Health for all bv the vear 2000... - IRIS PAHO

Health for allbv the vear 2000...

Pan AmericanHealth Organization

Pan American Sanitary BureauRegional Office of theWorld Health Organization

525 Twenty-third Street, N.W.Washington, D.C. 20037, U.S.A.

-

Published also in Spanish with the title:Informe Anual del Director, 1984.

ISBN 92 75 17201 2

ISBN 92 75 37201 3

© Pan American Health Organization, 1985

Publications of the Pan American Health Organization enjoy copyright protection in accordance with the provisionsof Protocol 2 of the Universal Copyright Convention. For rights of reproduction or translation of PAHO publications, inpart or in toto, application should be made to the Office of Publications, Pan American Health Organization, Washing-ton, D.C. The Pan American Health Organization welcomes such applications.

The designations employed and the presentation of the material in this publication do not imply the expression of anyopinion whatsoever on the part of the Secretariat of the Pan American Health Organization concerning the legal statusof any country, territory, city, or area of its authorities, or concerning the delimitation of its frontiers or boundaries.

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Annual Report of the Director 1984

eOfficial Document No. 201

July 1985

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 the PanAmerican Health Organization

1 have the honor of submitting for your consideration the Report of the Director of the Pan Ameri-can Sanitary Bureau (PASB), Regional Office of the World Health Organization, for 1984. Furtherinnovations have been introduced to make this Report a useful working and analytical document andsource of reference.

It has already been said more than once that the Annual Report of the Director is part of the Coun-try/PAHO joint programming cycle, in which in each country problems are identified; priorities aredetermined; and those actions which the governments have decided to develop with the Organiza-tion's collaboration in the frame of reference of health for all by the year 2000 are programmed,carried out, and evaluated. The essential matter of the Report is an analysis of the facts of this processin the Region during the year. Hence, the document presents the results of the efforts of each govern-ment acting separately, and collectively as the Organization, in addressing priority problems and at-taining regional goals and objectives. The document must also show the level of coherence of theactivities promoted and conducted and their relationship to both the Regional Strategies and thepolicies established by the Governing Bodies of PAHO/WHO. To this end, the Report has beenstructured as follows:

Part I presents a Region-wide review of the situation in the health sector, the leading problemsconfronting it, the approaches being taken to solve them, and possible measures for the near future.

Part 11 examines at the regional level the joint Country/PAHO activities in basic areas of healthservice infrastructure and the development of health programs, including special program areas. Italso examines the mobilization of technical and financial resources and summarizes the major prob-lems.

Part III views the work of the Organization's Governing Bodies in light of the Regional Objectivesand Goals. It also describes the measures taken by the governments and the Secretariat to implementthe resolutions they have adopted.

Part IV summarizes the steps taken by the Secretariat to implement the "Managerial Strategy" insupport of national priorities and those taken to implement the resolutions of the Governing Bodies.

Part V discusses the activities that each government carried out with PAHO/WHO cooperation in

relation to national objectives. A first attempt is made to describe the levels of health in the individual

countries and to identify some substantive information on the mobilization of external resources.The Report must be read in conjunction with the Interim Financial Report of the Director for 1984,

which is also presented to the Directing Council for examination. Hence, this document contains noinformation on or analysis of financial aspects.

By virtue of its purposes and structure, this Report is a working document of the Governing Bodiesof PAHO. Therefore, it is hoped that its structure, content, and implications will be examined anddiscussed; its interpretations and innovations will be analyzed; and its general approach and practicalutility to the governments, the Organization, and the Secretariat will be reviewed.

Respectf0

Ca uer de M doDirector

Contents

Part 1I. Regional Overview

Overall Analysis and Trends xi

Part II. Regional Analysis of Joint Government/PAHO/WHO Actions

Chapter 1. Development of the Health Service Infrastructure 1Development of Health Service Systems 1

Situation and Trends 1Planning and Administration 1Organization and Development of the Health Service Network 3Intrasectoral Coordination 5National Information Systems 6Project Formulation and Administration 6Health Service Research 7Health Education and Community Participation 7

Human Resource Development 7Management of Human Resource Development 8Training of Health Personnel 9Educational Technology and Teaching Materials 11Bibliographic Information Systems 11Community Health Training Program for Central America

and Panama (PASCCAP) 11Administration of Fellowships 12Expanded Textbook and Instructional Materials Program 16

Diagnostic and Therapeutic Technology 16Laboratory Services 16Radiation Health 17Essential Drugs 18Vaccine and Biologicals Production 19

Chapter 2. Development of Health Programs 23Health Promotion and Care 23

Food and Nutrition 23Institute of Nutrition of Central America and

Panama (INCAP) 26Caribbean Food and Nutrition Institute (CFNI) 29

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Maternal and Child Health and Family Planning 31Latin American Center for Perinatology and Human

Development (CLAP) 34Workers' Health 35Health of the Elderly 36Health of the Disabled 37Oral Health 38Mental Health 38Accident Prevention and Control 39

Environmental Health 40Water Supply and Excreta and Wastewater Disposal 40Solid Waste Management 42Human Settlements and Housing in Urban and Rural Areas 43Prevention and Control of Environmental Pollution 44Development of the Environmental Health Infrastructure 44Pan American Center for Sanitary Engineering and

Environmental Sciences (CEPIS) 46Pan American Center for Human Ecology and Health (ECO) 49

Disease Prevention and Control 51Epidemiology 51Caribbean Epidemiology Center (CAREC) 52Expanded Program on Immunization (EPI) 53Diarrheal Diseases 59Control of Vector-Borne Diseases 60

Malaria 60Aedes aegypti eradication 63Chagas' disease 63Leishmaniasis 64Schistosomiasis 64Onchocerciasis 64

Intestinal Parasitic Diseases 64Acute Respiratory Infections 64Tuberculosis 65Leprosy 66Diseases Subject to International Health Regulations 67

Cholera 67Plague 67Yellow fever 67

Viral Diseases 68Sexually Transmitted Diseases 68Prevention and Control of Noncommunicable Diseases 69

Cardiovascular diseases 69Cancer 71Blindness prevention 72

Veterinary Public Health 73Zoonoses 73Food protection 74

iv

Foot-and-mouth disease 74Nonhuman primates 74

Pan American Zoonoses Center (CEPANZO) 76Pan American Foot-and-Mouth Disease Center (PANAFTOSA) 79

Special Programs 81Priority Health Needs in Central America and Panama 81Emergency Preparedness and Disaster Relief Coordination 83Women, Health, and Development 84Health Statistics 86

Chapter 3. Mobilization of Technical and Financial Resources 87Generation of Knowledge 87

Health Research 87Technology Development 88

Dissemination of Knowledge 89Latin American Center on Health Sciences Information (BIREME) 89Latin American Cancer Research Information Project (LACRIP) 90Health Information and Documentation Center 90Other Information Networks 90

Mobilization of Institutional Capacity 91Networks of National Centers 91Activities of PAHO/WHO's Regional and Subregional Centers 92

Technical Cooperation Among Developing Countries (TCDC) 92Mobilization of International Resources 93Mobilization of External Financial Resources 94

International Lending Agencies 95Bilateral Financial Cooperation 95Foundations and Government Agencies 96

Pan American Health and Education Foundation (PAHEF) 96

Chapter 4. Relevant Problems 97Economic Crisis 97Operational Capacity of the Health Sector 98Essential Drugs 98Technological Problems 99

Part III. Relevant Activities of the PAHO Governing Bodies

Chapter 5. PAHO Governing Bodies 103Action in 1984 on Resolutions of the XXIX Meeting of the

Directing Council (1983) 103Executive Committee and Directing Council (1984) 107Preliminary Draft Program and Budget of the World Health

Organization for the Region of the Americas for the Biennium1986-1987 112

V

Part IV. Activities of the PAHO Secretariat

Chapter 6. Managerial Strategy 115Implementation of the Managerial Strategy 115American Region Programming and Evaluation System (AMPES) 116

Chapter 7. Support Services 117Technical Support 117

Publications 117Translations 119PASB Information Systems 119Public Information 120Legal Matters 120

Administrative Support 121General and Conference Services 121Personnel 121Procurement 122

Part V. Countries' Activities with PAHO/WHO Cooperation

Chapter 8. Summary of Each Country's Activities with PAHO/WHOCooperation 125

Antigua and Barbuda 127Argentina 130Bahamas 134Barbados 136Belize 139Bolivia 143Brazil 147British West Indies 151Canada 154Chile 156Colombia 159Costa Rica 163Cuba 167Dominica 171Dominican Republic 174Ecuador 178El Salvador 182French Antilles and Guiana 185Grenada 186Guatemala 189Guyana 193Haiti 197Honduras 200Jamaica 205Mexico 208

vi

Netherlands Antilles 211Nicaragua 214Panama 217Paraguay 221Peru 225St. Christopher and Nevis 229Saint Lucia 232St. Vincent and the Grenadines 235Suriname 238Trinidad and Tobago 242United States of America 245Uruguay 250Venezuela 253

Index 257

vii

HEALTH FOR ALL BY THE YEAR 2000FRAME OF REFERENCE

REGION OF THE AMERICAS °

1. Characteristics of the Goal of HFA/2000

Comprises the entire population

Priority human groups

Health levels

Levels of well-being

II. Regional Goals

Life expectancy at birth

Infant mortality

Mortality in the 1-4age group

Immunization

Drinking water and basic san-itation-goals for 1990b

Health services coverage

· Population in extreme poverty in rural and urban areas· Human groups exposed to high risk

* Increase of life expectancy at birth by means of:- reduction of the prevalent morbidity- control of communicable diseases- elimination of mainutrition- improvement of the environment

* Accessibility of the population to basic health services, education, shelter, and envi-ronmental services

* Improvement in the levels of family income and food supply* Production and consumption structure aimed at satisfying basic needs

* No country shall have a life expectancy at birth less than 70 years of age

* No country shall have an infant mortality rate higher than 30 infant deaths for chil-dren under 1 year of age per 1,000 live births

* No country shall have a mortality rate in the 1-4 year age group higher than2.4 deaths per 1,000

* 100% vaccination of all infants less than 1 year of age against diphtheria, tetanus,whooping cough, measles, and poliomyelitis

* 100% vaccination against tetanus of pregnant women in tetanus endemic areas

* Water: urban areas: 87% of the population (269 million inhabitants)rural areas: 59% of the population (78 million inhabitants)

* Excreta disposal: urban: 71% (219 million inhabitants)rural: 32% (43 million inhabitants)

* Access of 100% of population to health services system

III. Regional Objectives

* Reorganization and equitable, effective, and efficient extension of healthservices

* Promotion and improvement of intersectoral linkages* Promotion of intra- and interregional cooperation

IV. Regional Strategies to Attain the Goals and Objectives

Primary health care and itscomponents

Mobilization of technical andfinancial resources

* Development of the health services infrastructure* Health promotion and care* Disease prevention and control* Environmental health

* Research and technology* Technical Cooperation Among Developing Countries (TCDC)* International cooperation* Financial resources

°Health for All by the Year 2000, Strategies. PAHO Official Document 173 (1980).b lnternational Drinking Water Supply and Sanitation Decade. First Eyaluation. PAHO/WHO, November 1984.

Part IRegional Overview

Overall Analysis and Trends

The efforts of the governments, the Organi-zation, and its Secretariat to overcome prevail-ing health problems are conducted within thefollowing frame of reference: the goal ofhealth for all by the year 2000 in terms of thewhole population, priority human groups, andlevels of health and well-being; the regionalgoals, objectives, and strategies adopted bythe Member States of the Directing Council ofthe Organization based on HFA/2000; andthe national health priorities defined by thegovernments. An overall view of the state ofhealth of the countries of the Region of theAmericas in 1984 shows that efforts to achievethe regional goals and objectives have encoun-tered substantial obstacles, both within thehealth sector and arising from external prob-lems which have become unusually complexand pervasive.

Foremost among the major constraints is thecrisis the world is going through, especially thedeveloping countries and among them thecountries of the Americas. Some of the mostoutstanding symptoms of that crisis are the in-stability of the balance of payments and thepressures of external debt, as well as domesticproblems such as high rates of inflation, unem-ployment, decreases in income, deteriorationin income distribution, and uncontrollable fi-nancial deficits. Added to this is the reductionof resources to finance social sector programs,especially health activities and those for satisfy-

ing basic needs. The scarcity of resources ismaking it impossible to operate services at thelevels demanded by a steadily growing popu-lation, constituting an additional threat to thehealth situation. Nevertheless, it is possible todetect some symptoms of economic recoveryin several countries which, together with someprospects of moderate economic growth in thedeveloped countries, permit the expectationof better future times. From the political stand-point, changes have occurred that favor insti-tutional normialization and are aimed at estab-lishing democratic governments in which thesociety plays a larger role. It is expected thatthose changes may generate decision mecha-nisms more socially sensible and consequentlywith more priority for the social sectors. How-ever, there are other concerns. The CentralAmerican Isthmus conflict has been aggra-vated and is adding constraints to the solutionof subregional problems.

Even if the crisis wanes and adjustments aremade in social structures that will help improvethe well-being of the population, the recoverywill be slow and lengthy. For that reason, it re-mains imperative for the health sector toachieve greater equity, efficiency, and effec-tiveness in its services. Thus, the thesis is reaf-firmed that the situation will steadily worsenunless changes that make it possible to findnew ways of achieving the objectives comeabout within the sector itself. By itself, the

xi

xii Annual Report

health sector cannot overcome the crisis but itcan mitigate its effects through a better ration-alization of its order of priorities and the fullutilization of its resources.

The major difficulty in the sector is the prob-lem of the timely and effective use of re-sources, revealing serious deficiencies in theoperating capability of health systems. In thisregard, the sector faces enormous challengesin the areas of organization and operation. Themany agencies that provide health services,their lack of coordination, and the scarcity oftrained personnel are factors that lead to dupli-cation and lack of coherence in the care of per-sons at the different levels of complexity of theservices. Waste in the use of resources-eitherbecause of idleness, unnecessary delivery ofservices, deficiencies in organization and man-agement, or the use of inadequate technolo-gies-is a fundamental obstacle. The still in-adequate coverage of the services and the factthat large segments of the population (30-40%) do not have access to basic health ser-vices are matters of serious concern. To facethis situation, health planning and administra-tion should be adjusted and strengthened toenable the health sector to mobilize, organize,and utilize its own resources, as well as to com-plement them with resources from other sec-tors. Special challenges will be assuring thetechnological and organizational adequate-ness of all levels of the health services withinthe primary health care strategy and comply-ing with prevailing conditions in the Region.

In 1984, the governments, with the cooper-ation of the Organization, undertook a numberof projects that have important implications forthe future. Indeed, when the Region as awhole is examined, at least five areas of action,all well defined and closely related, stand out.Their purpose is to achieve better use of re-sources through the adoption of new proce-dures and solutions, the linkage of internal re-sources of the sector and its coordination withother sectors, joint actions by groups of coun-tries in order to combine and make better useof the resources available, effective mobiliza-

tion of national and external resources, andstrengthening of the Bureau's capacity to sup-port national efforts effectively.

New Approaches andTechnology Development

Several steps are now being taken to definenew policies and solutions. Epidemiology isbecoming increasingly important as a usefuland essential element in discovering the fac-tors that influence changes in the health pro-files of the population, which in turn will have adecisive effect on the appropriate distributionof health resources and on decisions concern-ing health policy. Accordingly, developmentand expansion of epidemiological practice arebeing promoted in the countries in order to im-prove knowledge, evaluation, control ofhealth problems, and development of the ser-vices. Specifically, efforts are being made tostrengthen the capabilities of generating andusing information in order to obtain a betterunderstanding of the manifestation, distribu-tion, and causes of disease and of health; eval-uate the impact of the health services; and in-tegrate them within the development process.Strengthening and promoting the epidemio-logical approach also will make it possible toforecast needs, identify and qualify risks, andredefine priorities in the planning and techni-cal-administrative management of services; inother words, prospective epidemiology willmake it easier to define strategies and proposesolutions.

In the area of maternal and child health, vul-nerability due to the demands of the reproduc-tive, growth, and development processes andthe exposure of mothers, children, and fami-lies to factors derived from the biological, so-cioeconomic, and ecological systems highlightthe importance of using the risk factor ap-proach, both for promoting health and con-trolling diseases, as well as for adapting re-sources and efforts to the basic health needs ofthis priority group. This approach follows epi-

Overall Analysis and Trends xiii

demiological criteria for resource allocationand guides Member Governments to formu-late projects in which priority is given to mar-ginal groups, so that major attention is chan-neled to those people who really need it. Atthe same time, specific procedures in childhealth based on high-impact and low-costtechnology have been identified and groupedunder the heading of infant survival. The riskfactor approach together with a rational tech-nology selection for maternal and child carehave been the fundamental guidelines forCountry/PAHO/WHO program formulationand implementation in this field.

The adoption of new approaches has alsobecome urgent in planning and administrationbecause of the changing situation of the healthphenomenon as a whole, the growing de-mand for services by a steadily increasing pop-ulation, and the real decrease in the resourcesof the sector. Based on the countries' experi-ence in this area, PAHO/WHO, together withseveral schools of public health-in particularthat of the University of Antioquia, Colom-bia-has prepared strategic approaches to theplanning and administration of health servicesthat are intended to increase the operating ca-pacity of the system. These conceptual andmethodological developments, aimed at satis-fying the requirements of the goal of health forall, were designed in the light of the endoge-nous and exogenous factors that influenceboth the health of society and service deliverysystems. Their distinguishing features are thatthey are flexible, are inherent in practice, andrecognize and deal with the conflict and itsconjunctures. Instrumental developments incritical areas such as sectoral analysis and fi-nancial analysis are also included. These ap-proaches will be made available to publichealth schools in Latin America as teachingmaterial in planning and administrationcourses; they will also be distributed to institu-tions that make up the health sector.

The need for innovative solutions has alsobecome clear in problems related to water sup-ply and sanitation. An analysis of the status of

water supply and sanitation problems showsthat coverage in urban areas continued to in-crease in 1984, and that by 1990 the goal ofproviding 87 % of the population with serviceswould be achieved. However, this is not thecase for water supply in rural areas, where only42% of the population is covered. Accord-ingly, efforts will have to be redoubled if thegoal of 60% is to be achieved by 1990. A simi-lar deficit is found in urban sewage systemsand rural excreta disposal systems. To over-come these problems, in the frame of refer-ence of the International Drinking Water Sup-ply and Sanitation Decade, activities havebeen aimed at consolidating and acceleratingcoverage through effectively using the limitedfinancial resources and giving preference tomarginal populations of large cities and ruralareas, thereby helping to improve the livingstandards of communities. The new approachemphasizes linking water supply and sanita-tion institutions with those of other sectors in-volved in this task, using the existing mecha-nisms for community participation, rehabilitat-ing services, and strengthening the operationand maintenance of the systems. Of conspicu-ous importance in the implementation of thisstrategy are sectoral analyses and the formula-tion of national plans, which in turn have givenrise to priority projects; the efforts of the gov-ernments to strengthen the managerial capa-bilities of the institutions; and the developmentof effective and low-cost technologies. Thesteps which the governments and the Organi-zation are to take must be aimed at rehabilitat-ing the existing water supply and sewage sys-tems; making optimum use of resources; andextending coverage, giving priority to under-privileged groups.

There is an explicit trend towards reorient-ing the selection of health technology and in-creasing its generation and use in accordancewith the characteristics of the national healthproblems and the resources available. Never-theless, still of concern is the lack of criteria forimportation and utilization of technology, es-pecially the transfer of high-cost technology.Current trends in technology development in

xiv Annual Report

health delivery services show that the healthsector is imparting and utilizing technology in-compatible with the aims and goals alreadyspelled out by the governments. Such incom-patibility is a fundamental factor in the waste ofresources, with negative repercussions inhealth delivery services, staff and patient atti-tudes, and institutional structure and func-tions. Even more serious, it unnecessarily in-creases the operational costs and producesmisleading sectoral policies. Consequently, in-corporation of high-cost technology withoutselection criteria is producing serious distur-bances in resource allocation and utilization,efficiency and efficacy of the health services,and the extension of health services to the un-derserved population.

To deal with these problems, several gov-ernments, with the cooperation of PAHO/WHO, have decided to strengthen their mech-anisms for the selection and importation oftechnologies while increasing their domesticcapability for generating technology. Fore-most among these is the definition of the basesfor analyzing technology development that Ar-gentina, Brazil, Colombia, Costa Rica, Mexico,and Paraguay agreed upon during the Interna-tional Meeting on Technological Developmentin Health, held in Brazil in 1984. Those analy-ses included selection, cost, allocation, dis-semination, and use of technology, and will beput into operation in 1985. Furthermore, pre-liminary steps have been taken to organize anetwork of technological information.

In addition, as part of the PAHO/WHOprograms of cooperation with the govern-ments, new approaches have been developedsuch as simplified systems of x-ray diagnosis,simplified dental systems, effective and low-cost environmental health technologies, sim-ple instruments for measuring nutritional sta-tus, educational technology in the training ofhuman resources, and standards for vaccineproduction. For their part, the PAHO/WHOregional and subregional centers have contin-ued to generate and use techniques and pro-

cedures in specific areas of their responsibility.This field, essential for the effective use of re-sources, will demand greater effort and atten-tion by the governments and the Organizationif it is to be developed.

Intra- and Intersectoral Linkages

The linkage of the resources assigned toeach component of the health sector is particu-larly important for their efficient use. Duringthis period, the linkage of the Ministries ofHealth and Social Security Institutions has be-gun to show concrete results with encouragingprospects for the future. This linkage was ana-lyzed in 1979-1984 in the 16 countries inwhich the two institutions share responsibilitiesin providing health services. The studyshowed that linkage existed at different levelsof development in accordance with the char-acteristics of each country, and that there wasa trend towards delimiting the areas of respon-sibility of the sector's components; spelling outfinancing policies, including the role of the pri-vate sector; and determining the extent of realcoverage in the provision of services. The find-ings of this study were examined at the XXXMeeting of the Directing Council of PAHO andat the Joint Meeting of Ministers of Health andDirectors of Social Security Institutions held inJuly in Medellín, Colombia. The Ministers ofHealth of Central America and Panamaadopted a resolution on the incorporation ofthe directors of social security institutions andthe conversion of their annual meeting into aMeeting of the Health Sector of Central Amer-ica and Panama, clearly indicating the prog-ress achieved in coordination. Other signs ofprogress are the interinstitutional agreementsbeing implemented in Colombia, Costa Rica,Ecuador, Honduras, Panama, and Peru in theareas of planning, organization, and mainte-nance of health services. These agreementsembody the joint approaches of the two sub-systems for dealing with common problems,with PAHO/WHO cooperation. This process

Overall Analysis and Trends xv

should lead to the gradual elimination of dupli-cation and the filling of gaps, making it possibleto extend the delivery of services to the unpro-tected population and consequently to use theresources of the sector equitably.

Foremost among the efforts for promotingthe linkage of the sector with other sectors arethe joint activities of the Organization and theLatin American Institute for Economic and So-cial Planning (ILPES). Those efforts are aimedat developing the conceptual, technical, andmethodological foundations for the introduc-tion of the health dimension and its intersec-toral linkage into the decision-making mecha-nisms of the administrations of the LatinAmerican and Caribbean countries. It is thushoped to define criteria that will be of use to thegovernments in incorporating the health sectorinto their overall and social planning by meansof decision-making and resource allocation.Furthermore, the food and nutrition area alsooffers examples of the implementation of inter-sectoral policies. The Intersectoral Workshopon Nutrition and Food Safety was held in Co-lombia for the purpose of implementing theNational Food and Nutrition Policy, includingthe definition of objectives for the agriculturalsector, and of elements for intersectoral coor-dination. Another example was the effortmade to increase the availability of food inpoor households in Argentina, Bolivia, Nica-ragua, and Peru. Finally, mention should bemade of the limited availability and accessibil-ity of essential drugs for the entire population;several countries are attempting to solve theproblem by using a multisectoral approach, es-pecially in formulating and implementing poli-cies.

Joint Activities by Groups ofCountries

One of the most important expressions ofthe combination of efforts and resources forjointly dealing with the solution of commonhealth problems has been the dynamic process

followed by the Governments of the CentralAmerican Isthmus in formulating the Plan forPriority Health Needs in Central America andPanama. At their Special Meeting held inCosta Rica (March 1984), the Ministers ofHealth adopted that Plan and undertook tocarry it out. It was subsequently given favor-able consideration by the Ministers of ExternalRelations when they met in Panama in April1984. In addition, the governments that makeup the Contadora Group reaffirmed their sup-port for it. Three facts are of importance in thisprocess: the active participation in multidiscip-linary groups of more than 200 national ex-perts of the ministries of health, universities,and economic planning units of the countriesinvolved; the effective coordination of interna-tional cooperation' agencies (PAHO/WHO,UNICEF, UNFPA, IDB, and the like); jointaction by the governments, PAHO, and UN-ICEF to support each proposal with requestsfor financial resources from European andAmerican governments and donor agencies.The Plan comprises seven priority areas: thestrengthening of health service systems; thedevelopment of human resources; the avail-ability of essential drugs and critical supplies;the improvement of the food and nutrition sit-uation; the control of malaria and other tropi-cal diseases; immediate action for infant sur-vival; and the strengthening of water supplyand sanitation systems. It includes 40 subre-gional projects and 267 national projectswhich it is hoped will mobilize national re-sources estimated at US$625 million and ex-ternal resources in the amount of almostUS$1.3 billion in a 5-year period.

With regard to its significance and projec-tions, the Plan has two fundamental purposes.The first is to satisfy basic health needs thathave long been postponed or accumulated inthe historical evolution of the countries andwhich now have worsened because of the eco-nomic, social, and political crises that affect thesubregion in particular. The second is to usethe consensus that health is a basis for promot-ing understanding and cooperation among

xvi Annual Report

countries, peoples, and governments for es-tablishing peace. This unusual collective effortshows that the strengthening of links amongcountries of the Central American Isthmus ispossible if the international community sup-ports and strengthens political understandingand contributes constructive solutions to thesocial and economic problems of the subre-gion.

Several groups of countries have decided tocombine and coordinate their efforts to dealwith the problem of the availability and accessi-bility of essential drugs for the entire popula-tion. In this regard, at an intersectoral meetingorganized by PAHO/WHO, representativesfrom Argentina, Brazil, Mexico, and Spainrecommended the formulation and develop-ment of an intercountry program for the pro-duction and marketing of raw materials andfinished products based on the linkage of exist-ing production facilities. The aim of the pro-gram is to ensure that the developing countriesincrease their self-sufficiency in national pro-duction wherever it is economically and tech-nically feasible, as well as their capacity to ne-gotiate purchases of raw materials and finishedproducts. In the latter regard, the Organizationand the Central American Bank for EconomicIntegration (CABEI) made a study with a viewto establishing a revolving fund and a system ofjoint purchases by the Governments of CentralAmerica and Panama. A similar initiative is be-ing promoted and implemented in the English-speaking Caribbean, with the sponsorship ofthe Caribbean Community (CARICOM). Fur-thermore, the availability and accessibility ofdrugs is a basic priority of the Plan for satisfyingthe Priority Health Needs in Central Americaand Panama. In addition, the Andean Pactcountries have established a system of infor-mation exchange on prices, sources of rawmaterials, and finished products imported bythose countries. As a guide for national offi-cials involved in taking decisions on this mat-ter, in 1984 PAHO published a document en-titled Policies for the Production andMarketing of Essential Drugs.

Mobilization of NationalResources and ExternalFinancing

It must be emphasized that no solution to theproblems of health and of general develop-ment is lasting unless it is based on the nationalcapacity of a country to conduct and sustain itsown development. With the cooperation ofPAHO/WHO, some governments have be-gun to shape a policy in this field aimed at shift-ing the use of the resources already allocatedto the sector by increasing the efficiency oftheir use through the rationalization of priori-ties; coupled with this is the simultaneous iden-tification of national resources that may bechanneled towards essential activities in thehealth field. Certain requirements for imple-menting this policy tend to strengthen the as-signment of priorities and establish the consis-tency of the proposals requiring additionalresources; these requirements are the need todefine the viability and feasibility of the healthproposals.

, The national development policies and thepriority assigned to the social sectors, both intheir linkage with other sectors and in the allo-cation of national resources to health, are thenational frame of reference for the formulationof health plans and programs. Consequently,their viability is determined, on the politicallevel, by the formal support of governmentalauthorities and the commitment of agencies,institutions, and groups that participate in deci-sions about society. On the institutional level,viability is determined by the extent of the sup-port of all the institutions that make up thehealth sector. In other words, the implementa-tion of health activities involves the govern-ment and society, and not only the ministriesof health.

Furthermore, the operating capacity ofhealth institutions to make better use of the re-sources available and to make optimum use ofthe additional resources determines technical-administrative feasibility. Thus, the issue is to

Overall Analysis and Trends xvii

avoid the contradictory situation and its con-comitant problems-that is, mobilizing andchanneling additional resources to the sectorwithout the capacity for efficient absorptionand utilization. Financial feasibility depends onboth the national policy of financing the publicsector, especially the health sector, and theanalysis of available counterpart resources andthe possibilities to finance operational costs.The purpose of these mechanisms is to ration-alize the process of making better use of theresources available and endeavoring to obtainadditional resources within the national sphereitself.

One valuable instrument for the mobiliza-tion of external resources that is becoming in-creasingly important as its procedures becomesystematized is technical cooperation amongdeveloping countries and between them anddeveloped countries. To strengthen this pro-cess, an analysis has begun of the priority areasof countries and of their potential both for re-ceiving and supplying cooperation. Mecha-nisms for the financing of Technical Coopera-tion Among Developing Countries (TCDC)projects are being designed jointly with ILPES.Actual instances of TCDC and Economic Co-operation Among Countries (ECDC) exist,such as the development of networks of na--tional centers, the joint action taken to draw upthe Plan for Priority Health Needs in CentralAmerica and Panama, training in essentialdrugs in the Andean countries, and the nutri-tion and training programs in the CaribbeanCommunity.

As regards the mobilization of.external fi-nancial resources, experience has shown thatit must meet two fundamental requirements:the resources must supplement the national ef-fort, and they must be short-term in nature. Atthis time of crisis through which the countriesare going, international financial corporationcan in special cases temporarily replace do-mestic financing capacity. However, domesticfinancing capacity is of particular importancewhen concessionary funds or grants are in-volved. To that end and to make the work of

governments easier, PAHO/WHO preparedand distributed to the health authorities a doc-ument entitled Guidelines for the Mobilizationof External Financial Resources which pro-vides important information on sources of fi-nancing, requirements and procedures, andmobilization strategies. It also identifies themany private agencies and foundations thatcan make grants to specific programs.

In this context, the Organization has cooper-ated with the Member Countries in definingthe external financing needs of several proj-ects; foremost among these is the Plan for Pri-ority Health Needs in Central America andPanama. It is hoped that support will be forth-coming from the international community, es-pecially bilateral cooperation, both from NorthAmerica and from several European govern-ments. Nevertheless, international creditagencies-the Inter-American DevelopmentBank and the World Bank-continue to be thecommon financing sources for national watersupply and sanitation programs, health ser-vices, and development of human resources inLatin America and the Caribbean.

Preparation of the Bureau toMeet the Needs of TheseProcesses

To meet the requirements for implementa-tion of the initiatives already discussed in thischapter and for the attainment of equity, effec-tiveness, excellence, and sufficiency in the useof resources for technical cooperation pro-grams, the implementation of the "ManagerialStrategy for the Optimum Use of PAHO/WHOResources in Direct Support of Member Coun-tries" has been strengthened. A notable com-ponent of this process is an increase in themanagerial and operating capacity of the Cen-tral and Field Offices. At the central level, wehave consolidated the program areas, the ar-ticulation of their functions, and the develop-ment of multidisciplinary approaches; person-nel of different categories also have been

xviii Annual Report

retrained. In the field, the former Area Officeshave become Country Offices. The "Plan forDecentralized Administrative Development"has been implemented and comprises a reviewand adjustment of administrative systems,analysis of the operating capacity of the Coun-try Offices and PAHO/WHO Centers, and afeasibility analysis of the components of thedecentralization process. The results point togains in the design and application of modulesfor the management of programming cooper-ation and of the budgeting, financial, and ac-counting subsystems; in the decentralizedmanagement of personnel, fellowships, travel,seminars, and courses; and in informationsystems for the monitoring of programs andbudgets.

Noteworthy instances of real participation ofthe governments in the Organization's work-a basic principle of the Strategy-are the jointCountry/PAHO/WHO reviews of health poli-cies and programs, which have led to a deter-mination of national priorities and needs forPAHO/WHO cooperation and, in manycases, external funding.

Official and informal relations with interna-tional and national agencies and foundationshave also been strengthened as a basic aspectof the Strategy for the coordination of interna-tional cooperation and the mobilization of re-sources for health. This has been the basis ofoperations with the Inter-American Develop-ment Bank, the World Bank, the EconomicCommission for Latin America, UNDP,UNICEF, UNFPA, and other national and pri-vate technical and financial agencies. Theseefforts have given rise to official agreements forjoint activities in specific countries and regionalprograms. The Organization has also cooper-ated with individual countries in setting up ef-fective machinery for coordinating interna-tional cooperation, including permanentgovernment agencies and joint Country/PAHO/WHO committees which participate inthe identification of the external resourcesneeded to complement local resources for car-rying out national health programs.

Possible Future Courses

Despite the implications of the economicand social crisis, the Organization and its Sec-retariat have reaffirmed their purpose of inten-sifying measures for attaining the regionalgoals and objectives. Meanwhile, the govern-ments, in accordance with their national priori-ties, are channeling efforts to the solution ofleading problems and thereby contributing tothe attainment of regional purposes. There arefour main areas of action-the evaluation andreorientation of technological development,intra- and intersectoral articulation, combinedoperations by groups of countries, and re-source mobilization-for maximizing re-sources, strengthening the operating capacityof institutions and the system in support ofthese areas, and updating and strengtheningthe structure and operations of the Organiza-tion.

These undertakings are in their first stages.Hence, if it is agreed that these approaches canlead to useful and practical solutions, the firststeps would be to consolidate and strengtheninitiatives in progress. Flexibility is needed toadjust them to changes in and outside the sec-tor and to take advantage of situations as theyarise to revitalize the process.

The outlook for the economic and social sit-uation is profoundly uncertain. However itdevelops, the health sector must hone its crea-tivity and ingenuity to accelerate the develop-ment of mechanisms for serving the popula-tion with equity, efficiency, and effectiveness,and for extending health services to under-served urban and rural populations. There-fore, in addition to strengthening the afore-mentioned initiatives in progress, it is impera-tive to continue the search for new approachesand solutions and, at the same time, to givehigh priority to the generation of useful knowl-edge and the development of technology andprocedures that are socially workable andhave the greatest impact. Moreover, encour-agement and support should be given to com-binations of resources and efforts in mutually

Overall Analysis and Trends

supportive operations by groups of countriesas a device for both addressing common prob-lems and promoting understanding and peacein the Region.

This proposition is subject throughout to abasic condition, which is that it receive the sup-port of government as a matter of policy. Infact, the conviction that there are effectiveways of improving levels of health and welfareof the population while at the same time mini-mizing the baneful effects of the crisis in the

sector must be given overt expression in eachcountry in firm policies and decisions that en-gage the government and society as a whole.This enterprise is not for the health sectoralone but, to the contrary, requires compre-hensive, articulated measures by a country asa whole. The implementation of those policiesjoined to the resolve of those responsible forthe process will result in optimal use of re-sources, a strengthening of the operating ca-pacity of the sector, and a quest for new solu-tions.

xix

Part IIRegional Analysis of Joint

Government/PAHO/WHO Actions

Chapter 1. Development of the Health ServiceInfrastructure

Development of Health ServiceSystems

Situation and Trends

1.1 Severe constraints on funding for thehealth sector as a result of the economic crisis,together with the pressing requirements of apopulation in rapid growth, have created seri-ous problems for government activities. Nev-ertheless, it is possible to point to a number ofefforts aimed at improving the organization ofhealth systems, achieving greater coverage byseeking appropriate ways of extending theservice networks, and increasing the opera--tional capacity of health service systemsthrough linkage with other sectors that influ-ence health conditions.

1.2 Efforts continued in Costa Rica andPanama to coordinate the services of publichealth facilities with those of social security in-stitutions. Several countries were pursuing thesame objectives through changes in the orga-nization of the health sector. A case in point isArgentina, where the social security agenciesare being brought within the jurisdiction of theMinistry of Health and Social Action. In Mex-ico, the Ministry's authority was broadened

with a view to improved sectoral perfor-mance, and a constitutional amendment wasadopted providing for the establishment of co-ordination and deconcentration-decentraliza-tion nuclei to further integrate services at sub-national levels.

1.3 Other countries of the Region contin-ued their efforts to consolidate the coverageand extension process through practical appli-cation of the primary care strategy, in somecases by means of externally aided projects(Barbados, Bolivia, Brazil, Cuba, Dominica,Dominican Republic, Ecuador, Guyana,Haiti, Honduras, Nicaragua, Paraguay, andPeru).

Planning and Administration

1.4 Reference has been made to thesharp financial constraints on the health sectorand the problem of the rising demand for ser-vices. These factors are making it necessary tofocus national and international efforts onhelping the health sector develop the operat-ing capacities that will enable it to make thebest possible use of available and potential re-sources. This, in turn, necessitates an urgentreview of the approaches and methodology

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traditionally employed in health systems ad-ministration, particularly with respect to plan-ning and management. The experience ac-quired by the countries in the planning areaand the advances made in other socioeco-nomic sectors have been basic elements in re-orienting the course of the work, especiallythe training of national officials responsible foradjusting processes to current conditions. Fur-ther efforts were made to develop more flexi-ble planning techniques that adjust to situa-tions prevailing at a given time. Thus, theUniversity of Antioquia's School of PublicHealth in Medellín, with PAHO/WHO coop-eration, continued its work on the develop-ment of strategic planning and managementapproaches, the results of which are gatheredin a technical publication to be made availableto the governments. Several critical planningareas requiring instrumental developmentwere identified in this process. Initial prioritywas given to analysis of the health sector,analysis of financing, and formulation of in-vestment projects as vehicles for strengthen-ing specific areas of service planning and ad-ministration. Some methodological tools forthe analysis of financing have already beendesigned in Uruguay.

1.5 In order to consolidate theseschemes, the Latin American Institute of Eco-nomic and Social Planning cooperated withPAHO/WHO in laying the groundwork forjoint participation in planning courses con-ducted at schools of public health. This willalso include the exchange of experience andof instructional staff. It is worth noting thatsome of the strategic planning approaches arebeing utilized in Honduras, Nicaragua, andPanama.

1.6 In keeping with the high priority thatthe English-speaking Caribbean countrieshave assigned to health systems develop-ment, a regional seminar on health systemsplanning and administration was held in Anti-gua in October, with 34 participants from 15countries of the area. The objectives of theworkshop, in which the Secretariat of the Car-ibbean Community (CARICOM) and the

Commonwealth (Great Britain) also partici-pated technically and financially, were to eval-uate the present initiatives for the develop-ment of systems in the Caribbean subregion,examine the management process for the de-velopment of national health services and itsrelevance to the Caribbean, and select priorityareas for strengthening the planning and ad-ministration process in the next 2 years. A Na-tional Health Plan was prepared in Belize,while in other countries-including Brazil, Co-lombia, Jamaica, Mexico, Trinidad and To-bago, and Uruguay-the situation analysis ofthe health sector was consolidated, and in Ar-gentina the basic provisions for the formula-tion of a National Plan were established.

1.7 To help strengthen the decentraliza-tion and administration of health systems, aseminar on that subject was held in Mexico,with eight countries participating: Argentina,Brazil, Chile, Colombia, Costa Rica, Cuba,Ecuador, and Mexico. The participants ex-changed experiences and examined possibleapproaches. To discuss these initiatives, par-ticularly those on strengthening the legal foun-dations of health service systems, a Consulta-tive Group on Legislation in Public andPrivate Administration convened at PAHO/WHO Headquarters in September, consistingof officials from seven countries: Argentina,Brazil, Chile, Colombia, Ecuador, Mexico,and Uruguay. It was hoped that the meetingwould lead to a definition of national strategiesand workplans in this field.

1.8 In Bolivia, work continued on the ad-justment of administrative methods and pro-cedures for development in the areas ofhealth, local programming, and communityparticipation. In Colombia, the administrativedevelopment project was evaluated, leadingto the establishment of guidelines for strength-ening institutional development. In CostaRica, further progress was made on restruc-turing the health sector and implementing theSocial Security Institutional DevelopmentProgram, in search of a suitable managerialresponse to the problems presented by thesector's institutional plurality. In Dominica,

Development of the Health Service Infrastructure

Saint Lucia, and St. Vincent and the Grena-dines, administrative systems applicable to es-sential drugs were improved through simpli-fication of procedures for procurement, stor-age, distribution, and inventory control. InEcuador and the Dominican Republic,PAHO/WHO cooperated in the identificationand analysis of critical areas in the present ad-ministrative systems, leading to better utiliza-tion of technical and administrative instru-ments. In Barbados, Guyana, and Suriname,draft legislation on institutional developmentof the health sector was prepared in close co-operation with the Inter-American Develop-ment Bank (IDB). In Guatemala, consider-ation was given to an adjustment of theadministrative structure of the Ministry of Pub-lic Health and Social Welfare and to the tech-nical and administrative innovations neededin the support services. An institutional analy-sis of the Guatemalan Social Security Institutealso was carried out, including considerationof improvements in the supply area.

Organization and Development ofthe Health Service Network

1.9 Priority continued to be given to theextension and consolidation of the network ofhealth services. To this end, with PAHO/WHO cooperation an analysis of the organiza-tional characteristics of health services in 19countries of the Region was initiated: Argen-tina, Bolivia, Brazil, Chile, Colombia, CostaRica, Cuba, Dominican Republic, Ecuador, ElSalvador, Guatemala, Honduras, Mexico,Nicaragua, Panama, Paraguay, Peru, Uru-guay, and Venezuela. These studies made itpossible to identify constraints and problemsat the national level, to formulate strategies,and to define areas for PAHO/WHO cooper-ation in reorganizing and consolidating theservice systems. Significant activities in thisarea were: the establishment of integrated ar-eas in Bolivia; the development of a local pro-gramming module and an analysis of the roleof hospitals in the primary care strategy in Bra-zil; the formulation of a project to support the

process of consolidating the national healthsystem in Colombia, using World Bank re-sources; the development of local service pro-grams in various regions of Honduras; and theformulation of decentralized State plans andlocal programs in Mexico.

