 26, 29, 30, 52, 53, 62, 70, 88, 90, 93, 96, 99,107, 108, 114, 116, 119, 121,123, 131, 136

United Nations Educational, Scientific, and CulturalOrganization (UNESCO), 18, 29, 95

United Nations Environmental Program (UNEP), 131United Nations Fund for the Development of Women

(UNIFEM), 30United Nations Fund for Drug Abuse Control

(UNFDAC), 83, 84, 126United Nations High Commissioner for Refugees,

Office of (UNHCR), 114United Nations Population Fund (UNFPA), 6, 7, 29,

30, 31, 60, 93, 97, 98, 99, 102, 107, 108, 114, 116,123, 124, 126, 129, 138

United Nations University, 50United States Agency for International Development

(USAID), 49, 55, 58, 60, 62, 70, 72, 74, 93, 99, 111,114, 116, 123, 124, 126, 129, 147

United States of America, xiv, 7, 11, 18, 27, 29, 30, 32,35, 39, 42, 54, 67, 68, 70, 74, 93, 108, 109, 110, 144,145-147

United States Army Research and Development Com-mand, 62

United States Congress, 14, 66United States-Mexico Border Health Association, 144University and Health in Latin America and the Carib-

bean in the Twenty-first Century (USALC-XXI), 9,37

University of Valle (Colombia), 50, 63University of the West Indies, 15, 16, 50, 81, 100, 105University of Wisconsin (U.S.A.), 70, 72Uruguay, 16, 25, 26, 70, 136, 139-140

Vaccination, xv, 55, 57, 59, 61 (see also Expanded Pro-gram on Immunization)

Vaccines and biological products, 21-23, 56, 62, 70, 71,72

Vector-borne diseases, 61-63 (see also individual dis-eases)

Venezuela, 12, 15, 18, 23, 24, 25, 26, 27, 31, 39, 42, 67,70, 97, 100, 130-131

Veterinary public health, 29, 68-74, 131Violence, 11, 67

Water supply, xv, 51-53, 102, 110"With Healthy Living," 50Women, health, and development, 3, 7, 29, 30-31, 32-

33, 77Advisory Committee of the Director on, 30Regional Program on, 30-31, 32-33, 60Subcommittee on, 4, 76Technical discussions on, 30

Workers' health (see Occupational health)World Bank, 6, 7, 20, 29, 37, 39, 52, 53, 54, 62, 70, 97,

98, 102, 108, 123, 124, 126, 136World Food Program, 49, 119, 123World Health Assembly, 57World Health Organization, vii, viii, 1, 7, 20, 21, 25, 27,

39, 62, 67, 75, 81, 90, 122World Summit of Ministers of Health on Programs for

AIDS Prevention, 66

X rays (see Radiological services)

Yellow fever, 61

Zoonoses, 69, 70-71, 72-73, 136 (see also Pan AmericanFoot-and-Mouth Disease Center; Pan AmericanZoonoses Center)

Index 153

Acronyms and Corresponding Agencies or Programs

ACHRAMPESBIREMECARECCARICOMCDCCEPANZOCEPISCFNICIDACLAPCOSALFAECLACECOEECEPIFAOGTZIAEAIBRDIDBIDRCIICAINCAPLACRIPNIHOASPAHEFPAHOPANAFTOSAPASBPASCAPUNUNDPUNEPUNESCOUNFDACUNFPAUNHCRUNICEFUNIFEMUSAIDWFPWHO

PAHO/WHO Advisory Committee on Health ResearchAmerican Region Planning, Programming, Monitoring, and Evaluation SystemLatin American and Caribbean Center on Health Sciences InformationCaribbean Epidemiology CenterCaribbean CommunityCenters for Disease Control (U.S.A.)Pan American Zoonoses CenterPan American Center for Sanitary Engineering and Environmental SciencesCaribbean Food and Nutrition InstituteCanadian International Development AgencyLatin American Center for Perinatology and Human DevelopmentSouth American Foot-and-Mouth Disease Control CommissionEconomic Commission for Latin America and the Caribbean (UN)Pan American Center for Human Ecology and HealthEuropean Economic CommunityExpanded Program on ImmunizationFood and Agriculture Organization (UN)Agency for Technical Cooperation of the Federal Republic of GermanyInternational Atomic Energy AgencyInternational Bank for Reconstruction and Development (World Bank)Inter-American Development BankInternational Development Research Center (Canada)Inter-American Institute for Cooperation on AgricultureInstitute of Nutrition of Central America and PanamaLatin American Cancer Research Information ProjectNational Institutes of Health (U.S.A.)Organization of American StatesPan American Health and Education FoundationPan American Health OrganizationPan American Foot-and-Mouth Disease CenterPan American Sanitary BureauHealth Training Program for Central America and PanamaUnited NationsUnited Nations Development ProgramUnited Nations Environmental ProgramUnited Nations Educational, Scientific, and Cultural OrganizationUnited Nations Fund for Drug Abuse ControlUnited Nations Population FundOffice of the United Nations High Commissioner for RefugeesUnited Nations Children's FundUnited Nations Development Fund for WomenUnited States Agency for International DevelopmentWorld Food ProgramWorld Health Organization

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