1.10 The Organization also cooperatedwith the governments of the Central AmericanIsthmus in the identification of factors that hin-der the extension of services to the entire pop-ulation and in the formulation, within the Planfor Priority Health Needs in Central Americaand Panama, of 34 project proposals for sur-mounting those obstacles. The proposalsaimed to achieve universal coverage and ac-cess to the system of services. Four of the proj-ects were subregional in scope, covering theareas of organization and delivery of services,formulation and implementation of projects,facilities maintenance, and critical inputs. Theother 30 were national projects for Costa Rica(4), El Salvador (2), Guatemala (14), Hondu-ras (3), Nicaragua (4), and Panama (3) andcovered the extension and consolidation ofthe infrastructure and the strengthening oftechnical, administrative, and financial pro-cesses.

1.11 In the implementation of the pri-mary health care strategy in rural and urbanareas of various countries, including Brazil,Colombia, Honduras, and Nicaragua, therewas a trend toward gradual involvement ofthe nursing profession in the delivery of ser-vices to the community and toward the use ofsimplified methods in peripheral units. In Bra-zil, priority continued to be given to the sys-tem's primary level services; to this end,PAHO/WHO collaborated in efforts tostrengthen the State health departments' tech-nical capabilities and to develop the networkof units for expanding the coverage of healthservices. A consultative meeting in Jamaica,sponsored jointly by UNICEF and WHO, wasattended by representatives from Burma, Nic-aragua, Papua New Guinea, DemocraticYemen, PAHO, WHO, and UNICEF. Partici-pants reviewed the development of primaryhealth care, its critical areas, and its lessons;

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suggested basic guidelines to follow in redi-recting the process; and proposed actions tobe undertaken in the future by the govern-ments and by PAHO/WHO and UNICEF.Multidisciplinary teams including nursing per-sonnel were set up in a number of countries(Argentina, Bolivia, Brazil, Chile, Colombia,Costa Rica, Guatemala, and Panama) to pro-vide primary health care to underserved pop-ulations in urban areas.

1.12 In the field of nursing, three subre-gional workshops were held on the changingdemands on nursing in terms of the goal ofhealth for all by the year 2000. The work-shops were conducted in Argentina, Brazil,and Panama for nurses from the ministries ofhealth, social security agencies, universityhospitals, and nursing schools of Argentina,Brazil, Chile, Costa Rica, El Salvador, Guate-mala, Honduras, Nicaragua, Panama, Para-guay, and Uruguay. In Canada, a workshopon the contribution of nursing to primary careprograms was held for nurses from Canada,Haiti, Suriname, and 18 countries or territo-ries of the English-speaking Caribbean area.The standards of nursing care in hospitals andhealth centers of the Caribbean, formulated ata workshop in 1983, were examined at theMeeting of Ministers of Health of the Carib-bean in 1984 and were subsequently circu-lated to the Caribbean countries as a guide forsetting up nursing care standards consistentwith conditions in each country. In Argentina,Bolivia, Chile, and Peru, workshops wereconducted for the purpose of designing instru-ments for auditing and evaluating communityand hospital nursing services. In the Domini-can Republic, a central-level working groupwas organized to devise national nursing carestandards. In El Salvador, efforts to developand improve nursing services and to reviewand evaluate national nursing school pro-grams were intensified.

1.13 In the medical records area, workproceeded on reorganizing medical recordsdepartments of four national hospitals in Trini-dad and Tobago. In Costa Rica, PAHO/WHO cooperated in the adoption of unified

maternal and child and pediatric clinical his-tory forms for use at all health centers, clinics,health posts, and hospitals. Dominica imple-mented a plan to reorganize its medical re-cords service according to recommendationsput forth by PAHO/WHO in 1983. In the Do-minican Republic, PAHO/WHO participatedin an assessment of the medical records situa-tion and the development of a manual ofmedical records rules and procedures for min-istry of health hospitals and subcenters. InGuatemala, the Organization collaborated inthe determination of responsibilities for medi-cal records in the country and in the CentralAmerican area. Training was intensified fortechnical staff in Costa Rica and Venezuelaand for auxiliary staff in Uruguay. Mexico con-tinued its development of health records foruse in primary care in rural and underservedurban areas. The Ministry of Public Health ofUruguay received assistance in a project to re-view medical records to determine their use-fulness in evaluating the quality of the servicesprovided, the technologies used, and the con-tinuity and completeness of the care ofchronic diseases. Lastly, cooperation was ex-tended to Colombia and Peru for evaluationand reorganization of social security medicalrecords.

1.14 A highlight in the architecture andmaintenance area was the meeting held inLima, Peru, to examine critical aspects of hos-pital planning, design, equipping and mainte-nance, and to define action guidelines. Themeeting was attended by representatives fromthe Andean Group countries, the Office ofPhysical Infrastructure of the Ministry ofHealth of Peru, and PAHO/WHO. El Salva-dor's methodology, plans, programs, andmanuals on maintenance service administra-tion and logistics were being designed. InHonduras, equipping modules were definedthat reflect the requirements of priority activi-ties of peripheral-level health programs, in-cluding the preparation of a plan for redistrib-uting health center equipment. In Nicaragua,a national inventory of health service equip-ment and installations was begun to serve as a


basis for adjusting the national maintenanceplan; staff training was stepped up; andPAHO/WHO assistance was also provided indesigning the organizational and technicalstructure of the Division of Engineering andMaintenance and revising the national and re-gional program. In Paraguay, the architecturalprogramming for the various health establish-ments was reviewed and an assessment wasmade of plant and equipment maintenance.In Peru, a workshop on hospital equippingwas conducted, a methodology for preparingnational physical infrastructure standards wasdefined, and standards were developed forthe first level of care.

Intrasectoral Coordination

1.15 PAHO/WHO cooperation effortswere directed toward the strengthening oflinkages among health sector components,especially ministries of health and social secu-rity agencies, with shared responsibilities forthe provision of health services in the follow-ing 16 countries: Argentina, Bolivia, Brazil,Colombia, Costa Rica, Dominican Republic,Ecuador, El Salvador, Guatemala, Honduras,Mexico, Panama, Paraguay, Peru, Uruguay,and Venezuela. Pursuant to resolutionCD28.R34 of the XXVIII Meeting of thePAHO Directing Council, a study of the pro-cess of coordination in the 16 countries duringthe period 1979-1984 was carried out. Thestudy shows a tendency to delimit sectoralcomponents with increasingly greater accu-racy and identifies policy definitions, the fi-nancing of services, and levels of linkage ascentral elements in the process. The XXXMeeting of the Directing Council consideredthis study in September 1984 and, by meansof resolution CD30.R15, urged the MemberCountries, once again, to strengthen the tiesbetween ministries of health and social secu-rity agencies so as to make a more effectiveuse of the sector's technical and financial re-sources and extend health care to under-served population groups. The study was alsoexamined at the Meeting of Ministries of

Health and Directors of Social Security Institu-tions of Central America and Panama.

1.16 In addition to such regional and sub-regional statements of policy, there are spe-cific instances of intersectoral linkage. Theseincluded, first of all the agreements concludedin Colombia, Costa Rica, Ecuador, Hondu-ras, Panama, and Peru for interagency coop-eration in the areas of planning and organiza-tion of health programs, development andmaintenance of health facilities, administrativeanalysis, and human resource development.

1.17 The strategy followed in implement-ing these agreements has been to focus coop-eration on areas where by mutual accord theinstitutions concerned are taking joint ap-proaches to the solution of common prob-lems. Thus, PAHO/WHO provided technicalassistance to the National Institute of SocialServices of Argentina for the Program of Ser-vices to Retirees and Pensioners. In Colom-bia, PAHO/WHO is playing an active role inthe development of a planning model for theSocial Security Institute. In Costa Rica, it con-tinued its cooperation in medical care organi-zation, nursing services administration, infor-mation systems, and personnel training. In ElSalvador, the Organization cooperated withthe Social Security Institute in the identifica-tion of health facility maintenance require-ments and potential areas for interinstitutionalcoordination. In Panama, where the Organi-zation continued to collaborate in the develop-ment of the health service network, long-termproposals were formulated in the areas of in-frastructure requirements, adjustments to keyhospitals, and unificaton of administrative ser-vices. PAHO/WHO's cooperation in Guate-mala centered around maintenance services,specifically the design and application of stan-dards and manuals and the training of staff atthe operational level. A technical cooperationagreement was signed with the Ibero-Ameri-can Social Security Organization (Spain) forthe development and promotion of technicaland administrative training for staff of socialsecurity entities to improve the operation of

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health care programs and stimulate coordina-tion with the health ministries.

National Information Systems

1.18 Strengthening of the national healthinformation systems continued in Costa Rica,El Salvador, Guatemala, Honduras, and Par-aguay. In each of these countries, emphasiswas placed on achieving interdisciplinary co-ordination in planning, administration, andnational information systems; strategies ofchange were formulated; and intercountry co-operation to improve the linkage among infor-mation services was intensified.

1.19 Four specific information subsys-tems were identified for development. Thefirst was drug supplies, with emphasis on theestablishment of intercountry technical coop-eration nuclei in the Andean area (HipólitoUnanue Agreement). The second referred toprograms to extend the coverage of services,including the immediate action for infant sur-vival programs, whose information subsys-tems are being developed in the CentralAmerican countries and Panama. The thirdarea was that of budget control subsystems,whose operations were being initiated in Gua-temala. Lastly, the fourth group referred tothe information subsystems on planning andprogramming currently being developed inArgentina, Chile, Paraguay, and Uruguay,based on the exchange of experience and us-ing electronic data processing.

1.20 The training of national personnel incourses combining the subjects of planning,administration, and information continued.Two workshops were held for this purpose;the workshop for the English-speaking Carib-bean countries also included the sanitationprogram. The member countries of the An-dean Pact-Bolivia, Colombia, Ecuador,Peru, and Venezuela-participated in the sec-ond workshop. The primary purposes of bothworkshops were to promote coordinationamong the areas involved and to lay thegroundwork for the subsequent developmentof information systems and subsystems.

1.21 The Organization has intensified itsefforts in the technological development of in-formation systems. Outstanding in this regardwere the incorporation of qualitative evalua-tion techniques for use in the health services,the utilization of modern computer techniquesat different levels of the system, and the revi-sion and adaptation of sections of the Interna-tional Classification of Diseases.

1.22 The activities pertaining to the Inter-national Classification of Diseases continuedin 1984, notably those directed to the estab-lishment of a network of national centers. Inaddition to the centers in Sao Paulo (Brazil)and Venezuela, a center was established inPeru, and centers were being formed in Ar-gentina and Mexico. The centers adopted astrategy of coordinated work within the Tech-nical Cooperation Among Developing Coun-tries (TCDC) framework; within this scheme,a cooperative study of various coding meth-ods, to be carried out by the Sao Paulo Cen-ter, the Government of Mexico, and PAHO/WHO, was designed. The governmentscontinued to take an active part in the prepa-ration of the 10th Revision of the InternationalClassification of Diseases to adjust it to themonitoring and evaluation of health systems.

Project Formulation andAdministration

1.23 Within the Plan for Priority HealthNeeds in Central America and Panama, thegovernments aided by PAHO/WHO identi-fied priorities and formulated 29 preliminaryprojects for the development of health ser-vices. Of these, four projects were subregionalin scope and 25 were national, correspondingto Costa Rica, El Salvador, Guatemala, Hon-duras, Nicaragua, and Panama. The prelimi-nary projects are now under consideration byfinancing agencies. The proposals for securingexternal funding total US$332 million.

1.24 Cooperation was provided to Barba-dos, Guyana, Haiti, Mexico, Suriname, and


Venezuela in the development, with externalfunding, of preliminary projects in the area ofservice infrastructure. PAHO/WHO con-tinues to be the executing agency for IDBtechnical cooperation in projects under way inEcuador, El Salvador, Honduras, Nicaragua,and Paraguay for the development of healthservices.

Health Service Research

1.25 A survey of health service researchtrends in 15 countries of Latin America andthe Caribbean was carried out. The study in-cluded a review of national and institutionalpolicies on health service research and an in-ventory of studies made in those countriesduring the period 1974-1983. Proposals toPAHO's Advisory Committee on Health Re-search concerning possible areas of collabora-tion were formulated on the basis of the analy-sis of those trends. In the Caribbean area,specifically in Antigua and Barbuda,Dominica, St. Christopher and Nevis, andSaint Lucia, a study was made for the purposeof obtaining qualitative and quantitative infor-mation for health service planning and financ-ing, as well as for determining health condi-tions.

Health Education and CommunityParticipation

1.26 As a follow-up to the study made in1983 to determine the scope and effective-ness of health education activities and com-munity involvement in maternal and childhealth and family planning projects in 10countries (Bolivia, Brazil, Guatemala, Haiti,Honduras, Jamaica, Mexico, Panama, Para-guay, and Peru), the final report of the studywas distributed early in 1984 to the govern-ments of those countries and associated finan-cial institutions. An analysis of case studies oncommunity participation in urban and rural ar-eas of eight countries of the Region (Barba-dos, Brazil, Colombia, Cuba, Ecuador, Guy-

ana, Jamaica, and Mexico) was publishedduring the year, as was the first title in a newseries of documents for community workersentitled Development and Use of Health Edu-cation Materials. A guide for identifying edu-cational methods and techniques available inthe community and applying them to healthactivities was being field tested, and a guideon simple methods of evaluating the impact ofhealth education and communication activi-ties was scheduled for preparation in 1985.Cooperation was extended to Colombia,Guatemala, Honduras, Mexico, Paraguay,and Uruguay in reorganizing the health edu-cation departments of their Ministries ofHealth, training health education staff in com-munity diagnosis techniques, and planningand evaluating health education programs.The health education and community partici-pation component was gradually being incor-porated into perinatology training programs.This trend was evident at the Latin AmericanPerinatology Center (CLAP) workshop onnational perinatology standards, as well as inCLAP's course on perinatology and publichealth and at the Interregional (PAHO andEURO) Conference on Appropriate Technol-ogy in Prenatal Care. Additional informationon these courses will be found in chapter 2 ofthis Report, under CLAP. Also worthy ofmention is the course conducted in Mexico onevaluation of the impact of health educationand mass communication activities on the uti-lization of health services. A total of 80 offi-cials from a majority of the Latin Americancountries attended this course.

Human Resource Development

1.27 In the context of the Regional Strate-gies for health for all by the year 2000 and inkeeping with medium-term regional program-ming, efforts in 1984 in human resource de-velopment were focused on meeting the re-quirements of the health services' nationalplans and programs in two closely related ar-eas: management of human resource devel-opment and health personnel training.

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Management of Human ResourceDevelopment

1.28 Promotion of policies and plans.Preliminary steps were taken toward a jointanalysis of policies in the Central Americancountries and Panama. In addition, 5 subre-gional and 26 national human resource pro-grams were prepared and incorporated intothe Plan for Priority Health Needs in CentralAmerica and Panama. In the English-speak-ing Caribbean countries, a number of subre-gional workshops analyzed mechanisms forstrengthening health personnel managementsystems and promoting the inclusion of hu-man resources in the general planning pro-cesses. Also in the Caribbean and in coopera-tion with CARICOM, a human resource avail-ability survey was conducted for use in subse-quent programming.

1.29 An Interregional Meeting on Coordi-nation of Health Personnel Programs washeld for the purpose of reviewing the me-dium-term regional programming and adapt-ing it to the governments' requirements andefforts. The meeting also examined possibleapproaches to the problems involved in teach-ing-service integration, utilization of person-nel, research, and personnel requirements forprimary care. Finally, human resource plan-ning courses were offered in Colombia andthe Dominican Republic.

1.30 In the strengthening of national ca-pacity for research on human resources, ahighlight was the identification by the RegionalAdvisory Committee-on Health Research ofthe following study areas: analysis of the labormarket, production functions (the relationshipbetween human resources and technology),sociology of the professions, and educationaldevelopment. The PAHO/WHO grant pro-gram gave priority to these areas, within thecontext of market analysis, because of thecontribution it can make to a better under-standing of the national profiles. In this re-gard, the study on the nursing labor marketsin Brazil, Colombia, Ecuador, Honduras,Mexico, and Peru was completed in 1984,

and a comparative analysis of the findings wasscheduled to be made for reprogramming pur-poses. Special importance also was given totraining in research. The School of Nursing ofthe University of Valle in Cali, Colombia, andthe advisory research group of the Commu-nity Health Training Program for CentralAmerica and Panama (PASCCAP) contrib-uted to the design of various modules for self-instruction and research. Courses on researchmethodology were offered in El Salvador,Guatemala, Honduras, and Panama throughPASCCAP.

1.31 In the development of informationsubsystems, three areas were identified andlater added to the system: available human re-sources and their utilization in the services;training institutions and programs, with theirrespective characteristics, teaching capacity,and resources; and technical-scientific level ofthe health sector professions. These elementsserved as a basis for designing the subsystemto be implemented in the countries in 1985.Also in 1984, the National School of PublicHealth of Brazil, using the latest census re-turns, selected and analyzed the data on thecategories of personnel, employment, wages,and functions.

1.32 Reorientation of policies on per-sonnel utilization. This is a priority area inmost of the countries, given the serious prob-lems created for governments by scarcity ofpersonnel in certain categories and poor distri-bution in others. At the regional level, a meth-odology was prepared for use in the definitionof educational and occupational profiles,and an evaluation methodology based onfunctional requirements was developed as asupport instrument for supervision and con-tinuing education. At the national level,PASCCAP conducted workshops designed,like the one in Panama, to review the occupa-tional profiles for all the health professions, or,like the one in El Salvador, to prepare the oc-cupational and educational profiles for physi-cians. In Peru, the profile for nursing person-nel was defined, and the staffing table formiddle technical and auxiliary level personnel

Development of the Health Service Infrastructure 9

of the Ministry of Health was established. Fi-nally, in Cuba, the study of nursing personnelperformance was completed.

1.33 Continuing education and supervi-sion. In accordance with the recommenda-tions of the regional meeting held in the latterpart of 1983, these two programs were com-bined into a single operating unit. To imple-ment the combined program, workshopswere conducted in El Salvador, Guatemala,Honduras, and Panama, and programs weredesigned for seven other countries. Coopera-tion was also given to Cuba's continuing edu-cational program through educational tech-nology.

Training of Health Personnel

1.34 Training continued within the broadapproach of teaching-service integration. Pro-grams in this field encompassed the training ofphysicians, nurses, odontologists, and publichealth personnel, as well as administrators.

1.35 Medical education. Noteworthyevents were the establishment of the School ofMedicine in Guyana, the evaluation of theSchool of Medicine in Guatemala, the devel-opment of the teaching-service integrationprogram at the Medical School of the Autono-mous Metropolitan University of Mexico, andthe study of the integrated units of the Schoolof Medicine of Cayetano Heredia University inPeru. In addition, the medical residencies pro-gram in Honduras was evaluated, and thenew School of Medicine in Managua, Nicara-gua, was consolidated. Further progress wasmade in the ongoing study of the program-ming and structure of Brazil's medical schools,with a view toward reorganization.

1.36 PASCCAP participated in the devel-opment of the medical curriculum in Hondu-ras. A plan of work was formulated for aca-demic upgrading of the health-related facul-ties of the University of El Salvador.

1.37 Nursing education. In keepingwith the relevant resolutions of PAHO's Gov-

erning Bodies and recommendations of theConsultative Group in Nursing (1981), theOrganization continued to promote the estab-lishment of networks for exchanging experi-ences in the development of nursing educa-tion in Latin America. To this end, a proposedinformation subsystem on science and tech-nology in nursing was developed as part of theregional information system with the aim ofsupporting and facilitating the production, cir-culation, exchange, and use of informationand technology in the field of nursing. Ananalysis of nursing documentation centersand libraries was initiated in several LatinAmerican countries. Two studies were carriedout to examine the contribution of nursing tothe health care delivery system so that trainingprograms may be adjusted to national reali-ties. One of the studies, dealing with the train-ing of professional nurses, revealed a high de-gree of heterogeneity within this group;consequently, the study programs and theprofessional practice of nursing are currentlyunder revision in a number of countries. Thesecond study, with similar characteristics,dealt with the training of nursing auxiliaries.

1.38 In addition, a reorientation of nurs-ing curricula within a framework of teaching-service integration was promoted in Argen-tina, Paraguay, Peru, and Uruguay, and withthe support of PASCCAP, nursing educationwas being reformulated in El Salvador andPanama. With regard to intermediate techni-cal personnel, the second period of activitiesunder the technical cooperation agreementamong Cuba, Nicaragua, and PAHO/WHOwas directed toward intensifying efforts totrain such personnel in those countries.

1.39 Dental education. Efforts to inte-grate the teaching programs with the deliveryof health services were continued, especiallyin Central America and Panama. The analysisof this topic at the Meeting of Dental Associa-tions of the Isthmus (FOCAP), attended by of-ficials of associations, ministries of health, anduniversities, should facilitate coordinatedaction and a better utilization of the participat-ing entities' resources. In this area, PAHO/

10 Annual Report

WHO cooperated with Brazil, Costa Rica, Do-minican Republic, Ecuador, El Salvador,Guatemala, Honduras, Mexico, Nicaragua,Panama, Peru, and Venezuela. Constructionof the building for the School of Dentistry ofTrinidad and Tobago progressed during theyear; the school is expected to provide serviceto the English-speaking Caribbean countriesin 1985.

1.40 In the area of research, a survey wasinitiated to assess the effect of dental caries onthe children of a community in Antioquia, Co-lombia, in which salt fluoridation had been in-stituted several years before. A total of 30 par-ticipants from eight countries attended acourse on pedodontics and social periodonticsconducted jointly by the University of Panamaand the University of Illinois (USA). Attentionwas given once again to problems in the provi-sion of dental care to children in the MemberCountries and to present-day technologiesavailable in the United States of America andother countries of the Region for the deliveryof preventive and therapeutic services.

1.41 Veterinary public health. Activitiescontinued under the 1982-1986 RegionalProgram of Training in Animal Health forwhich the IDB had provided a loan of US$2.2million. In 1984, seven courses on epidemio-logical surveillance, administration of animalhealth programs, and social communicationwere offered, as was a regional seminar onfoot-and-mouth disease vaccine. A total of208 professionals participated in coursesgiven in Argentina, Bolivia, Brazil, Chile, Co-lombia, Dominican Republic, Ecuador, El Sal-vador, Guatemala, Guyana, Mexico, Nicara-gua, Peru, Uruguay, and Venezuela. By theend of the year, 592 national technicians-mostly employees of veterinary public healthservices-had received training. This staffprovides a basis for the institutionalization ofsimilar training within the countries.

1.42 With the completion of studies by itseighth graduating class in 1984, the RegionalEducation Program for Animal Health andVeterinary Public Health Assistants

(REPAHA) had trained a total of 239 assis-tants from 17 countries and territories of En-glish-speaking countries in the Caribbean.More than 82% of the graduates of REPAHAcurrently are working in their countries of ori-gin in fields related to their training. An evalu-ation of the impact of this project, made dur-ing 1984, revealed progress in continuingeducation and in linkages between REPAHAand the future School of Veterinary Medicinein Trinidad and Tobago. Since the United Na-tions Development Program (UNDP) fundingexpired in 1984, the Member Countries,wishing to ensure the program's continuity,established a fund which they will finance andconverted REPAHA into an agency ofCARICOM.

1.43 Public health and health adminis-tration. Within the Plan of Priority HealthNeeds in Central America and Panama, theGovernments of the Isthmus prepared a pro-posal for a program of education in publichealth that calls for the training of 600 profes-sionals and 2,000 middle-level and auxiliarystaff. Exchanges of experience, personnel,and educational materials among the Region'sschools of public health were encouraged. Inthis regard, the School of Public Health ofPeru was evaluated, and the priority activitiesfor 1985 of the School of Public Health ofMexico were identified.

1.44 In the area of education in health ad-ministration, in addition to the support ex-tended to specific country programs, the pro-file for middle-level, technical-administrativepersonnel was defined through PASCCAP foruse in conducting a training program for thisgroup in conjunction with the National Dis-tance Education University (UNED) of CostaRica. In health services administration,PAHO/WHO collaborated with the LatinAmerican Institute of Economic and SocialPlanning (ILPES) in the preparation of an in-tersectoral project to be carried out jointly bythe two agencies. The project primarily willanalyze the impact of the present economiccrisis in the social sectors of the Latin Ameri-


can and Caribbean countries and the effect onthe training of personnel. A working groupwas set up and activities were carried out inArgentina, Brazil, Colombia, Nicaragua, andespecially Cuba to promote the developmentof education in epidemiology and the practiceof new approaches in this field.

Educational Technology andTeaching Materials

1.45 Impetus was given to the productionand distribution of educational materials in pri-ority fields of training. Continued support wasextended to the national educational technol-ogy centers in Brazil, Cuba, Ecuador, Hondu-ras, Nicaragua, Panama, and Peru. Particularattention was given to the Educational Tech-nology and Health Nucleus (NUTES) at theFederal University of Rio de Janeiro, Brazil,which serves as the focal support and coordi-nation point for centers in other countries.NUTES initiated computerized training evalu-ation activities in Cuba. In Peru, regulationswere approved for the Educational Technol-ogy in Health Centers (CENTES), a combinedproject of the Ministry of Health of Peru, theNational University of San Marcos, andPAHO/WHO. As part of the process of struc-turing the network of educational technologycenters, an analysis of the existing centers inCentral America and Panama was conducted.Support was given to the development ofCENTES in Nicaragua, with an effort made toachieve an interinstitutional arrangement simi-lar to that of CENTES in Peru. Two courseswere conducted in Haiti, one on integratedevaluation of the training and service processfor officials of the National Malaria Serviceand the other on educational technology.

1.46 Beginning with the distribution ofquestionnaires to students and educationalinstitutions, PAHO's Expanded Textbook andInstructional Materials Program (PALTEX)was evaluated with a view toward possible re-structuring. The decentralized program inBrazil and the medical, veterinary, and dental

textbook programs of Argentina, Chile, Co-lombia, Mexico, Uruguay, and Venezuelawere evaluated.

Bibliographic Information Systems

1.47 Concerted efforts were madethrough the Latin American Center on HealthSciences Information (BIREME) to consoli-date the Latin American Health InformationSystems. A summary of the activities ofBIREME appear in chapter 3 of this Report.

Community Health Training Programfor Central America and Panama(PASCCAP)

1.48 PASCCAP continued to serve as avehicle for promoting the formulation of na-tional human resource policies with the partic-ipation of the ministries of health, social secu-rity institutions, and universities of CentralAmerica and Panama. As part of this effort, ascheme was developed for human resourceplanning in accordance to each government'sprimary health care strategy and health poli-cies. National health and human resourcestudies were being conducted in Guatemalaand Honduras, and assistance was providedto El Salvador and Guatemala in the design ofan information subsystem.

1.49 Research. PASCCAP continued tocooperate with national groups in charge ofhealth personnel research. Survey projects onthe performance of community health agentswere prepared in Guatemala, Honduras, andPanama. Guatemala also formulated projectsto assess and strengthen the continuing edu-cation system in the areas of educationalmethodology, identification of needs, and de-velopment of educational materials. and todetermine ways of linking supervision withcontinuing education. Eight training work-shops on research methodology applied topersonnel development were conducted in ElSalvador, Guatemala, Honduras. and Nicara-

11

12 Annual Report

gua for a total of 564 professionals. A manualof research methodology prepared by the Uni-versity of Honduras was published withPASCCAP assistance.

1.50 Development of technology. Sup-port was given to the establishment of educa-tional technology units at the Universities ofCosta Rica and Honduras. Pedagogical train-ing models were designed for El Salvador,Guatemala, and Honduras. Training in edu-cational methodologies was provided to 324instructors from ministries of health and uni-versities, and a distance education model wasbeing devised. A model for the developmentof occupational and educational profiles ofcommunity and nursing personnel was com-pleted and was being applied in all countriesof the Central American Isthmus. Educationaland occupational profiles were developed inconjunction with the School of Medical Sci-ences of the University of Honduras and willserve as a basis for reformulating the school'scurriculum.

1.51 Dissemination of information.Technical training materials were distributedwidely, especially manuals on x-ray diagnosis,research methodology, and formulation ofhuman resource policy. PASCCAP continuedto publish its quarterly bulletin for staff of ruralhealth centers and posts. Educational materialwas distributed for use in the Center for Re-search and Health Studies (CIES) in publichealth courses in Nicaragua, and in coursesoffered by the Medical Technology Section ofthe University of Costa Rica.

1.52 Training. Support was given tocontinuing education programs for health per-sonnel in Costa Rica, Guatemala, and Hon-duras in an effort to link them to supervisionand research and convert the programs intoan ongoing process covering all staff. In thisfield, a plan of operations involving groupsfrom three health regions was designed inGuatemala. In Costa Rica, assistance was pro-vided in the teaching of an educational unitwithin the Ministry of Health's continuing edu-cation program; 423 officials from the Ministry

and the Social Security Agency participated inthis training.

1.53 Within the guidelines for bringingthe universities into the countries' effort toachieve the goal of health for all by the year2000, PASCCAP initiated a program of coop-eration with various Central American univer-sities, as follows: (1) with the University ofCosta Rica, the production of educational ma-terials and support of the health research andeducation units; (2) with the University of ElSalvador, the initiation of a process to reform-ulate curricula in the various health area pro-grams; and (3) with the School of Medical Sci-ences of the University of San Carlos ofGuatemala, the design of an educational pro-gram including teaching-service integration,research, and faculty training at the San Juande Dios General Hospital.

1.54 Technical cooperation. Within thePlan for Priority Health Needs in CentralAmerica and Panama, PASCCAP collabo-rated in the formulation of 16 human resourceprojects. It also coordinated the preparation offive intercountry human resource projects inthe areas of public health, training of middle-level technicians, health personnel surveys,educational development and continuing ed-ucation, and the start-up activities for the Cen-tral American Network of Documentation andInformation Centers. Three of these projectswere expected to begin in 1985.

Administration of Fellowships

1.55 In 1984, PAHO/WHO awarded atotal of 1,441 fellowships in the Americas, ofwhich 990 or 69% were awarded at countrylevel. Under decentralized administration,113 fellowships were awarded in the Carib-bean subregion and 877 in Latin Americancountries for studies within the respective so-cioeconomic subregions. Awarding fellow-ships to individuals in countries of similar lan-guage, culture, and health conditions fostersTechnical Cooperation Among DevelopingCountries, enhances the accessibility of the


learning experience, and increases the likeli-hood of acquiring appropriate technology(table 1).

1.56 Group fellowships continued the in-crease begun in 1983, going from 31% to32% of the total. Long-term fellowships re-mained the same, and short or travel fellow-ships declined slightly (tables 1 and 2).

1.57 Of the 1,441 fellowships awarded in1984, 368 (26%) were in public health andother administrative fields, a decrease fromthe 31 % of 1983 and a reverse of the prevail-ing trend. Environmental health fellowshipsrose from 9% to 12% of the total awarded;nursing continued its decline by droppingfrom 5% to 4%; maternal and child healthrose from 5% to 7%; and other health ser-

Table 1. Fellowships awarded in the Americas, by country of originand type of training, 1984

Type of training

PAHO/WHOorganizedor assisted Long-term Short-term

Country of origin of fellows group courses fellowships felli

Antigua and BarbudaArgentinaBahamasBarbadosBelizeBoliviaBrazilCanadaChileColombiaCosta RicaCubaDominicaDominican RepublicEcuadorEl SalvadorGrenadaGuatemalaGuyanaHaitiHondurasJamaicaMexicoNicaraguaPanamaParaguayPeruSt. Christopher and NevisSaint LuciaSt. Vincent and the GrenadinesSurinameTrinidad and TobagoUnited States of AmericaUruguayVenezuelaBritish TerritoriesFrench Antilles, Guiana

Total

- None.

223141

1825

20185

431

3419201

1418

104

311718255721

21

14252

467

17

190

owships Total

3 713 36

3 513 292 113 26

100 1278 10

25 4725 4922 4680 1277 12

27 6319 4022 49

1 733 6622 2424 4416 3129 4245 8067 93

9 4223 5037 981 46 137 108 12

15 2317 1715 2924 5011 202 2

784 1,441

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14 Annual Report

Table 2. Fellowships awarded in the Americas, by field of study and country of origin, 1984

Country of origin of fellows

o <ol a , Q U

-E c n o r > E o o.c .E m <o - Ñ

Field of study < c a m a E E

Health OrganizationPublic Health Administration 1 3 - 2 1 1 1 4 8 1 1 3 3 - - 9 2Hospital and Medical Administration - - - - - - - - - - - 3 - 1 - 3 - 3 -Other PHA Sub-fields 1 8 1 6 3 3 23 1 10 6 3 35 1 10 14 15 1 5 8

SanitationSanitary Inspection - 1Sanitary Engineering - - 6 - - - - - - - - 1 - 1-Other Specialized Fields 1 - 1 2 16 - 1 5 3 13 1 10 5 3 - 22 -

NursingNursing Education - - 1 1 - - 2Public Health Nursing - - - - 3 - - - - 2 - - 5 - 1Nursing Services - - - 3 2 - 1 - - 1 - - - - - - - 4Other - - - - - - - 2- - - 1

Maternal and Child Health - 6 - - - - 12 - 3 3 3 1 - 2

Other Health Services - - 1 4 1 - 6 1 2 1 3 3 4 3 - - 2 2 -Mental Health 2 - - 3 - - 2 - - - 1 - -Health Education - - - - -- 1 - 2 1 1 1- - 1Occupational Health - - - - 1 1- - - - - 1Nutrition 1- 1 4 - - 1 - - 1 4 -Health Statistics 1 - - - - 1 1 - 1 - - 2 - 1 - - - 1 4Dental Care - - - - - - 3 - 3 2 - 2 - 7 - 16 -Rehabilitation - - - - - - - 1 - -Control of Pharmaceutical Preparations - - - - - - - - - - - - - - - - - 4

Communicable DiseasesMalaria - - - - - 2 - - 1Tuberculosis - - - 2 1 -- - -- - 2Zoonoses - 1 - - - - 2Foot-and-Mouth Diseases - 1 - - - 1 - - 1 1 - - - - 1Leprosy - - - - - 1 -- - - - 1 1Other Communicable Diseases - - - - - - 5 - - - 1 - - - - - 2Laboratory Services - 3 1 1 - 1 4 - 1 4 - 8 - 2 1Veterinary Public Health - 12 - 1 - 10 6 1 8 6 - 1 - 6 7 3 - 4 -Other 2 2 - - - 3 9 - 5 9 2 12 1 4 5 2 1 2 -

Medical Education and RelatedSciences - 1 - 3 - - 11 5 7 5 7 38 - 6 2 3 1 7 1

Clinical Medicine - 1 - 1 2 - 13 - 2 2 10 6 - - 1

Total 7 36 5 29 11 26 127 10 47 49 46 127 12 63 40 49 7 66 24

-None.


Table 2. Fellowships awarded in the Americas, by field of study and country of origin, 1984 (Cont.)

Country of origin of fellows

Ql

-, , U

Ql -

Field of study I I - ° u u > C ~ c

Health Organization

Public Health Administration 12 3 5 1 7 12 - 4 - - - 1 1 - - - 1 1 88Hospital and Medical Administration - - - - 1 2 - 1 - - - - 1 - - 1 - - 16

Other PHA Sub-fields 11 4 6 23 12 5 4 15 1 - - 3 4 4 5 7 5 1 264

SanitationSanitary Inspection - - 10 - - - - - - - - - - - - - - 11

Sanitary Engineering - - - 1 1 1 1 - - - - - - - 3 - - - 15Other Specialized Fields 3 - 1 12 10 2 11 7 1 2 9 1 3 4 1 - 150

NursingNursing Education - 2 - - 5 - - - - - - - - - - 1 1 - 13Public Health Nursing - - 1 - 1 - - - - 2 - - 2 1 - - 1 - 19Nursing Services - - - - 2 1 1 6 - - - - - - - - - 21Other - - - - - - - - 1 4 2 - - - - - - - 10

Maternal and Child Health 2 - - 8 12 6 5 24 - 1 - - - 3 2 1 - - 94

Other Health Services - 9 4 1 8 3 5 4 - 3 3 - - - 2 4 - - 79Mental Health - - 2 - -- 1 1 - - - - - - 2 - 15Health Education 4 - - 1 - - - - - - - - - - - - 14Occupational Health - - - - 1 - - - - - - - - - - - - - 3

Nutrition - 4 - - 2 1 - 3 1 - - - - - - - 24

Health Statistics 3 1 - 1 1 - - - - 1 1- - - - - 20Dental Care 1 1 2 1 3 - 1 3 - - - - - - - 4 - - 49Rehabilitation - - - - - - - - - - - 1 - - - - - - 2Control of Pharmaceutical Preparations - - - - - - - 2 - - - - - - - - - 6

Communicable DiseasesMalaria 3 - - 1 - - 2 5 - - - - - - - - - - 14Tuberculosis 2 - -6 1-1- 1 - 1 2- 1 1- 20

Zoonoses - - - - - - - - - - - - - - - 1 - - 4Foot-and-Mouth Diseases - - - - - - - 1 - - - - - - - - - - 6Leprosy - - - 2 - - - - - - - - - - - - - - 5Other Communicable Diseases - - - 1 - - - - - - - - - - - - 9

Laboratory Services 1 - 1 3 4 - 1 - - - - 2 - - - 8 - - 46

Veterinary Public Health - - - 9 5 - 9 9 - - - - - - 10 6 - - 113

Other 2 3 2 11 1 1 6 8 1 2 3 2 3 - 3 8 2 - 117

Medical Education and Related

Sciences - 3 1 3 16 5 - 11 - - - - - 8 1 3 - 148

Clinical Medicine 1 1 1 1 - - - 1 1 1- - 46

Total 44 31 42 80 93 42 50 98 4 13 10 12 23 17 29 50 20 21.441

-None.

15

16 Annual Report

vices fell from 17% to 15%. Communicabledisease studies rose from 20% to 23%, con-tinuing the recent trend; studies of medical ed-ucation and related sciences rose from 9% to10%, and clinical medicine from 2% to 3%.The increases in maternal and child healthand in communicable disease control in thecountries of the Region reflect the prioritiesbeing accorded in these areas (table 2).

1.58 Awarding 1,441 fellowships and 83extensions involved 4,004 months and re-quired US$4,837,805 resulting in an averageper month cost of US$1,208, a decrease ofalmost 2% from 1983. The decrease occurredin all categories except group course fellow-ships in Latin America and the Caribbean.Several factors contributed to the unusual de-crease in the overall cost of fellowships in1984. In the United States of America andCanada, efforts to identify and utilize institu-tions which offer education and training ofequal quality for lower costs have continuedsuccessfully. In Latin America and the Carib-bean, stipends-which are established andpaid in local currency-as well as other localcosts, have not risen at the same rate as therevaluation of the United States dollar. Also,many of the awards made under decentraliza-tion were for studies in neighboring countries,requiring lower travel and tuition expendi-tures.

1.59 Finally, in 1984, 653 fellowshipswere awarded to women, 45% of the total.This exceeds the highest previous percentageof 43% reached in 1981. Efforts to improvethe awarding of fellowships to women as anessential element in health for all appear to beachieving some success.

Expanded Textbook andInstructional Materials Program

1.60 Despite low student buying powerbrought about by the continuing economic cri-sis in Latin America, the quantity of materialsold through the program during 1984 was es-sentially equal to that sold during the previous

year. The 1984 sales projection at the time ofpreparation of this Report was US$115,000.

1.61 PAHO/WHO is continuing to studyways to make the Program more responsiveto the needs of the Member Countries, includ-ing financing the efforts of Latin Americanauthors and working groups to produce inno-vative textbooks and other instructional mate-rials. Considerable progress was made during1984 in publishing and distributing primaryhealth care manuals in two basic series. In thefirst PALTEX series, seven manuals and setsof modules were made available to techni-cians and auxiliaries in the areas of mentalhealth, laboratory techniques, maternal andchild health, basic eye care, preparation ofcommunity education materials, basic trainingfor the Expanded Program on Immunization,and principles of epidemiology. In the secondPALTEX series, manuals in the areas of drugsupply administration and hypertension con-trol were provided to persons in Latin Ameri-can health services in charge of planning andexecuting primary health care programs.

Diagnostic and TherapeuticTechnology

Laboratory Services

1.62 In 1984, the recommendations ofthe Regional Seminar on Laboratory Pro-grams, held in Chile in October 1983, beganto be applied in the countries. The initial em-phasis was on expansion of quality controlservices in the national networks, creation of.biosafety programs, and production and dis-tribution of reagents. Chile's Institute of PublicHealth strengthened its programs in those ar-eas and consolidated its role as Central Labo-ratory of the national system. It also expandedits activities as a WHO Collaborative Centerby increasing its cooperation with other coun-tries. Mexico continued to bolster its NationalLaboratory System by training staff of refer-ence laboratories and peripheral centers and


strengthening its food protection and epidemi-ology programs. In Brazil, the laboratory net-work infrastructure was reinforced by settingup national reference centers and an intensivetraining program. In view of the impact of theUNDP project on the improvement of labora-tories in the Caribbean, in progress since1981, the countries of that subregion pre-sented a request for its extension.

1.63 In an effort to assist governments instrengthening the management of their labo-ratories, regional and national courses wereconducted in cooperation with the UnitedStates of America's Centers for Disease Con-trol (CDC). In addition, coursés aimed at theprevention of potential hazards continued tobe offered in Argentina, Brazil, and Trinidadand Tobago, and biosafety committees wereestablished in Argentina, Chile, Colombia,Mexico, and Venezuela.

1.64 Regarding quality control problems,besides the existing quality control programsof syphilis serology, clinical chemistry, identifi-cation of Mycobacterium tuberculosis, micro-biology, and parasitology, a program of qual-ity control in hematology was initiated in1984. By the end of the year, 10 countrieswere participating in this new program. Thisfield is related to the production and availabil-ity of biological reagents. In 1984 a programwas started in which Brazil (Lutz Institute andthe Oswaldo Cruz Foundation), Chile (HealthInstitute), and Mexico (General Managementfor Biological Products and Reagents) collabo-rated in supplying some 900 reagents to 11countries. Argentina and Cuba have adheredto this scheme and are offering, respectively,monoclonal antigen and antibodies for Cha-gas' disease.

1.65 As an outcome of the regional work-shop on standardization of antibody sensitivitytests (Caracas), a network of national centers(Argentina, Chile, Colombia, Mexico, andVenezuela) was established to detect antibioticsensitivity of etiological agents. The analysesof such tests are being made by PAHO/WHOCollaborating Center in Boston. This informa-

tion is afterwards distributed to all countries ofthe Region.

1.66 Advances were made in the denguevirological surveillance program (Caribbeancountries, El Salvador, Guatemala, and Mex-ico) and in hybridoma technology and mono-clonal antibody production.

1.67 Immunology services in CentralAmerica and Panama were evaluated with aview to establishing a network of immunologycenters similar to those in operation in the En-glish-speaking Caribbean countries. With theaim of making maximum use of modern bio-technology for the benefit of human, animal,and environmental health, a network of bio-technology centers engaging in research,training, and information exchange was de-signed.

Radiation Health

1.68 PAHO/WHO continued its pro-gram aimed at fostering the use of the "essen-tial radiology system" in areas lacking radio-logical services. An evaluation was made ofthe program in Colombia, where four unitshad been installed on a pilot basis in the De-partment of Antioquia in 1983. The findingsof the evaluation indicated that the systemwas covering the most common diagnosticneed, the training of auxiliaries for a 1-weekperiod was sufficient, supervision by a profes-sional technician was needed, and the opera-tion of the system was posing no problems. InNicaragua four units were obtained and in-stalled, the necessary staff was trained, andthe basic arrangements for an evaluation weremade. Chile is planning to utilize the system in1985. A survey conducted in collaborationwith the Governments of Argentina, Brazil,Colombia, Costa Rica, Dominican Republic,Ecuador, Mexico, and Nicaragua on the useof x-ray equipment revealed that its utilizationin diagnosis was very low in small hospitals,ranging from 1 to 5% as compared to 20 to30% in referral hospitals. A total of 120 radia-tion therapy services in Barbados, Bolivia,

17

18 Annual Report

Chile, Colombia, Costa Rica, Cuba, Ecuador,El Salvador, Guatemala, Panama, Paraguay,Peru, Trinidad and Tobago, Uruguay, andVenezuela were participating in 1984 inPAHO's Collaborative Program with WHOand the International Atomic Energy Agency(IAEA) aimed at accurately measuring thedosage of radiation received by patients undertreatment. While there is clearly a trend to-ward the improvement of dosimetry, 40% ofthe centers were not as yet fulfilling the preci-sion criteria. In Danbury Hospital in Connecti-cut (USA), a pilot study was undertaken inconjunction with the WHO CollaboratingCenter in Nuclear Medicine to determine theprecision of dosages in nuclear medicine inArgentina, Bolivia, Brazil, Chile, Colombia,Costa Rica, Ecuador, Mexico, Peru, and Uru-guay. A comparative analysis of the findingswill be made and is expected to contribute toan improvement in diagnostic procedures.

1.69 In the radiation protection area,PAHO/WHO collaborated with Argentina inthe application of new diagnostic and protec-tive techniques, with Colombia in studies onprotection in four localities, with Mexico in theoperation of a radiological protection pro-gram, and with the Netherlands Antilles in theidentification of protection requirements andthe preparation of proposed legislation.

Essential Drugs

1.70 Expenditures for drugs continue toincrease in the public and private sectors, al-though the large cost figure for pharmaceuti-cals marketed in 1983 in Latin America andthe Caribbean-more than US$5 billion-does not reflect the real health needs of theRegion. Another serious problem is the dis-parity between the frequently inadequate pro-vision of drugs resulting from the extension ofhealth coverage and the ready availability ofpharmaceuticals mainly to urban populationswith economic means and access to medicalcare. Several actions have been promoted by

Member Governments with PAHO/WHOsupport to assure availability of drugs to allpopulations at a reasonable cost.

1.71 The Technical Discussions held inSeptember 1983 during the XXIX Meeting ofthe PAHO Directing Council on "Policies forthe Production and Marketing of EssentialDrugs" drafted a resolution, subsequentlyadopted by the Council, recommending thatgovernments encourage self-sufficiency in thedrug sector. In support of this strategy, the Or-ganization coordinated a study on the produc-tion of raw materials in Argentina, Brazil, andMexico which served as the basis for propos-ing regional approaches for integrating exist-ing production facilities and expanding theirmarkets. Representatives of the above coun-tries and Spain discussed the proposals at aJuly 1984 meeting in Mexico and recom-mended an intercountry program on the pro-duction and marketing of raw materials andfinished products, as well as on pharmaceuti-cal research and development. PAHO/WHOMember Governments endorsed these rec-ommendations at their XXX Directing Coun-cil Meeting in September 1984. PAHO/WHO will be cooperating with thedevelopment of this long-term, complex pro-gram, which will require high-level politicalcommitment and intersectoral coordinationwithin the participating countries.

1.72 PAHO/WHO gave priority to theessential drugs component of the comprehen-sive plan entitled "Priority Health Needs inCentral America and Panama" agreed uponby the governments of this subregion. Inter-country and national project profiles were de-veloped in the areas of drug policy formula-tion, production, quality control, joint pro-curement and supply systems. PAHO/WHOalready is cooperating with Central Americaand Panama within the framework of theseproject profiles. For example, the Organiza-tion, in collaboration with the Central Ameri-can Bank for Economic Integration (BCIE),completed a study on the establishment of arevolving fund and a joint procurement sys-


tem for Central America and Panama. In ad-dition to the Central American activities,PAHO/WHO is collaborating with the An-dean Pact in promoting the exchange of infor-mation on prices and sources of raw materialsas well as on finished products imported intothe Andean countries.

1.73 PAHO/WHO's cooperation withgovernments stresses the need for a coherentnational drug policy, and during 1984 the Or-ganization carried out a number of activitiesaddressing this subject. In Argentina, studiesand preliminary activities were undertaken to-ward the establishment of a special program toprovide free essential drugs to the populationin need. In Colombia, an intersectoral work-shop was developed on the need for a na-tional policy, and health authorities preparedan initial program for 1985. In Nicaragua,studies and proposals were carried out for theformulation of national drug policies and thepreparation of essential drug lists and a thera-peutic formulary; the Government also estab-lished a national body (COFARMA) to assurean integrated intersectoral approach to phar-maceuticals. Technical cooperation relating tospecific aspects of drug policy also was pro-vided to Cuba, Ecuador, and Peru.

1.74 Regarding pharmaceutical supplysystems, the Barbados Drug Service (BDS)has been designated as a WHO CollaboratingCenter on Drug Management in the English-speaking Caribbean. Through BDS staff tech-nical cooperation was provided to Dominicafor the publication of its national formularyand to St. Vincent and the Grenadines for im-proving their pharmaceutical supply system.Similar activities are being initiated in SaintLucia.

1.75 Great emphasis was placed on man-power development during 1984. Subre-gional "train the trainer" courses on drug sup-ply management were held in Colombia(March) and Costa Rica (November) with thecooperation of the Javeriana University andthe Central American Institute of Public Ad-ministration, respectively. This activity led tonational courses on drug management in Bo-

livia, Ecuador, Peru, and Venezuela, organ-ized with the collaboration of the HipólitoUnanue Agreement in 1984; courses in Cen-tral American countries will be held in 1985-1986. In Brazil, the National Drug Center(CEME) conducted a course addressing thepolitical, technical, and administrative aspectsof an essential drugs program.

1.76 To strengthen training in the area ofdrug quality control, activities were increasedwith the participation of the Specialized Labo-ratory of Analysis of the University of Pan-ama, which in 1984 was designated a WHOCollaborating Center in Drug Control. Re-gional courses on drug approval and registra-tion and on drug bioequivalence were heldduring the year, and courses on postmarket-ing surveillance and on chromatographicanalysis are being prepared for 1985.

1.77 UNDP-funded projects in drug regu-lation and control continued in two countries.The Brazil project provides the resources re-quired for the infrastructure development ofthe Federal Laboratory responsible for thecontrol of foods, drugs, and biologicals. InGuatemala, the project stresses the imple-mentation of the drug approval process andstrengthening of the official drug control labo-ratory which is progressing satisfactorily.

Vaccine and Biologicals Production

1.78 Surveillance of the potency andsafety of vaccines used in national immuniza-tion programs is a basic PAHO/WHO cooper-ation activity. As a result of this scrutiny, in1984 three manufacturers were discardedfrom the list of suppliers for 1985 becausetheir products did not satisfy PAHO/WHO re-quirements. In another instance the contractof a polio (live) vaccine manufacturer was re-voked after a breach in the consistency of thesterility of the product supply to one of thecountries.

1.79 Checking on the stability of the polio(oral) and measles (live) vaccines is now anestablished routine in the health laboratories

19

20 Annual Report

of Argentina, Brazil, Chile, and Mexico. Dur-ing 1984 four more national laboratories qual-ified to perform the test: Colombia, Ecuador,Honduras, and Venezuela. All laboratoriesparticipating in testing viral vaccines had re-ceived reference materials from collaboratinglaboratories in Mexico and the United Statesof America. Also, virologists from laboratoriesin Brazil, Chile, Colombia, Dominican Repub-lic, Ecuador, and Honduras were trained inMexico on the titration of viral vaccines.

1.80 To enable the vaccine-producinglaboratories in Latin America to become self-sufficient and to participate in the internationalbids for vaccines purchased through the Ex-panded Program on Immunization (EPI) Re-volving Fund, direct PAHO/WHO consulta-tions were maintained, the laboratories wereperiodically assessed, and the potency of theirproducts was tested in PAHO/WHO-desig-nated reference laboratories. Three vaccinemanufacturers in the Region should be able toqualify: Brazil (BCG), Chile (DPT), and Mex-ico (BCG).

1.81 The stability of yellow fever vaccineproduced in Brazil and Colombia is monitoredby the National Center for Drugs and Biologi-cals of the U.S. Food and Drug Administra-tion, the PAHO/WHO-designated referencelaboratory for yellow fever vaccine. Studiesare being pursued with funds from the Inter-national Development Research Center (Can-ada) to improve the stability of the 17D vac-cine at a higher temperature (37°C). In orderto support the development of yellow fevervaccine, PAHO/WHO had agreed to providea grant to the Oswaldo Cruz Foundation (Bra-zil) and to the National Institute of Health (Co-lombia). The two laboratories exchange infor-mation on production and control, and Braziltrained the scientist in charge of productionand control in the Colombian laboratory.

1.82 Regarding smallpox vaccine, WHOkeeps an emergency reserve stock of freeze-dried vaccine, estimated at 105 million nomi-nal doses. In 1984, at the request of the WHOOrthopoxvirus Committee, the status of pro-

duction and of vaccine stocks held by theAmericas was surveyed. Amounts of vaccinestock are maintained in the United States ofAmerica (15 million doses), Colombia (6.6million doses), Peru (4 million doses), andCanada (1 million doses). Canada maintainsboth the primary and secondary seeds, as wellas an undetermined volume of pulp; the lattershould enable Canada to resume productionin the event of an emergency situation.

1.83 Mexico has gradually emerged as areliable partner that provides services to manyof the other countries in the Region. Its Na-tional Institute of Virology and National Refer-ence Laboratory rendered the following ser-vices: checked the stability and potency offield samples of polio and measles vaccines re-ferred by the national EPI programs in Bolivia,Chile, Colombia, Guatemala, Honduras,Panama, Nicaragua, and Peru; providedtechnical consultation to Cuba on DPT andmeasles vaccines; held (October-November)a regional training course in viral vaccines forcontrollers from Latin American countries;and made available to control laboratories ref-erence polio 1, 2, and 3 neutralizing antise-rum. In conjunction with the National Centerfor Drugs and Biologicals of the U.S. Foodand Drug Administration, the National Refer-ence Laboratory in Mexico is taking steps tooperate a quality assessment scheme in micro-titration of viral vaccines-polio (oral) andmeasles (live). Laboratories from Argen-tina, Brazil, Chile, Colombia, Cuba, Ecua-dor, Honduras, Peru, and Venezuela areparticipating.

1.84 The Clodomiro Picado Institute inCosta Rica and the Oklahoma State Univer-sity (USA) are conducting research on thecharacterization and standardization of ven-oms and homologous antivenoms ofBothrops atrox. Venomous factors will beused in preparing improved immune antiseraof high specificity and potency.

1.85 Steady and unprecedented growthof biologicals programs in Latin America hasincreased the levels of biotechnology re-


sources in the countries. An important conse-quence has been the designation of 12 expertsfrom the Region on WHO panels-6 on bloodand blood production, 4 on biological stan-dardization, and 2 in the new WHO programfor the development of vaccines.

1.86 Blood Program. To carry out theactivities of the mid-term program on effectiveblood transfusion services at the level of thecountries, PAHO/WHO relies on a networkof collaborating blood banks. A recent surveyidentified that the blood banks in Brazil, Co-lombia, Costa Rica, Cuba, Ecuador, Jamaica,Nicaragua, and Uruguay qualify for referenceand training in blood banking. During 1984,PAHO/WHO responded promptly to all thecountries that had requested PAHO/WHOtechnical cooperation in assessing their bloodtransfusion services in order to help define na-tional policies. In Belize, the operation of acommercial plasmapheresis plant underminesthe Code of Ethics and undercuts the efforts ofvoluntary organizations. The Government hasadopted legislation regulating the use ofblood. A project proposal was drafted and po-tential funding sources identified. In Peru, thehealth service has commissioned a task forceto advise on the feasibility of a national policyon blood. At the request of the Secretariat ofthe Hipólito Unanue Agreement, the avail-ability and need for hemoderivatives in Co-lombia, Peru, and Venezuela have been as-

sessed, particularly in terms of hemophiliaes.One central blood bank per country would beadequate to supply the required amounts ofcryoprecipitate for those cases.

1.87 In Brazil, technical cooperation wasprovided to a local industry that manufacturesdisposable plastic blood bags from source ma-terials available locally and processes the com-ponents from whole blood. The Governmentdesignated the National Institute for the Con-trol of Health Quality (INCQS) to control thesafety and quality of blood bags.

1.88 Blood transfusion services in Barba-dos, Belize, Dominica, Grenada, Haiti, Ja-maica, and Trinidad and Tobago wereassessed in May. A proposal was made to es-tablish an intercountry project to service theblood banks in the Caribbean subregion, usingthe National Blood Transfusion Center inKingston, Jamaica, as a reference center forteaching, training, and production of reagentsand the Queen Elizabeth Hospital in Bridge-town, Barbados, as a collaborating blood bankfor the Eastern Caribbean. In December,blood banks in Argentina, Brazil, Colombia,Costa Rica, Cuba, Dominican Republic,Ecuador, Nicaragua, and Uruguay began toparticipate in a WHO-sponsored quality as-surance scheme of laboratory tests to enableblood banks to standardize their testingprocedures.

21

Chapter 2. Development of Health Programs

2.1 During 1984, the development ofhealth programs involved activities in the fol-lowing areas: (a) health promotion and care forthe population, especially those groups moreexposed to risk factors; (b) development of ini-tiatives to improve environmental conditions,with particular reference to marginal groups oflarge cities and rural areas; and (c) disease pre-vention and control. These three areas areclosely related. This chapter also considers sev-eral priority programs identified by the Organi-zation's Governing Bodies: priority healthneeds in Central America and Panama, emer-gency preparedness and disaster relief coordi-nation, women, health, and development, andhealth statistics.

Health Promotion and Care

Food and Nutrition

2.2 PAHO/WHO's cooperation in thisgovernmental priority area was directed tostrengthening national plans and programs toincrease food supply and consumption levelsand establishing mechanisms for food and nu-trition surveillance and the prevention of spe-cific deficiencies. PAHO/WHO also cooper-ated in the incorporation of food and nutritionas an important element of primary healthcare and in strengthening national and subre-gional food and nutrition institutions.

2.3 Increase in availability of food. Witha view to developing strategies for increasingthe availability of basic foods in poor homes,PAHO/WHO, in collaboration with the Insti-tute of Nutrition and Food Technology (INTA)of the University of Chile, is performing stud-ies in Chile, Colombia, and Peru to acquiremore precise information on various food sub-sidy programs in Latin America and their ef-fectiveness. A deep analysis of these studieswill be made and supplemented by surveys tobe initiated in 1985. In Brazil, the NationalFood and Nutrition Institute, the National Hu-man Resource Center of the Secretariat forPlanning, and the Joaquím Nabuco Founda-tion were working toward similar ends. Theseinstitutions examined the food subsidy anddonation programs formulated on the basis ofthe National Family Pantry Survey (ENDEFE)and the Basic Food Supply (PROAB) and Nu-trition in Health (PNS) programs. In Colom-bia, as a result of the intersectoral workshopon nutrition and food safety (1983), a workinggroup was established including representa-tives of the National Planning Department,the Ministers of Health, Agriculture, and Edu-cation, and the Colombian Institute for FamilyWelfare. The group recommended continua-tion of the Food and Nutrition Plan (PAN) andthe Integrated Rural Development Program(DRI), both of basic importance for imple-menting the country's food and nutrition poli-cies. In food assistance. PAHO/WHO coop-

23

24 Annual Report

erated in the technical analysis of new projectsunder the World Food Program (WFP) andthe evaluation of projects under way. In 1984,the WFP supplied assistance to 20 countries ofthe Region through 42 projects that provided396,902 metric tons of food valued atUS$270,293,900.

2.4 Increase in food consumption. Therecommendations of the food and nutritioneducation workshop held in Jamaica in 1983were examined with a view to finding ways ofenhancing the role of the family and the com-munity in the improvement of food consump-tion levels. A working group was convened atthe Institute of Nutrition of Central Americaand Panama (INCAP) in September 1984 todetermine the priority activities that should bestarted immediately and the need for action-oriented research to be submitted by PAHOfor the Member Countries' consideration inthe areas of social communication; educationat the community level; and the training ofstaff-from community health workers to uni-versity-trained personnel-in health, nutritionand food, and related areas. These activitieswere expected to provide a basis for generat-ing action plans at the country level.

2.5 Food and nutrition surveillance.Cooperation with the countries in this fieldwas given renewed impetus by two events.The first was the organization of a PAHO/WHO Consultative Group on Food and Nutri-tion Surveillance, which revised the opera-tional concept of surveillance and formulatedrecommendations for orienting PAHO/WHOcooperation toward operations research, stafftraining, and intercountry technical coopera-tion. The second event was a regional semi-nar-workshop on the contribution of school-children's height surveys to food and nutritionsurveillance systems, sponsored by INCAPand its Central American member countriesand Panama. The governments' activities inthis area in cooperation with PAHO/WHOwere also outstanding. Thus, in Brazil, the Na-tional Food and Nutrition Institute and theJoaquím Nabuco Foundation established a pi-lot food and nutrition project in the State of

Pernambuco. In Chile, INTA was organizingthe first international course on food and nu-trition surveillance (CIVAN-85) to be con-ducted in March-July 1985 in conjunctionwith Cornell University (USA) and PAHO/WHO. In Colombia, the nutrition project atthe University of Valle was continued, and theprogram for nutritional surveillance of the De-partments of Valle and Cauca (Kellogg Foun-dation, German Agency for Technical Coop-eration, and PAHO/WHO) was evaluated.With a view toward applying this experiencecountry-wide, a national workshop will beconducted in 1985 on incorporating food andnutrition surveillance into health informationsystems. In Ecuador, INCAP/USAID/CDC/LATINRECO jointly supported the planningfor a national survey of nutrition, health, andfood consumption, also to be carried out in1985. In Peru, a national health and nutritionsurvey was designed and the data were beinganalyzed at the end of the year. In The Do-minican Republic, the nutritional surveillanceactivities were revised to include communityhealth workers' application of anthropometricindicators to the infant population.

2.6 Prevention of specific deficienciesby means of mass-scale actions. The Orga-nization promoted the control of iodine defi-ciency, endemic goiter, and cretinism espe-cially in the Andean countries, where theproblem is most serious. In Bolivia, acting to-gether with the joint PAHO/WHO-UNICEFNutritional Support Program, the Ministry ofSocial Welfare and Public Health imple-mented the action plan prepared in 1983,achieving the following results: (1) the pro-duction of iodized salt with the installation oftwo new plants at La Paz and Chuquisacawhich, together with two other scheduled togo on stream in 1985, are expected to result inthe iodization of more than 85% of the salt forhuman consumption in Bolivia; (2) organiza-tion of small salt producers to form coopera-tives for the production, iodization, and mar-keting of iodized salt; (3) initiation of a broadcampaign of public education on the benefitsof using iodized salt; (4) establishment of a re-volving fund to cover the cost of inputs

Development of Health Programs 25

needed for continuing the salt iodization pro-gram; (5) identification of high-risk communi-ties requiring other types of transitional actionto combat this deficiency; and (6) implemen-tation of an iodine deficiency monitoring andsurveillance system in the primary health careservices. In Colombia and Venezuela, actionwas taken in 1984 to implement the recom-mendations of the V Meeting of the PAHO/WHO Technical Group on the Control of En-demic Goiter and Cretinism, held in Lima inNovember 1983. In Ecuador, various groupscooperated with Belgian scientific groups in astudy on the eradication of iodine deficiency,to serve as a basis for subsequent program-ming. In Peru, also with support from thePAHO/WHO-UNICEF Joint Program, theMinistry of Health prepared a plan of action,to be implemented beginning in 1985, for theeradication of iodine deficiency.

2.7 The World Health Assembly gave itsapproval in 1984 to the global program for theeradication of vitamin A deficiency. Existingprograms currently are being strengthenedthrough food fortification in Guatemala andHonduras and the systematic administrationof massive doses on a periodic basis in Haitiand the northeast of Brazil.

2.8 With regard to iron deficiency and nu-tritional anemias, the long-term study on forti-fication of sugar with NaFeEDTA conductedby INCAP/PAHO/WHO in four Guatemalancommunities was completed in mid-1984.The results of the study were highly satisfac-tory and opened up new avenues for the pre-vention and control of this deficiency.

2.9 Lastly, in 1984, PAHO/WHO andINCAP promoted the preparation of salt fluo-ridation programs in Costa Rica, Nicaragua,and Peru to counteract the deficiencies of thismicronutrient, so important for oral health.

2.10 Food and nutrition in primaryhealth care. In close coordination withUNICEF and with funding provided by thejoint WHO/UNICEF Nutrition Support Pro-gram, PAHO/WHO cooperated with severalgovernments in the implementation of nutri-

tion support projects as part of primary healthcare activities. The projects reached varyingstages of development in 1984. In Brazil, withPAHO/WHO technical and financial cooper-ation, the University of Pernambuco and theNational Nutrition Institute conducted the firstinternational course on nutrition and primarycare in August, attended by 25 physicians,nurses, and nutritionists. In addition, the Or-ganization cooperated with the governmentsof the Central American Isthmus in develop-ing the food and nutrition component of thePlan for Priority Health Needs in CentralAmerica and Panama, described in this samechapter under Special Programs. Dominica,with support from the Caribbean Food andNutrition Institute (CFNI), has a program al-ready in effect which provides for broad com-munity participation and includes activities forthe prevention and control of nutrition-relateddiseases (such as obesity, hypertension, dia-betes, and arteriosclerosis) and their compli-cations, which are highly prevalent on thatisland and in the Caribbean countries ingeneral. In Haiti, where the project had beenoperational for 18 months, activities were cen-tered around promoting the widespread prac-tice of oral rehydration, developing means forevaluating the project, and defining strategiesfor extending it. In Nicaragua, with INCAPsupport, the 5-year plan of operations wasprepared, as was the plan of action for the firstyear of the project, scheduled to begin early in1985. The project in Peru was at the stage ofconsolidating the operational structure, andthe Government was planning to inaugurate itin the Puno area at the beginning of 1985. InSt. Vincent and the Grenadines, the projectwas being implemented with the assistance ofCFNI; its activities included training staff, de-veloping educational components, and in-creasing community participation.

2.11 In the area of preventive nutrition,three pilot studies of the PRECAVAS project(the contribution of food and drug interven-tions to the prevention and control of chroniccardiovascular diseases) were completed inBrazil, Jamaica, and Mexico. The resultingdata were being processed and analyzed for

26 Annual Report

the purpose of designing a common and stan-dard methodology, to be used in 1985, for ini-tiating an epidemiological study of risk factorsand their food and lifestyle determinants incontrasting populations of the various coun-tries of the Hemisphere.

2.12 Strengthening of national andsubregional food and nutrition institutions.Component agencies of the Regional Opera-tions held their first consultation meeting in1984. In this meeting, in which three UnitedStates of America institutes, three from LatinAmerica, the two PAHO centers dealing withfood and nutrition (CFNI and INCAP) and theUnited Nations University, the CoordinatingCommittee for the Network was established,and agreement was reached on priority activi-ties for the Network to undertake in 1985. TheOrganization acts as the Secretariat of the Net-work. One of the Network's primary objectivesis to contribute to the strengthening of nationalinstitutions to develop national capability forsolving food and nutrition, health, and develop-ment problems, and to carry on operationalresearch, staff training, and information dissem-ination. INCAP and CFNI are part of thisprogram.

Institute of Nutrition of CentralAmerica and Panama (INCAP)

2.13 The following stand out amongINCAP's activities in 1984 in the areas of gen-eration and dissemination of knowledge,training, and cooperation with the countries ofthe Central American Isthmus.

2.14 Research. In nutrition and health,INCAP initiated research on epidemiologicaland operational aspects of various compo-nents of the primary health care strategy, in-cluding the feeding of infants with diarrhea,the epidemiology of acute respiratory diseasesin urban areas, health and nutrition educa-tion, the utilization of health services, andfood and nutrition surveillance. The findingswere applied in the formulation of infant sur-vival programs to be conducted beginning in1985. In Costa Rica, the dietary data obtainedfrom the national nutritional survey was ana-lyzed in conjunction with the Department of

Nutrition, and a national survey on food prac-tices of schoolchildren and mothers wasplanned. The Costa Rican Nutrition andHealth Teaching Institute received assistancein formulating a proposal, "Evaluation of theImpact of Social Development Programs onthe Status of Health and Nutrition, 1970-1984," and negotiations for external financingwere begun. In Panama, INCAP collaboratedwith the Ministry of Health in a study of thecost and nutritional value of the meals servedat 33 of the country's hospitals, with a view tomaking appropriate improvements. Studieswere conducted on pollution of food sold inthe street and of crops irrigated with waste-water, for the purpose of defining strategiesand plans to protect the population. Studieson food and nutrition and socioeconomic fac-tors continued in Guatemala. INCAP contin-ued its studies on the utilization of nontradi-tional products that can help to solve nutritionproblems. The studies on the nutritional valueof amaranth were completed, and those on"alado" and "gandul" beans were continued.

2.15 Technology development. Thefield testing of the "Nutricta" corn strain, onwhich studies were started in 1983, was ahighlight in INCAP's effort to improve the sta-ple grains forming part of the subregion's diet.In view of the significant post-harvest losses oflegumes, INCAP is working on the develop-ment of household, community, and regionaltechnologies for solving this problem. The Di-etary Services Manual of San Juan de DiosHospital in Guatemala and the Supervisionand Evaluation Manual of the Social SecurityAgency's Nutrition Department of Panamawere revised and updated.

2.16 Dissemination of information. Themain activities in 1984 in the dissemination oftechnical information were the publication ofthree issues of the bulletin INCAP Reports,distributed primarily on the Central AmericanIsthmus; the publication and distribution ofthree numbers of the Supplement on Maternaland Child Nutrition, Breastfeeding, andWeaning; the publication and distribution ofdocuments entitled Guidelines for the Estab-lishment of Milk Banks and Selected Bibliog-


raphy on Breastfeeding; and the preparationof 2,975 kits of materials on maternal andchild nutrition, breastfeeding, and weaning,which were distributed at 21 events in CentralAmerica, Panama, and the Dominican Re-public.

2.17 Training. Studies on human re-source requirements for food and nutritionprograms were carried out in 1984 in El Sal-vador, Guatemala, Honduras, Nicaragua,and Panama. The study in Costa Rica will beconducted in 1985. The findings of thesestudies will enable the countries to plan thetraining of human resources for such pro-grams more effectively. The Institute contin-ued to collaborate with San Carlos Universityin Guatemala in training nutritionists, with theUniversity of Panama in planning the nutritioncurriculum, and with the schools of nutritionof the University of Costa Rica and the CentralAmerican University in Nicaragua. INCAPcontinued to offer its graduate course in foodscience and technology, which is open to pro-fessionals from any country in the Region.Given the priority extended by the subregionto infant survival programs, the Institute of-fered short courses on breastfeeding, foodand nutrition education, and information sys-tems for staff of ministries of health and inten-sified the training in breastfeeding of healthprofessionals in the various countries, includ-ing a subregional course in Costa Rica on clini-cal management of breastfeeding for hospitalpersonnel. A subregional seminar-workshopon the contribution of height and weight sur-veys in primary schools to the operation offood and nutrition surveillance systems wasconducted in Antigua, Guatemala, as part ofan effort to analyze the food and nutrition sur-veillance plans of INCAP's member countries.The workshop was attended by 52 profession-als. from the agricultural, educational, plan-ning, and health sectors of the Central Ameri-can countries and Panama.

2.18 INCAP collaborated with the Minis-try of Public Health and Social Welfare of ElSalvador in the preparation of a preliminaryproposal for an inservice training plan for hos-pital personnel and in a review of the food and

nutrition aspects of the training program forrural health assistants. Finally, INCAP collab-orated in a seminar-workshop conducted for40 physicians, nurses, and nutritionists on theevaluation of nutritional status. The Divisionof Human Resources of the General HealthService Directorate of Guatemala, with thecooperation of INCAP, offered a course-workshop on research methodology appliedto health service manpower.

2.19 Table 3 summarizes INCAP's train-ing activities in 1984 by participant's countryand Region of origin and by type of trainingoffered.

2.20 Technical cooperation. Togetherwith other technical resources of PAHO/WHO, INCAP collaborated with the Govern-ments of the Isthmus in preparing the follow-ing subregional projects forming part of apriority plan entitled "Improvement of Foodand Nutrition in Central America and Pan-ama" which aim at: (1) strengthening and de-veloping the nutrition surveillance system; (2)food and nutrition education; (3) technicaland administrative reinforcement of food aidprograms; (4) food fortification; (5) training;and (6) food supply. INCAP carried out stud-ies on the mobilization of resources for priorityareas of this plan, and in December 1984USAID provided a US$7.5 million grant,available for a 5-year period, to assist thecountries in their oral rehydration and nutri-tion activities in the infant survival area. Aspart of this arrangement, INCAP continued toprovide support to the countries in the formu-lation and implementation of national projectsin the priority area of food and nutrition. Withregard to breastfeeding, to which particular at-tention was given, a module was developedfor collecting information on significant activi-ties in this field. The module provided forfeedback for decision-making. Direct cooper-ation was given to health authorities in the de-sign of protocols for a number of breastfeedingprojects, some of which were subsequentlyapproved and provided with external financ-ing. In Panama, INCAP collaborated with theMinistry of Health in the development of a na-

28 Annual Report

Table 3. Participants in INCAP teaching programs, by country and Regionof origin and by type of training, 1984

TrainingCountry and Region School of Graduate Advanced Tutorial in nationalof origin Nutrition courses residency training courses Total

INCAP member countries:Costa Rica 1 1 - 2 20 24El Salvador - - - 20 40 60Guatemala 13 7 - 46 213 279Honduras 5 - - 2 39 46

Nicaragua 2 - - 8 33 43Panama - 1 3 162 166

Total 21 8 1 81 507 618

Other countries of the Americas:Bolivia - - 3 - - 3

Colombia - 1 - 1Ecuador - 1 - - 1

Mexico - 1 -- 1

Peru - 1 - 1 - 2United States of America - - 1 - 1

Total - 2 5 2 - 9

Other Regions:Bangladesh - - 3 - - 3

Bulgaria - - 1 - - 1England - - - 1 - 1

Philippines - 1 - 1

Total - - 5 1 - 6

Grand total 21 10 11 84 507 633

- None.

tional breastfeeding promotion project whichincluded the design, organization, and imple-mentation of an information center, periodicevaluations of the project, and the preparationof operating plans; the holding of 2 nationaland 23 regional seminars to promote breast-feeding, attended by 1,200 professionals fromthe health, education, agriculture, and laborareas; the production and testing of the Guidefor the Promotion of Breastfeeding at the Pri-mary School Level; and hospital studies to de-termine the feasibility of establishing "breast-milk banks." In Honduras, a workshop wasconducted on the treatment of special breast-feeding situations, and a documentation cen-ter was established for the Breastfeeding Sup-port Project.

2.21 Institutional studies were made of 65food aid programs under way in the CentralAmerican Isthmus, with the directors of thenational programs and representatives of do-nor agencies participating in the study in eachcountry. The findings of the survey were dis-cussed first in each country and later at IN-CAP with representatives of the World FoodProgram (WFP), the Food and AgricultureOrganization of the United Nations (FAO), theUnited Nations Children's Fund (UNICEF),the United States Agency for International De-velopment (USAID), CARE, and PAHO/WHO. Based on the results of the subregionalstudy, a proposal was developed for coopera-tion with the food aid programs in CentralAmerica and Panama. The project. with a


cost of US$6 million for 5 years, will be sub-mitted to lending agencies with a request forfunding.

2.22 In Honduras, the institutional studyof food aid programs was completed and ana-lyzed, and an impact evaluation report wasprepared on stage 2 of the project on masscommunication applied to child health (PRO-COMSI). In Nicaragua, in cooperation withthe Ministry of Health and UNICEF, INCAPformulated the food program forming part ofthe country's proposed Five-Year Food andNutrition Plan, which was submitted to thePAHO/WHO-UNICEF Joint Nutrition Pro-gram. Funding in the amount of US$4.8 mil-lion was obtained from the Government ofItaly.

Caribbean Food and NutritionInstitute (CFNI)

2.23 During 1984, CFNI fulfilled its man-date of service to the 16 governments of theEnglish-speaking Caribbean and one Dutch-speaking country, Suriname. In April 1984,ground was broken for a new headquartersdue for completion in mid-1985. The newbuilding will include laboratories for simpletesting, monitoring, and evaluation; a foodprotection and demonstration kitchen; andaudiovisual production and training facilities.

2.24 Research. The research project de-signed to evaluate the impact of food priceand subsidy policies and practices on foodproduction and marketing, consumption, andnutrition was continued. Data were collectedin selected countries on type, rationale, andscope of these policies, and a survey offarmers, fishermen, and food farms was con-ducted. A study on infant feeding practices,women's work, and social support resourceswas initiated in Jamaica as a collaborativeventure of CFNI, the International Center forResearch on Women (Washington, D.C.),and the University of the West Indies, withfunding from the Carnegie Corporation ofNew York. A disaggregated data study of nu-tritional status at family level continued as a

follow-up study to a 1982 household socio-economic and nutrition survey in Jamaica. Astudy was conducted of hemoglobin levels inhealthy nationals of the West Indies to deter-mine normal hemoglobin values and establishcutoff points applicable to the Caribbean.Iron-folate replenishment was started on 700school-age children living in the Turks andCaicos Islands to determine whether iron orfolate deficiency is a cause of anemia. Anemiacontrol mechanisms in member countries alsowere investigated. A feasibility study on thefortification of foodstuffs was completed.Studies were completed on the behavior andconstraints of family groups in relation toweaning, as well as to the nutritional status ofthe elderly in selected communities.

2.25 Technology development. To helpachieve consistency in charting child growth inmember countries and to address deficienciesin the present system, CFNI developed notonly growth charts specifically to be used inthe Caribbean, based on the WHO acceptedstandards, but also a take-home chart formothers of young children, which has beenfield tested in one country. An evaluation ofthe charts is being conducted. A system of col-lection, collation, analysis, and utilization ofthe information on nutrition also is beingdeveloped.

2.26 The Nutrition Handbook for Com-munity Workers was revised on the basis offield-test responses and was reprinted. TheFood Guide for the Caribbean, a joint publica-tion of CFNI and the Caribbean Association ofNutritionists and Dietitians (CANDI), waspublished. It contains basic dietary guidelinesto help consumers prevent or control chronicnutrition-related diseases. The outline for aproposed project on the development of edu-cational materials for the prevention, manage-ment, and control of diabetes mellitus wasdrafted and a project proposal was prepared.In response to widespread requests, the DietManual for the Caribbean was reprinted to-gether with its companion volume, A Physi-cian's Guide to Diet Ordering. The final ver-sion of a dietary guide for chronic renal failure

30 Annual Report

also was published following field testing ofdata. The Food and Nutrition Manualfor Chil-dren in Primary Schools was field tested underthe Joint Nutrition Support Program (JNSP).

2.27 Technical information. A docu-ment on food and nutrition profiles of the En-glish-speaking Caribbean countries and Suri-name was compiled as the basis for establish-ing an effective food and nutrition surveillancesystem. The quarterly nutrient cost tables con-tinued to be used as a valuable indicator offood surveillance. NYAM News features con-tinued to be published; the book Food andBudgeting for Caribbean Families, a compila-tion of these NYAM News feature stories, waspublished as a consumer education tool. TheInstitute's quarterly bulletin, CAJANUS, andan index were published.

2.28 Training. The major training activityundertaken in 1984 was the 7-month coursein community nutrition in which 19 studentsfrom 15 member countries participated. Post-graduate lectures in nutrition continued at theTropical Metabolism Research Unit and theDepartment of Social and Preventive Medi-cine of the University of the West Indies(UWI), as well as undergraduate lectures inthe Faculty of Agricultut:e of the UWI. A work-shop for nurses on patient education in hyper-tension was conducted in the British Virgin Is-lands. Refresher training for professionalnutritionists and dietitians in hypertensionmanagement also was provided.

2.29 CFNI cooperated in the implemen-tation of the nurse practitioner training pro-gram in the Eastern Caribbean, in programsfor the community control of diabetes in Bar-bados, and in the design and implementationof a 4-month course held in Kingston for foodservice supervisors. An attempt was made tostrengthen intersectoral, nonformal nutritiontraining at the community level through theestablishment of a pilot distance teachingcourse, using the facilities of the University ofthe West Indies Distance Teaching Experi-ment (UWIDITE). A total of 30 communityworkers in the countries and centers linked bythis satellite network participated in a 6-week

inservice course, using as a basic tool the Nu-trition Handbook for Community Workers. Aworkshop on food and nutrition education inpreservice teacher training institutions washeld jointly with the Faculty of Education(UWI) and FAO. In St. Vincent and the Gren-adines and Dominica, under JNSP, trainingworkshops were held for community healthaides, nurses, nursing assistants, agricultureand community development officers, exten-sion workers, and family nurse practitioners.

2.30 Technical cooperation. Collabora-tion between CFNI and CARICOM wasstrengthened mainly in the area of RegionalFood and Nutrition Strategy (RFNS) by devel-oping and implementing programs and proj-ects at the national and community levels.One of these was an intersectoral workshopon "Household Food Availability and Nutri-tional Status in Jamaica: The Challenge forthe Future." The aim was to sensitize principaldecision makers in the public and private sec-tors to food and nutrition problems, with spe-cific reference to socioeconomic factors affect-ing household food availability and nutritionalstatus. A meeting was held to create a frame-work for establishing collaboration amongagencies involved in food and nutrition proj-ects in Jamaica. Another significant area ofCFNI technical cooperation was the JNSP,administered through UNICEF/PAHO/WHO with funding from the Italian Govern-ment. Coordinated by the Institute, this pro-gram began in May 1984 in Dominica and St.Vincent and the Grenadines and is an ap-proach to incorporating nutrition into primaryhealth care. Its intent is to reduce infant andyoung child mortality, improve child growthand development, improve maternal nutri-tion, and contribute to the prevention andcontrol of chronic nutrition-related diseasessuch as obesity, hypertension, and diabetes.Program components in both countries in-clude support of the Food and NutritionCouncil, the training of health and allied per-sonnel, and primary health care activities. Un-der this program, the food and nutrition policyfor Dominica was revised. CFNI also partici-pated in the creation of the Regional Opera-


tive Network of Food and Nutrition Institu-tions. CFNI developed a project for improvingnutrition through primary health care and initi-ated it in Belize, with major technical supportfrom CFNI/PAHO/WHO and UNICEF. Thesecond meeting of the CFNI Scientific Advi-sory Committee (SAC) and the 17th Meetingof the Policy Advisory Committee (PAC) wereheld in Kingston, Jamaica, in December 1984to review the Institute's work program.

Maternal and Child Health andFamily Planning

2.31 Most of the countries in the Regioncontinued to experience declines in maternal,infant, and preschool mortality rates (table 4

and figure 1) along with increases in the cov-erage of basic health services for mothers andchildren. Fertility and population growth ratesalso followed a downward trend, largely be-cause of educational and social progress in thecommunities with respect to the use of contra-ceptives.

2.32 PAHO/WHO cooperated with gov-ernments by furnishing orientation for their ef-forts to develop methodologies for expandingthe coverage of underserved populationgroups and socially depressed areas. The riskcriterion continued to be a useful manage-ment tool for determining the most vulnerablecommunities and families, organizing intersec-toral activities to control disease factors, andguiding the rational allocation of resources. Anumber of national and local seminars on this

Table 4. Infant mortality rate per 1,000 live births in some countriesof the Americas, 1960-1985'

Country 1960-1965 1965-1970 1970-1975 1975-1980 1980-1985

Argentina 59.5 56.4 51.3 47.2 43.2Barbados 60.8 46.4 33.8 27.0 25.5Bolivia 163.6 157.5 151.3 138.2 124.4Brazil 111.8 102.3 94.9 82.4 72.4Canada 26.3 21.3 16.4 12.2 10.4Chile 110.5 95.1 69.5 46.3 40.0Colombia 84.5 74.2 66.9 59.4 53.3Costa Rica 80.6 65.6 50.9 29.3 25.7Cuba 59.6 47.8 33.8 22.5 20.4Dominican Republic 110.0 96.3 83.6 73.1 63.5Ecuador 132.3 114.5 100.1 86.0 77.2El Salvador 128.0 112.0 101.0 84.8 71.0French Guiana ... .. 57.6 47.9 40.5Guatemala 114.9 101.5 90.2 79.0 67.7Haiti 170.5 150.2 134.9 120.9 108.2Honduras 136.8 124.0 110.7 95.4 81.5Jamaica 54.4 47.0 42.0 30.1 26.2Martinique 47.7 42.5 34.8 23.0 21.0Mexico 86.2 78.6 68.6 59.8 52.1Nicaragua 136.4 122.2 108.9 96.5 84.5Panama 62.6 53.9 43.8 36.2 32.5Paraguay 80.6 66.9 52.6 48.6 45.0Peru 152.2 132.8 106.5 93.5 81.9Suriname 63.5 54.6 46.7 39.2 33.8Trinidad and Tobago 48.0 45.0 40.4 34.6 29.9United States of America 25.2 22.2 18.1 14.0 12.1Uruguay 47.9 47.0 46.3 41.7 37.6Venezuela 76.9 64.9 52.4 44.8 38.6

... Data not available.'Source: CELADE, Rome. April 1984. Document CESA/ICP/1984/EGIV/12.

32 Annual Report

Figure 1. Infant mortality trends in the subregions of the Americas,from 1955-1960 to 1980-1985

rnm,

-

Uia.

u

rr

Years

~_-- North America --. --- Tropical South

.-.-.-.. Continental Middle America AmericaCaribbean Temperate South

Caribbean America

Source: Publicatlon CESA.ICP 1984/EGIV/12, Ltlin American DemoDraphic Cent-r (CELADE).

subject were held in 1984, while the regionaleffort was focused on three workshops for in-structors and "multiplier agents," conductedat La Falda (Argentina), Medellín (Colombia),and Lima (Peru). A total of 83 professionalsfrom 14 countries of the Region participated.An outgrowth of the workshops was the prep-aration of a manual on the risk approach tohealth care, which was edited during the yearand scheduled for publication early in 1985.Further risk factor studies were conductedwith PAHO/WHO support in Argentina, Bra-zil, Chile, Colombia, Cuba, Guatemala, Mex-ico, Nicaragua, and Uruguay.

2.33 In the area of child growth and de-velopment, the network of cooperating insti-tutions-consisting of the centers at La Plata(Argentina), Havana (Cuba), Mexico City,and Denver (USA), other national institu-tions, and the Latin American Center forPerinatology and Human Development(CLAP), Montevideo (Uruguay) -intensified

its work. A Regional Consultative Group onthis subject held a meeting in Washington,D.C., in September, with UNICEF and otheragencies interested in human growth partici-pating. The group determined the type of in-struments to use for monitoring growth anddevelopment and the research projects to sup-port.

2.34 At the regional workshop on "Pri-mary Health Care Strategies and Infant Mor-tality," held in May in Mexico, papers werepresented on infant mortality in the Americasand its implications for the health services; in-fant mortality trends in Chile, Costa Rica, andCuba; and experiences of local programswhich have managed to reduce infant mortal-ity. In addition to discussing the papers, theworkshop examined the characteristics of pro-posals to extend these studies to other areas.Publications in preparation since 1983 werecompleted, and a book entitled Maternal andChild Health and Primary Care-Facts and


Trends was edited and distributed widely, aswas a pamphlet on children's health in theAmericas and an annotated bibliography onmaternal and child mortality.

2.35 More than 50 researchers from theCaribbean area, Europe, Latin America, andthe United States of America attended theInterregional Conference on Appropriate Pre-natal Technology, held in November in Wash-ington, D.C. Guidelines for the developmentof useful prenatal monitoring technologieswere developed during the conference.

2.36 Work proceeded intensively on thetraining of a wide variety of maternal and childhealth personnel, from practical midwives toprofessionals with specialized training in thisfield; emphasis was given to the administra-tion of maternal and child health programs.Six international courses were adapted andconducted to meet the requirements of theprograms in Buenos Aires, Argentina; San-tiago, Chile (2); Cali, Colombia; Medellín,Colombia; and Montevideo (CLAP), Uru-guay. Approximately 200 Latin Americanparticipants attended these programs. Theanalysis, conclusions, and recommendationsof the meeting in December 1983 on maternaland child health education were sent to theparticipating countries and donor agencies. Inaddition, a guide for the design, utilization,and evaluation of educational materials waspublished and distributed. First steps were un-dertaken to implement specific measures inthis field.

2.37 PAHO's Executive Committee andDirecting Council, at their 92nd and XXXmeetings held in June and September, re-spectively, considered the report by the Direc-tor of PASB on "A Basis for the Definition ofthe Organization's Action Policy with Respectto Population Matters." The Directing Counciladopted resolution CD30.R8 urging all gov-ernments to strengthen maternal and childprograms, bearing in mind the population dy-namics problems, as well as to promote theformulation of population policies with multi-sectoral participation. The identification of pri-

ority groups and high-risk populationsthrough demographic analysis was also em-phasized. This report was later submitted tohealth and population groups at the WorldBank, the Inter-American DevelopmentBank, and USAID to stimulate coordination inthis field.

2.38 Outstanding among the studies onmaternal and child health and family planningwere the study on the sociodemographic char-acteristics and problems of adolescent unwedmothers, conducted in Colombia jointly withthe Javeriana University; the study on contra-ceptive education, a model program for ado-lescents, conducted in St. Christopher andNevis jointly with the University of the WestIndies; and the design for a study on the re-productive behavior of adolescents, to be car-ried out in Cuba with the Health Sciences In-stitute. Based on these initiatives, a surveymethodology will be available to the othercountries in 1985. At the country level, infantmortality surveys were carried out in Bolivia,Paraguay, and Uruguay as projects of theUnited Nations Fund for Population Activities(UNFPA). In addition, a survey on the inci-dence of abortion was conducted in Paraguayin conjunction with the National University.

2.39 Using the experience acquired inevaluating the training of traditional midwivesin Bolivia, Colombia, El Salvador, Honduras,and Peru, a multidisciplinary group was con-vened to prepare a more complete model forevaluating training programs for traditionalmidwives.

2.40 The Organization cooperated withUNFPA in providing basic information for theevaluation of projects on health and educationfor family life that countries were conductingwith the assistance of PAHO/WHO. The find-ings of an assessment of the approaches fol-lowed in maternal and child health in 1983were used in revising and adjusting the techni-cal cooperation strategies for the English-speaking Caribbean countries. In response torequirements set forth by these countries,UNFPA financed an additional course in fam-ily health for nurses. A total of 35 projects, in-

34 Annual Report

cluding 31 at country and 4 at regional level,were conducted jointly with UNFPA duringthe year. The budgeted funds amounted toUS$7.5 million, and available information in-dicates that project implementation will ex-ceed 95%. New 4-year projects with a com-bined budget of approximating US$18 millionwere started in Brazil, Ecuador, and Grenada,and existing projects in Antigua, Honduras,Nicaragua, and Peru were extended for 4years at a total cost of nearly US$10 million.

2.41 All 18 maternal and child healthprojects financed by the W. F. Kellogg Foun-dation continued to receive technical supportfrom PAHO/WHO during 1984, especially inthe qualitative aspects of health activities andin training and research. International courseson maternal and child health with emphasison primary care received technical and finan-cial support from the Kellogg Foundation.During the annual meeting of coordinators offamily planning projects held in Santiago,Chile, it was recognized that the projects hadmade significant advances, largely as a resultof the growing involvement of local institu-tions and communities in the development ofprimary care. The meeting also recognizedthat national and international networks offervery real opportunities for working togetheron the development and evaluation of healthtechnologies and on health service research.The new work plan for the next 3 years, whichthe Kellogg Foundation approved, calls forthe establishment of six or seven networks inwhich the efforts and resources of maternaland child health projects will be pooled to-gether with those of health administrationprojects.

Latin American Center forPerinatology and HumanDevelopment (CLAP)

2.42 CLAP continued its activities in peri-natal care research and technology, dissemi-nation of information and training, as well astechnical cooperation with countries in the or-ganization of perinatal health services.

2.43 Research and technology devel-opment. Research formerly carried out atCLAP gradually is being transferred to thecountries to strengthen national capacities andincrease their impact. In 1984, CLAP workedwith 17 countries of the Region in joint activi-ties. In the growth and development area, astudy was conducted on the accuracy of vari-ous techniques for estimating gestational ageand monitoring fetal weight and health, and aprogram was under way for developing simpleprocedures for estimating fetal pulmonarymaturity in the event of premature rupture ofovule membranes and the correlation be-tween placental maturity and fetal pulmonarymaturity. With regard to breastfeeding, stud-ies were made on sucking patterns in verylow-weight infants, feeding procedures forpremature babies, and variance in the flow ofmilk during lactation. The epidemiology oflow birthweight was researched, standardswere developed for the management of pre-maturity during the perinatal period, patternsof contractions during labor were studied, andintracerebral hemorrhaging in low-birthweightinfants was investigated. Perinatal record sys-tems based on the use of traditional and sim-plified perinatal clinical history forms and thepediatric chart were evaluated.

2.44 Regarding the risk approach, studieswere made of the time of discharge in low-riskcases and the implications for the mother andinfant, the risk presented by perinatal factors,and habits and drug use during pregnancy.Studies also were carried out on patterns ofarterial pressure during pregnancy and onperinatal assessments at maternal and childhealth services.

2.45 Dissemination of information. Atotal of 45 scientific articles prepared at CLAPwere published and distributed. Automationof the Center's library in 1984 facilitated thepreparation of technical series and the provi-sion of specialized bibliographic assistance tocountries. The semiannual bulletin PerinatalHealth increased its press run to 10,000copies.

2.46 Training. A total of 258 fellows at-


Table 5. Participants in the CLAP training courses by subject and country of origin, 1984

o o

Subject of the course m Ñ u u E U a a ' :D

Scientific foundations for comprehensive perinatal care ac-cordingto degree of risk - 1 1 1 4 - 1 1 - - - - 1 1 1 12

Specialization in healthbc - - - 1 - - - 2 - - - 1 4Methodology for epidemiological, operational, and clinical

research in perinatologyd 3 1 1 1 4 - 2 1 - - - 1 2 1 27 44Evaluation of fetal growth and developmente 6 1 1 2 5 1 1 2 - - - 1 5 1 21 47Standards for prenatal monitoring according to degree of

risk 9 1 1 2 6 2 2 2 - 1 2 - 5 - 19 52Postnatal growth and developmente 1 1 2 2 4 - 1 1 - 1 1 1 3 1 15 34Introduction to public health for the perinatal and maternal

and child health areasd 5 1 1 3 5 - 1 1 3 - 7 2 8 1 27 65

Total 246 7 11 293 8 8 3 2 125 24 5 111258

- NoneaA 7-month course bContinuation of the course on integrated perinatology assistance according to risk CA 2-year course dA 4-weekcourse. 'A 2tweek course.

tended CLAP courses in 1984 (table 5). TheCenter also offered study visits with specifictraining programs.

2.47 Technical cooperation. A total of310 days of consulting services were providedto 14 countries (Argentina, Bolivia, Brazil,Chile, Colombia, Costa Rica, Cuba, Ecuador,Honduras, Mexico, Nicaragua, Paraguay,Uruguay, and Venezuela) in response to re-quests for specific activities. Cooperation wasprovided mainly in the areas of health serviceorganization, training, research, and stan-dards.

Workers' Health

2.48 The main objective of PAHO/WHO's cooperation in the area of workers'health, as determined in 1983, is to support,promote, and assist in strengthening nationaloccupational health activities within the gen-eral health services. Of regional interest in thisfield was a seminar-workshop on occupa-

tional health activities in the health service net-work, held in March in Campinas, Brazil. Theobjectives of the seminar were to discuss theimplications of the interrelationship betweenoccupational health and the health services, toexamine the experiences of the Region'scountries in conducting occupational healthactivities through the network of health ser-vices, and to discuss mechanisms and pro-pose strategies for making use of those experi-ences. A total of 40 participants from .11countries of the Region attended the seminar,which presented the experience acquired andmodels applied in various countries, includingBrazil, Chile, Colombia, Cuba, and the Do-minican Republic. Significant byproducts ofthis event were the publication (now in pro-cess) entitled Anthology of Experiences andthe distribution of the seminar's final report,which contains useful guidelines for integrat-ing occupational health within the network ofhealth services. During the VII Inter-AmericanCongress on the Prevention of OccupationalHazards, sponsored by the Inter-AmericanCommittee on Social Security (CISS) and

36 Annual Report

held in Oaxtepec, Mexico, in November,PAHO/WHO contributed a document on oc-cupational health activities in medical careprograms which described action based on theexperiences discussed at the Campinas semi-nar.

2.49 In 1984, Bolivia and Suriname re-vised their occupational health programs withthe assistance of PAHO/WHO. Bolivia tookpreliminary action to strengthen the NationalInstitute of Occupational Health (INSO) andtransfer responsibility to the health regions formonitoring the working conditions of high-riskworkers such as miners and farmhands ex-posed to organophosphate pesticides. WithPAHO/WHO's assistance, Suriname hopesto control the problem of pesticide poisoning,particularly by Paraquat. A number of Brazil-ian States, including Sáo Paulo and Rio de Ja-neiro, are in the process of integrating work-ers' health activities into their adult healthprograms. Colombia decided to assign an im-portant role in occupational health to the So-cial Security Institute (ISS) and to strengthenthe National Occupational Health Committee.The practical implications and the strategiesaimed at developing occupational health inColombia were examined at the Novemberseminar-workshop on occupational health.

2.50 Agreement was reached with Cubaon terms of reference and on a tentative pro-gram for securing the cooperation of theWorkers' Medicine Institute in Havana as anadditional Regional Collaborating Center in itsfield. With the cooperation of PAHO/WHO,Chile conducted the first Chilean Congress onOccupational Health and Occupational Dis-eases, held in Concepción in November.PAHO/WHO also contributed practical sug-gestions, including the teaching of occupa-tional health in medical schools. Guatemalaassigned an important occupational healthrole to the Guatemalan Social Security Insti-tute (IGSS). Formal arrangements were con-cluded during 1984 to designate the School ofPublic Health of the University of Texas inHouston (USA) as a Collaborating Center inoccupational health.

Health of the Elderly

2.51 Scientific, technological, and ad-ministrative advances have led to significantincreases in the 60-and-over age group. InLatin America, this group is expected to growfrom the 1980 figure of 23 million (6.4%) to aprojected 41 million (7.2%) in the year 2000.The increase in the absolute and relative sizeof the elderly population has made it neces-sary for many countries to expand and adapttheir health services to meet the demand ofthat group in a manner consistent with eachcountry's degree of social, economic, and cul-tural development and national policy on ag-ing.

2.52 In 1984 a number of governments,with PAHO/WHO cooperation, evaluatedtheir programs for the care of the elderly to de-termine the strategies to follow and the train-ing activities needed. With PAHO/WHO sup-port, Argentina, Chile, and Uruguay held ameeting in Punta del Este for the purpose ofestablishing specific liries of action on chronicdiseases and care of the elderly. This initiativeis to be supplemented by a seminar on policiesfor the care of the elderly, to be held inBuenos Aires in 1985. With technical cooper-ation from the Organization, Argentina's Na-tional Institute of Social Services for Pension-ers and Retirees, the agency responsible forthe care of 3 million elderly people (i.e., 90%of this group), organized a workshop for up-dating the training-of its staff. Argentina, Bar-bados, Chile, Colombia, Costa Rica, Cuba, ElSalvador, Guyana, Honduras, and Jamaicaplayed an active role in preparing and con-ducting a survey on needs of the elderly spon-sored by PAHO/WHO and assisted finan-cially by the United Nations. Three of thosecountries (Chile, Costa Rica, and Guyana)completed their studies during 1984.

2.53 The countries that participated in thecollaborative study mentioned above wererepresented at a meeting on orientation ofhealth policies for the elderly, organized by


PAHO/WHO and the Kellogg Foundationand held in Washington, D.C. (USA). A totalof 25 experts from Belgium, Canada, CostaRica, Denmark, the Netherlands Antilles, theUnited Kingdom, the United States of Amer-ica, and Venezuela participated in this eventand shared their experiences with delegatesfrom Argentina, Barbados, Chile, Costa Rica,El Salvador, Guyana, Honduras, Jamaica,and Uruguay. The meeting was also attendedby representatives from the United NationsCenter for Social Development and Humani-tarian Affairs (Austria) and the InternationalCenter for Social Gerontology (France). Themeeting identified a number of major ques-tions to consider in planning for the care of theelderly, based on the experience of the devel-oped countries. These included such mattersas demographic, scientific, economic, social,and psychological parameters; public infor-mation aspects; staff training; social securityalternatives; self-care; the role of the healthservices, with special emphasis on primarycare and family and community participation;and the role of nongovernmental organiza-tions, and their collaboration with govern-ments, in the promotion of the relevant poli-cies. It is hoped that the summaries of thepapers presented at this event and its conclu-sions, to be issued shortly by PAHO/WHO,not only will contribute to a better understand-ing of this basic aspect of public health in LatinAmerica, but also will serve as a source of in-formation and guidance for the promotion ofinitiatives at the national level.

Health of the Disabled

2.54 The promotion of rehabilitation as acomponent of primary care and of the generalhealth services has led the countries of the Re-gion and PAHO/WHO to adjust certain as-pects of the programming, coordination, andimplementation of activities. At its XXX Meet-ing held in September-October 1984, the Di-recting Council of PAHO considered the Di-rector's report on this matter and adopted

resolution CD30.R7 urging the governmentsto continue policies and programs on the pro-tection and comprehensive care of the dis-abled and the prevention of the causes of dis-ability, placing special emphasis on thedevelopment of rehabilitation technologies informulating family- and community-basedprograms for the disabled within primaryhealth care. This decision constitutes the basisfor promoting the activities of the govern-ments and PAHO/WHO.

2.55 Some governments, with the coop-eration of PAHO/WHO, are putting the com-munity-based rehabilitation (CBR) strategyinto practice. Argentina provided inservicetraining to health agents from the Provinces ofJujuy, La Rioja, and Neuquén. National offi-cials from Chile, Ecuador, Peru, and Uruguayalso examined the possibility of applying theCBR approach. In Mexico, the CBR guide-lines were examined in suburban areas. Train-ing activities continued to receive attention insome countries. In Chile, Ecuador, and Uru-guay, PAHO/WHO cooperated in the devel-opment of courses on orthotics and prosthe-sis, and in Colombia, in a national congresson physical therapy. Finally, in the English-speaking Caribbean countries, a conferenceon deafness was held in which 14 countriesand territories of the area and Haiti partici-pated.

2.56 Coordination between the Inter-American Institute of the Child and HelenKeller International Incorporated wasstrengthened in order to jointly prepare amanual of community-based rehabilitation. Ameeting was held in Panama, with the coop-eration of UNICEF and the International Re-habilitation Agency, to promote the develop-ment of national programs for the preventionand rehabilitation of disability in children un-der age 6. The meeting was attended by rep-resentatives of the Central American coun-tries, Panama, and Mexico. A highlight in thearea of dissemination was the distribution tothe relevant national authorities and privateorganizations of a publication in Spanish, En-glish, and Dutch on self-care of paraplegics.

38 Annual Report

Oral Health

2.57 In the area of dental prevention, ma-jor emphasis was placed on the developmentof the capability of countries to implement thefluoridation of refined table salt as an alterna-tive to the fluoridation of water supplies, in ac-cordance with resolution CD26.R39 of theXXVI Meeting of the PAHO Directing Council(September 1979). A travelling seminar washeld involving six participants from five coun-tries (Colombia, Costa Rica, Cuba, Jamaica,and Mexico) to review at first-hand the imple-mentation of salt fluoridation in Switzerlandand the appropriate machinery, procedures,and materials in West Germany and Holland.During 1984, Colombia and Peru both passeddecrees permitting the fluoridation of tablesalt, and Jamaica advanced in the consider-ation of this method. In July, the ministers ofhealth of the Commonwealth Caribbean rec-ommended the implementation of salt fluori-dation, and steps were taken to identify possi-ble approaches. In Costa Rica, a survey wasundertaken to identify the needs of such aprogram and to estimate table salt consump-tion. In Mexico and Peru, the requirementsfor implementing salt fluoridation in thosecountries were identified. Basic project de-signs were prepared for modifications of saltplants in Colombia, Costa Rica, Cuba, Ja-maica, and Mexico in connection with the re-quirements of such programs. A follow-upstudy was initiated in Colombia to evaluatethe incidence of dental caries in a village previ-ously involved in a salt fluoridation project.Prevention of dental caries continued throughthe use of other vehicles containing fluoride inBermuda's 5-year project. This programshowed a reduction of approximately 80% inthe incidence of dental caries over the 5-yearperiod. In Dominica, a training program forschool teachers in oral health and preventionof dental caries was developed. Support wasalso provided for the initiation of a massivefluoride rinse program for schoolchildren inLima, as well as preventive programs in ElSalvador, Panama, and Venezuela. A nation-wide project for the implementation of a caries

preventive program was developed in the Do-minican Republic.

2.58 In connection with the developmentof dental preventive or curative services, anew system for the delivery of dental care wasinaugurated in the health services of Viña delMar, Chile; and, with the Government of Ar-gentina, the provision of dental services withinthe overall health service programs was re-viewed. A multidisciplinary meeting was heldin the Dominican Republic to review alterna-tive approaches for the development of dentalresources and delivery of services. Likewise, ajoint working group finalized a survey to beconducted on the availability of dental materi-als and equipment and the extent to whichsuch items are imported or exported from theRegion.

2.59 Nevertheless, a major concern stillexists in the provision and accessibility of den-tal services to rural and urban marginal popu-lations. With this in mind, initial steps weretaken to identify the barriers to the develop-ment of oral health in developing countries ofthe Region which are scheduled to be subjectsof discussions during a meeting in Brazil in1985.

2.60 During 1984, considerable empha-sis was placed on the development of audiovi-sual materials. Notable among these were vi-deotapes on the dental preventive program inBermuda, simplified systems and equipmentin use in programs in Mexico, and aspects ofthe Organization's program in oral health.Production of audiovisual materials for massuse by community personnel in preventiveprograms was initiated in the Dominican Re-public.

Mental Health

2.61 Programs promoting children's psy-chosocial development by stimulating their in-teraction with the environment continued in11 countries of the Region. Special attentionwas given to the group of children at greatestrisk of retardation of their intellectual develop-


ment because of their vulnerability to biologi-cal or social agents. Barbados, Cuba, andPanama initiated activities for coping with dis-ease-inducing psychological factors by meansof behavioral modification and tension reduc-tion. Cuba has stationed 600 psychologists athealth centers for this purpose. At the Interna-tional Seminar on the Psychology of Health,held in Cuba in December 1984, the pro-grams of three countries were examined andthe relevance of the psychosocial approach tothe control of chronic diseases, problems ofadolescenrts, and accidents was underscored.Aid to the parents of retarded children was thetopic of a seminar held in Guyana, while themanagement of psychological problemswithin the family was the subject of threecourses for health center workers in Belize,Costa Rica, and Honduras. In the secondCaribbean seminar (the first was held in 1983)on transcultural psychology, held in the VirginIslands (USA) in March 1984, representativesof the English-speaking Caribbean countriesexamined the models used in the area for thetreatment of mental diseases. Prominentamong the recommendations were those onthe impact of ethnic factors and the impor-tance of community support. In Peru, a groupof pediatricians and general practitioners re-ceived training in the identification and treat-ment of certain mental problems and prob-lems of psychosocial development highlyprevalent in infants.

2.62 In response to the progressive in-crease in problems resulting from alcoholismand drug dependency in the Region and thegovernments' demand for advisory services,the Organization extended technical coopera-tion to eight countries and the Caribbean sub-region in connection with the preparation ofproposals for securing external financing.

2.63 PAHO/WHO collaborated with theCaribbean subregion, through the CaribbeanAlcoholism Institute, in the organization of aseminar on traffic accident prevention and theplanning of a seminar on the prevention ofdrug dependency. To deal with the growingcocaine problem in the Region, a seminar for

clinical physicians from the countries of theAndean area was sponsored in Bogotá. TheOrganization, acting jointly with WHO and theGovernment of Colombia, organized a meet-ing in September of 22 cocaine experts to pre-pare a world-wide prevention and controlstrategy. The WHO Collaborating Centers-including the U.S. National Institute on DrugAbuse and the National Institute on Alcohol-ism and Alcohol Abuse, the Addiction Re-search Foundation of Canada, the MexicanPsychiatry Institute,- and the University ofMiami-have made available consultantsfrom their staff to provide technical coopera-tion to the national programs. In Guatemala,the Organization participated with the Univer-sity of Alabama (USA) and the Governmentin holding the first Latin American seminar onalcoholism in industry.

2.64 Workshops on the organization ofcommunity mental health services were heldin Anguilla, Chile, and Uruguay. The rehabili-tation of chronic mental patients was sup-ported in Chile, Dominican Republic, Guate-mala and Peru. In Argentina, Bolivia,Dominica, and Grenada, the national authori-ties decided, pursuant to PAHO/WHO coop-eration, to institute mental health and psychi-atric care programs as part of their newnational health plans. With the technical co-operation of PAHO/WHO, the mental healthprograms of Colombia, Costa Rica, El Salva-dor, Guatemala, and the State of Rio de Ja-neiro (Brazil) were evaluated, and a new ori-entation based on decentralization of servicesand community participation was suggested.Colombia, Costa Rica, El Salvador, Hondu-ras, and Panama continued to extend the cov-erage of their mental health services by using anetwork of primary care centers supported bymore sophisticated facilities.

Accident Prevention and Control

2.65 Pursuant to a resolution of the 8thConference of Caribbean Ministers of Health,a workshop on the prevention of traffic acci-dents in the English-speaking Caribbean

40 Annual Report

countries was held in June in Bridgetown,Barbados, under the auspices of the Carib-bean Community (CARICOM), the Govern-ment of Barbados, and PAHO/WHO. Theprincipal purposes of the meeting were toidentify the nature and causes of traffic acci-dents in the Caribbean, recommend methodsfor reducing their frequency and amelioratingtheir impact, and develop a plan for reducingthe extent of the problem. The meeting wasattended by 21 delegates from 10 Caribbeancountries, including epidemiologists, policeand transportation officials, and health admin-istrators. Salient conclusions included a rec-ommendation calling for the prompt establish-ment of national highway safety committeesand the designation of the Caribbean Epide-miology Center (CAREC) as the agency to co-ordinate training, epidemiological surveil-lance, and research in the traffic accident field.

2.66 With the cooperation of the Interna-tional Bank for Reconstruction and Develop-ment (IBRD-World Bank) and PAHO/WHO, a study was made of the trafficaccident prevention program in Colombia,particularly with respect to the areas of infor-mation and evaluation, as well as highwayconstruction and maintenance. The study'sfindings will be incorporated into the nationalaccident prevention programs in the form ofprovisions for specific activities. In Cuba, aworkshop was held on the conduct of re-search on accident prevention in children. Cu-ba's experience with a survey of morbidity ofchildren under 15 years of age due to acci-dents was discussed during the meeting. Themethodology developed will be offered toother countries of the Region as an instrumentfor determining the extent of the problem andthen establishing appropriate programs.

Environmental Health

Water Supply and Excreta andWastewater Disposal

2.67 The information obtained in 1983

on coverage achieved in 26 Latin Americanand Caribbean countries with a combinedpopulation of 369 million (i.e., 96% of the to-tal Latin American and Caribbean population)was analyzed within the context of the Inter-national Drinking Water Supply and Sanita-tion Decade (IDWSSD), the goal of which isto achieve total coverage of the population,with special emphasis on underprivilegedgroups (figure 2). The analysis revealed that86% of the urban population and 42% of therural population were being served by watersupply systems, and 61% and 14% of the ur-ban and rural populations, respectively, bysewage and excreta disposal facilities. Com-pared with 1982, these figures indicated in-creases of 2% in water supply in urban andrural areas and in urban sewage and sanitationservices, and 3% in rural excreta disposal fa-cilities. Should these trends be maintained, by1990 the water supply goal for urban areasmight be attained, and both the water supplyand sewerage goals would be close to attain-ment in rural areas.

2.68 The implementation of strategies forthe Decade continued with a view to imple-menting the national plans formulated in 1983by Bolivia, Haiti, Honduras, and Paraguay.Under the cooperative program between theAgency for Technical Cooperation of the Fed-eral Republic of Germany (GTZ) and PAHO/WHO, and in addition to Peru's National Planfor the Decade, action was undertaken in Bo-livia and Honduras to strengthen the nationalinstitutions responsible for water supply andsanitation services in rural areas. A plan wasdesigned for the provision of water supply andsanitation services in rural areas of Haiti; theplan envisages an increase in the managerialand operational capacity of the national insti-tutions responsible for providing those ser-vices in the countryside. As part of the coop-erative program, a planning workshop wasconducted in Coroico, Bolivia, at which man-agers of water supply and sewerage compa-nies evaluated progress in the implementationof the national IDWSSD Plan. As a result ofthis assessment, coordination was improvedand a National Association of Water and Sani-


Figure 2. Urban and rural population served by water supply and seweragesystems in 26 Latin American and Caribbean countries, 1980, 1983,

and goals to be reached in 1990

RURAL

0 0 50 100 150

1980

1983

1990

¡

¡

GOALSOF THE

COUNTRIES

Population

Water supply with houseconnections or easy access

i..:I;I Sewerage system

tation Companies was established. In the the total ¿Caribbean area, PAHO/WHO collaborated and thewith Antigua in the analysis of appropriate 1984 carwaste disposal methods; with Dominica in the water anipreparation of the first stage of master water other secsupply and sewage plans; and with Trinidad tional coland Tobago in the formulation of the plan of ing the satechnical cooperation (UNDP) in training, billion. Inmapping systems, leaks, maintenance, and opment Epollution control. Within the rural water and eration csanitation project financed by UNDP, in El works toSalvador training in underground water and the city cits use was conducted. Also with UNDP re- bamba'ssources, the elaboration of the National Plan age Servifor the Decade was finished in Guatemala and seweragea project for institutional strengthening of the be concllwater sector was financed at a cost ofUS$314,000 for 1985-1986. eration F2.69 Despite the countries' problems of tance waindebtedness in the present economic crisis, vestment

42%/

14%

32%

Water supply withconnection and easyaccess

Sewerage systemand other solutions

amount of loans provided by the IDBIBRD during the fiscal year 1983-ne to US$669.5 million, exclusive ofd sewerage components in loans forctors, such as agriculture. The na-unterpart funds made available dur-.me period were estimated at US$1.7I Bolivia, with Inter-American Devel-3ank (IDB) financing, technical coop-ontinued for the implementation ofimprove the water supply facilities ofof Tarija. Collaboration with Cocha-Municipal Water Supply and Sewer-ice (SEMAPA) in the construction of! works also continued, and shouldided by the end of 1985.

Within the Global Technical Coop->rogram (IDB/PAHO/WHO), assis-is given in the preparation of the in-t project for the construction of water

URBAN

300 250 200 150 100 50

84%

59%

86%

61%

87% i/////71% _ _

42 Annual Report

supply and sanitation systems for San Salva-dor, El Salvador, four Honduran cities, andTijuana, Mexico. As a result of a meeting onproject development and financing of waterand sanitation systems, held in Jamaica in1983 under the sponsorship of the CaribbeanDevelopment Bank, an inventory of projectsin the Caribbean in need of financing was pre-pared and circulated.

2.71 As part of the Plan for PriorityHealth Needs in Central America and Pan-ama, PAHO/WHO collaborated with theGovernments of the Isthmus in the formula-tion of 70 national projects: 42 for water sup-ply, 16 for sewage and excreta disposal, 4 forsolid waste management, and 8 involvingother aspects of sanitation and pollution. Theestimated investment cost is US$572 million,including US$177 million in external financ-ing. In addition, four subregional projectswere identified, dealing with the investigationof water supply sources, solid waste manage-ment, production of inputs, and human andtechnological resources. The cost of these isestimated at US$21 million, including US$11million in external financing.

2.72 A significant event in project formu-lation was the cooperation of the EconomicCommission for Latin America and the Carib-bean (ECLAC) and PAHO/WHO in four wa-ter supply and sewage disposal projects inCuba. In addition to determining the amountsof external resources needed, areas wereidentified in which horizontal cooperation withother Member Countries (TCDC), includingBrazil and Mexico, would be required.

2.73 Possible approaches and solutionsto the institutional, economic, technical, andsocial constraints on the provision of waterand sanitation services to marginal popula-tions in periurban areas were examined at theRegional Symposium on Water Supply andSanitation in Low-Income Neighborhoods ofUrban Areas. The symposium, organized byPAHO/WHO under the sponsorship ofUSAID, AIDIS (Inter-American Association ofSanitary and Environmental Engineering),ECLAC (Economic Commission for Latin

America and the Caribbean), and IAWPRC(International Association on Water PollutionResearch and Control), was held in Chile inNovember 1984; a total of 105 participantsfrom 22 countries and 9 international and bi-lateral agencies attended. The joint analysis ofthe problems cited will be followed up, at thelevel of each interested country, by an exami-nation of the political, technical, and financialfactors to be considered in national program-ming.

2.74 A sludge treatment guide, producedas a result of the workshop on transportation,disposal, and utilization of sewage sludge(1983), was distributed to the pertinent na-tional authorities. Sludge may be used as afertilizer in the English-speaking Caribbeancountries.

2.75 With the assistance of CARICOMand the Caribbean Development Bank, aworkshop was conducted in Saint Lucia forthe purpose of examining the new WHOguide on potable water quality and determin-ing the procedures for its application in thecountries of the area. The promotion of theuse of simplified systems of water fluoridationin the Dominican Republic, Uruguay, andVenezuela continued. In Mexico, 40 profes-sionals from five States were trained in tech-niques of fluorine removal from potable waterin areas where the fluorine content is high.

Solid Waste Management

2.76 Solid waste management problemscontinued to intensify as a result of the volumeincrease and nature of such waste, the rapidgrowth of cities and underserved urban areas,the limited funding for these services, thetransformation in technology, and the eco-nomic crisis and recession affecting countriesof the Region.

2.77 In this context, PAHO/WHO's col-laboration with the governments is addressedto the performance of sectoral studies and theformulation of policies, plans, and programs;


project identification and preparation; promo-tion of safety in the management of hazardouswaste; the mobilization of national resourcesand intercountry cooperation; and the trans-fer of experience and technology pertaining tosolid waste management. Thus, the Organiza-tion cooperated with Paraguay in the formula-tion of a national solid waste managementplan, and with Uruguay in the implementationof a national urban public sanitation plan.Brazil, for its part, issued national urban sani-tation directives to govern solid waste man-agement throughout the country. Coopera-tion with the Caribbean countries centeredaround the formulation of solid waste man-agement programs.

2.78 In Mexico, PAHO/WHO collabo-rated with the Secretary of Urban Develop-ment and Ecology (SEDUE) in the prepara-tion of urban sanitation projects to be financedby the IBRD (World Bank). In Paraguay, it co-operated with the Municipal authorities ofAsunción in preparing an application forWorld Bank financing. In Nicaragua, it collab-orated in the public sanitation project for Ma-nagua. The Organization continued to sup-port projects for the improvement of urbansanitation service in Guatemala City and invarious cities of Peru. It also helped preparethe Petrolina urban sanitation project in Braziland cooperated in an assessment of a plan forimprovements to urban services in the Baha-mas.

2.79 In the field of urban solid waste dis-posal, PAHO/WHO cooperated in sanitarylandfill projects in the Caribbean island ofDominica; Santo Domingo, Dominican Re-public; Managua, Nicaragua; and PanamaCity, Panama. The striking improvement inUsina 5 sanitary landfill in Montevideo, Uru-guay, deserves special mention. In Cuba,action began in a number of solid waste pro-grams, notably in the sanitary landfill area, inwhich significant progress was made with theprotection and fencing of 80% of the coun-try's dumping places. In regard to the promo-tion of safety in the management of specialand hazardous solid wastes, the Organization

collaborated with Guatemala and withSEDUE of Mexico in a search for solutions tothe problem of poultry solid waste and theconsequent proliferation of flies.

2.80 An example of the support providedfor strengthening community involvement inpublic sanitation services was the internationalmeeting held at the Pan American Center forSanitary Engineering and Environmental Sci-ences (CEPIS) to examine experiences withnonconventional trash collection systems inunderserved urban areas. The meeting wasattended by 35 professionals from 11 LatinAmerican countries.

2.81 A meeting of urban sanitation ser-vices of Latin American Metropolitan areaswas held in Rio de Janeiro, sponsored byPAHO/WHO and the Rio Municipal UrbanSanitation Company, for the purpose of fos-tering mobilization of national resources andhorizontal cooperation among countries andamong regions within a single country. Themeeting was attended by 26 participants and12 observers from the public sanitation com-panies of eight major Latin American cities(Bogotá, Buenos Aires, Caracas, Lima, Mex-ico City, Santiago, Sao Paulo, and Rio de Ja-neiro) and from other related institutions. Themost important decision taken was to establisha Latin American Network of CollaboratingInstitutions in Urban Sanitation.

2.82 Significant activities in institutionaland human resource development were: theIX Latin American Course on Urban Sanita-tion in Buenos Aires; national courses in Ar-gentina; the workshop on planning, adminis-tration, and financing of sanitation services inSanta Cruz, Bolivia; the workshop on techno-logical aspects of solid waste in Tarija, Bolivia;and the workshop on public sanitation in Chi-clayo, Peru.

Human Settlements and Housing inUrban and Rural Areas

2.83 A highlight event was the technicalconference on urban climatology and its appli-

44 Annual Report

cation, especially in tropical areas, held inMexico under the sponsorship of the WorldMetereological Organization (WMO) and theUnited Nations Environmental Program(UNEP), with assistance from PAHO/WHO.The conference examined the current state ofknowledge concerning the influence of cli-mate on the life of communities, land use, ur-banization, and construction and its potentialcointribution to the improvement of humanhealth, the environment, energy utilization,and other social and economic gains. Theresults of the conference should be highly use-ful to the countries of the Region in future ac-tivities. In Argentina, work,began on the col-lection of information needed for resumingprograms to introduce rural housing improve-ments to control Chagas' disease. In Mexico,the Organization assisted in the formulation ofa program to provide basic sanitary equip-ment for underserved rural communities.

Prevention and Control ofEnvironmental Pollution

2.84 Pursuant to resolution CE873.R10of the Executive Board of WHO adopted inJanuary 1984, on the International Programfor Chemical Safety (IPCS), PAHO's Execu-tive Committee and Directing Council urgedthe Member Governments to participate inIPCS global activities and to support the im-plementation of regional policies and strate-gies. An evaluative study on the status ofchemical safety in the Region was initiated asa step toward the preparation Qf medium-termchemical safety programs. Both proposals areto be submitted to the Directing Council ofPAHO for its consideration in 1985.

2.85 In the harbor pollution program ofHavana, Cuba, the national authorities' workon the UNDP/UNESCO/CUB project wasevaluated, and technical cooperation pro-gramming for 1985 and 1986-including theidentification of other aspects of monitoringenvironmental quality-was formulated. InSaint Lucia, potential environmental prob-lems related to the textile industry were identi-

fied, and the basic conditions were establishedfor PAHO/WHO collaboration in a study ofthe environmental impact of certain industrialactivities. In the English-speaking Caribbeancountries, plans were made with the assis-tance of the national authorities of Jamaica fora workshop on techniques for environmentalimpact analysis, scheduled for March 1985.With the participation of UNEP and CARI-COM and as part of a project on "Manage-ment of the Coastal Waters of the CaribbeanIslands," the evaluative study on pollution ofthe coastal waters of Antigua, Belize,Dominica, Grenada, St. Christopher andNevis, Saint Lucia, and St. Vincent and theGrenadines was completed during the year.The study's findings were considered by therespective governments and a consolidatedstudy was prepared for CARICOM. Supportcontinued to be given to the Caribbean Envi-ronmental Health Institute. Further informa-tion is provided on PAHO/WHO collabora-tion on environmental pollution in the sectionscorresponding to CEPIS and ECO.

Development of the EnvironmentalHealth Infrastructure

2.86 The Organization continued to helpMember Countries develop and strengthenthe management, operation, and staff of envi-ronmental health institutions. As a follow-upto the two subregional workshops held in Pan-ama and Colombia in 1983 on the applicationof water and sanitation information systems tothe monitoring and evaluation of theIDWSSD, a third workshop on the subject wasconducted in Georgetown, Guyana, in May1984. A total of 22 participants attended(from Bahamas, Barbados, Belize, Guyana,Haiti, Jamaica, Suriname, and Trinidad andTobago), along with 15 PAHO/WHO advis-ers in planning, health information systems,and environmental health. Subsequently,PAHO/WHO cooperated directly with sixcountries of the Region in implementing themethodology proposed in the workshops. Amicrocomputerized information system for


monitoring and evaluating progress under thenational water supply and sanitation plans wascompleted in October.

2.87 Three seminars, forming part of thewater and sanitation project planning programof the World Bank's Economic DevelopmentInstitute (EDI), were held in the Region. Thefirst, held in March at the Pan American Cen-ter for Sanitary Engineering and Environmen-tal Sciences (CEPIS) in Lima, was attended byparticipants from Argentina, Bolivia, Brazil,Chile, Colombia, Ecuador, and Peru. Thesecond seminar was conducted in May in Pan-ama under the auspices of the National Waterand Sewerage Institute (IDAAN) for 40 repre-sentatives from Brazil, Colombia, Cuba, Gua-temala, Honduras, Mexico, Nicaragua, Pan-ama, Paraguay, and Venezuela. The thirdwas held in November in Rio de Janeiro un-der the sponsorship of the National HousingBank (BNH) and was attended by 22 partici-pants from Brazil, Dominican Republic, Para-guay, and Uruguay. The topics centeredaround project planning concepts and metho-dologies, including analysis of technical, eco-nomic, financial, institutional, and human re-sources.

2.88 In Brazil, the Operational Portfolioand Sanitation Finance System of the Na-tional Housing Bank (COSAN/BNH) contin-ued its operation aimed at improving the fi-nancing system's capacity in the areas ofinformation, evaluation, contracting, and su-¡pervision so that it can better support the im-plementation of the National Sanitation Plan(PLANASA). PAHO/WHO and the BNH re-scheduled the technical cooperation agree-ment, extending it for 3 more years at an addi-tional cost of US$1 million. The technicalcooperation agreement with COSAN/BNHto strengthen the program for institutional de-velopment of State water and sanitation com-panies (PRODISAN) also was extended toSeptember 1985. By means of this programand its line of credit, BNH resources underPLANASA are made available for accelerat-ing the institutional development of State

companies, reducing their operating costs,and raising productivity levels.

2.89 In the Dominican Republic, imple-mentation of the IDB-financed project for in-stitutional development of the National Drink-ing Water and Sewerage Institute (INAPA)began in 1984 (the agreement was signed in1983). In Ecuador, the Guayaquil SewerageCompany (EMAG) obtained a US$400,000loan, also from thé IDB, for a 30-month insti-tutional development program to be initiatedearly in 1985 with PAHO/WHO technical co-operation. In Nicaragua, the National Waterand Sewerage Institute (INAA) project, fi-nanced by a World Bank loan, for develop-ment of a national system of rates for waterand sanitation service, was completed duringthe year. INAA was provided with microcom-puterized information systems that will enableit to monitor and evaluate its economic and fi-nancial performance and ensure equitableservice charges. PAHO/WHO also collabo-rated with INAA in setting up a national ruralwater supply and sanitation program througha directorate established especially for the pur-pose.

2.90 In Paraguay, the results of the tech-nical cooperation for institutional develop-ment of the National Environmental HealthService (SENASA), for which IBRD fundshad been made available, were evaluated. Di-rectives were established to guide the agencyin implementing the water supply investmentprogram with the participation of the country'srural communities. PAHO/WHO collabo-rated with the Lima Drinking Water and Sew-erage Service (SEDAPAL) in the organizationof a meeting of high-level officials held in Feb-ruary to formulate strategies for making opti-mal use of managerial and operational capac-ity in the provision of services. A proposal forthe preparation and implementation of thestrategic, practical, and operational levels of aplanning system also was prepared.

2.91 PAHO/WHO designed a method-ology for intensifying its regional technical co-operation with the countries in matters per-

46 Annual Report

taining to the operation and maintenance ofwater and sewage systems, with emphasis onoptimal utilization of installed capacity, includ-ing the detection and elimination of leaks.With support from the IDB and GTZ, the sys-tem for training paraprofessional technicalpersonnel in water and sanitation institutionswas launched in August in Costa Rica, Do-minican Republic, El Salvador, Guatemala,Honduras, and Nicaragua. The aim of theproject is to institutionalize, in each of the par-ticipating national agencies, an ongoing andself-sustaining system for training paraprofes-sional technical staff members responsible forthe operation and maintenance of water andsewage systems. The project receives institu-tional and supervisory support from the Com-mittee of Directors and Managers of Waterand Sanitation Services for the Subregion(CAPRE).

2.92 In collaboration with the CanadianInternational Development Agency (CIDA)and the Caribbean Development Bank(CDB), the Organization continued support-ing the Subregional Project for Human Re-source Development for the water and sanita-tion sector of the Eastern Caribbean (Anguilla,Antigua, Barbados, British Virgin Islands,Dominica, Grenada, Montserrat, St. Chris-topher and Nevis, Saint Lucia, and St. Vin-cent and the Grenadines). The Organizationcontinued to cooperate in the strengthening ofthe Water and Sewage Authority (WASA)training center in Trinidad and Tobago andthe formulation and execution of its trainingprogram. PAHO/WHO cooperated with Bo-livia, Honduras, Paraguay, and Peru in theformulation of national training plans for theIDWSSD. In support of these activities, thefirst version of a personnel planning guide forthe water and sanitation sector was prepared.

2.93 A meeting of the United StatesSchools of Engineering (AIDIS) was held inMarch in Washington, D.C., under PAHO/WHO auspices, to identify potential areas ofcooperation between those schools and theirLatin American counterparts in improving theteaching of sanitary and environmental engi-

neering. Plans made at the meeting of the As-sociation of United States and Latin AmericanSchools for the execution of joint programscurrently are being implemented.

2.94 A start was made on producing aux-iliary teaching materials on potable water sup-plies and excreta disposal for use in trainingsanitation inspectors and primary care staff ofhealth services.

Pan American Center for SanitaryEngineering and EnvironmentalSciences (CEPIS)

2.95 CEPIS is a basic technical resourcefor PAHO/WHO cooperation with the Mem-ber Governments' environmental health pro-grams. Its responsibilities include research andtechnology, dissemination of information,training, and technical cooperation with gov-ernments.

2.96 Research. Research was directedmainly to a search for practical, low-cost solu-tions to water supply and sanitation problems.In Peru, with financial support from GTZ,work went forward on design studies, con-struction, and evaluation of slow filters for usein combination with gravel prefilters in ruralsupply systems. In Peru, with the cooperationof the University of Surrey (United Kingdom),a new system of dual slow filters for smallcommunities was being field tested, along withlow-cost equipment for monitoring the bacte-riological and physicochemical properties ofwater in rural supplies. In addition, assistancewas provided in the evaluation of laminarrapid filtration plants in Brazil and Peru. In wa-ter pollution control, a related priority area,CEPIS collaborated with the General Direc-torate for the Environment (DIGEMA) ofPeru's Ministry of Health in a study on control-ling second washing in mine concentratorsand prepared a proposal for construction andevaluation of pilot plants for that purpose.CEPIS continued to coordinate a network ofresearchers collaborating on a study of eutrofi-cation of tropical lakes and ponds. A manualwas prepared on planning and designing off-


shore underwater outfalls to control pollutionalong the coast.

2.97 In low-cost sanitation procedures,CEPIS continued its studies on the treatmentand recycling of wastewater in the stabilizationponds at San Juan de Miraflores (Lima,Peru). With support from the World Bank andGTZ, a study was completed on the monitor-ing and quality control of effluents for reutiliza-tion in fish farming, with a view to low-costproduction of protein for staple consumption.A protocol was drawn up for a study to evalu-ate the epidemiological and socioeconomiceffects of reusing effluents for irrigation. CE-PIS, together with GTZ, collaborated with theBolivian national authorities on an evaluationstudy of high-altitude (4,000 m.) stabilizationponds for the treatment of sewage from LaPaz.

2.98 A project entitled "Present Situa-tions, Trends, and Promotion of Water Sup-ply and Sanitation Research" was launched in1984 with financial support from the Cana-dian International Development ResearchCenter (IDRC) and was under way in Chile,Colombia, Guatemala, and Peru. It is hopedthat the project will enable the countries to de-fine their relevant research policies and priori-ties, and that a regional system can be estab-lished to provide information on researchbeing done in the countries. With the aim ofpromoting research and disseminating itsresults, CEPIS published the report of the re-gional seminar on nonconventional waterpumping technology in rural systems and pre-pared and distributed the final report of the re-gional seminar on rural water treatment stud-ies in Argentina, Chile, Colombia, Costa Rica,and Peru. In addition, it organized an interna-tional meeting, sponsored by IDRC and GTZ,of researchers studying nonconventional solidwaste collection systems in marginal urbanareas, which was attended by 45 specialistsand mayors. CEPIS continued its training ofnational researchers. In the course of the year,seven Peruvian professionals and students re-ceived training in stabilization pond researchtechniques and in procedures for monitoring

the quality of water and sewage laboratoryanalysis.

2.99 Technology development. Themain focus was on the development of effi-cient, low-cost, and socially acceptable tech-nologies, particularly for use in underservedcommunities subject to higher-than-averagehealth risk. Examples included the evaluationand adjustment of the water treatment plant atCutzamala, Mexico; the assessments of over10 pilot water treatment facililities in ruralPeru, carried out with the support of USAID,the Overseas Development Administrationand the University of Surrey (both of theUnited Kingdom), and GTZ; the feasibilitystudies for the Puno and Chiclayo water treat-ment system in Peru; the design of a series ofexperimental ponds for the recycling of waterin Piura; and the recycling of householdwastewater in Ica, Pisco, and Trujillo, also inPeru.

2.100 Seminars on technology for leak-age control in water supply systems were con-ducted in Brazil, Colombia, Mexico, and Peruwith a view toward building a regional net-work of agencies to cooperate in the develop-ment of control procedures. In sanitation, aworking group was formed to consider trashdisposal problems in Lima's shanty towns;material was prepared and distributed illustrat-ing the problems and showing how they havebeen dealt with in similar communities ofBrazil and Peru with the help of the commu-nity. CEPIS coordinated the meeting of direc-tors of urban sanitary services of Latin Ameri-can Metropolitan areas, held in Rio deJaneiro, Brazil, under the auspices of the RioMetropolitan Urban Sanitation Company andattended by 38 participants. Technical coop-eration was provided to the Municipality ofLima (Peru) in connection with the Marbellasanitary landfill and to Argentina's NationalSanitation Directorate in the treatment of haz-ardous industrial solid wastes. Highlights inpollution control were CEPIS' role in the re-gional coordination of the World Environ-mental Monitoring System (SIMUVIMA) Proj-ect and the dissemination of the findings of

48 Annual Report

analytical quality control evaluations to thenational laboratories participating in theGEMS/Water and Preliminary LaboratoryEvaluation Projects. These evaluations werecarried out with the cooperation of the UnitedStates of America's Environmental ProtectionAgency.

2.101 Dissemination of information.The Pan American Network for Informationand Documentation in Sanitary Engineeringand Environmental Sciences (REPIDISCA)continued to foster the development of na-tional capacities for the utilization and ex-change of information and bibliographical ser-vices in the fields of water supply, basicsanitation, and environmental health. A totalof 53 additional centers joined the Network in1984, bringing the number of collaboratingunits to 130. To strengthen the Network, CE-PIS cooperated with Argentina, Bolivia, Bra-zil, Chile, Cuba, Ecuador, Mexico, Nicara-gua, Paraguay, and Peru in training 195officials in the management, dissemination,and utilization of technical information. Sevencountries drew up proposals for the develop-ment of national information centers and net-works. In addition, the Network's five basiccoordination manuals were reviewed and ad-justed as an essential activity at the stage ofsystem consolidation. In order to increase thecapacity of the Network's computer system, aplan was developed for expanding CEPIS'computation facilities bb acquiring an HP-3000 mainframe and microcomputers and in-stituting a minicomputer system (MINISIS) toprocess REPIDISCA data. The plan alsocalled for decentralizing the data processingfunction from CEPIS to the countries.

2.102 REPINDEX, a computerized indexcontaining 700 summaries and having a circu-lation of 750 copies, continued to be pub-lished quarterly for distribution in MemberCountries. Several countries made additionalcopies to increase the number available for lo-cal users.

2.103 Documents compiled or publishedin 1984 under the CEPIS publications pro-gram included: Management of Training Ac-

tivities in Water and Sewerage Institutions;Basic Information for Supervisors of WaterSupply and Sewerage Systems; Basic Hy-draulics for Sanitary Engineers; Hydraulics ofUnderground Water; Guidelines for Design-ing Slow Filtration Plants for Rural Areas;Evaluation of Water Treatment Plants; Pito-metry; and Design and Management of Stabi-lization Ponds and Other Simplified Systemsfor the Treatment of Wastewater. In addition,14 reports and minor technical documents, 23urban sanitation and water treatment mod-ules, and 3 documents in English on the lattersubjects were issued.

2.104 Training. With the aim of encour-aging activities of the Regional CooperatingNetwork, CEPIS is planning to achieve a mul-tiplier effect in the use of resources throughsuch strategies as the building up of a regionaltraining program, the training of instructors,the joint preparation of manuals and instruc-tional materials, the testing and adjustment ofsuch materials in pilot courses, and the puttingtogether of audiovisual training packages thatnational institutions can duplicate economi-cally and use. The Center compiled the expe-rience acquired in the design and teaching of30 courses in a document entitled Informationon the Assistance that CEPIS Can Provide toCountries of the Region in Their Training Ac-tivities in Sanitary, Environmental, and Sani-tation Engineering. The document summa-rizes the technical details, content, andorganization of the courses, all of which canbe adapted to meet the needs of an individualinstitution. In 1984, the Center organized 29courses that were attended by 732 profession-als from most of the countries of the Region.The distribution of the courses by program ar-eas is shown in table 6.

2.105 Technical cooperation. Advisoryservices under the Drinking Water Quality Im-provement Program were provided to Peru(Environmental Quality Board-Lima, Puno,and Chiclayo) and Mexico (Guadalajara andCutzamala plants). Technical information onthis subject was furnished to institutions inBrazil, Colombia, Dominican Republic. Ecua-


Table 6. CEPIS training courses and number of participants, by program area, 1984

Courses Courses Number ofat the in the partici-

Program area Center countries pants Residencies

Water treatment and improvement ofwater quality for human consumption 1 6 171 5

Water supply and distribution and con-trol of water leakage 1 6 178 -

Water supply in cases of emergency - 1 39 -Planning of drinking water and sanitation

projects 1 - 39 1Management of training activities - 1 24 -Wastewater disposal and reuse - - - 7Ocean outfalls - 1 20 -Solid wastes and urban sanitation 1 2 131Information on sanitary and environ-

mental engineering 1 7 130 4

Total 5 24 732 17

- None.

dor, Peru, Uruguay, and Venezuela. Organi-zations in Brazil, Colombia, Cuba, Mexico,and Peru received assistance in reviewing andadjusting national leakage control programs toextend coverage by reducing the volume ofwater unaccounted for.

2.106 In sewage collection and disposal,CEPIS collaborated with the executing unit forthe IDB Tarija Sanitation Project (Bolivia) in astudy on pollution of the Guadalquivir River.Also in Bolivia, major problems arising fromthe pollution of Lake Titicaca were evaluatedand a determination was made of technicalstudies that should be carried out in order todetermine the necessary control measures.CEPIS also advised Paraguay in connectionwith a preliminary evaluation of the quality ofthe water in Lake Ypacaraí and the manage-ment of that resource; collaborated with theEnvironmental Quality Board of Puerto Ricoin the analysis of pollution problems resultingfrom industrial discharges from the Caño LaMalaria; and cooperated with Argentina,Ecuador, Nicaragua, and Saint Lucia in thereview of technical studies and preliminary de-signs of underwater outfalls for Mar del Plata,the Galápagos, Bluefields, and Castries, re-spectively.

Pan American Center for HumanEcology and Health (ECO)

2.107 ECO continued studying the inter-actions between humans and their physical,biological, and sociocultural environment. Inaddition, it continued to conduct research andtraining activities, develop technology, dis-seminate information, and cooperate with theMember Countries in the fields of human ecol-ogy and health.

2.108 Research. Research during theyear was closely linked to ECO's projects fortechnical cooperation with the countries. Withthe Government of Honduras, ECO partici-pated in the El Cajón hydroelectric project, es-pecially in the studies on relocation of dis-placed communities and potential ecologicalproblems. At the request of the DominicanRepublic, ECO formulated a proposal onaction to prevent potential harmful effects re-sulting from development of the El Madrigaldam. ECO collaborated with the Governmentof Guatemala in studies of ways to reduce theharmful public health and environmental ef-fects of arsenic contamination in the PazRiver, as well as on a study of environmentalpollution from lead. Based on a document

50 Annual Report

prepared by ECO on the possible impact onhealth of the Tempesque River irrigation proj-ect, the authorities of Costa Rica continuedthe necessary studies to formulate a plan fordealing with this situation. The Governmentof the Bahamas reviewed the plan of actionsuggested by ECO for preventing and moni-toring industrial pollution in the Freeport area.

2.109 As a first stage in a program of re-search aimed at determining the frequencyand distribution of cancer pathology due tochemical contamination of the environment,research was initiated to determine the corre-lation between chemical substances and histo-pathological cancer. In the second stage, asurvey of Latin American industry will be car-ried out to identify those activities using sub-stances which the International Agency forResearch on Cancer has identified as carcino-genic. The School of Public Health of Chile isresponsible for the first stage of the study; theEnvironmental Sanitation Technology Com-pany (CETESB) of Sáo Paulo, Brazil, for thesecond stage.

2.110 Technology development. Draw-ing on experience of Latin American coun-tries, including field tests in the Mexican Statesof Aguas Calientes and Mexico, simplified an-alytical methods were developed for rapidlyevaluating sources of air, water, and soil pol-lution. To facilitate the evaluation of the envi-ronmental impact of development projects,ECO, in collaboration with the United NationsEnvironmental Program (UNEP), initiated theadaptation of environmental analysis tech-niques to meet the requirements of the coun-tries in the Region. The results of this method-ology will be applied in the English-speakingCaribbean countries. In 1984, ECO prepareda manual on the evaluation of public healthrisks associated with accidents involvingchemical agents. An Inter-American Sympo-sium on Emergency Preparedness and Disas-ter Relief Coordination was held in July underjoint ECO/PAHO/WHO sponsorship andwith support from USAID. Subsequently, asimilar national symposium was held in De-cember in Brazil under CETESB coordina-

tion. With the support of various agencies,particularly the University of Sáo Paulo andCETESB, ECO prepared and distributed twoguides addressing the problem of scarcity oftoxicology laboratories, one on minimumstandards for development of a toxicology lab-oratory and the other on procedures for im-plementing the most common toxicologicaland analytical techniques. Both guides werewritten with the working conditions in LatinAmerica and the Caribbean in mind. To assisthealth services in the prompt identificationand treatment of communities and individualsexposed to potentially hazardous substances,the preparation of a manual on epidemiologi-cal surveillance of the effects of exposure toheavy metals, plastics, solvents, hydrocarbonderivatives, and fibers was begun in 1984.

2.111 Dissemination of information.ECO restructured its library and entered intoan arrangement with the Autonomous Uni-versity of Mexico providing for the sharing ofinformation and computer equipment, jointdata analysis, and joint technical publicationson the environment and health. The Centerbegan issuing its monthly publication, ECOTABCONT, a systematically arranged indexcovering approximately 100 specialized peri-odicals, and published three bibliographies-on the evaluation of the impact of watersheddevelopment projects, on pesticides, and onenvironmental impact evaluation. A total of72 technical information requests from 11countries were answered. The informationnewsletter Human Ecology and Health con-tinued to be distributed quarterly in Spanish(3,000 copies) and English (1,500). The tech-nical publications program was intensified,with a total of 26 titles issued in the variousseries. Two directories, one on toxicology andthe other on toxicology laboratories in LatinAmerica, were published in an effort to facili-tate information exchange.

2.112 Training. Training focused onmethods for evaluating the exposure of indi-viduals to chemicals, with special emphasis onepidemiological and toxicological aspects andenvironmental impact, and the prevention


and monitoring of the effects of exposure tohazardous substances such as pesticides andasbestos. The training materials publisheddealt with theoretical aspects, simulations,and analysis. Areas covered included: epide-miological evaluation of chemical environ-mental risks, fundamentals of toxicology, en-vironmental toxicology, food toxicology,rapid evaluation of environmental pollutionsources, environmental and health impact,evaluation, appropriate uses of pesticides,and prevention of risks from exposure to as-bestos. Workshops and training sessions wereconducted in Argentina, Brazil, Chile, Colom-bia, Costa Rica, Cuba, Dominican Republic,Guatemala, Honduras, Mexico, Panama, andUruguay for an estimated total of 2,500 par-ticipants. Local reproduction of educationalmaterials prepared by ECO was encouragedin order to make them available to a largernumber of people.

2.113 Technical cooperation. In 1984,ECO cooperated in the implementation of anumber of programs and projects with a widevariety of official institutions in its host coun-try, Mexico, including those concerned withhealth, ecology, and agriculture; social secu-rity agencies; universities; and research insti-tutes. Its assistance included inter alia supportfor a study on the structure of the national re-search program on environmental impacts onhealth; establishment, together with a consor-tium of universities, of a Master's degree pro-gram in human ecology and organization ofan environmental health component in theMaster of Public Health programs; inaugura-tion of a national reference laboratory in toxi-cology; support for field and laboratory re-search on cases of intoxication by pesticidesand other chemicals; development of chemi-cal exposure standards and regulations; andan extensive information program.

2.114 ECO collaborated with the Gov-ernment of Cuba in a toxicological analysis ofpollution problems in Havana Bay, and withPanama in the institution of procedures for theanalysis of pesticide residues in food productsfor export. In Peru, ECO collaborated with

CEPIS in the preparation of a protocol for so-cioeconomic and epidemiological research onthe health implications of using treated efflu-ents for irrigation at San Juan de Miraflores. InHonduras, it examined the possibility of estab-lishing a pesticide laboratory to serve CentralAmerica.

2.115 The Center, designated in 1984 asa Focal Point by the panel of experts in envi-ronmental management of the WHO/UNEP/FAO interagency project, continued to furnishtechnical assistance to the various compo-nents of the Regional Program on ChemicalSafety.

Disease Prevention and Control

Epidemiology

2.116 In 1984, priority was given totranslating the conclusions and recommenda-tions of the Regional Meeting on Uses andProspects of Epidemiology, held in BuenosAires, Argentina in 1983, into strategies andpractical activities and strengthening the na-tional capacity to develop epidemiology as auseful tool in the prevention and control ofdiseases, the planning of health services, deci-sion-making, and evaluation. The final reportof the meeting was published in PAHO's Epi-demiological Bulletin and was distributedwidely in the countries of the Region in orderto bring these approaches to the attention ofthe national health authorities. Subsequently,the Directing Council of PAHO, at its XXXMeeting, recognized the far-reaching impor-tance of this topic and adopted resolutionCD30.R16, urging the governments tostrengthen the practice of epidemiology andexpand its area of activity. Implementationwill continue with the publication of the entireproceedings of the meeting and the promo-tion of specific actions in the individual coun-tries.

2.117 To strengthen epidemiological ser-vices and encourage new approaches, the

52 Annual Report

governments are reorganizing and reorientingthose services with the assistance of PAHO/WHO. Plans for the establishment of a na-tional epidemiology center were examined inBrazil. In Colombia, Cuba, Dominican Re-public, and Mexico, reorganization efforts inepidemiology services were stepped up. In ElSalvador, Guatemala, Honduras, Nicaragua,and Panama, guidelines for the assessment ofavailable information on national health con-ditions and trends were developed in collabo-ration with the Ministry of Health of eachcountry. In the Caribbean area, Trinidad andTobago, with support from CAREC, initiatedan analysis of health conditions based on theepidemiological method. Among the efforts toimprove the countries' epidemiological capac-ity, mention should be made of the dissemina-tion in the Epidemiological Bulletin of infor-mation on epidemiological principles andmethods, national and regional analyses ofepidemiological data, and experience ac-quired. On the regional level, surveillanceagainst significant diseases was maintained toallow the governments to act promptly in theevent of outbreaks. CAREC has proven to bean effective instrument in such circumstances.

2.118 To strengthen their epidemiologi-cal capacity, Colombia, Cuba, and Venezuelaare mobilizing national resources and have ini-tiated pilot plans aimed at achieving a betterdefinition of what the practice of epidemiologyinvolves. In Cuba, a pilot project was carriedout in which the new functions of municipaland regional epidemiologists were put to atest. The national epidemiological services arescheduled to be restructured in 1985 in keep-ing with the results of that test. In Colombia, astudy is being conducted in five distinct geo-graphic areas to arrive at a better understand-ing of the epidemiological systems and deter-mine the optimal characteristics of those whopractice epidemiology. In Venezuela, a startwas made on preparing plans for a similarstudy. Once the national requirements havebeen determined, networks of national institu-tions will be established to provide more ap-propriate training to personnel in epidemiol-ogy. A pilot plan to restructure the

epidemiology component of training pro-grams in public health is under way in the Do-minican Republic and Nicaragua. CARECcontinued to conduct important training pro-grams in epidemiology, including its applica-tions in the monitoring of primary health care,food protection, and selected problems of dis-ease prevention and control.

Caribbean Epidemiology Center(CAREC)

2.119 The Caribbean Health MinistersConference (CHMC), held in Dominica inJuly 1984, unanimously supported a 3-yearextension of CAREC's Agreement and de-cided that at the expiration of this term thereshould be an additional 3-year period ofPAHO/WHO management (i.e., throughDecember 1990). By December 1984 all butone government had signed the extension ofthe Agreement.

2.120 The practice of epidemiology in theCaribbean area can be characterized by a vari-ety of situations and problems: noncommuni-cable chronic diseases are surpassing commu-nicable diseases as the major health problemsin recent times; passive surveillance systems,which are traditionally not representative ofthe whole population, have been geared to-wards communicable diseases; health infor-mation lacks details regarding characteristicsof the population and factors influencing theutilization of health services; refinement of in-dicators is needed for the evaluation of healthconditions; health information is noted for itslate compilation and limited analysis of data;epidemiological research, training of healthpersonnel in epidemiology, and assessment ofhealth programs and technologies are limited.Within recent years CAREC and other re-gional institutions have taken steps to improvethe use of epidemiology in member countries.

2.121 Research. CAREC continued tobe actively involved in investigating Campylo-bacter, viral hepatitis (four outbreaks). re-ported suspicious cases of smallpox. food-borne disease outbreaks (salmonellosis).


typhoid, cryptosporidiosis, excess neonataldeaths, and alleged skin rashes from environ-mental hazards (such as painting a building).In addition, consultations were provided on awide range of disease and environmentalproblems, from the disturbance of choleragraves to the handling of suspect food items.Preparations were made to undertake epide-miological assessments of the health status ofeach member country. These assessments willbe made available to member countries fortheir consideration in adjusting programs to-wards the achievement of health for all by theyear 2000. This activity is also intended todemonstrate the usefulness of epidemiologicaltechniques in the management of health ser-vices.

2.122 Training. Training continued as amajor function of the Center. Efforts havebeen concentrated in two major areas: epide-miology and food safety practices. In epidemi-ology, workshops in the member countries onprimary health care surveillance have boostedlocal capabilities for data collection, analysis,and use for problem identification and pro-gram planning and evaluation. As a result ofthe training of nursing tutors in epidemiologyat CAREC, epidemiology is part of the basicnursing course in nursing schools of the Re-gion. The development of training materials(e.g., the CAREC manual of epidemiologyand CARIBA data base with practical exer-cises, together with the audiovisual library) al-lows training in epidemiology to continue atthe local level. CAREC also assists in dissemi-nating epidemiological information throughpublications such as the Surveillance Report(CSR) and EPI Notes.

2.123 Broadened services in food safetyare available to countries. In addition to train-ing, the Center is developing new capacities infood microbiology and entomology and anaudiovisual lending library for continuing ser-vices to the member countries. The USAIDgrant of US$225,000 for a program of foodsafety training, to be executed from June1984 to June 1985, has enabled the Center tolaunch an intensive postbasic training pro-

gram for inspectors, health educators, andfood plant supervisors. The food safety pro-gram has included local courses on foodestablishment inspection for public healthinspectors in Barbados, Jamaica, andSuriname, and courses on the food trade inthe British Virgin Islands, Jamaica, and Trini-dad and Tobago. In cooperation with the U.S.Food and Drug Administration, a course washeld for 10 food plant inspectors in Trinidadand Tobago.

2.124 The program for training physi-cians and nurses in the diagnosis and treat-ment of sexually transmitted diseases, startedin 1983, continued successfully throughoutthe year. A new manual was developed withthe participation of two West Indian consul-tants and a consultant from the Centers forDisease Control (USA), and 500 copies weredistributed. A second edition of 2,500 copieswas scheduled for late 1984.

2.125 Technical cooperation. Duringthe year, programs for sexually transmitteddiseases were assessed in Bahamas, Belize,Dominica, Grenada, Guyana, Jamaica, SaintLucia, St. Christopher and Nevis, and St.Vincent and the Grenadines. Consultants in-volved were provided through the TechnicalCooperation Among Developing Countries(TCDC) program by the Governments of Ja-maica and Trinidad and Tobago and by theGovernment of Suriname for the Guyana pro-grams. CAREC continues to assist the Carib-bean countries in developing and strengthen-ing laboratory diagnostic surveillance andanalytical capabilities at the national level.

Expanded Program on Immunization(EPI)

2.126 Progress to date. EPI programmanagers from Latin America (20 countries)and the Caribbean (17 countries) held subre-gional meetings during the past year to reviewprogress made and to set immunization cover-age targets for 1985. These meetings were or-ganized in response to resolution CD29.R16

54 Annual Report

of PAHO's XXIX Meeting of the DirectingCouncil (1983), which recognized that accel-erated progress will be necessary to achievethe 1990 EPI goals. At each meeting, partici-pants reviewed one another's work plans anddiscussed appropriate targets for the next 2years. Each country then rewrote its workplan in accordance with those recommenda-tions deemed appropriate and feasible. Thesejoint analyses show the following outstandingfeatures:

2.127 Immunization coverage in theAmericas has improved considerably over thelast several years. An important indicator ofEPI impact is shown in figure 3, which plotsthe incidence rates of polio, tetanus, diphthe-ria, whooping cough, and measles from 1970to 1983 in the 20 countries which make up theLatin American subregion. Though programsare at many different stages of development, itcan generally be said that important advanceshave been made in the areas of vaccine sup-

Figure 3. Incidence of five vaccine-preventable diseases in the Regionof the Americasa, 1 9 70 -198 4 b

200

100

o 2 s

0.2

0 .

nA1

76 77 78 79 80 81 82 83

Year

-_.iu, uu Measles

, , m, , Whooping Cough

",.,,,,, ,,, .Diphtheria

,_-_.__,:, Tetanus

_,,//,,_~ Poliomyelitis

A/ Excluding Bermuda, Canada, and the United States of America

b/ Provisional data for measles, whooping cough, dlphtherla, and tetanus for 1984.


ply, extension of the cold chain, selection ofeffective vaccination strategies tailored to par-ticular needs, training, evaluation, and com-munity participation. Most countries still re-port significant difficulties in the areas of su-pervision, information systems, and epidemi-ological surveillance, and the work plans for1985 reflect these concerns.

2.128 Almost all countries report they arereceiving sufficient quantities of vaccines tocover their target populations and have alsomade notable strides in improving and ex-panding the cold chain: Several countrieshave had problems obtaining enough toolsand spare parts to keep their equipment run-ning. A few countries are testing solar refriger-ation equipment and have programmed activ-ities relating to this new technology.

2.129 Another important advance inmost country programs has been the identifi-cation of an appropriate combination of vacci-nation strategies to meet their particularneeds. Besides vaccination in establishedhealth centers, these strategies include house-to-house vaccination in urban areas, mini-campaigns in rural areas, and mobile brigadesto reach remote areas. The importance ofcommunity participation was emphasized dur-ing the workshop discussions. Activitiesplanned in this area can be divided into twogeneral areas: use of the mass media, and useof community organizations to promote andactively take part in delivery of immunizationservices. Several countries use already estab-lished community organizations, while otherstrain community leaders.

2.130 Supervision is being increasinglyemphasized in many countries. About three-quarters of them plan such activities as sched-uling a minimum number of supervisory visits,acquiring additional vehicles and budgetingmore per diem for supervisory personnel,conducting training courses for supervisors,and implementing supervisory guidelines.

2.131 Over half the countries have pro-grammed specific surveillance activities, suchas surveys to determine immunity levels or

target populations in specific areas, institutionof a weekly telephone reporting system, re-porting and follow-up on vaccine reactions,and the use of seroepidemiological studies.Among the activities mentioned in the workplans to improve disease notification are thedesign of computer programs to collect andanalyze data, new systems to motivate per-sonnel to submit monthly reports, andpromulgation of legislation to make diseasenotification obligatory.

2.132 In rewriting work plans, the majoractivities for which financial or technical sup-port is being requested in 1984-1985 are:training, cold chain acquisitions and evalua-tions, the purchase of vaccines, national EPIevaluations, and intercountry visits. Amongthe external agencies involved in meetingthese requests are PAHO, USAID, UNFPA,the European Economic Community (EEC),and UNICEF.

2.133 1985 Targets-Latin America.All 20 countries set 1985 vaccination cover-age targets for DPT, poliomyelitis, measles,and BCG vaccines. These targets are com-pared to the actual 1983 levels of coverage intable 7. Almost half the countries of LatinAmerica had coverage levels of at least 50%with DPT, polio, and measles vaccines in1983, although a much smaller fraction at-tained coverages of 70% or more. BCG cov-erage was generally higher, with 12 countriesreporting coverages of greater than 50%, 7 ofwhich had coverages of greater than 70%.Figure 4 shows the progress made in increas-ing immunization coverages from 1978 to1983 and the dramatic improvement whichwould result if all countries were successful inmeeting their coverage targets by 1985.

2.134 1985 Targets-Caribbean. Table7 shows each country's 1985 coverage targetsfor complete immunization of children under1 year of age with DPT, polio, BCG, andmeasles vaccines, together with the reported1983 coverages. Immunization coverage gen-erally improved between 1980 and 1983, par-ticularly in the 12 smaller countries of the sub-region with populations of less than 130,000

56 Annual Report

Table 7. Percentage of vaccination coverage for 1983 and vaccination coverage targetsfor 1985 in children under 1 year of age, in 39 countries and territories of the Region

DPT Poliomyelitis(3rd dose) (3rd dose) Measles BCG

1985 1985 1985 1985Country or territory 1983 targets 1983 targets 1983 targets 1983 targets

AnguillaAntigua and BarbudaArgentinaBahamasBarbadosBelizeBermudaBoliviaBrazilBritish Virgin IslandsCayman IslandsChileColombiaCosta RicaCubaDominicaDominican RepublicEcuadorEl SalvadorGrenadaGuatemalaGuyanaHaitiHondurasJamaicaMexicoMontserratNicaraguaPanamaParaguayPeruSt. Cristopher and NevisSaint LuciaSt. Vincent and the GrenadinesSurinameTrinidad and TobagoTurks and Caicos IslandsUruguayVenezuela

97100

65656959537

49908970415691k

932423k

45h.k

6844h

56

70

309524613820k

9081808560707049

959070807560a.d

6080959590808595a

70608585557555806580947080

80/40m3090

100959080a.d

8565

100 95100 9094 9065 8062 7561 6053 a.d

11f 85

10 0s.h 95

75 9590 9563 9042 8054 8593h 9592 a

22 9027k 6041h.k 8572 8544h 5559 75.. . 5568 80

7085 8095 8629 f 8060 8047 80/40m

19k 3591 9080 10084 9083 9061 8079 a.d

74h 9067 80

70486266554360e

14528387e',

100

4273716323

2 8 k

47i7

1244i

66

85i83e23603727b

3659710b

806242

95

80806550a.d

60959595e.i

95809595

60608580408595585608051e

8080

80/40"4380

75n

90P

a.d

9560

96b

64b

81b

3056b

698578

9 1 k

10041

6 4 k49k

b

2573

74

9189815458k

69b

b

b

989548

95

85

75a.d

7075a

95i

95859598a

608085

458565857080991

9085

80/40"6275'

85

a.d

9580

... Data not available. almmunization coverage target for 1985 not established. bVaccine not included in national program in 1983.C5 years of age. dinformation unavailable since country did not attend Second Regional Meeting of EPI Managers held in Trinidad in

November 1983. eMeasles, mumps. and rubella vaccine used. fDoes not include national poliomyelitis campaigns. aReported number ofdoses exceeded estimated target population. hSecond dose. '15 months old. Jl year of age. kProjected. 10-5 years of age. t"Urban andrural targets. "2 years of age. 012-35 months. P1-3 years of age.


Figure 4. Proportion of Latin American children under 1 year of age in countries whereimmunization coverage is at least 50% or 70%, 1978-1983 (reported coverages),

1985 (coverage targets)

1

zwC w 3/4.1<I LO

,,r

a.Zo M 1/4

o,-

rercu

1978 1983 1985 1978 1983 1985 1978 1983 1985 1978 1983 1985

|- DPT -- FPoliomyelitis- I -Measles -A |- BCG -

M Coverage of 50% or more

(in order of ascending population size: An-guilla, Turks and Caicos Islands, British VirginIslands, Montserrat, Cayman Islands, St.Christopher and Nevis, Bermuda, Antiguaand Barbuda, Dominica, Grenada, St. Vin-cent and the Grenadines, and Saint Lucia).The seven larger countries (Belize, Bahamas,Barbados, Suriname, Guyana, Trinidad andTobago, and Jamaica) have also improvedtheir coverages, but none has yet reached lev-els greater than 80% with any vaccine.

2.135 Training. From the time EPI train-ing activities were launched in early 1979through 1984, it is estimated that at least15,000 health workers attended courses andworkshops. Over 12,000 EPI modules havebeen distributed in the Region, either directlyby the EPI Program or through the PAHOTextbooks Program. Continued emphasis isbeing given to the training of personnel in themaintenance and repair of refrigerators; 30technicians were trained during 1984 in Bra-zil. As an immediate activity of the Child Sur-

- Coverage of 70% or more

vival Program for Central America and Pan-ama, a subregional cold chain and logisticscourse for 29 supervisors was held in Guate-mala in November 1984. Agreements withthe schools of public health in Rio de Janeiroand Buenos Aires are permitting the produc-tion of training materials adapted to meet na-tional needs. In addition, operational researchon immunization, including diarrheal diseasecontrol, has' been included as part of the de-velopment of training materials in Argentina.

2.136 Cold chain. The Regional FocalPoint for the EPI cold chain in Cali, Colombia,continues to provide testing services for theidentification of suitable equipment for storingand transporting vaccines. The evaluation ofsolar refrigeration equipment is being increas-ingly emphasized in cooperation with the De-partment of Thermal Sciences (University ofValle). A summary report of the units testedwill be published in the EPI Newsletter. Atime-temperature indicator for measles vac-cine has been also field-tested in three coun-

O-

58 Annual Report

tries; the results of these trials are being ana-lyzed and incorporated into a global report. A0.5-liter vaccine container developed at theFocal Point is now ready for production. Dur-ing 1984, the cold chain Focal Point providedassistance to the Secretary of Health in Mex-ico in the production of two sizes of ice packs.In addition, technical assistance was given tothe Ministry of Health and Social Welfare in ElSalvador for the construction of vaccine coldrooms.

2.137 Revolving Fund. PAHO's Revolv-ing Fund for the purchase of vaccines and re-lated supplies received strong support fromthe United States of America, which contrib-uted US$1,686,000 to the Fund's capitaliza-tion. This contribution, together with theUNICEF contribution of US$500,000 madein 1983, raised the capitalization level toUS$4,531,112. Despite the economic crisisfacing many countries of the Region, Revolv-ing Fund procurements have helped to con-trol vaccine costs during a time of rapid infla-tion, and the Fund continues to provide goodquality vaccines at low prices. Figure 5 shows

the number of doses of each of the five vac-cines procured through the Revolving Fundfor the period 1979-1984 and the estimatedprocurements for 1985. By the end of 1983,the quality of the vaccines used in over 95%of the countries and territories in the Americaswas known to conform to WHO require-ments. During its first 6 years of operation, theEPI Revolving Fund placed vaccine ordersworth over US$19 million (table 8).

Table 8. Dollar value of vaccines purchasedthrough the EPI Revolving Fund,

1979-1984

Year Value (US$) F.O.B.a

1979 2,259,0641980 3,250,1781981 4,303,2461982 4,209,5481983 2,763.2351984 2,342,473b

Total 19,127,744

aFree on Board (represents the price at originating shippingpoint).

bTotal value includes cost (F.O.B.) for diphtheria and tetanusvaccines (pediatric and adult).

Figure 5. EPI Revolving Fund vaccine procurements, in doses, 1981-1984

U)z0-I

-Iz

¢/)uJ0C>o

30

28

26

24

22

20

18

16

14

12

10

8

6

4

2

0DPT Poliomyelitis Measles BCG Tetanus Toxoid

Vaccine Types"1 a 1981 . 1982 1983 1984


2.138 Evaluation. To improve their im-munization services, most countries are evalu-ating their programs in order to identify prob-lems which impede operations and to definepertinent solutions. Since November 1980,PAHO/WHO has cooperated with 18 coun-tries in conducting comprehensive EPI evalu-ations. Six countries have also held follow-upevaluations (table 9) to assess the extent towhich the recommendations from the firstevaluation were implemented. EPI has devel-oped a computerized system to monitor vacci-nation coverages and disease incidence in allcountries of the Region. The first phase of theproject, recently completed, involved datacollection from each country on target popula-tions from 1979 to the present and on thenumber of doses administered. Annual re-ports are produced on vaccination coveragesand dropout rates by country, subregion, andregion. The second phase of the project,scheduled for completion by early 1985, willpermit the generation of reports and linegraphs showing reported incidences of each ofthe EPI diseases from 1970 to the present.

Table 9. Number of EPI evaluations by countryin the Region of the Americas, 1980-1984

Country 1980 1981 1982 1983 1984 Total

Argentina - x - - - 1Belize - - - x 1Bolivia x - x - 2Brazil - x - 1Chile - - - x 1Colombia x - x x 3Cuba - x - - 1Ecuador - x x - - 2El Salvador - - - - x 1Dominican Republic - x - x 2Guatemala - - - x - 1

Honduras - - x - x 2Jamaica - - x - 1

Nicaragua - - - x - 1Panama - x 1Peru - - x - - 1

Uruguay - - x - x 2Venezuela - - - - x 1

Total 2 4 5 5 9 25

- None.

Diarrheal Diseases

2.139 Plans of operations were formu-lated in six more countries. In three of them(Suriname, Uruguay, and Venezuela), thoseplans became operational by using mainly lo-cal resources; in the other three (Bolivia, Do-minican Republic, and Mexico), considerableregional resources were invested. As a resultof regional promotion during 1984, Cuba,Guatemala, and Peru will prepare and imple-ment work plans during the first quarter of1985. Consequently, there is a total of 23countries in which control of diarrheal dis-eases is being promoted as part of a compre-hensive program in the American Region. Inthe rest of the countries, the activities consistmainly in the promotion of oral rehydrationtherapy (ORT).

2.140 Large-scale local production of oralrehydration salt (ORS) is now under way inArgentina, Brazil, Colombia, Mexico, theUnited States of America, and Venezuela,while in seven other countries ORS is pro-duced on a smaller scale. As a whole, regionalORS self-sufficiency has been attained. How-ever, the international demand for ORS sup-plies will probably increase as ORT use ex-pands, not only because virtually all countriesare stressing the use of ORS in the home forearly diarrhea treatment, but also because ofincreases in local ORS production costs, forc-ing countries to reduce local production andprocure ORS packets from internationalsources.

2.141 Regarding training during 1984,two manager training courses on national con-trol of diarrheal diseases were held in Brazil (inPortuguese) and in Mexico (in Spanish).Health personnel in charge of the control ofdiarrheal diseases (CDD) were trained in themanagerial aspects of the program. In Brazil,45 Brazilian and 9 African Portuguese-speak-ing individuals from Angola, Cape Verde,Mozambique, and Sáo Tome were trained. InMexico, a Guatemalan and 57 Mexicans at-tended the course. The regional program ismaking plans to train newly appointed coun-

60 Annual Report

try CDD coordinators. The CDD mid-level su-pervisory training course was held in six coun-tries, with a total of 282 participants.Countries have found this course very usefuland plan to repeat it using locally availablefunds. Two seminars were organized, one inChile and the other in Mexico, as part ofCDD-ORT promotional activities. A secondtraining course, entitled "CommunicationsSupport to Diarrheal Disease Control," washeld in Bogotá, Colombia, in March 1984 toevaluate the projects devised after the firstcourse held in Rio de Janeiro, Brazil, in 1982.Participants from 10 countries attended thissecond course. It was found that the educa-tional materials developed in the projects arebeing used at the country level.

2.142 Two surveys of diarrheal diseasemorbidity and mortality were conducted dur-ing 1984, one in Belize and one in Suriname.Cooperation was provided to Bolivia andMexico for the organization of similar surveys.Both countries will conduct them during1985. Comprehensive reviews of nationalCDD programs were conducted in Colombiaand Costa Rica. These reviews provided use-ful information for reprogramming the coun-tries' CDD activities.

2.143 Regional efforts were increased tomake technical instructional material availableto national programs. The technical docu-ments prepared by the Global Program weretranslated into Spanish and distributed ac-cordingly. Also, in collaboration with PAHO'sTextbook Program, in December 1984, agroup of experts prepared a handbook on theTreatment of the child with diarrhea. Plans toprint the modules for a supervisory skillscourse, as well as other instructional materialat the country level, will be implemented dur-ing 1985 to ensure their local availability inlarge scale.

2.144 In research, during 1984, theSteering Committee (SC) of the Regional Sci-entific Working Group received and evaluated24 new CDD operational research proposalsfrom scientists within the Region. Of these,two were approved without modifications and

six were accepted in principle pending modifi-cations. A total of 32 projects have been ap-proved since 1982; 8 projects have been com-pleted, 15 are currently being carried out, and9 are pending modifications suggested by theSC for final funding. The Scientific WorkingGroup has formulated new recommendationsfor preparing country projects in order to con-duct and evaluate CDD activities, includingplanning interventions to reduce diarrheal dis-ease as well as to evaluate the impact of CDDstrategies at the community level.

Control of Vector-Borne Diseases

2.145 Persistent upward trends in thenumber of cases of malaria, dengue, Chagas'disease, leishmaniasis, and schistosomiasispose an urgent need for a critical examinationof existing knowledge and methods and asearch for new approaches and technology,as well as effective ways of pooling the use ofintra- and intersectoral resources for the pre-vention and control of these diseases.

2.146 Malaria. Of the 255.4 million in-habitants of the 33 countries and political unitsthat were originally malarious, 122,8 million(48%) are living in areas which are now at themaintenance phase, and where there is notransmission. Approximately 132,6 million(52%) still are exposed to the risk of contract-ing malaria. The number of registered cases in1984 was 902,799 (see table 10). While somecountries succeeded in halting the continuousworsening of the malaria situation, others wit-nessed a striking increase in the number ofcases reported. For the Region as a whole, thesituation in 1984 was the worst in the last 20years. This regression was particularly evidentin settlement areas in the Amazon Region andnorthern South America. The economic crisisthat the countries of the Region were facinghad a negative effect on the purchase of basicinputs and on the salaries of workers in healthprograms. Other problems were the wear andtear and irreparable deterioration of equip-ment for control operations and the high cost


Table 10. Reported cases of malaria in the Americas, 1981-1984

Populationin malarious Reported casesareas, 1984

Country or territory (in thousands) 1981 1982 1983 1984

Argentina 3,752 323 567 535 431Belize 160 2,041 3,868 4,595 4,117Bolivia 2,469 9,774 6,699 14,441 8,156 a

Brazil 55,927 197,149 221,939 297,687 378.257Chile 261 0 0 0 0Colombia 18,600 60,972 78,601 105,360 55,268Costa Rica 718 168 110 245 569Cuba 3,350 573 335 298 401Dominica 16 0 0 0 0Dominican Republic 6,060 3,596 4,654 3,801 2,370Ecuador 5,276 12,745 14,633 51,606 78,599El Salvador 4,133 93,187 86,202 65,377 66,874French Guiana 73 769 1,143 1,051 1,021Grenada 44 0 0 0 0Guadaloupe 283 0 1 1 0Guatemala 3,104 67,994 77,375 64,024 74,132Guyana 836 2,065 1,700 2,102 3,017Haiti 4,818 46,703 65,354 53,954 54,896Honduras 3,867 49,377 57,482 37,536 27,332Jamaica 1,705 1 1 4 5Martinique 194 1 7 1 0Mexico 41,639 42,104 49,993 75,029 81,640b

Nicaragua 3,165 17,434 15,601 12,907 15,702Panama 2,037 340 334 341 125Paraguay 2,701 73 66 49 554Peru 6,361 14,812 20,483 28,563 32,621cSaint Lucia 108 0 0 0 0Suriname 281 2,479 2,805 1,943 3,849Trinidad and Tobago 1,159 3 4 3 6United States of America 67,338 1,010 622 605 791

Puerto Rico 3,399 11 2 2 2Virgin Islands 96 0 0 0 0

Venezuela 11,580 3,377 4,269 8,388 12,058b

Total 255,510 629,081 714,850 830,448 902,799

. . Data not available.aUp to June.bProvisional information.CUp to October.

62 Annual Report

of imported equipment and supplies used incontrol programs.

2.147 The social and political conflicts be-ing waged over extensive areas also nega-tively affected malaria control. These conflictsresulted in the displacement of local residents,who took refuge along the borders with othercountries or in temporary shelters in the majorcities. Very little use was made of epidemio-logical methods to determine the extent towhich certain social variables were influencingthe transmission of malaria and other vector-borne diseases.

2.148 The revised strategy for a system-atic attack on these problems-that is, devel-oping the control programs within the healthservices and with community participation-was applied only very weakly. Malaria trans-mission increased sharply in certain countriesof the Andean subregion as a result of naturaldisasters. Information systems in the nationalprograms are inadequate because the epide-miological information is transmitted within avery limited circle. The process of epidemio-logical stratification to allow the use of local re-sources and the adoption of measures com-mensurate with the magnitude of problemshas yet to be implemented completely. More-over, professional training centers have notadjusted their curricula so as to update the in-formation the students receive on the epide-miological conditions of specific countries andon surveillance, prevention, and controlmethodology.

2.149 With the cooperation of PAHO/WHO, the governments are implementing avariety of initiatives to overcome these prob-lems. The governments of Central Americaand Panama conducted joint studies of prob-lems created by the tropical diseases prevail-ing in Central America and developed plansunder the primary health care approach tostrengthen the programs for the control of ma-laria, Aedes aegypti, and other vector-bornediseases. In the context of the Plan for PriorityHealth Needs in Central America and Pan-ama, basic regional priorities and intrasectoral

and intersectoral links and operational mecha-nisms were established; programs and admin-istrative procedures were developed; staff wastrained; research and information collectionactivities were pursued; national centers oftechnical excellence were identified; and thepotential levels of participation of the coun-tries of the Central American Isthmus in eachcomponent were determined.

2.150 A similar process was undertakenin the Andean subregion with the cooperationof the Secretariat of the Hipólito UnanueAgreement. Epidemiological and operationalstratification continued to be promoted in theareas affected by these diseases with the aimof making the most effective and rational useof existing local resources. The strategy pro-moted was the primary health care approach,with the participation of the relevant intra- andintersectoral levels and with community in-volvement.

2.151 To strengthen community partici-pation, antimalaria activities were included inthe popular mobilization in Bolivia. Brazil suc-ceeded in keeping its maintenance areas freeof malaria. Transmission of the disease occursin areas of the Amazon Basin where coloniza-tion, mining, and natural resource activitiesare under way. Malaria control has been in-cluded in the development projects for theseareas. In Colombia, where the epidemiologi-cal situation has deteriorated substantially, ini-tial steps were taken to strengthen control op-erations through agreements with thesectional health units and promotion ofstronger involvement of the university sector.In Mexico, the malaria program was decen-tralized outward to the States, which receivesupport from normative units at the centrallevel. Nine States accounted for 90% of thetotal number of cases reported country-wide,and two of them (Chiapas and Oaxaca) ac-counted for 54% of that total. The new struc-ture provides for coordinated participation bythe State government, Municipal authorities,health sector institutions, and extrasectoralentities concerned with the problem. During1984, the Governments of Ecuador, Haiti,


and Peru prepared preliminary proposals forobtaining external resources, while the Gov-ernments of Argentina, Belize, Bolivia, andBrazil developed plans for activities under theconcept of TCDC.

2.152 Training staff in the basic principlesof malaria epidemiology and control was iden-tified as a pressing need for implementing thestrategy of incorporating malaria control intothe regular health services. Training of the ba-sic nucleus of monitors was begun in order toensure a multiplier effect of extending thetraining to the entire staff of the general healthservices. Action was also taken to modernizethe information system and adapt it for effec-tive use within the new control strategy.

2.153 Research is critically important forthe future of malaria control in the Hemi-sphere. In Brazil, a study on drug susceptibilityand genetic differences in Plasmodium falci-parum strains was carried out. Antimalariadrugs were evaluated for their effectivenessunder different treatment schemes, and theactivity of macrophagocytes in experimentalmalaria infections was studied. In Brazil andMexico, monoclonal antibodies were used ex-perimentally to detect plasmodia in mos-quitoes; in Mexico, studies also were con-ducted on the transmission capacity ofanophelines and by density gradients of cen-trifuging techniques for detecting infection inthe vector. Serology, a useful tool in epidemi-ological analysis, was promoted in Honduras,Nicaragua, and Venezuela, where researchprojects were under way. Brazil, Colombia,Dominican Republic, and Nicaragua contin-ued their studies on the influence of selectedsocial variables in the malaria epidemiologicalprofile, including migrations, forms of produc-tion, and housing.

2.154 Technical problems associatedwith vector resistance to insecticides were ad-dressed through studies aimed at finding othermethods of control, involving either the use ofnew chemical products or the application ofbiological and physical controls to reduce thenumber of breeding places. A solution to theproblem of P. falciparum resistance was

sought through the use of new drugs (meflo-quine) or new treatment regimens based onthe use of already known drugs, alone or incombination.

2.155 Aedes aegypti eradication. TheAedes aegypti eradication and control pro-grams have met with setbacks, and the vectorhas accordingly reinfested areas from which ithad previously been eradicated and has in-vaded others where it had never been en-countered. The information on yellow fever israther fragmentary, since the disease gener-ally occurs in isolated jungle areas. Informa-tion is received only on serious and fatal casesconfirmed through laboratory diagnosis. In1984, PAHO/WHO received reports of 5cases in Bolivia, 45 in Brazil, 13 in Colombia,1 in Ecuador, and 23 in Peru, indicating a per-sistence of its endemicity in five countries ofthe Region. As for dengue, which had beenrelatively active in 1981 and 1982, most ofthe countries reported only minimal or spo-radic cases of transmission in 1983. While noepidemic outbreaks of the disease were ob-served in 1984, the circulation of dengue viruswas documented in a number of countries bythe isolation of serotypes 1, 2, and 4.

2.156 Chagas' disease. Studies of theprevalence of Chagas' disease undertaken in1983 were continued in Bolivia, Colombia,Ecuador, Honduras, Panama, Paraguay, andUruguay. These studies are already facilitatingprogramming by priorities determined by therisk of transmission and the amount of re-sources available. Thus, Chagas' disease con-trol projects based on the primary care strat-egy and on intra- and intersectoral coopera-tion (agriculture, education, and rural devel-opment) were developed in Bolivia, Para-guay, and Uruguay. A study group consisting_of the directors of Chagas' disease study andcontrol programs in Argentina, Brazil, Ecua-dor, Honduras, Paraguay, and Venezuelawas convened in November 1984 in Washing-ton, D.C., for the purpose of strengtheningthe multisectoral strategy for solving the prob-lem and formulating guidelines for epidemio-logical surveillance. Argentina, Brazil, Colom-

64 Annual Report

bia, Honduras, and Venezuela experimentedwith simplified immunological procedureswith a view toward applying them more gen-erally in the diagnosis of Chagas' disease.Venezuela, with community participation,continued its surveys on the effect of housingconstruction modifications on triatomidae in-festation and on the vectoral capacity of differ-ent species of triatomidae. The longitudinalstudies on cardiopathies due to Chagas' dis-ease also were continued.

2.157 Leishmaniasis. The number ofcases of leishmaniasis continued to increase ascolonization and projects were undertaken foropening up new areas to agricultural and min-ing development. With the exception of Bra-zil, Colombia, Costa Rica, and Panama, mostof the countries have not initiated organizedcontrol of leishmaniasis, either because of alack of epidemiological studies measuring themagnitude of the problem or a lack of humanand financial resources for identifying the ap-propriate treatment of leishmaniasis in the en-demic zone. A subregional seminar onleishmaniasis epidemiology and control in Be-lize, Central America, Mexico, and Panamawas held in Mexico in October 1984 to definea strategy for the monitoring and epidemio-logical surveillance of this disease. The experi-ences of Costa Rica and Panama, which havea structured program for the identification andtreatment of cases of leishmaniasis within thegeneral health services, served as a basis forrecommendations that should enable theother countries to undertake the study andcontrol of leishmaniasis in 1985-1986. Para-guay formulated a project to study and controlthe disease in a priority area in 1985. In Peru,the Alexander von Humboldt Institute ofTropical Medicine continued its work on char-acterization of specimens of Leishmania.

2.158 Schistosomiasis. In the Domini-can Republic, the endemic zone was definedmore precisely, which is expected to make itpossible to extend the area of the present con-trol measures in 1985. In Suriname, the re-search and control project initiated in 1983 incollaboration with the UNDP/World Bank/

WHO Special Program for Research andTraining in Tropical Diseases (TDR) was eval-uated. In addition, the training of personnel incomputerized analysis of epidemiological datawas completed.

2.159 Onchocerciasis. In Ecuador, theNational Institute of Hygiene continued itsstudy on the taxonomy and biology of oncho-cerciasis vectors. This study, conducted withthe cooperation of TDR and the London Mu-seum of Natural History, will be helpful in thefuture in defining the area of onchocerciasistransmission in the Province of Esmeralda andin orienting control activities. The onchocer-ciasis epidemiological studies being conductedby the tropical disease research and controlprogram in the Amazon Region of Venezuelacontinued to receive technical support fromthe Organization and from TDR.

Intestinal Parasitic Diseases

2.160 Training in diagnosis, surveillance,and control of intestinal parasitoses was inten-sified in Cuba, Dominican Republic, and Gua-temala. In the Dominican Republic, a jointstudy of PAHO/WHO with the Laboratoryand Blood Bank Division of the Ministry ofPublic Health and Social Welfare (SESPAS)determined the content and orientation thatparasitology training programs directed tobioanalysts should have in order to reflect thecountry's most prevalent diseases. In Guate-mala, a training program for health servicelaboratory workers was formulated for 1985-1986. This program will make it possible toimprove the diagnosis of intestinal parasi-toses, malaria, leishmaniasis, Chagas' dis-ease, and filariasis at the level of the generalhealth services.

Acute Respiratory Infections

2.161 The control of acute respiratory in-fections (ARI) in the Americas was increasedin 1984. The strategy adopted by the Region


is based on the implementation, with maxi-mum coverage, of standard activities for treat-ing infant cases of ARI within primary healthcare. These activities, together with the treat-ment of dehydration resulting from diarrhealdiseases and vaccination against immunopre-ventable diseases, complete the triad for re-ducing morbidity and mortality rates in chil-dren under age 5 in developing countries. Inthe State of Pará, Brazil, the simplified controlactivities initiated in 1982 were incorporatedinto the social security services, and their cov-erage continues to extend gradually to otherStates. In the first 2 years, 160,000 childrenwere treated under the program, 40,000 ofwhom required antimicrobial treatment. Only1% had to be hospitalized. A similar programwas begun in the State of Rio Grande do Sul.At the national level, a handbook of standardsfor the treatment of ARI in children, preparedwith the cooperation of societies of health pro-fessionals and the ministries of health and so-cial welfare, was approved. Panama contin-ued its efforts to implement the ARI program,which was receiving financial support fromWHO/Arab Gulf Fund (AGFUND). The proj-ect, initiated in April 1984, advanced to 50%of completion, and the Government was plan-ning to extend its activities to the rest of thecountry as part of the projects under the Planfor Priority Health Needs in Central Americaand Panama, together with activities for thecontrol of diarrheal diseases. Guatemala pre-pared the operational program and materialsfor ARI training and community education.Incorporation of the activities into the healthservices was scheduled to begin in January1985.

2.162 In the area of research, etiologicalstudies on ARI in children continued in Argen-tina, Brazil, Costa Rica, Panama, Peru, andUruguay. A subregional training workshop forlaboratory staff engaged in bacteriological andvirological research was conducted in Argen-tina, with participants from that country aswell as from Brazil, Chile, and Uruguay. Withthe aim of promoting initiatives in the MemberCountries, PAHO/WHO and UNICEF spon-sored a second regional seminar on ARI and

infant survival. The event, held in October inBrazil, was attended by 130 professionalsfrom Argentina, Bolivia, Brazil, Chile, Colom-bia, Costa Rica, El Salvador, Guatemala,Mexico, Panama, Paraguay, Peru, the UnitedStates of America, Uruguay, and Venezuela.The seminar examined the status of pro-grams, the training of personnel, and researchpriorities. As a result, the Governments of Bo-livia, Colombia, El Salvador, and Venezuelatook steps to formulate or intensify their pro-grams.

Tuberculosis

2.163 Tuberculosis mortality rates contin-ued to decline gradually in most countries ofthe Region. The number of cases reported hasincreased in several countries, mainly becauseof better registration and the achievement ofwider coverage in the program through the in-tegration of tuberculosis control into the gen-eral health services. In other countries, thenumber of cases reported has declined be-cause of a drop in incidence. In the latest yearfor which information was available, morethan 240,000 new cases were reported. How-ever, the last 2 years have seen advances un-der the programs in Brazil, Chile, and Colom-bia, along with a decline in the risk of infectionin Chile, Cuba, and Venezuela.

2.164 As a result of shortages and irregu-larity in the free distribution of drugs, manyprograms have deteriorated and a high per-centage of patients are abandoning treatmentbefore they are authorized to do so. Someprograms (e.g., the Peruvian program) havenot secured the expected benefits after achiev-ing noteworthy advances in the organizationand supervision of activities. Generally speak-ing, official support for the programs de-creased despite recommendations by theWorld Health Assembly (WHA33.26 of 1980and WHA36.30 of 1983). At the same time,both the interest of nongovernmental and pro-fessional groups and international support areon the rise. In the Americas, PAHO/WHO

66 Annual Report

continued to extend support to the programsin Nicaragua and Peru in collaboration withthe International Union Against Tuberculosisand in Colombia with funding provided byWHO/AGFUND. In Colombia, there was anincrease in the number of new cases reported;this may be attributable to wider coverage andintensive control efforts.

2.165 The number of cases reported inBrazil in 1983 was the same as in 1982 despitea 10% increase in the number of case-findingfacilities-an indication that diagnostic tech-nology has reached its highest level of produc-tivity. In Rio Grande do Sul, Brazil, the studyon the prevalence of tuberculosis infectionamong unvaccinated first-year students wasconcluded, bringing to completion the firstphase of the study on the risk of infection. Asecond study, to be carried out in 1988, willmake it possible to measure any change in therisk of infection and thereby assess the real ex-tent and trend of the problem and its correla-tion with the incidence of discovered cases.The inclusion of the State's preschool group inthe system of regular vaccination with BCG,begun in 1984 with infants under age 1, willmake it possible to estimate the extent towhich tuberculosis morbidity and mortalityrates are reduced as a result of vaccination,especially with reference to tuberculosismeningitis.

2.166 Chile prepared a brief and practicalrevised handbook of standards and adopted alow-cost scheme of short, highly effective su-pervised treatment for the entire country.Training courses for administrative staff of tu-berculosis programs were offered in Argen-tina, Brazil, Chile, Cuba, Mexico, and Vene-zuela. In the production of BCG, Braziladjusted its system to cover the requirementsfor shipment to other countries of the Region.The Pan American Zoonoses Center(CEPANZO) cooperated actively in BCGquality control and the distribution of tubercu-lin (PPD), and the training of personnel.Courses in bacteriology of tuberculosis wereheld in Jamaica and Mexico with the partici-pation of CEPANZO.

Leprosy

2.167 The resistance of Mycobacteriumleprae to dapsone is posing an increasingly se-rious problem to countries where this drug,used alone, has been the basis of chemother-apy for more than three decades. Multidrugtherapy is one way of averting bacterial resis-tance; unfortunately, the countries have onlylimited resources with which to purchase theessential drugs employed in the new thera-peutic regimens (rifampicine, clofazimine,protionomide-ethionamide). The new treat-ment schemes also require extensive utiliza-tion of the general health services and primaryhealth care in extending the coverage and en-suring that the drugs are actually used. Thisrequires a mobilization of technical and finan-cial resources for the training and supervisionof large numbers of personnel.

2.168 PAHO/WHO's collaboration withthe governments in their efforts to solve theseproblems consisted primarily of seeking outsources of funding for multidrug therapy. Thefollowing initiative was considered with this inmind: mobilization of extrabudgetary re-sources under bilateral or multilateral arrange-ments with volunteer agencies of the Interna-tional Federation of Associations AgainstLeprosy (ILEP) to finance drug purchases andother activities involved in the institution ofmultidrug therapy schemes. Colombia andEcuador entered into agreements with theGerman Leprosy Relief Association. Othercountries are negotiating with the same andother institutions and with PAHO/WHO onpossible program financing.

2.169 The Japanese Shipbuilding Indus-try Foundation (JSIF) financed technical co-operation components (evaluation, reorgani-zation, and staff training) of the leprosycontrol programs in the Region. In addition,its financial assistance made it possible to se-cure specific drugs for therapeutic experi-ments in Brazil and Mexico and to initiatemultidrug therapy in Ecuador. In the Carib-bean area, a 2-year extension was approvedin the agreement between the Leprosy Relief


Work of Emmaus, Switzerland, and the Gov-ernments of Anguilla, Antigua, Bahamas,Barbados, Dominica, Grenada, Montserrat,St. Christopher and Nevis, St. Vincent andthe Grenadines, and the Turks and Caicos Is-lands on financing the programs in each ofthose countries. In the Dominican Republic,the Damien Foundation of Belgium continuedto finance the leprosy control program. Braziland Venezuela opened their yearly courses onpublic health dermatology to students fromother countries of the Region, and in the Car-ibbean area workshops were conducted forstaff of the general health services.

Diseases Subject to InternationalHealth Regulations

2.170 Three diseases are subject to inter-national health regulations: cholera, plague,and yellow fever. No cases of cholera were re-ported in the Region of the Americas in 1984.Plague reports for the past 5 years are sum-marized in table 11. Two major plague fociwere identified in 1984 in Bolivia and Peruand, in collaboration with national authorities,

Table 11. Reported cases of plague and yellowfever in the Americas, 1980-1984

1980 1981 1982 1983 1984'

Plague 142 128 182 215 501Yellow fever 119 231 137 50 90

'Provisional data up to 24 May 1985.

PAHO/WHO provided training for improvingfield investigation, laboratory diagnosis, andflea and rodent control. National guidelinesfor plague were revlewed and recommenda-tions for revisions were made. With the excep-tion of an outbreak of jungle yellow fever inthe Amazon Region of Brazil, only sporadicreports of the disease were received during1984. Reported cases during the past 5 yearsare also summarized in table 11. Reintroduc-tion of yellow fever into urban areas remains apotential threat due to widespread relinfesta-tion by Aedes aegypti. Consequently,PAHO/WHO organized a major workshop inBrazil to review the pathophysiology of yellowfever infection and advances in modern ther-apy for this disease. PAHO/WHO has re-newed its efforts to secure funding to developa tissue culture-based 17D yellow fever vac-

Table 12. Cases of acquired immune deficiency syndrome (AIDS) in the Americasby country, 1980-1984

Country 1980 1981 1982 1983 1984' Total

Argentina - - 6 5 11

Brazil - - 5 43 134 182Canada 2 5 18 48 92 165Chile - - - - 3 3

Colombia - - 4 4

Grenada - - - - 2 2Guadaloupe - - 2 1 5 8Haiti - - - 232 108 340

Mexico - - - 8 4 12

Saint Lucia - - - - 1 1

Suriname - - - - 2 2Trinidad and Tobago - - 9 7 16

United States of America 46 255 980 2,644 4,462 8,387Uruguay - - - 2 1 3

Venezuela - - - - 9 9

Total 48 260 1,005 2,993 4.839 9.145

- None.° Provisional data up to 24 May 1985.

68 Annual Report

cine. Meanwhile in 1984, through mediationefforts by PAHO/WHO, the vaccine produc-tion laboratories in both Brazil and Colombiamodernized their production facilities withgrants from Canada's International Develop-ment Research Center.

2.171 PAHO/WHO requested its Mem-ber Countries to notify the occurrence of ac-quired immune deficiency syndrome (AIDS).Table 12 summarizes the available data.

Viral Diseases

2.172 Since viral disease epidemiologydepends more on laboratory than on clinicaldiagnoses, major efforts were made tostrengthen laboratory diagnostic capabilities.Viral hepatitis continues to be a major threatto public health despite the technologies avail-able for its control. As part of a WHO GlobalHepatitis Control Program, PAHO/WHOconvened a small working group to collectand analyze information on the extent of hep-atitis A, B and non-A-non-B in the Americas.With PAHO/WHO cooperation, Brazilstrengthened local production of hepatitis lab-oratory reagents.

2.173 Although there were no major out-breaks of dengue, sporadic isolations of types1, 2, and 4 were reported. In addition, possi-ble cases of dengue hemorrhagic fever (DHF)syndrome were investigated in Mexico. To as-sist countries at risk for DHF in preparing forlarge-scale epidemics, PAHO/WHO con-ducted a national training seminar on the rec-ognition and case management of DHF in Co-lombia. Efforts to strengthen diagnosticcapabilities of local and reference laboratoriescontinued.

2.174 With PAHO/WHO and U.S.Army cooperation, Brazil identified a virus be-longing to the Hantaan virus complex (caus-ative agent of hemorrhagic fever with renalsyndrome). The virus was from an urban ratand was the first isolation of this agent inSouth America. Argentina and Brazil begansetting up surveillance for the human disease.

In Colombia, a special workshop on arthro-pod-borne viral encephalitis was held, andsteps were taken to provide national laborato-ries with diagnostic reagents. A workshop onthe vectors of arbovirus encephalitis also wasorganized to úpdate national entomologists.

2.175 No major outbreaks of influenzaoccurred. However, the PAHO/WHO Na-tional Influenza Center in Chile isolated a newHlN1 influenza variant. This strain has beenincorporated into WHO's recommended in-fluenza vaccine. A set of monoclonal antibod-ies was evaluated as typing reagents for Her-pes simplex isolates from Argentina, Brazil,Chile, and Trinidad and Tobago. The meth-ods used and results obtained were in agree-ment with those of the reference center (Labo-ratory Center for Disease Control, Canada);therefore, monoclonal antibodies will bemade available to selected laboratories.

Sexually Transmitted Diseases

2.176 The control of sexually transmitteddiseases (STD) remains a relatively low prior-ity for most Member Countries. The lack of in-formation on the epidemiology of the majorSTD and their sequelae contributes to the lackof awareness of the public health importanceof these diseases and fosters traditional dis-ease control measures. To improve availableSTD information, PAHO/WHO and the Cen-ters for Disease Control (USA) entered into acooperative agreement to develop pilot pro-jects in one to six collaborating countries in1985. The project calls for improved surveil-lance for STD using a variety of epidemiologi-cal approaches. STD control program activi-ties were evaluated and recommendationswere made in Nicaragua, Panama and Surin-ame. PAHO/WHO maintained an updatedinventory of training courses in STD clinicalcase management and laboratory diagnosis.In the Caribbean area, CAREC implementeda series of training seminars, financed by agrant from USAID, designed to upgrade andstandardize clinical diagnosis and therapy of


STD, the first step in the development of STDcontrol efforts.

Prevention and Control ofNoncommunicable Diseases

2.177 The countries of the Region in-creasingly are recognizing noncommunicablediseases as a priority health problem. The in-crease in life expectancy has been very signifi-cant in countries which have achieved ade-quate coverages in maternal and child careand, consequently, a considerable reductionin infant mortality rates. This situation, to-gether with the transformation in lifestyles andother psychosocial factors, has stepped up thepace of important changes in the patterns ofmorbidity and mortality, especially with re-spect to the incidence of chronic degenerativediseases. Cardiovascular disease and malig-nant tumors figure among the five leadingcauses of death in all of the Latin Americanand Caribbean countries.

2.178 Based on past experience in thecontrol of noncommunicable diseases such asarterial hypertension, diabetes, rheumatic fe-ver, and cervical cancer, the countries-withassistance from PAHO/WHO-are adoptingan integrated approach to the promotion,ofhealth and to the control of risk factors anddiseases within the general health services,giving emphasis to primary health care. Thisapproach has been followed in the Project forthe Regional Monitoring of Integrated ChronicDisease Programs (MORE). Brazil, Cuba,and Venezuela have undertaken integratedchronic disease programs on a limited scalefor the purpose of acquiring experience thatwill make it possible to extend them in the fu-ture.

2.179 With the participation of Argen-tina, Chile, and Uruguay, a meeting onchronic diseases was held in Uruguay in April1984 to define subregional strategies involv-ing the use of the three countries' resources todeal with common problems related tochronic disease. The reports of this meeting

and of the Regional Meeting on Control ofCervical Cancer held in Mexico in January1984 were reviewed by PAHO's ExecutiveCommittee in June 1984 which decided thatthe Adult Health Program be a topic of discus-sion by PAHO's Directing Council in 1985.

2.180 Health promotion activities in-cluded a meeting of a group of experts onsmoking and health convened in Washington,D.C., to discuss future action by govern-ments, particularly strategies for the promo-tion of policies-a subject to be discussedmore broadly at a subregional meeting for theSouthern Cone in 1985. In addition, withPAHO/WHO assistance, national meetingswere held in Brazil and Panama on the controland status of arterial hypertension, in Mexicoon diabetes, and in Colombia on gynecologi-cal cancer. A cancer information seminar washeld in Brazil; a national course on cancer re-gistration in the Bahamas; and an interna-tional course on cancer epidemiology in CostaRica. Initial action was taken to promote thethree support elements of the MORE project(strategic planning, integrated programs, andhealth services) and to prepare the basic pro-tocols to be proposed to the countries in1985.

2.181 Cardiovascular diseases havepriority within the group of noncommunicablechronic diseases. Table 13 shows the mortalityrates for these diseases and the share of thetotal number of deaths they account for in se-lected countries.

2.182 Some Latin American and Carib-bean countries have rates comparable to thoseof the United States of America and Canada.Also, cerebrovascular diseases are highlyprevalent in a number of countries, includingTrinidad and Tobago and Uruguay, where ar-terial hypertension is a priority health prob-lem. For use in the ongoing promotion of hy-pertension control, PAHO/WHO madeavailable to all the countries a manual entitledHypertension as a Community Health Prob-lem. Priority has been given to the detectionand control of hypertension not only as a car-diovascular problem but also as a hazard to

70 Annual Report

Table 13. Mortality rates for heart and cerebrovascular diseases with per cent of all deathsa

Heart diseasesb Cerebrovascular diseasesc

Mortality rate Per cent of Mortality rate Per cent ofCountry or territory Year (per 100,000 population) all deaths (per 100,000 population) all deaths

Antigua and Barbuda 1978 86.5 15.9 97.3 17.9Argentina 1979 251.5 29.2 79.9 9.3Bahamas 1981 108.1 18.8 60.0 10.4Barbados 1982 156.2 24.4 96.7 15.1Belize 1982 87.1 21.2 29.2 7.1Bermuda 1978 194.8 31.2 79.3 12.7Brazil 1980 97.7 15.5 52.4 8.3Canada 1982 243.5 34.4 59.0 8.3Chile 1982 94.0 15.5 58.2 9.6Colombia 1977 94.8 16.3 34.4 5.9Costa Rica 1980 73.4 17.8 26.0 6.3Cuba 1978 169.2 29.8 53.6 9.5Dominica 1978 121.8 23.7 39.4 7.7Dominican Republic 1978 41.7 9.2 18.3 4.1Ecuador 1978 61.8 8.6 23.6 3.2El Salvador 1981 32.0 4.3 17.0 2.3French Guiana 1978 60.0 7.7 96.7 12.4Grenada 1978 163.6 23.5 63.6 9.2Guadeloupe 1978 129.1 20.3 50.3 7.9Guatemala 1980 33.2 3.4 10.6 1.1Guyana 1977 125.2 17.2 83.5 11.5Honduras 1979 43.3 8.3 3.1 0.6Jamaica 1971 131.6 17.3 115.8 15.2Martinique 1975 108.1 15.8 49.1 7.2Mexico 1976 77.5 10.6 21.3 2.9Montserrat 1979 172.7 17.3 181.8 18.2Nicaragua 1977 60.7 11.2 19.1 3.5Panama 1980 69.4 16.0 29.9 6.9Paraguay 1980 108.6 14.6 60.7 8.2Peru 1978 31.7 6.5 13.1 2.7Puerto Rico 1982 169.9 31.3 32.8 6.1St. Christopher and Nevis 1980 167.3 16.6 175.5 17.4Saint Lucia 1980 125.0 17.4 90.0 12.5St. Vincent and the Grenadines 1979 148.1 24.2 11.5 1.9Suriname 1980 90.9 12.6 45.6 6.3Trinidad and Tobago 1977 162.3 24.8 82.0 12.5United States of America 1980 338.4 38.6 74.9 8.6Uruguay 1978 237.5 24.3 119.8 12.2Venezuela 1978 82.5 14.9 32.2 5.8

aBased on official reports received in PASB.binternational Classification of Diseases (ICD) 390-429 (8th and 9th Revisions).cInternational Classification of Diseases (ICD) 430-438 (8th and 9th Revisions).


the health of adults and the elderly. Bolivia, ElSalvador, and Jamaica are planning to de-velop intensive prevention programs on thecardiopathology of rheumatic fever, the re-sults of which subsequently may be useful toother countries, under a project to be financedwith resources from AGFUND. Rheumatic fe-ver, still important in some countries, is beingmonitored under Country/PAHO/WHOprograms based on the use of the rheumaticfever manual of the Organization.

2.183 Diabetes mellitus has been recog-nized as a priority problem in Argentina,Chile, Colombia, Costa Rica, Cuba, Mexico,Panama, Uruguay, Venezuela, and the En-glish-speaking Caribbean countries, where lifeexpectancy is longer and diabetes prevalencerates are high.

2.184 Cancer. Health authorities arepaying increasing attention to cancer as an im-portant public health problem through suchactivities as: establishment or improvement ofcancer registries; cancer screening programs,particularly in cervical and gastric cancer; en-hancement of equipment and laboratory facil-ities for adequate diagnosis; reinforcement ofthe four major components of treatment (sur-gery, radiotherapy, chemotherapy, and hor-monotherapy); dissemination of technical in-formation; public health education; and thetraining of personnel involved in the pro-grams.

2.185 With respect to studies and re-search, as a result of a meeting on cancer epi-demiology which PAHO/WHO organized in1982, Bolivia and Mexico with PAHO/WHOsupport became involved in a study of gallbladder cancer, the third most common can-cer in women in Bolivia. With support fromthe U.S. National Cancer Institute (NCI), thisproject for a biochemical epidemiologicalstudy of biliary tract cancer began in March1984; the study is being carried out by the Au-tonomous University of Mexico and the Meth-odist Hospital in La Paz, Bolivia. In October1984, a workshop was organized with thepurpose of exploring a study on the etiology

of gastric cancer. Chile, Costa Rica, and Ven-ezuela-countries with very high incidencerates for gastric cancer-participated in themeeting, along with staff from the NCI andPAHO/WHO. Three specific studies wereidentified: a case control study focusing on di-etary factors associated with gastric cancer; afood composition analysis; and an ecologystudy of food, water, and vegetable analysis.

2.186 The Collaborative Cancer Treat-ment Research Program (CCTRP), begun in1977 with the purpose of designing and carry-ing out clinical therapeutic protocols, placedits major emphasis during 1984 on increasingthe quality of the data reported by the partici-pating institutions. An institutional reviewboard has been established in all of the institu-tions to review and approve all the protocolsfor human subject concerns. A total of 13 pa-pers were submitted to the American Associa-tion of Cancer Research and the AmericanSociety of Clinical Oncology, and articles on12 protocols were published during 1984.The annual meeting was held in May in San-tiago, Chile, and six disease-oriented commit-tees (gastric, cervix, head and neck, pediat-rics, hematology, and breast) were organizedwith the purpose of developing multinationalprotocols in these diseases.

2.187 Regarding technology, a survey ofthe dosimetry in the radiotherapy units ofmembers of the CCTRP continued in 1984. Areport of a site visit conducted to the radio-therapy departments of four institutions inCosta Rica, Mexico, Peru, and Venezuela hasbeen completed and circulated; the reportemphasizes that a trained physicist should reg-ularly supervise the cobalt source. Emphasishas been placed on the need for a list of anti-neoplastic drugs which are effective againstcurable cancers (e.g., acute lymphoblasticleukemia, Hodgkins germ cell tumor of thetestis, Wilms tumor, etc.), as well as for train-ing medical personnel working in canceron effective administration. Consequently,PAHO/WHO is preparing a plan for the ac-quisition and rational use of antineoplasticdrugs by the countries and has worked with

72 Annual Report

WHO in developing a document on essentialdrugs for cancer chemotherapy.

2.188 With reference to program devel-opment, it should be mentioned that PAHO/WHO has reformulated its cooperation policyregarding uterine cervix cancer by strengthen-ing national programs for early detection, di-agnosis, and treatment. This type of cancer isthe primary cause of death in the adult femalepopulation of the Region. A manual of normsand procedures for cervical cancer control wascompleted and distributed to the countriesearly in 1984. In a meeting held in MexicoCity in January 1984, participants from 18countries discussed all aspects of a cervicalcancer control program and new strategies tocoordinate the different components of a cen-tral program, with a focus on increasing earlydiagnosis and reducing mortality. Barbados,Brazil, and Colombia revised activities or pro-grams for cervical cancer control. PAHO/WHO prepared guiding principles for the for-mulation of national cancer programs indeveloping countries. These guidelines de-scribe the basic components of a cancer con-trol program: assessing the cancer "burden"of a country; evaluating the current status ofcancer control in a country; identifying poten-tial new activities; setting priorities; and evalu-ating and monitoring control programs andcancer trends.

2.189 The lack of sufficiently trained per-sonnel continues to be a main impediment foran effective cancer control program. For thisreason, the Organization collaborated with theGovernment of the Bahamas in a course onhospital-based cancer registries conducted atthe Princess Margaret Hospital in Nassau inApril. Costa Rica organized a course on theapplication of epidemiology to cancer, whichwas held in May with 23 participants fromcountries of the Region and 17 from CostaRica. The purpose of the course was tostrengthen the abilities of those already work-ing in cancer, as well as the countries' capabili-ties to carry out cancer epidemiology studies.Also in May, a workshop for clinicians and on-cologists on statistics for cancer epidemiology

and control was organized. This was a collab-orative effort involving the NCI, the Schoolsof Public Health of Harvard University (USA)and of Chile, and PAHO/WHO. The Organi-zation cooperated with the InternationalUnion Against Cancer (UICC) in advancedcourses in clinical oncology in Panama andBuenos Aires. Furthermore, oncology train-ing fellowships in the CCTRP supported 10fellows from Argentina, Brazil, Chile, CostaRica, Peru, Uruguay, and Venezuela during1984.

2.190 Blindness prevention. PAHO/WHO's cooperation with the governments fo-cused on the formulation and updating ofstandards to reflect the concept that eye carein general, and the prevention of blindness inparticular, should be integrated into generalhealth services and extended to the entirepopulation, including marginal groups.

2.191 The Government of Bolivia initi-ated a blindness prevention program as anoutcome of advisory services PAHO/WHOrendered in 1983. In Costa Rica, the Depart-ment of Public Health Ophthalmology contin-ued to train and evaluate personnel. Aroundtable on blindness was conducted at theNational Medical Congress with the coopera-tion of the Costa Rican Ophthalmology Asso-ciation, and in June 1984 the first nationalEye Disease Education Week was organized.In addition, a national foundation against pig-mentary retinosis, the leading cause of blind-ness in Costa Rica, was established. In Brazil,the Sáo Paulo Public Health OphthalmologyService, a WHO Collaborating Center for theprevention of blindness, completed a surveyon intraocular pressure (IOP). Of a total of10,319 people examined, 416 were found tohave an IOP of more than 24, and 122 of thisgroup (26.5%) were diagnosed as havingglaucoma. The survey was completed withthe examination of 293 people with IOP in therange of 20 to 23, 30 of whom (10.2%) werediagnosed as having glaucoma. The HealthDepartment of Sáo Paulo State approved aneye health program providing for the trainingof staff at four levels of complexity, the instal-


lation of 77 ambulatory referral centers, andthe recruitment of 118 ophthalmologists to ex-tend the coverage. The state of Paraíba wasorganizing a similar program. The Ministry ofPublic Health and Social Welfare of Guate-mala, through the National Committee for theBlind and the Deaf and Dumb, designed asurvey to determine the prevalence of dis-eases leading to blindness and conducted acourse on primary eye care for auxiliary staff.PAHO/WHO's Primary Eye Care Manual(PALTEX Series, No. 4) was tested success-fully in that course. Peru's Luciano BarrereCenter (a WHO Collaborating Center for thePrevention of Blindness) intensified its effortsto broaden the coverage of eye care at allthree levels of service. The manual on Funda-mentals of Ophthalmology for General Practi-tioners, prepared by PAHO/WHO, wastested at that center with satisfactory results.With the support of the Helen Keller Interna-tional Project, the eye care program in Peruwas continued in four areas, including a mar-ginal district of Lima. The WHO CollaboratingCenter and the Helen Keller InternationalProject were both evaluated during the year tolay the groundwork for future programming.

2.192 Activities in a number of English-speaking Caribbean countries during the yearwere related to the recommendations of thePAHO/WHO-sponsored seminar held' inBarbados late in 1983. In Barbados, the mainactivity centered around a program to im-prove the ophthalmological skills of a group ofgeneral practitioners in the fields of medicaland surgical technology, utilizing the QueenElizabeth Hospital in Bridgetown as a tertiarycenter. These courses are being conductedwith the cooperation of the National Eye Insti-tute in Bethesda, Maryland (USA-a WHOCollaborating Center for the prevention ofblindness), the Helen Keller International Or-ganization, the Royal Commonwealth Societyfor the Blind, the International Eye Founda-tion, and PAHO/WHO.

2.193 Venezuela organized an Interna-tional Workshop on Prevention of Blindnesssponsored by PAHO/WHO and gave neces-

sary support to the III Meeting of the PAHOAdvisory Committee on Prevention of Blind-ness.

Veterinary Public Health

2.194 In 1984, coordinated utilization ofPAHO/WHO's resources in this field, includ-ing the Pan American Foot-and-Mouth Dis-ease and Zoonoses Centers, made possible aneffective response to the governments' re-quirements in the areas of zoonoses, foodprotection, foot-and-mouth disease, andtraining of personnel. Some highlights ofPAHO/WHO's cooperation with govern-ments during the year are described below.

2.195 Zoonoses. Efforts were made toencourage implementation of the recommen-dations of the III Inter-American Meeting onAnimal Health at the Ministerial Level,RIMSA III, held in April 1983 in Washington,D.C., and the recommendations of the meet-ing of heads of national rabies control pro-grams, held in Ecuador in December 1983,for which a document entitled Strategy andPlan of Action for Eliminating Urban Rabies inLatin America by the End of the 1980's waspublished and distributed. This documentprovides guidelines for the governments andthe Organization in pooling efforts to eliminateurban rabies from the Hemisphere. With theactive involvement of the governments, a de-tailed program was formulated with eachcountry for PAHO/WHO cooperation in po-litico-administrative, planning, and program-ming activities; laboratory services; develop-ment of human resources; information andsurveillance; community participation; inter-sectoral collaboration and coordination; andintercountry cooperation. The status of rabiesin the Americas during 1984 may be summa-rized as follows. The rabies-free countries re-mained free of the disease. Argentina was atthe phase-of final consolidation of its program,as were the southern States of Brazil. Chile,Costa Rica, Cuba, and Panama were at theeradication stage of the disease. Colombia,Mexico, and Venezuela made significant ad-

74 Annual Report

vances in their respective programs. The re-maining countries, while making some pro-gress, did not achieve the anticipated levels.

2.196 A significant event was the inaugu-ration of the new facilities of the Pan Ameri-can Zoonoses Center (CEPANZO) in Novem-ber 1984. The Center's new headquartersbuilding is endowed with the latest technologi-cal advances and offers better facilities for theregional program of technical cooperation inveterinary public health, especially researchand reference activities related to the principalzoonoses and food microbiology and the de-tection of residues in meat and other food ofanimal origin. Also, the regional reference lab-oratory for leptospirosis was reestablished atCEPANZO, which should make it possible torespond to growing demands in this field.

2.197 Food protection. Pursuant to res-olution CD28.R39 of the XXVIII Meeting ofPAHO's Directing Council, pertaining to foodprotection, PAHO/WHO focused its activitieson the promotion of national policies in thisarea and the formulation and development ofprograms. Outstanding events were: the revi-sion and reformulation of laws and regulationsin Brazil, Colombia, Costa Rica, Ecuador, andPanama; the workshop on food standardiza-tion and health, conducted in Cuba in March1984 during the II Meeting of the Codex Ali-mentarius Coordinating Committee for LatinAmerica and the Caribbean, examining themajor aspects of the work entrusted to thiscommittee; the technical advances in thefields of chemical and biological food contami-nants, administrative organization of services,and food quality assurance; the holding of acourse in Medellín, Colombia, attended by 21professionals and technicians, on methodol-ogy for instruction on food protection; thepreparation of specific programs in Brazil (san-itary inspection of milk and its byproducts),Argentina (national food protection program),Colombia (epidemiological surveillance offood-related diseases), Costa Rica (nationalfood protection program), and Panama (sani-tary inspection of milk and its byproducts);and the strengthening of control laboratories

in Brazil, Colombia, Mexico, and Panama toimprove their efficiency and effectiveness,standardize procedures, train personnel, andestablish reference laboratories.

2.198 A Commission on Veterinary In-spection of Meat from the River Plate Basin(CINVECC) was created pursuant to resolu-tions of the XI and XII Meetings of ForeignMinisters of the River Plate Basin countries.The aims of this Commission, for whichCEPANZO serves as secretariat, are tostrengthen and improve the veterinary inspec-tion of meat, promote trade in meat productsand byproducts, and provide assurances of asupply of wholesome food. The Commis-sion's budget is funded by the River Plate Ba-sin countries.

2.199 Foot-and-mouth disease. Withthe cooperation of PAHO/WHO, Argentina,Bolivia, Brazil, Colombia, Ecuador, and Ven-ezuela formulated national foot-and-mouthdisease control and eradication plans for sub-mittal to international financial agencies.Handbooks for use in simulated outbreaks offoot-and-mouth disease and other exotic dis-eases were prepared under a joint project ofFAO and PAHO/WHO. With the aim ofavoiding duplication of efforts and assuringoptimal use of available resources, two meet-ings were held to coordinate technical cooper-ation in the field of animal health with the fol-lowing international organizations: Inter-American Institute for Cooperation on Agri-culture (IICA), International Office of Epizoot-ics (IOE), Board of the Cartagena Agreement(JUNAC), and International Regional Organi-zation for Health in Agriculture and Livestock(OIRSA).2.200 Nonhuman primates. The Orga-nization continued to collaborate with theGovernments of Brazil, Colombia, and Peruin the establishment of stations for the repro-duction of nonhuman primates for use inbiomedical research, and in the promotionand development of programs to determinethe distribution, density, population dy-namics, biology, and state of preservation ofwild populations of these primates. At the Pri-


mate Reproduction and Preservation Stationin Iquitos, Peru, research was done on the re-production of these animals in semicaptivity.Similar research was done on two AmazonRiver islands with the community's coopera-tion. During 1984, more than 700 nonhumanprimates were dispatched from the station tovarious research institutions in the People'sRepublic of China, France, Japan, the SovietUnion, the United States of America, andWest Germany. This project has enjoyed fi-nancial support from the National Institutes ofHealth (NIH, USA). In 1984, PAHO/WHOentered into a new agreement with NIH andUSAID to continue the program during theperiod 1985-1987 at a budgeted cost ofUS$1.2 million.

2.201 Training of human resources.The Regional Program for Training in AnimalHealth in Latin America (PROASA), under-taken in 1982 with financial support from IDBfor the purpose of providing institutionalizedtraining in basic aspects of foot-and-mouthdisease, offered three courses on epidemio-logical surveillance in Argentina, Brazil, andEcuador; three courses on social communica-tion in Brazil, Chile, and Colombia; a regionalseminar on evaluation of programs for the sys-tematic administration of oil-adjuvant foot-and-mouth disease vaccines in Brazil; and acourse on administration of animal health pro-grams in Uruguay. A total of 208 profession-als from Argentina, Bolivia, Brazil, Chile, Co-lombia, Dominican Republic, Ecuador, ElSalvador, Guatemala, Guyana, Mexico, Nic-aragua, Paraguay, Peru, Uruguay, and Vene-zuela participated in the seven courses and theseminar, raising to 592 the total number oftechnicians trained under the program sinceits inception.

2.202 One of this project's most signifi-cant activities was the preparation of autotuto-rial material for use in these courses and to fa-cilitate learning. This material has been helpfulin increasing the multiplier effect of the pro-ject. The IDB has expressed satisfaction withthe way in which the scheduled activities havebeen carried out. In view of the benefits ob-

tained, the governments are planning to orga-nize national courses using the content andteaching material prepared in the project.

2.203 The number of graduates of theRegional Program for the Training of AnimalHealth and Veterinary Public Health Assis-tants (REPAHA) increased in 1984 to 239, in-cluding its eighth graduating class, who com-pleted their studies during the year. Studentsin the program have come from 17 English-speaking countries and territories. REPAHAwas initiated with funds from UNDP and theGovernment of Guyana, with PAHO/WHOacting as executing agency. An evaluation ofthe impact and future of this project in 1984identified future needs for training and contin-uing education in the relevant fields, as well asREPAHA's relationship with the School ofVeterinary Medicine of Trinidad and Tobago.In view of the termination of UNDP funding in1984, the Member Countries established afund of their own for continuing the programand converted REPAHA into an autonomousinstitution within CARICOM. It is worthy ofnote that more than 82% of REPAHA's grad-uates currently are working in their homecountries in fields related to their training.

2.204 Environmental quality. Effortsare being made to analyze problems arisingfrom the use of pesticides and disseminatetechnical information in this regard in LatinAmerica. Spanish translations of two publica-tions designed to further these objectives-WHO's scientific data sheets on pesticides andthe University of Miami's (USA) report on anagronomic approach to pesticide manage-ment-were completed during the year andwere scheduled to be distributed in the firsthalf of 1985 under the titles of Pesticide DataSheets and Agromedical Approach to Pesti-cide Management, respectively. This project,initiated in 1983, received financial supportfrom USAID.

2.205 Primary health care. A jointPAHO/WHO Expert Group meeting held inApril 1983, in Washington, D.C., examinedthe role of veterinary medicine in primaryhealth care. Based on this analysis, the I An-

76 Annual Report

dean Meeting of Veterinary Public Health Ex-perts was held in Santa Cruz, Bolivia, in Sep-tember 1984 with the cooperation of theHipólito Unanue Agreement. The meetingprepared a proposed Andean subregional vet-erinary public health program to be submittedto the governing bodies of the Hipólito Un-anue Agreement, which will consider its inclu-sion as part of the joint action plan being im-plemented in cooperation with PAHO/WHO.

Pan American Zoonoses Center(CEPANZO)

2.206 In 1984, CEPANZO inauguratedits new headquarters building and the state-of-the-art facilities made available through the ef-forts of the Government of Argentina and theother countries of the Americas. While everyprecaution was taken to avoid a slowdown ofthe Center's activities as a result of the move,the pace of the work inevitably declined.

2.207 Research. The Center conductedresearch projects of immediate benefit to theMember Countries. It completed a series ofimmunobiological, serological, and protectivestudies to determine the immunobiologicalvalue of the strains of rabies virus used in theproduction of unweaned-mouse-brain vac-cine for the treatment of human cases. Thestudy indicated that it was not advisable toeliminate any of the strains at the presenttime. Studies to detect the presence of rabiesin various species of Argentine wild animalsalso continued.

2.208 A project to assess the degree ofprotection provided by BCG vaccine adminis-tered shortly after birth was initiated in cooper-ation with the public health authorities of Ar-gentina. A cooperative study being conductedwith the National Institute of Microbiology ofArgentina seeks to determine the public healthimportance of the mycobacterioses and of bo-vine tuberculosis in humans. The health ser-vices of Argentina, Brazil, and Mexico re-ceived advisory services from CEPANZO infield tests of the administration of BCG to in-

fants and schoolchildren. Studies were madeto determine the stability of veterinary rabiesvaccines under different environmental condi-tions; to evaluate the arc-5 electrosyneresistest in cellulose acetate for the diagnosis of hu-man hydatidosis, which makes it possible toobtain presurgical confirmation in only a fewhours; and to test systems for the improve-ment of brucellosis vaccine in veterinary use.Studies also were undertaken on the applica-tion of the contraimmunoelectrophoresis andELISA techniques with a soluble antigen tostandardize the serodiagnosis of leptospirosisin humans. In Argentina, further progress wasmade in the study of wild animals suspected ofbeing carriers of microorganisms which arecausative agents of human diseases, espe-cially tuberculosis, brucellosis, and leptospiro-sis, as well as of gastroenteric infections.

2.209 CEPANZO, in collaboration withthe Centers for Disease Control (CDC) of theUnited States of America, designed a study onthe application of the "control of criticalpoints" approach in the household prepara-tion of infant formulas in rural and semiruralareas, the first stage of which was scheduledto begin in Peru in January 1985. Studiescontinued to be carried out on the influence ofpsychotropic flora on the quality of dairyproducts. In Peru, a joint CEPANZO/CEPISresearch project was designed to examineproblems stemming from the use of waste-water for irrigation and its effects on the micro-biological quality of food.

2.210 Development of technology. Incooperation with laboratories in Argentina,Canada, Chile, Costa Rica, and Ecuador,CEPANZO undertook a study to test a sim-pler, quicker, and more effective procedurefor detecting resistance to pyrazinamide. Inaddition, working with laboratories in Argen-tina and Venezuela, the Center evaluated thecontraimmunoelectrophoresis procedure todetermine the presence of antibodies thatneutralize rabies virus in the blood of peoplewho have been immunized. The findingsshowed that this procedure can be routinelyused in rabies diagnosis laboratories.


2.211 The advantages and shortcomingsof immunological methods for the diagnosis ofhydatidosis were determined, and standardswere established for using them in the identifi-cation and characterization of this disease. Incollaboration with the Veterinary Diagnosisand Research Center in Formosa, Argentina,the Center studied the immunodiagnosis ofhydatidosis in naturally infected sheep andcattle.

2.212 Dissemination of information.The Center completed a review of its informa-tion system to strengthen and broaden thecoverage of the countries' data on zoonoses.The system of information on Colombia'sfood protection programs was reviewed andadjusted, and an assessment of this situationin Argentina was completed. CEPANZO con-tinued to publish its bulletin on epidemiologi-cal surveillance of rabies in the Americas. Thefirst part of the PAHO/WHO tuberculosis bac-teriology standards, aimed at achieving uni-form application of the most appropriate tech-niques, was published in 1984.

2.213 Training. Stronger emphasis wasplaced on training in the countries and inser-vice training at the Center in order tostrengthen national programs and institutionsand better meet their requirements for trainedpersonnel to perform highly specific functions,particularly in the laboratory. Training wasprovided to 106 professionals, including 37from nine countries who received inservicetraining at the Center, 11 who attendedcourses at Headquarters, and 58 who partici-pated in courses away from Headquarters (ta-bles 14 and 15).

2.214 The Center collaborated in the pre-sentation of a national course in Brazil on tu-berculosis bacteriology and subregionalcourses on the same subject in Jamaica andMexico, with the joint participation of publichealth and animal health laboratory workersfrom eight countries. The courses stressed reli-able diagnostic methods, standardization ofdiagnosis, and the role of the laboratory incontrol programs. In Argentina, the Centercooperated in a course on bovine tuberculosis

epidemiology and diagnosis and controlmethods.

2.215 Technical cooperation. A total of19 countries in the American Region and onein Southeast Asia conducted programs withthe cooperation of CEPANZO in rabies, bru-cellosis, bovine tuberculosis, leptospirosis, hy-datidosis, and trichinosis, as well as in foodprotection. Argentina received assistance inbringing the rabies program up to projectedstrengths. The Paraguayan authorities wereassisted in preparing a project for prospectiveIDB financing and in the continued analysis ofmethods for strengthening the rabies surveil-lance and information system. Similar supportwas extended to Peru. In addition, the Centercooperated with 10 institutions in five coun-tries of the American Region and one inSoutheast Asia (India) in rabies diagnosis,vaccine quality control, and rabies controlprograms.

2.216 Argentina and Brazil prepared co-operative programs in bovine tuberculosis.Paraguay was reviewing an extension of itsprogram to cover the entire country. TheCenter continued to act as regional referencelaboratory to control the quality of PPD tuber-culins for both human and animal use and ofBCG vaccines. Information and cooperationwere provided to central laboratories and hu-man and bovine tuberculosis programs of 18countries of the Region and India.

2.217 Argentina prepared and began toimplement a project for the control of brucel-losis in goats in the provinces most severely af-fected by Brucella melitensis. Brazil devel-oped a proposal to systematize efforts againstbrucellosis and evaluated strategies for possi-ble application in Rio Grande do Sul. A sero-logical survey of brucellosis in Camelidae wascompleted for the agriculture and livestockservice of Chile. In Colombia, where thehealth and agricultural services are addressingthe problem comprehensively, the Centerparticipated in an assessment of the bovinebrucellosis situation. CEPANZO supplied offi-cial laboratories of the countries of the Region

78 Annual Report

Table 14. Training of human resources, by country and type of training,in CEPANZO, 1984

Courses Courses InserviceCountry at CEPANZO in countries training Total

Argentina 10 11 19 40Barbados - 2 - 2Brazil - - 4 4Chile - 1 - 1

Colombia - 1 4 5

Cuba - 1 2 3Dominican Republic - 1 - 1Guatemala - 1 - 1Guyana - 2 - 2Jamaica - 6 - 6

Mexico - 25 - 25Nicaragua - 3 3

Paraguay - 3 - 3Peru - 1 1Suriname - 1 - 1

Trinidad and Tobago - 2 - 2

Uruguay - 1 - 1

Venezuela 1 - 2 3

Subtotal 11 58 35 104

Other WHO RegionsIndia - - 1 1People's Republic of China - 1 1

Total 11 58 37 106

-None.

Table 15. Training of human resources, by program area and type of training,in CEPANZO, 1984

Courses Courses InserviceProgram area at CEPANZO in countries training Total

Laboratory animals - - 3 3Brucellosis - - 5 5

Hydatidosis - - 5 5

Immunodiagnosis of human hydatidosis - - 1 1Immunodiagnosis of trichinosis - - 3 3Food protection 11 15 9 35Leptospirosis - - 1 1Rabies - 6 6

Tuberculosis - 43 4 47

Total 11 58 37 106

-None.


with standards for the diagnosis of animal bru-cellosis. In addition, in its capacity as an inter-national reference center, CEPANZO per-formed vaccine quality control tests andclassified strains from seven countries.

2.218 Following reestablishment of theCenter's leptospirosis program, assistance inlaboratory diagnosis was furnished to Braziland reference services were resumed. In re-gard to problems of parasitic zoonoses, theCenter collaborated with the health authoritiesof Argentina in the development of a nationaltechnical standard for the control of hydatido-sis, the conducting of control programs, thestrengthening of national institutions produc-ing and testing reagents for immunodiagnosisof the disease, the consolidation and exten-sion of laboratory networks, and the conduct-ing of immunodiagnostic studies of cases re-lated to outbreaks of trichinosis in humans.

2.219 In food protection, the Center fur-nished technical cooperation to Argentina incarrying out a situational assessment and inpreparing the basic document for the nationalfood program. It also cooperated with Argen-tina, Brazil, Colombia, Mexico, and Peru invarious matters pertaining to the improve-ment of food control laboratories and with theCuban authorities in connection with the ac-tivities of the Codex Alimentarius Coordinat-ing Committee for Latin America and theCaribbean.

2.220 The Center continued to encour-age intercountry contacts and the work of in-tersectoral committees. A notable examplewas the meeting of Argentina, Brazil, and Par-aguay, at which the three countries reachedan agreement on conducting significant jointand cooperative activities for the control ofbrucellosis and tuberculosis. In Brazil,CEPANZO cooperated with the new healthand agriculture authorities in reviewing vari-ous aspects of intersectoral coordination andaction in the field of health. Finally, in its ca-pacity as secretariat of CINVECC, CEPANZOplayed an active role in the organization andconducting of the Commission's first meeting,held in December 1984.

Pan American Foot-and-MouthDisease Center (PANAFTOSA)

2.221 The fundamental objectives ofPANAFTOSA are to promote action and pro-vide technical cooperation for the eradicationof foot-and-mouth disease in the countries ofthe Hemisphere.

2.222 Research, Work continued on theantigenic and immunological characterizationof field viruses of foot-and-mouth disease andvesicular stomatitis and of viruses used in theproduction of foot-and-mouth vaccine. Dur-ing 1984, the Center analyzed 234 field and36 laboratory samples from eight affectedcountries and 21 samples from two countriesfree of this disease. Panama and the CentralAmerican countries (except Guatemala) usethe Vesicular Disease Diagnostic Laboratory(LADIVES) of Panama for this purpose. Thevirus was characterized with the collaborationof the Animal Virology Center (CEVAN) inArgentina. In addition, the earlier studies onoptimal conditions for inactivation by binaryethylenimine made it possible to transfer thismethodology to official and private laborato-ries in several countries, including Argentina,Colombia, Ecuador, and Peru. Methods andresults of research on evaluation of the integ-rity of the polypeptide components of vaccineantigens were applied routinely. Research onoil-adjuvant vaccine centered around the se-lection of optimal methods of production andconcentration of antigens, inactivation, andemulsification, depending upon the inputsavailable in the various countries. Its use in thefield included the successful vaccination of 1.3million head of cattle in nine affected countriesof the Region. Standardization of reagents forvaccine quality control was performed in Ar-gentina, Brazil, Colombia, and Paraguay, aswell as in Uruguay and other countries thatfollow a practice of controlling the quality of allbatches of foot-and-mouth disease vaccine,including those produced in Ecuador. Studiesand methods for the epidemiological charac-terization of foot-and-mouth disease, the find-

80 Annual Report

ings of which will serve as a basis for decisionmaking for the control of this disease, alsowere continued.

2.223 Technology. Methodology for de-termining the risks of the introduction of foot-and-mouth disease from abroad and recogniz-ing its predominant characteristics in zones ofpossible entry was tested successfully alongChile's border with Argentina. Similar actionwas being taken in Cuba and Mexico. Anoverall characterization was developed for usein diagnostic assessments and the formulationof programs in Argentina, Brazil, Colombia,Ecuador, Peru, and Uruguay. A manual forpreserving and expanding the areas free offoot-and-mouth disease was prepared duringthe year; it is now being used in Colombia andis scheduled for application in Argentina, Bra-zil, and Uruguay in the near future. Finally,technology related to the production and useof oil-adjuvant foot-and-mouth vaccine wasconveyed to all the governments throughtraining and technical advisory services.

2.224 Dissemination of information. Allof the South American countries continued toprepare weekly reports by quadrants andmonthly reports specifying the number ofherds affected and the type of virus. The Cen-tral American countries joined the hemi-spheric system in 1983 on the basis of a proj-ect implemented by PAHO/WHO with finan-cial assistance from the United Nations in sur-veillance against vesicular stomatitis. TheCenter's role in the Hemisphere-wide systemis to condense, analyze, and publish weeklyand monthly bulletins for distribution to all thecountries and interested organizations. TheCenter continued to publish the Scientific Bul-letin, monographs, and technical manuals.

2.225 Training. The following activitieswere notable: an international seminar toevaluate the 14 courses on utilization and pro-duction of oil-adjuvant foot-and-mouth dis-ease vaccine that were conducted during1982 and 1983, within the framework of thePROASA project, in all of the South Ameri-can countries affected by foot-and-mouth dis-

ease; a course on vaccine reference, diagno-sis, and quality control for appropriate officialsof Argentina, Bolivia, Ecuador, and Peru; acourse on cellular cultures used in virology,with seven participants from Argentina, Bra-zil, Colombia, and Venezuela; inservice labo-ratory training for 44 participants from LatinAmerican countries; a seminar on the preven-tion of foot-and-mouth disease, offered inAntigua for 16 veterinarians from the English-speaking Caribbean; the preparation of audio-visual materials on prevention of foot-and-mouth disease for the English-speakingCaribbean countries; a roundtable, cospon-sored with FAO, on the development of stan-dards for the organization of simulation exer-cises pertaining to the prevention anderadication of exotic diseases; the preparationof audiovisual aids on production and use ofoil-adjuvant foot-and-mouth disease vaccine;and cooperation with FAO in the holding ofthe Regional Seminar on Epizootiology andAnimal Health Economics in Lima, Peru.

2.226 Technical cooperation. Argentinaformulated an animal health plan for 1985-1994, the goal of which is to eradicate foot-and-mouth disease throughout the countryand establish a quarantine security station.Brazil revised its national foot-and-mouth dis-ease control and eradication plan andstrengthened the Federal network of animalhealth diagnosis and biological control labora-tories. A technical report in this regard wasprepared for the International Bank for Re-construction and Development (IBRD). InBolivia, stage II of the National Foot-and-Mouth Disease, Rabies, and Brucellosis Con-trol Service (SENARB) project was reformu-lated for submittal to an international financialagency. The project is currently awaiting gov-ernmental approval. In Chile, a program toprevent the introduction of foot-and-mouthdisease and other exotic diseases was estab-lished. In addition, Chile received assistancein eradicating an outbreak along the borderarea with Argentina. In Colombia, the II Na-tional Foot-and-Mouth Disease Control Plan.which includes goals for eradication in en-


demic areas, was prepared; the Plan will besubmitted to external financing agencies forconsideration. In Ecuador, the new authori-ties prepared and adopted stage II (1985-1990) of the National Foot-and-Mouth Dis-ease, Rabies and Brucellosis Plan. Eradicationinitiatives in Peru focused on strengtheningthe preventive programs along the border andsolving vaccine production problems.

2.227 In Paraguay, the foot-and-mouthdisease control program was revised and pri-ority areas for the use of oil-adjuvant vaccinewere defined. Uruguay prepared an eradica-tion plan to be implemented in the River PlateBasin concurrently with operations in the Bra-zilian State of Rio Grande do Sul and the Ar-gentine Mesopotamia. With a view to redirect-ing its control program, Venezuela decided tobegin producing inactivated foot-and-mouthdisease vaccine instead of live attenuated virusvaccine. PANAFTOSA continued to furnishtechnical support for the production of oil-ad-juvant foot-and-mouth disease vaccine in Ar-gentina, Brazil, Colombia, Ecuador, Para-guay, Peru, and Venezuela. Varying degreesof progress have been made in these coun-tries, with Brazil and Colombia reaching thestage of commercial production.

2.228 During 1984, all of the SouthAmerican countries held meetings of jointcommittees established under the provisionsof border animal health agreements. The Ar-gentina-Chile, Ecuador-Peru, and Colom-bia-Venezuela agreements were reactivatedduring the year. The Center continued to actex officio as Secretariat of the South AmericanFoot-and-Mouth Disease Control Commis-sion (COSALFA), which organizes annualmeetings of directors of animal health to re-view and evaluate the countries' foot-and-mouth disease control activities. In 1984, anassessment was made of the countries' com-pliance with the commitments undertaken inthe document entitled Policy and Strategiesfor the Control of Foot-and-Mouth Disease inSouth America During the Decade 1981-1990, approved by the IX meeting ofCOSALFA in 1982.

Special Programs

2.229 Outstanding emergent healthproblems which demand joint and specificactions have been recognized by the PAHO/WHO Governing Bodies. Special programswere designed and now are in full implemen-tation on regional and subregional bases.

Priority Health Needs in CentralAmerica and Panama

2.230 The Plan for Priority Health Needsin Central America and Panama represents ajoint undertaking by all the governments ofthe Central American Isthmus. Its goals are tointensify the mobilization of resources for satis-fying basic needs and to contribute to the well-being of the most vulnerable populationgroups, especially children, the poor in urbanand rural areas, and displaced persons.

2.231 In the past 5 years, several coun-tries of the Central American Isthmus have ex-perienced an unfortunate combination of po-litical and social conflict within the criticaleconomic conditions prevalent throughoutthe Region as a whole. The world recessionhas affected adversely the domestic econo-mies of all of the countries. Per capita incomehas declined, and unemployment rates andpoverty have increased. Upwards of 50,000people have died and over half a million havebeen displaced as a result of internal conflictsand violence. These circumstances are con-spiring against the people's access to healthservices, thereby exacerbating health prob-lems among the groups at greatest risk.

2.232 To deal with this critical situation,the ministers of health of the countries of thesubregion, in consultation with PAHO/WHO,decided to pool their resources and undertakejoint efforts to identify common problems andpropose solutions of collective interest, alongwith designing internal strategies and actionstailored to the requirements of each country.These efforts led to the development of thePlan, which in March 1984 the Ministries of

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Health of the countries of the Central Ameri-can Isthmus unanimously supported at a spe-cial meeting held in Costa Rica and later wassupported by the "Contadora Group." InApril of the same year, the Ministers of For-eign Affairs, gathered in Panama, gave thePlan their unqualified support and stated thatone of its aims was to use the value system ofhealth to build a "bridge" contributing to theestablishment of peace. The Plan receivedsimilar support in May from the World HealthAssembly, which recommended that the in-ternational community cooperate in this initia-tive. PAHO's Directing Council, in resolutionCD30.R17 at its XXX Meeting, unanimouslyreiterated its support, decided to include Be-lize in the Plan, and recommended that PASBcollaborate in the formulation of projects andcoordinate the international efforts to obtainexternal financing.

2.233 The Plan includes seven priority ar-eas: strengthening of health services throughhigher productivity and better use of availableresources, development of health personnel,increased availability of essential drugs andcritical inputs, improvement of the food andnutrition situation, control of malaria andother tropical diseases, prompt action for in-fant survival, and improvements to water andsanitation systems. The Plan identifies 40 sub-regional and 250 national projects. The pre-liminary estimate of external financial re-sources needed is US$1.4 billion over a5-year period. The identification of priorityareas and the formulation of project profileswere characterized by three highly significantfeatures: active participation by more than200 national personnel from the Ministries ofHealth, universities, and National EconomicPlanning Units of the countries involved, as aresult of the establishment and operation ofmultidisciplinary teams; close coordination ofthe work of international cooperation institu-tions, particularly PAHO/WHO, UNICEF,UNFPA, IDB, and other agencies; and, fi-nally, joint action by the governments,PAHO/WHO, and UNICEF in bringing initia-tives and resource requirements to the atten-

tion of governments and donor agencies inthe Americas and Europe.

2.234 The strategy adopted for resourcemobilization was to channel the search con-currently toward potential domestic resourcesin each country of the subregion and potentialfunding from outside sources. Vital impor-tance was attached to assuring optimal use ofthe resources assigned to the health sector byallocating them in accordance with a predeter-mined order of priorities, increasing produc-tivity levels in the sector, and providing for ap-propriate linkage among sectoral compo-nents. With respect to external resources,every effort was being made to obtain them inthe form of grants or on concessionary terms.By the end of the year the negotiations wereshowing promising results. A case in point wasthe agreement to finance the immunizationprogram in El Salvador. This national pro-gram was designed to cover most of the coun-try's regions, the expectation being that inter-nal hostilities would temporarily cease duringa vaccination drive. At year's end, USAID wasgiving favorable consideration to an infant sur-vival project with a strong oral rehydrationand nutrition component (estimated to costUS$8 million over 4 years), a subregional ma-laria project (US$3.5 million), and an essen-tial drug project (US$3 million). The IDB wasconsidering several projects relating to healthservices, water supply systems, and diseasecontrol.

2.235 This initiative offers promisingprospects. The international community,however, is faced with the serious dilemma ofdeciding either to support and strengthen po-litical understanding by providing constructivesolutions to the socioeconomic problems ofthe subregion or to accept passively the con-tinued deterioration of living conditions andthe intensification of conflicts that may degen-erate into a regional confrontation. The con-cept of health as a social objective is widely ac-cepted by all nations and therefore it can andshould be used to build a bridge of under-standing, cooperation, solidarity, justice, andpeace.


Emergency Preparedness andDisaster Relief Coordination

2.236 In 1984, PAHO/WHO pursued itsobjective of preparing the health sector ofMember Countries to face natural and man-made disasters through the following majoractivities:

2.237 Development of training/educa-tional material. Demand for the generictraining package developed in previous yearsincreased with the rise in the number of na-tional courses and workshops on disaster pre-paredness and relief. In the area of visual aids,sets of slides on vector control and bacterio-logical analysis of water supplies after.naturaldisasters were prepared. In order to serve in-creasing interest in case studies, PAHO/WHO also produced a slide show on theearthquake in Popayán, Colombia, in collab-oration with the Ministry of Health and theUniversity of Valle. Planning meetings wereheld to outline the contents of a new slide se-ries on vulnerability analysis and planning forwater supply and sewerage systems and hos-pital disaster preparedness which will be pro-duced for field testing in 1985. A demandemerged for new simulation exercises. Onewas developed on water supply and sewagesystems for hurricane situations in the Carib-bean and another on intrahospital emergencyand mass casualty management in LatinAmerica.

2.238 Modules for self-instruction inemergency health management were devel-oped as a result of the meeting of the schoolsof public health of Latin America and the Car-ibbean, held in Washington, D.C., at the endof 1983. These modules were field tested dur-ing 1984 and will be available to the schools ofpublic health and to national course organiz-ers. Regarding the role of public opinion in di-saster situations, during 1984, PAHO/WHOreached an agreement with the British Broad-casting Corporation to coproduce a film onemergency health management after acute-onset natural disasters. It is hoped that the filmwill be helpful in educating the public, therebymaking relief efforts more efficient.

2.239 Training in environmentalhealth. In collaboration with CEPIS, compre-hensive modules in Spanish on environmen-tal health management following floods weredeveloped and tested in an internationalworkshop in Ecuador. Adaptation into En-glish and simplification of all existing trainingmodules for use in the small Caribbean islandsis in progress. Emphasis placed in 1984 onwater supply will shift progressively to generalsanitation in 1985.

2.240 Hospital disaster preparedness.The explosion of gas holding tanks in MexicoCity illustrated the magnitude of the problemthe health services may face under emergencyconditions. In 1984, nine workshops on masscasualty management were held in the Re-gion, and seven hospitals were selected totake part in a pilot project to develop pro-cedures and train hospital personnel in pre-disaster planning. Among the problemsencountered is the relative scarcity ofSpanish-speaking experts in formulation of di-saster plans, as well as of drills in the absenceof organized emergency medical services, ra-dio networks, and centralized ambulance sys-tems. In the Caribbean, a feasibility study wasinitiated for a mechanism to address mass ca-sualties for the whole area rather than for eachindividual country; a hospital survey in theEnglish-speaking countries has been alreadycarried out to verify the potential response incase of disaster. The results of this feasibilitystudy will be used in formal consultation withparticipating countries and funding agencies.

2.241 Assessment of health needs.Lack of timely and reliable information re-mains the major challenge in managing the re-sponse to natural disasters. Reasonable prog-ress was achieved in 1984. In coordinationwith UNDRO and ECLAC, 25 regional expertsfrom various sectors met in Mexico in May1984 and developed an extensive list of indi-cators to estimate emerging needs in agricul-ture, feeding, health care, sanitation, trans-portation, and communication. PAHO/WHO staff members stationed throughout theCaribbean are on standby for the hurri-cane season to assist the countries in assess-

84 Annual Report

ing needsdisaster.

and coordinating relief in case of

2.242 Technological disasters. At itsXXVII Meeting (resolution CD27.R40), thePAHO Directing Council requested PAHO/WHO's emergency preparedness program tocooperate with countries also in facing techno-logical disasters such as chemical accidents,explosions, fires, and air crashes. The dra-matic fuel explosion in Mexico and the aircrashes in Quito, Ecuador, and La Paz, Bo-livia, have illustrated the urgent need for deci-sive action in the Region. In 1984, PAHO/WHO initiated a regional analysis of vulnera-bility and promoted a series of regional andnational technical workshops on chemicalaccidents.

2.243 Technical cooperation to na-tional programs. The governments havededicated substantial resources to establishingand strengthening national disaster prepared-ness programs in the health sector. In CentralAmerica, disaster preparedness units or of-fices are now operating in Costa Rica, Guate-mala, and Honduras. Support was providedfor 10 national or subregional meetings inCosta Rica, El Salvador, Guatemala, Hondu-ras, and Mexico; in line with the philosophy ofTechnical Cooperation Among DevelopingCountries (TCDC), PAHO/WHO reliedheavily on exchange of experience and collab-oration among countries. A topic of specialrelevance to this subregion is health care fordisplaced persons. In conjunction with theUnited Nations High Commissioner for Refu-gees (UNHCR), the Red Cross, and UNICEF,PAHO/WHO held a high-level meeting ofhealth officials in February 1984 in Mérida,Mexico, to discuss the health aspects of thisproblem. It was concluded that the ministriesof health should play a more direct role in en-suring that these vulnerable groups receiveprimary health care of the same quality andlevel as that of the surrounding populations.

2.244 In South America, most of thetechnical cooperation was directed to the An-dean countries most vulnerable to majorearthquakes-in particular, Colombia, Ecua-

dor, and Peru, which have established disas-ter preparedness programs in the health sector(ministries of health and social security agen-cies). Of particular interest is the successful fol-low-up of the 1983 meeting of public healthschool officials aiming to include disaster pre-paredness in the teaching curriculum; by andlarge, this objective is being met.

2.245 In the Caribbean, PAHO/WHOactivities are integrated into the multiagencyPan Caribbean Disaster Preparedness andPrevention Project with headquarters in Anti-gua, West Indies. This multisectoral approachof UN agencies-UNDRO, PAHO/WHO,and secondarily the World Meteorological Or-ganization (WMO), International Telecommu-nications Union (ITU), and others-is fundedby a pool of donor agencies (USAID, CIDA,EEC, and recently, through PAHO/WHO,the Government of the Netherlands). Activi-ties in 1984 took place in most countries of thesubregion, although at a pace significantlyslower than in 1983. Particularly significantwere a series of environmental health trainingcourses, vulnerability analyses of some hospi-tal facilities to hurricanes, participation of thehealth sector in a meeting of all Caribbean na-tional disaster coordinators, and the establish-ment of a radio emergency network.

2.246 Regional support in disaster reliefwas channeled to Ecuador (malaria controlfollowing 1983 floods); Colombia (technicalcooperation and supplies following the floods,thanks to the donation of US$23,000 fromCIDA); El Salvador (supplies for Rosales Hos-pital with the support of the Canadian Em-bassy); and Peru (follow-up of 1983 floods inPiura and Tumbes). Technical cooperationwas offered to Ecuador and Mexico followingthe mass casualties caused by an air crash anda gas holding tank explosion, respectively, inthese countries' capital cities.

Women, Health, and Development

2.247 The Five-Year Regional Plan ofAction on Women, Health, and Development(WHD), 1981-1985, is being implemented. In


this vein, improved coordination of WHD ef-forts at the national level was a focus for manycountries during the past year. The creation of33 national Focal Points out of PAHO's 37Member Countries to coordinate these effortshas proved to be a necessary and importantstep for mobilizing resources and promotingaction.

2.248 As part of its collaboration with thecountries in carrying out national WHD plansand activities, PAHO/WHO is conducting aseries of seminar-workshops in Washington,D.C. The first was held in December 1983and the second in April 1984. National FocalPoints, other key nationals, and PAHO/WHO field staff from a total of 12 countrieshave participated. As an immediate productof each seminar, participants have outlinedwork plans for 1984-1985 for integrating ac-tivities addressing WHD into their nationalhealth plans and programs. The next seminarin the series is scheduled for early 1985.

2.249 Some countries already have inte-grated WHD activities into national healthprograms and have increased awareness andunderstanding of the issues involved. For ex-ample, Colombia held a Regional Meeting onWomen and Health from 28 May to 2 June,with funding from PAHO/WHO and other in-ternational sources. Canada, Haiti, and Mex-ico held workshops in 1984 to introduce andpromote national WHD activities to healthpersonnel throughout these countries, to ex-change information and experiences, and todevelop specific activities at both Federal andState levels.

2.250 The XXIX Meeting of the PAHODirecting Council (September-October 1983,resolution CD29.R22), urged Member Gov-ernments to "increase the participation ofnongovernmental organizations, as well ascommunity groups that are concerned withwomen's issues, in the formulation of nationalhealth care priorities and programs." Startingin 1983, PAHO/WHO organized a series ofactivities to promote support for women'sgroups active in primary health care, including

a survey of these types of organizations in theRegion, an in-depth review of the activitiescarried out by some of these groups, and atechnical work group to identify ways to in-volve these types of groups more effectively inprimary health care. As a follow-up to theseand other international activities, Colombia,Cuba, and Honduras national women's orga-nizations are working with the ministries ofhealth and education to provide community-level education for women including familyplanning, breastfeeding, legal rights, andhealth services. Several countries, includingBarbados, Colombia, Ecuador, and Jamaica,have undertaken research in cooperation withPAHO/WHO on specific aspects of women'shealth, such as breastfeeding, maternal mor-bidity and mortality, women's impact on nutri-tion in the family and the community, and thehealth needs of single teenage mothers andtheir children. A number of countries havebetter incorporated women's health into theirnational health surveys and information sys-tems or have produced special studies on thestatus of women's health.

2.251 Despite the obvious progress beingmade in governmental coordination withwomen's groups, lack of interagency coordi-nation is still a major problem in many coun-tries. Furthermore, ministry representativeshave the problem of keeping abreast of thewide variety of programs being financed andadministered by a myriad of private organiza-tions.

2.252 In June 1984, PAHO published anannotated bibliography on Women, Healthand Development in the Americas (ScientificPublication 464). The purpose of the bibliog-raphy is to provide planners, policy makers,health professionals, and other interestedgroups with an overview of currently availableinformation that addresses the compelling is-sues of women's health needs and their rolesin the provision of health care. As mentionedin this chapter, under Disease Prevention andControl, cancer of the cervix is the most com-mon form of cancer among women in much

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of Latin America and the Caribbean, and thispublic health problem could be dramaticallyreduced through integrated screening andcontrol programs. In response to this problem,countries in the Region are working withPAHO/WHO to standardize norms and pro-cedures for implementing and evaluating cer-vical cancer control programs. In 1983, inMexico, the American Cancer Society andPAHO/WHO cosponsored an internationalmeeting which brought together governmentofficials, health professionals, and voluntarycancer societies from 18 countries to discussimplementation of collaborative cervical can-cer control programs. Since then, Barbados,Brazil, and Colombia have begun evaluationsof their cervical cancer control activities withPAHO/WHO support.

2.253 Some countries in the Region aretaking more definitive steps towards providingbetter training for women in health care pro-fessions and promoting greater participationof women in health sector decision making.For example, Colombia and Jamaica held na-tional workshops in 1984 focusing on variousaspects of continuing education and other ca-reer opportunities for women in the healthprofessions. Also, PAHO/WHO is currentlyworking with countries to identify the needs ofwomen working in these professions and howthey can be better supported. PAHO/WHO iscollaborating with national nurses' associa-tions and groups in Brazil, Colombia, Ecua-dor, Honduras, and Peru to conduct studiesof the nursing profession in terms of nurse'spositions, salaries, work hours, and the like asthey relate to other health professions.

2.254 The Special Subcommittee ofPAHO's Executive Committee on Women,

Health, and Development met in June to re-view progress made toward the Five-YearPlan's implementation. As a consequence,the PAHO Directing Council at its XXX Meet-ing (September-October 1984) urged thegovernments to provide more educational op-portunities for women, to support their impor-tant contributions as providers and users ofhealth care at all levels, and to enforce laws onthe protection of women's rights and rescindall discriminatory legislation. The Council alsoemphasized the need to ensure that the goalsand actions of the Five-Year Regional Plan ofAction on WHD continue to be pursued be-yond 1985 and fully integrated into the Planof Action for the implementation of the Re-gional Stategies of HFA/2000.

Health Statistics

2.255 At the end of the year, the PAHOstatistical data base was being implemented atHeadquarters. The base includes data onmortality, population, social, and economicfactors, and those health service componentsrequired for the programming of PAHO/WHO technical cooperation. During 1984,PAHO/WHO supplied statistical support forstudies and programs, especially for the prep-aration of the Plan for Priority Health Needs inCentral America and Panama. As the FocalPoint for health information on the AmericanRegion, the Organization responded to infor-mation requests from countries and interna-tional agencies. In addition, it cooperated withBrazil and Colombia in studies on maternalmortality, accidental deaths, and the feasibilityof analyzing social and economic factors re-ported in death certificates.

Chapter 3. Mobilization of Technical and FinancialResources

3.1 Technical and financial resourc.e mobi-lization is a fundamental point to promote anddevelop government actions in overcoming theexternal sectoral health problems and ensuringthe optimum use of available national re-sources. Based on the "Managerial Strategy forthe Optimum Use of PAHO/WHO Resourcesin Direct Support to Member Governments,"adopted in 1983, this chapter considers thegeneration and dissemination of knowledge,the mobilization of institutional capacity, techni-cal cooperation among developing countries,and mobilization of international and externalfinancial resources.

Generation of Knowledge

3.2 PASB continued to implement itsmanagerial strategy adopted in 1983 for thegeneration of knowledge. The strategy restson two basic supports: research and technol-ogy development.

Health Research

3.3 An overview of the Region revealsthat the Member Countries are endeavoring,with the cooperation of PAHO/WHO, to de-velop the infrastructures necessary for per-forming multidisciplinary research in priority

areas and applying the resultant knowledgeeffectively in the formulation of policies andplans and in the development of new ap-proaches, solutions, techniques, and proce-dures. Following is a summary account of thecountries' leading initiatives.

3.4 Bolivia, Honduras, and Nicaragua es-tablished research units in their ministries ofhealth. A traveling seminar took place inwhich representatives of those ministries par-ticipated along with an official of Peru's Re-search Council. The seminar afforded an op-portunity to examine the structure andoperation of institutions performing health re-search in Brazil, Colombia, Cuba, and Mex-ico. As a further result of the seminar, the Re-search Council of Peru established a set ofnational priorities for studies in the field ofhealth. With the cooperation of the BrazilianResearch Council, a meeting was held to carryout a comparative analysis of the organizationof health research in the countries of the Re-gion, including analysis of the implementationof research policies. Representatives of the re-search councils and health ministries of Ar-gentina, Bolivia, Brazil, Costa Rica, Cuba,Honduras, Mexico, Nicaragua, Peru, andVenezuela participated. Areas were identifiedfor cooperation in the programming and con-duct of research, training, exchange of techni-cal and scientific information, and implemen-tation of specific projects.

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3.5 With PAHO/WHO cooperation,Brazil designed and applied a methodologyfor research management in health institu-tions. This experience will be extended to vari-ous countries in the Region. Cuba and Ecua-dor conducted workshops on health researchmethodology. Peru offered a course on re-search management, and Uruguay a courseon operations research. A group of scientistsfrom Argentina, Brazil, France, Mexico, theUnited Kingdom, and the United States ofAmerica met in Washington, D.C., to exam-ine the trends and outlook for pharmacologi-cal research in Latin America and formulatedrecommendations for adjusting research andtraining activities to the requirements of thenational essential drug programs.

3.6 PAHO/WHO's Advisory Committeeon Health Research (ACHR) expanded itssphere of responsibility in 1984 to includeother priority health aspects along with thepurely medical. At the same time, the Com-mittee assumed the function of fostering themobilization of national resources, the ex-change of information, and the developmentof networks for cooperation in research in pri-ority health areas. In its new role, the Com-mittee examined the broad range of priorityPAHO/WHO activities and monitoring mech-anisms to be developed under its responsibil-ity. To overcome logistical problems and theshortage of research workers cognizant of thelatest developments in their field, the Commit-tee convened a study group to identify con-straints and suggest solutions, includingmechanisms for bringing researchers up todate in methods and technology. The Com-mittee stressed the urgent need to strengthenstudies on technology transfer and evaluationas well as the need to collect and disseminateinformation concerning studies on health ser-vices and the use of auxiliary personnel.Lastly, the Committee recommended that amultidisciplinary study on infant mortality becarried out. The Committee's recommenda-tions were designed not only to promote activ-ities but also to suggest guidelines to MemberGovernments and PAHO/WHO.

3.7 Within this context, the PAHO/WHOgrant program identified two major priorities:analysis of conditions in the health sector(health profiles, policy formulation, technol-ogy, market for health personnel, environ-mental health services, and financing) and thestudy of health problems affecting specificgroups (infant survival, chronic diseases of theadult, diseases of workers and the elderly).The objectives of this research are to dissemi-nate knowledge in the areas of planning, de-velopment, and the rational use of availableresources to strengthen the operating capacityof health systems; identify areas to bestrengthened so as- to cover the requirementsof intersectoral coordination in solving healthproblems; reorient the technical and financialcooperation among countries, PAHO/WHO,and other international institutions; and iden-tify critical areas of future research. The grantprogram serves as an instrument for coordi-nating scientific activities at the national, inter-national, and PAHO/WHO levels. Promo-tion and development of research and studiesis the basic function of PAHO/WHO's techni-cal cooperation programs, especially thoseconducted at the Regional and SubregionalCenters; their contribution to the solution ofpriority problems in the countries has becomeprogressively more dynamic. For an analysisof the progress achieved in 1984, see the fol-lowing chapters and sections: in chapter 1,Development of the Health Service Infrastruc-ture (health service research); in chapter 2,Health Promotion and Care (research byCLAP, INCAP, CFNI, and CAREC); Envi-ronmental Health (CEPIS and ECO re-search); and Veterinary Public Health(CEPANZO and PANAFTOSA).

Technology Development

3.8 Continuing the process initiated in1983 with the Inter-American Conference onthe Evaluation of Health Technology, an in-ternational meeting on technological develop-ment in health was held in Brazil in 1984. Thismeeting, attended by representatives from Ar-gentina, Brazil, Colombia, Costa Rica. and

Mobilization of Technical and Financial Resources

Uruguay, defined criteria for a series of analy-ses of technological development to be carriedout in collaboration with Member Countries.Following the meeting, a working group con-vened in Rio de Janeiro to design a Plan forResearch on the Evaluation and Developmentof Technology and laid the groundwork for aprogram in support of the relevant institutions.This provided the framework for initiating thefirst analysis on the exportation and importa-tion of health technology in the Region. Stud-ies on technology inputs-magnitude, cost,selection, allocation, dissemination, and utili-zation-will be done initially in Argentina,Brazil, Colombia, Costa Rica, Cuba, Mexico,and Uruguay. The first study on the infrastruc-ture of the medical equipment manufacturingindustry was conducted in Brazil under thesame context. In addition, a start was madeon the identification and analysis of legislationrelating to health technology, with emphasison regulations pertaining to medical equip-ment, procedures, and drugs.

3.9 The promotion of actions at countrylevel has led to the identification of a numberof priorities, particularly in maternal and childhealth, for which a project was prepared andsubsequently was approved by the W. K. Kel-logg Foundation. On the basis of this project,four working groups were organized-onperinatal technology, obstetrical care, neona-tal care, and growth and development-in ad-dition to two special groups, one to examinepolicies and innovations in maternal and childhealth and the other to study the aspects oflifestyle and community behavior. Specialmention should be made of the First Interna-tional Meeting on Technology in PrenatalCare, attended by experts from the AmericanRegion and Europe, which will be followed upby a meeting on obstetrical care technology.

3.10 With regard to the dissemination ofinformation on technology, two publicationsare to be issued for transferring knowledgeand experience from other sectors to thehealth sector. In support of this work, a con-sultative group was formed to design projectsfor a health technology information network

to facilitate contacts, collaboration, and infor-mation exchange among research groups andagencies in charge of formulating technologi-cal policy. One of the first projects of this net-work will seek to foster cooperation betweenmaternal and child health and primary careprojects and health administration trainingcenters and programs. Another will endeavorto link centers devoted to biomedical engi-neering to those concerned with the preserva-tion of technologies.

3.11 As part of PAHO/WHO programsof technical cooperation with governments,new forms of technology are being developedand utilized, including simplified x-ray ser-vices; simplified dental systems; effective andlow-cost environmental health technology;simple tools for evaluating nutritional status;and vaccine production standards. The Re-gional and Subregional Centers are promot-ing the generation and utilization of know-ledge in their respective areas of responsibility,each according to its workplans and priorities.Details on these activities are found in this Re-port in the summaries of the work of eachCenter.

Dissemination of Knowledge

3.12 One of the basic functions ofPAHO/WHO cooperation with the govern-ments is the dissemination of research-gener-ated knowledge and the development of tech-nology. Of special importance in this field arethe activities of the Latin American Center onHealth Sciences Information (BIREME), theLatin American Cancer Research InformatiQrpProject (LACRIP),' the Health Documentationand Information Center, and the RegionalCenter information networks.

Latin American Center on HealthSciences Information (BIREME)

3.13 As a regional information center,BIREME answered 47,720 requests from Bra-

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zil and other Latin American countries fortechnical and scientific information. TheMEDLINE and IMLA systems continued toperform bibliographic computer searches inBrazil through the subcenters in Belo Hor-izonte, Salvador, and Rio de Janeiro. Follow-ing an evaluation of the MEDLINE system in1983, a larger-capacity processing center willbe installed at BIREME to handle internationaldata of immediate usefulness to the countries.BIREME continued its two programs for theselective dissemination of information on can-cer (LACRIP, located at PAHO Headquar-ters) and on nutrition (National Institute ofFood and Nutrition, INAN, in Brazil). Thenew agreement with Brazil's INAN facilitatedthe publication of two annual issues of Nutri-tion Alert and the publication and distributionof Bibliographic Alert and the Index Medicusof Latin America.

3.14 BIREME is responsible for promot-ing and coordinating the Latin AmericanHealth Information Network. Argentina,Chile, and Colombia agreed to establish na-tional information systems as operating ele-ments of the network, while the national cen-ters of the network in Nicaragua and Uruguayconsolidated and strengthened their pro-grams. In Brazil, in an effort to strengthen theBrazilian Health Information Network, the di-rectors of the two national subcenters re-viewed the project prepared by BIREME forestablishing a regional data base on health inthe Region to commence operation in 1985.An advanced training course was conductedfor 12 medical librarians from Brazil and otherLatin American countries.

Latin American Cancer ResearchInformation Project (LACRIP)

3.15 This network continued to distributeselective information on cancer throughBIREME and the subcenters in Argentina,Chile, Costa Rica, Cuba, Mexico, Peru, andVenezuela. In 1984 its services covered 22countries, including Argentina, Chile, CostaRica, Mexico, Peru, and Venezuela, which

acted on a decentralized basis. Argentina andCosta Rica initiated their activities within thenetwork in 1984. Information on 15 subjectswas provided quarterly to more than 3,000users. The system was adjusted so that thesubjects covered would better meet the needsof physicians and other health workers in on-cology. For instance, the heading "symp-toms" now includes leukemia and myeloma.In addition, new subject headings were intro-duced, including rehabilitation and oncolog-ical nursing.

Health Information andDocumentation Center

3.16 The center, located at PAHO Head-quarters, expanded its capacity by addingmore than 27,000 new documents, all ofwhich are now available to the Member Coun-tries in microfiche form. In 1984 it supportedthe work of BIREME as a basic component ofthe system. The center played an active role inthe organization of documentation centers atthe PAHO/WHO Offices in Argentina, Bo-livia, Brazil, Colombia, Cuba, Dominican Re-public, Guatemala, Honduras, Jamaica, Pan-ama, and Trinidad and Tobago to serve theneeds of PAHO/WHO staff and the nationalauthorities.

Other Information Networks

3.17 Dissemination of information wasthe basic function of the PAHO Regional Cen-ters. The following networks and units wereimportant for their contribution in this field:Pan American Network for Information andDocumentation in Sanitary Engineering andEnvironmental Sciences (REPIDISCA), Net-work for Information on Zoonoses and Foot-and-Mouth Disease, and the epidemiologicalinformation and surveillance system at thePan American Center for Human Ecologyand Health (ECO). Chapter 2 provides detailsof the programs in operation in the descrip-tions of CEPIS, CEPANZO, PANAFTOSA,and ECO.


Mobilization of InstitutionalCapacity

3.18 The strategy of strengthening the in-stitutional capacity of national centers with re-sources and support of PAHO/WHO Re-gional and Subregional Centers continued tobe implemented. To achieve this purpose, thestrategy attaches vital importance to establish-ing mechanisms for continuous communica-tion and cooperation in the areas of research,technological development, dissemination ofinformation, and training. One such mecha-nism is the organization and operation of net-works of centers.

Networks of National Centers

3.19 The following networks were in op-eration or were established in 1984:

· The Regional Network on AdvancedTraining in Health Services Adminis-tration operates within the PROASAprogram. With a membership consistingof health administration training institu-tions and programs in Argentina, Brazil,Chile, Colombia, Costa Rica, DominicanRepublic, Mexico, and Peru, the net-work served as the coordination and sup-port unit for 58 courses in administrationoffered during the year at 35 institutions.

* The Regional Network of Schools ofPublic Health and Postgraduate Pro-grams in Preventive and Social Medi-cine (ALAESP) comprises 10 schools ofpublic health and 18 graduate programsin preventive and social medicine. Thenetwork has undertaken to regionalizeeducation in these fields with the aim ofcontributing to the development of cen-ters of technical excellence in publichealth education in the Latin Americancountries.

* The Network of Programs of Continu-ing Education and Supervision pro-

motes the incorporation of supervision inthe educational process. More than200,000 health professionals, techni-cians, and auxiliaries received trainingthrough this network up to 1984. Thenetwork operates in 12 countries in theRegion.

· The Regional Network of EducationalTechnology in Health Centers includesmore than 20 educational technologycenters in the Latin American countries.These centers were established with thedirect cooperation of the former LatinAmerican Center for Educational Tech-nology in Health (CLATES). The net-work is currently receiving support fromPAHO/WHO and from the Nucleus forEducational Technology in Health of theFederal University of Rio de Janeiro(NUTES), which is the national counter-part of CLATES.

· The Network of National CommunityHealth Training Nuclei for CentralAmerica and Panama. The CommunityHealth Training Program for CentralAmerica and Panama (PASSCAP) isconsolidating this network in all six coun-tries of the Central American Isthmus. Itsbasic aim is to facilitate technical cooper-ation among these countries in the devel-opment of human resources in the healthsector.

· Network of Perinatology Centers. Aninformal perinatology network is devel-oping by means of collaborative pro-grams involving groups of national pro-fessionals, most of whom attendedcourses at the Latin American Center forPerinatology and Human Development(CLAP). The groups presently makingup the network are distributed through-out 17 countries of the Region.

· The Operational Network of Food andNutrition Institutions is being organizedin all countries with highly reorganizedscientific and teaching institutes who fol-low food and nutrition multidisciplinary

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approaches. Its objective is to contributeto an adequate supply and consumptionof food and the prompt solution of nutri-tion diseases and problems within thecontext of Technical CooperationAmong Developing Countries (TCDC).

The Network of National Centers forthe Classification of Disease consists ofcenters in Brazil, Peru, and Venezuela.In 1984, centers in Argentina and Mex-ico were added, a working strategy basedon the TCDC approach was defined,and studies on coding methods were un-dertaken.

Activities of PAHO / WHO's Regionaland Subregional Centers

3.20 Reference was made previously tothe basic function of the Regional Centers asvehicles for the mobilization of technical re-sources in the countries, especially capabilitiesfor generating information, developing tech-nologies, disseminating information, andtraining personnel. Essential functions ofthese Centers are the identification of installedcapacities for these purposes in the countriesand the promotion of technical and opera-tional linkages among groups in the countriesand among the countries themselves, to cul-minate in the emergence of networks of mutu-ally supporting and complementing centers.As those centers in the countries and their net-works become more firmly established andgrow stronger, they will gradually take overthe present functions of the PAHO/WHOCenters.

3.21 Each Regional Center contributes tothe development of priority program areas:CLAP, INCAP, CFNI, and CAREC in healthpromotion and disease control programs;CEPIS and ECO in environmental health pro-grams; and CEPANZO and PANAFTOSA inanimal health. The activities of the differentCenters are reviewed in the correspondingprogram areas in chapter 2 of this Report.

Technical Cooperation AmongDeveloping Countries (TCDC)

3.22 The year was marked by a growingtrend toward a more systematic utilization ofTCDC as an effective tool for mobilizing tech-nical resources and putting them to use in theRegion.

3.23 At its XXX Meeting, held in Septem-ber, the Directing Council of PAHO sup-ported the Secretariat's study on guidelines forthe promotion of technical and economic co-operation among developing countries(TCDC/ECDC) in the health sector, whichcontained proposals for stimulating, facilitat-ing, and systematizing TCDC. The DirectingCouncil, in resolution CD30.R3 of that meet-ing, reiterated the urgent need for legal, ad-ministrative, and financial measures by indi-vidual countries to foster collective andbilateral actions in the field of health. This res-olution was intended to support initiatives bythe countries as well as by PAHO/WHO tofurther the process.

3.24 With the aim of developing system-atic approaches for and detecting constraintson the use of TCDC, PAHO/WHO conveneda working group consisting of representativesfrom Argentina, Brazil, Colombia, Cuba,Mexico, and Venezuela. The group examinedeach country's potential capacities for meetingdomestic health needs and cooperating withother countries. It also identified major obsta-cles such as a lack of information on and famil-iarity with TCDC, as well as funding difficul-ties. To surmount these problems, Brazil,Colombia, and Cuba initiated studies to ana-lyze existing capacities and systematize the in-formation. PAHO/WHO is requesting theMember Countries to include in their nationalbudgets the necessary funds to support suchactivities. In addition, together with the LatinAmerican Institute for Economic and SocialPlanning (ILPES), the Organization is design-ing mechanisms for financing TCDC with na-tional resources as a practical guide for boththe governments and PAHO/WHO. Finally,


PAHO/WHO is including funds for inter-country activities in its technical cooperationprogram.

3.25 The growth of the Regional Net-works of national centers for human re-sources, maternal and child health, and envi-ronmental health resulted in an intensifiedexchange of experience and technical infor-mation. Several advances also were made atthe subregional level. In the Central Americancountries, joint action by some 200 health offi-cials made it possible to identify priority areasand formulate national and intercountry proj-ects within the Plan for Priority Health Needsin Central America and Panama. In humanresources, the Community Health TrainingProgram for Central America and Panama(PASCCAP) consolidated the network of na-tional centers for joint study, programming,and training of health personnel of CentralAmerican Isthmus countries. In the context ofTCDC, the countries of the Andean group(Bolivia, Colombia, Ecuador, Peru, and Ven-ezuela) provided training to managers ofdrug supply systems by means of nationaland intercountry courses and established asubregional information system for drugregistration. In the Caribbean Community(CARICOM), the countries continued to uti-lize TCDC in nutrition and disease controlprograms with the support of CFNI andCAREC, respectively. Subregional trainingprograms for health and veterinary personnelalso were conducted.

3.26 PAHO/WHO's Regional and Sub-regional Centers have been operating as in-struments of TCDC for many years. INCAPserves as a vehicle for the exchange of infor-mation and experience on nutrition amongthe countries of Central America and Pan-ama. BIREME disseminates medical andhealth information, while CEPIS and ECOcollaborate in matters pertaining to environ-mental sanitation, and CEPANZO andPANAFTOSA in questions related to zoo-noses and foot-and-mouth disease. The initia-tives on essential drugs provide another signif-icant example of joint action. In addition to

the Andean group project, Argentina, Brazil,and Mexico agreed to conduct joint and sup-plemental activities, especially in the produc-tion of raw materials. Also, the countries ofthe Central American Isthmus formulated asubregional essential drugs program.

3.27 TCDC between two countries hasbeen a common practice in the Region, oftenbased on mutual understandings and formal-ized at times by agreements. Mexico's Na-tional Virology Institute and National Refer-ence Laboratory cooperated with Bolivia,Chile, Colombia, Guatemala, Honduras, Nic-aragua, Panama, and Peru in verifying thestability and potency of the poliomyelitis andmeasles vaccines used in those countries' pro-grams. Those institutions extended consultingservices to Cuba in the area of measles vac-cine and DPT production and in the holdingof a regional seminar on quality testing of viralvaccines. In quality control of reagents, inter-country activities involving Brazil, Chile,Cuba, and Mexico were carried out and re-agents were provided to other countries of theRegion (nearly 900 reagents supplied to 11requesting countries). Similarly, Argentina of-fered to supply Trypanosoma cruzi antigen forthe diagnosis of Chagas' disease. An instanceof formalized cooperation is the agreementbetween Cuba and Nicaragua for develop-ment of human resources in Nicaragua'shealth sector. This agreement was in its lastyear of effectiveness in 1984.

Mobilization of InternationalResources

3.28 The Regional Strategies emphasizethe need for increased efforts by the Organiza-tion to channel technical and financial re-sources from the international community tothe countries for the purpose of supplement-ing and stimulating national efforts and re-sources devoted to critical and priority healthareas. A summary of leading activities is pre-sented below.

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3.29 United Nations Development Pro-gram (UNDP). Within its 1982-1986 pro-gramming cycle, UNDP is contributing tohealth projects in the Region with an amountof US$11.2 million (US$8.9 million for coun-try projects and US$2.3 million for regionalprojects). During 1984, UNDP allocatedUS$2.6 million, of which US$2.1 million wasfor health projects in 17 countries and US$0.5million for regional projects. Most countryprojects, totaling US$9.6 million, were imple-mented in 17 countries; most projects were di-rected to the extension or consolidation of ser-vices based on the primary health carestrategy. The regional projects were mainlyconcerned with the training of health person-nel. Preparation of the fourth UNDP program-ming cycle was scheduled to begin in 1985,based on three items: service to low-incomepopulation of urban and rural areas, scienceand technology, and governmental policies.

3.30 United Nations Fund for Popula-tion Activities (UNFPA). The UNFPA pro-vided support to 35 projects totaling US$7.5million: 31 national projects in 27 countrieswith a total cost of US$7 million and 4 re-gional projects totaling US$501,000. UNFPAactivity in the Region increased as a result ofthe greater number of countries involved, thesize of projects, and the larger number of pro-gram components.

3.31 United Nations Children's Fund(UNICEF). UNICEF and PAHO/WHO con-ducted joint programming in a number ofcountries under the terms of an agreement be-tween the two agencies. It was hoped tostrengthen this coordination in 1985 in orderto benefit the countries. Within this scheme,UNICEF provided support in courses on nutri-tion, food, and breastfeeding (Costa Rica) andon cold chain maintenance and diarrheal dis-eases (Guatemala). Seminars on diarrhealdisease control were conducted in Hondurasand Nicaragua, and breastfeeding standardswere revised in Costa Rica. UNICEF has co-operated with PAHO/WHO in the formula-tion of a regional child-survival program, to beimplemented primarily in the Central Ameri-

can countries and Panama. An intensive vac-cination program (diphtheria, pertussis, teta-nus, poliomyelitis and measles) wasdeveloped by Colombia with UNICEF,PAHO/WHO, and UNDP cooperation.UNICEF was found to favor projects in lessdeveloped areas which involve the use of sim-ple technologies and exert a major impact onthe health of mothers and children.

3.32 United Nations Fund for DrugAbuse Control (UNFDAC). This fund spon-sored four projects totaling US$1.5 million-in Colombia, Ecuador, Jamaica, and Peru-in the areas of epidemiology, information,and drug abuse treatment and education, in-cluding the replacement of Cannabis indicawith other crops.

3.33 World Food Program (WFP). In1984, the WFP was active in 20 countries ofthe Region by means of 42 projects whichserved as a vehicle for supplying communitieswith 397,000 metric tons of food at a cost ofapproximately US$270 million.

Mobilization of External FinancialResources

3.34 As a further step in implementingthe strategy of increasing the Member Coun-tries' capacity to identify priority areas of theirhealth plans for which special resources areneeded and to determine potential sources offinancing for them, PAHO/WHO distributedto the Member Governments a documententitled Guidelines for the Mobilization ofExternal Financial Resources for Health, con-taining information on prospective fundingsources, procedures to follow, and mobiliza-tion strategy.

3.35 An analysis of available informationon external financing sources shows that inthe Americas the concessionary financing forall sectors increased from US$3.26 billion in1982 to US$3.37 billion in 1983 in the Ameri-cas. Of this total, US$279 million (approxi-mately 8.2%) went to the health sector; two-


thirds of this sum was channeled toenvironmental health programs.

International Lending Agencies

3.36 The Inter-American DevelopmentBank (IDB) continued to be the leadingsource of financial support for health pro-grams in the Americas. An IDB/PAHO meet-ing was held in June 1984 to determine jointactions to deal with the impact of the currenteconomic crisis on the health sector. Themeeting provided an opportunity to examinemeasures the Bank could adopt to stimulateinvestments in the social sectors, particularlyin health, with emphasis on the less devel-oped countries. The IDB defined its invest-ment policy for water supply: it will give prior-ity to projects for strengthening and improvingthe operation and maintenance of existingsystems. Community involvement, includingfinancial and administrative participation, isregarded as an essential factor.

3.37 According to information in its 1984Annual Report, the IDB approved five watersupply and sanitation loans totaling approxi-mately US$282 million for projects in Chile(US$2.5 million), Colombia (US$200 mil-lion), Costa Rica (US$28 million), Ecuador(US$28 million), and Honduras (US$24 mil-lion). In addition, it provided grants totalingUS$3.2 million for preinvestment studies andspecific projects in Brazil, Ecuador, Guate-mala, Haiti, and Honduras. The IDB also ap-proved some US$397 million for projects insocial sectors related to health programs, in-cluding projects in Chile (US$125 million),Colombia (US$115 million), Costa Rica(US$17.3 million), and Uruguay (US$40 mil-lion).

3.38 In 1984, PAHO acted as executingagency for 11 IDB-financed technical cooper-ation projects (9 national and 2 regional) total-ing US$4.3 million. The national projects rep-resented a total of US$1.9 million in fundsprovided on a nonreimbursable basis for thedevelopment of health services. The projects

were under way in five countries, some ofthem having started in earlier years. Promi-nent among the regional projects was a tech-nical cooperation agreement between the IDBand PAHO/WHO for the preparation of in-vestment projects for health, water supply,and basic sanitation in IDB beneficiary coun-tries. Approximately US$540,000 was ex-pected to be invested in these projects over a2-year period. In addition, technical coopera-tion projects were formulated to accompanyloan applications presented by Barbados,Guyana, Honduras, Mexico, Peru, and Ven-ezuela. Finally, the IDB was considering anumber of national and subregional projectsunder the Plan for Priority Health Needs inCentral America and Panama, in the follow-ing areas: health service development, nutri-tion, maternal and child health, malaria, es-sential drugs, and environmental health.

3.39 The International Bank for Recon-struction and Development (IBRD or WorldBank) approved two loans totaling an esti-mated US$28 million for water supply andsanitation systems (Honduras, US$19 million;Jamaica, US$9 million). According to prelimi-nary data, the IBRD disbursed approximatelyUS$600 million in 1984 for projects approvedin earlier years. The IBRD is considering twoprojects on foot-and-mouth disease and otherdiseases: one in Argentina with an estimatedcost of US$133 million and the other in Brazilfor US$120 million. PAHO/WHO cooper-ated in this project and, with funds providedby IBRD, assisted the Government of Brazil ina study on laboratory services for foot-and-mouth disease.

Bilateral Financial Cooperation

3.40 A total of 14 sources of bilateral co-operation operate in the Americas. Eight ofthem (Canada, Denmark, the Federal Repub-lic of Germany, France, Japan, the Nether-lands, Norway, and the United States ofAmerica) were active in 1984. According toavailable data, they channeled approximatelyUS$97 million into the health sector, 29% of

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which went for water supply and sanitationand 71% for health and service developmentprograms.

3.41 Canadaa supplied US$2.7 million toBelize, Brazil, Chile, Colombia, Cuba, Hon-duras, Mexico, Paraguay, Peru, and the En-glish-speaking Caribbean countries for pro-grams in urban planning, water supply,maternal and child health, insect control, anddengue.

3.42 Denmark, Japan, and Norwayacontributed to the health sector in amounts ofUS$3 million, US$2 million, and US$1.5 mil-lion, respectively.

3.43 Federal Republic of Germany°

contributed US$10 million for environmentalhealth in Brazil, Colombia, and Paraguay.

3.44 Francea provided US$9.9 millionfor construction and equipping of hospitals inBolivia, Colombia, and Paraguay.

3.45 Netherlandsa donated US$5.6 mil-lion to Brazil, Chile, Dominican Republic,Guyana, Haiti, Jamaica, Nicaragua, and Uru-guay for programs in hospital development,water supply systems, disaster preparedness,and nutrition.

3.46 United States of America. Duringthe fiscal year ending 30 September 1984, theAgency for International Development(USAID) provided US$27 million in grantsand loans for activities in the health field,along with US$14 million for family planning.The cooperative programs covered the areasof health services, sanitation, immunization,information systems, malaria, epidemiology,and nutrition in Central America and Pan-ama, the Caribbean, and South America. TheUSAID budget for the fiscal year 1 October1984-30 September 1985 includes US$76million for health projects and US$27 millionfor family planning. Salient among these proj-ects are: a 4-year, US$8 million oral rehydra-tion monitoring and management program inCentral America and Panama; a 2-year,

"The latest information available for these countries is for the cal-endar year 1983.

US$3.5 million malaria program; a US$3 mil-lion essential drugs program; and a US$9.5million health service program in Guatemala.

Foundations and GovernmentAgencies

3.47 A total of 174 private agencies havebeen identified as sources of aid in the field ofhealth in the Western Hemisphere. The majorfoundations include W. K. Kellogg, Ford,Rockefeller, Edna McConnell, Clark Hewlett,Tinker, Public Welfare Foundation, and theTrasher Research Fund. These agencies do-nated some US$19 million to the health sec-tor, US$18 million of which representedgrants by the W. K. Kellogg Foundation.

Pan American Health andEducation Foundation (PAHEF)

3.48 PAHEF is a nonprofit foundationdedicated to advancing the fundamental ob-jectives of PAHO and WHO. PAHEF is coop-erating with PAHO/WHO in the Program forTextbooks and Instructional Materials, most ofwhich it finances with a capital revolving fundderived from loans from the Inter-AmericanDevelopment Bank (IDB) and from incomefrom sales of textbooks, manuals, and otherinstructional materials. In 1984, net sales wereUS$2.46 million and unit sales wereUS$119,000. Technical supervision and ad-ministration of the program continued to bethe responsibility of PAHO/WHO. PAHEFalso receives grants and tax-deductible dona-tions to support designated health programs.With funds from these sources, in 1984PAHEF supported 47 projects costingUS$472,000. PAHO/WHO provided techni-cal and administrative supervision for theseprojects as required. Most projects werefor the Americas, but PAHEF also receiveddonations of antimalarial drugs valued atUS$99,000 for the WHO world-wide pro-gram in tropical diseases.

Chapter 4. Relevant Problems

4.1 Outstanding problems affecting thehealth sector as a whole in almost all the LatinAmerican and Caribbean countries have beenidentified in previous parts of this Annual Re-port. This chapter examines some of their rele-vant characteristics.

Economic Crisis

4.2 The serious economic crisis continuedto be the major problem the health sectorfaced in 1984, both because of its adverse in-fluence on development in the Latin Ameri-can and Caribbean countries and because ofits impact on living standards and well-beingof the population. All socioeconomic indica-tors registered significant declines. Rising in-flation, high interest rates, an overwhelminginternational debt, unemployment, a slow-down in private sector production, and stag-nant public services characterized this truly re-gressive situation in most of the countries. Astudy by the Organization showed that in1984 per capita income declined in 12 coun-tries and that average Region-wide Gross Do-mestic Product (GDP) at the end of the yearwas roughly equal to that in 1976.

4.3 When spiraling inflation is added to adrop in per capita income, living standards arebound to suffer a sharp decline. Thus, in virtu-ally all of the American countries, the ability ofa family to pay for food, housing, clothing,

and other basic needs regressed to the levelsof a decade earlier.

4.4 One of the strongest obstacles to eco-nomic growth is the heavy burden of foreigndebt carried by the governments of the Re-gion. In 1984 alone, the net transfer of re-sources from the Region to other areas cameto US$26.7 billion, 10% of which went for thepayment of interest on the outstanding debt.Total external indebtedness increased in 1984to US$360 billion.

4.5 In human terms these figures repre-sent very low living standards, unemploy-ment, and an increase in underdevelopment.ECLA estimates that, even if a variety of posi-tive conditions were factored in, a per capitaincome similar to that of 1980 would not beachieved in the Region as a whole by 1990.This hypothesis assumes a situation not onlyof stagnation but essentially of regression inmost of the Latin American and Caribbeancountries. Moreover, a comparison of livingstandards and development levels with thoseof industrialized countries makes it apparentthat the gap is growing wider daily betweenthe two groups.

4.6 The repercussions of this situation onthe social sectors have been dismal in manyrespects. In the health sector, the govern-ments are faced with a growing demand forservices by a population in constant growth, ata time when there is a heavy pressure for a

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significant reduction in funds allocated to thedaily operations of health services. This pres-sure also limits the possibility of extending thecoverage of services to unprotected popula-tions in rural and suburban areas and thecountryside. Signs of stagnation in certain in-dicators of health and living conditions are nolonger unusual.

4.7 The characteristics of this situationwere examined in a study which the PAHO/WHO Secretariat submitted to the XXX Meet-ing of the Directing Council entitled "The Eco-nomic Crisis in Latin America and theCaribbean and its Repercussions in the HealthSector." In addition to discussing the overallsocioeconomic situation in the Hemisphere,the report examined its irnplications for thehealth sector in most of the Region's develop-ing countries. The decline in national and in-ternational financing for health programs alsowas described. In the discussions on this sensi-tive matter within the Directing Council, theopinion was emphasized that the social sectorsought to view the crisis as a challenge to settheir own houses in order by examining the fi-nancing of activities in the public and privatesectors and carefully reviewing the utilizationof resources in terms of cost effectiveness andproductivity. The countries' human resourcescapacity and utilization also should be takeninto account, along with the selection of ap-propriate technology for carrying out activi-ties. Emphasis was also placed on the urgentneed for linkage among the sector's compo-nent entities in order to use resources moreproductively and expand the coverage ofhealth services.

Operational Capacity of theHealth Sector

4.8 The most serious obstacle to rationalutilization of the health sector's resources andto intersectoral linkage continued to be thesector's limited operational capacity. Thisproblem and possible ways of addressing itwere examined at the XXX Meeting of

PAHO's Directing Council during the techni-cal discussion on "Increasing the OperationalCapacity of the Health Services for the Attain-ment of the Goal of Health for All by the Year2000." The Council reviewed the problems ofhealth service administration and manage-ment at all levels, obstacles encountered in thetraining and utilization of human resources,the absence of controls to ensure that selec-tion and application of technologies are basedon social efficiency, and the absence of inter-sectoral linkage mechanisms to facilitate theexpansion of coverage and the reduction ofsocial inequities.

4.9 As a result of these discussions, thePAHO Directing Council, at its XXX Meeting,adopted resolution CD30.R28 calling uponthe governments to give priority to developingthe operational capacity of health services,with emphasis on high-risk groups, in the for-mulation of health policies; reviewing thestructure of funding for health services andfostering productivity; reviewing and adjustingtheir policies on the training and utilization ofpersonnel; introducing managerial and tech-nological innovations designed to increase theproductivity of the services; and seeking socialparticipation in decisions affecting health.

4.10 The governments' recognition of thefar-reaching importance of problems relatedto operational capacity of health services andof possible ways of addressing them lends ur-gency to the need for vigorous and consistentaction to be defined in each country, in keep-ing with its particular situation and problems,for the purpose of surmounting these obsta-cles over time and enabling the sector to copewith economic and social crises.

Essential Drugs

4.11 The problem of drug supplies, espe-cially for marginal groups, became increas-ingly more serious. The expenditure of morethan US$5 billion on drugs in Latin Americawas unresponsive to the Region's real needs,and in fact reflected problems in the consump-

Relevant Problems 99

tion and use of drugs. A glaring disparity existsbetween the scant supply of drugs for the un-derprotected or unprotected residents of ur-ban poverty belts and rural areas and the gen-erous supply of drugs for those who can affordto pay for them and have access to medicalcare. This disparity is evidence of the need tostrengthen the coverage of services and en-sure the availability of essential drugs to theunderserved.

4.12 In all countries but three, the patternof domestic production of essential drugs isnot responsive to domestic demand, creatinga reliance on imports and accordingly on thevagaries of the world market. Furthermore,local production is dependent on imports ofraw material. The absence of a comprehen-sive pharmaceutical policy in most of thecountries limits the possibility for cooperationamong the sectors involved, including health,industrial production, trade, and planning.The situation is compounded by quality con-trol problems and the absence of supply sys-tems. Although the governments have takensteps to deal with these problems, strongeraction is needed to ensure that currently dis-advantaged groups gain access to health careservices and essential drugs.

Technological Problems

4.13 The wide disparity between thetechnological capabilities of developed coun-

tries and developing countries is a source ofincreasing concern from the standpoint oftechnological dependency. High-cost tech-nology transfers, foreign investment, and in-ternational financing are priority questions inthis regard. The minimal scientific and techno-logical capabilities of developing countriesmakes them dependent on imported technol-ogy and limits the possibility of developing lo-cal technologies. It should be further notedthat foreign technologies often are unrespon-sive to the prevailing needs of health services.They are also subject to problems of inappro-priate use, which may favor the interests ofparticular professional, technical, industrial,and commercial groups at the cost of exacer-bating existing inequalities and contributing tothe wasteful use of social resources and to alower standard of living.

4.14 These factors have led the Organiza-tion's Member Governments to formulatestrategies for dealing with the problems inquestion, including intercountry cooperationand regional integration to achieve greaterbargaining strength in the selection and impor-tation of technology and greater endogenouscapacity to produce appropriate technology.Implementation of this strategy will begin in1985 with a regional collaborative surveywhich is expected to involve the active partici-pation of six Governments in the Region:Argentina, Brazil, Colombia, Costa Rica,Mexico, and Uruguay.

Part IIIRelevant Activities of

the PAHO Governing Bodies

Chapter 5. PAHO Governing Bodies

5.1 The American countries' joint commit-ment to the strategies of health for all involvesefforts by the Member Governments them-selves and the Secretariat, as well as initiativesand guidelines originating in the Organization'sGoverning Bodies: the Pan American SanitaryConference, the Directing Council, and the Ex-ecutive Committee. In 1984, the DirectingCouncil and the Executive Committee heldtheir regular meetings to perform their statutoryfunctions of reviewing the progress of the Orga-nization and its programs and formulating rec-ommendations to the governments and thePAHO Secretariat. The recommendations, in-cluded in resolutions of the Directing Counciland the Executive Committee, were intendedto serve as guidelines for national and regionalaction in specific fields. Accordingly, it is impor-tant to know the extent to which the decisionsof the Governing Bodies are helping to orientresources and efforts toward priority areas inthe Region, and the extent to which they arebeing translated into specific actions by the gov-ernments and the Secretariat.

5.2 The time that elapsed between the Di-recting Council Meeting in October and the endof the period covered by this Report was tooshort to warrant the expectation of substantialactivities and results. Consequently, it was notconsidered practical to attempt to measure the

progress achieved in implementing the resolu-tions adopted in 1984 at the XXX Meeting ofthe Directing Council. It was, however, possibleto examine the actions taken in 1984 by thegovernments and the Secretariat with respectto the resolutions approved in 1983 by the Di-recting Council's XXIX Meeting.

Action in 1984 on Resolutions ofthe XXIX Meeting of theDirecting Council (1983)

5.3 Table 16 shows the resolutions thatthe Directing Council discussed and adoptedin its XXIX Meeting on matters pertaining tothe priority areas of infrastructure develop-ment, health promotion and disease controlprograms, resource mobilization, and mana-gerial strategy. It also indicates the measureswhich the governments and the Secretariatadopted as a result of the 13 resolutions in-cluded in this analysis. Many of the actions arelong-term and will require continuous moni-toring in the years ahead. To facilitate analy-sis, the resolutions were arranged by contentunder headings pertaining to the priority areasof the Plan of Action and the PAHO Programand Budget.

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104 Annual Report

Table 16. Action by the Member Governments and PASB in 1984 on resolutionsof the XXIX Meeting of the PAHO Directing Council, 1983

Resolutions Action

Development of the Health Services Infrastructure

Preliminary report on the regional situation in regardto the strategies of HFA/2000 (CD29.R13)

To the Governments Governments

Urges them to expedite the monitoring and evalua- No actions to adjust the monitoring and evaluation processestion processes. reported.

The countries met with problems in completing the WHOcommon framework form for the global evaluation.

To PASB PASB

Requests it to support the national planning pro- Using the information available from the countries, PASB willcesses as a basis for the development of monitoring prepare the regional contribution on the strategies for theand evaluation. WHO Global Evaluation document.

Intensified its cooperation with schools of public health in theteaching of planning. Strategic planning and managementapproaches were developed with the school in Medellín (Co-lombia), which are now being used in Honduras, Nicaragua,and Panama. Intersectoral planning program has begun withILPES.

Nursing (CD29.R18)


Recommends that they strengthen nursing services Argentina, Bolivia, Brazil, Canada, Chile, Costa Rica, andand the training of nurses. Panama organized national and subregional meetings to ex-

amine the changes required in the information systems andthe training of nursing personnel. The meetings were at-tended by representatives of ministries of health, social secu-rity agencies, nursing schools, and nursing associations.

To PASB PASB

Requests it to support the governments' initiatives. Gave technical and financial support to above meetings.

Conducted the "Study of Nursing Practice" in Colombia,Ecuador, Honduras, Mexico, and Peru.

Blood transfusion services (CD29.R15)

To the Governments Gouernments

Recommends that they strengthen the national Brazil, Colombia, Costa Rica, Cuba, Ecuador, Jamaica, Nic-blood transfusion services by means of appropriate aragua, and Uruguay evaluated their blood banks. The eval-programming, funding, and regulation. uations showed that all of them fulfilled the reference and

training requirements.

To PASB PASB

Asks it to promote and support the development of Cooperated in the consolidation of the Network of Collabo-the program. rating Banks.

Supported the programs about to begin or under way in Bar-bados, Belize, Brazil, Dominica, Grenada, Haiti, Jamaica,Peru, Trinidad and Tobago, and Venezuela.

Production and marketing of essential drugs(CD29.R30)

To the Governments

Urges them to adopt intersectoral policies and toevaluate current practices in drug production, qualitycontrol, and supply.

Governments

Argentina, Brazil, and Mexico jointly adopted a strategyof self-sufficiency in the coordinated production of rawmaterials.

PAHO Governing Bodies 105

Table 16. Action by the Member Governments and PASB in 1984 on resolutionsof the XXIX Meeting of the PAHO Directing Council, 1983 (Cont.)

Resolutions Action

Development of the Health Services Infrastructure (Cont.)

Argentina, Colombia, and Nicaragua analyzed their nationalsituations as a basis for the formulation of policies.

To PASB PASB

Requests it to support the formulation of policies and Supported the countries mentioned above, in the two pre-implementation of programs and to collaborate in the ceding paragraphs, and also Cuba, Ecuador, Peru, and Ven-mobilization of resources. ezuela, in the mobilization of resources. Conducted studies

and negotiations on structuring a joint purchasing system forCentral America and Panama.

Development of Health Promotion and Disease Control Programs

Infant and young child nutrition (CD29.R21)


Urges them to: implement the WHO/UNICEF rec- The resolution reinforced the actions being taken by most ofommendations on infant and young child feeding; the countries since 1981. 1984 highlights: in Central Americaadopt legislation on breast-milk substitutes; and pro- and Panama, the intercountry meetings held to examine themote intersectoral actions for the improvement of in- situation and problems, review the practices being followed,fant and young child nutrition, particularly in low- and draw up breastfeeding programs; in the Caribbean area,income groups. Dominica, Haiti, Saint Lucia, and St. Vincent and the Grena-

dines examined their situation in this field and prepared pro-grams for 1985.

At the end of 1985, three governments were applying theInternational Code on Marketing of Breast-Milk Substitutesand another 15 had legal instruments of one kind or anotheron breast-milk substitutes.

To PASB PASB

Requests it to give full support to the governments- Provided support as requested in Central America and theincluding studies, research, and legislation-and to Caribbean, especially through INCAP and CFNI, respec-mobilize technical and financial resources. tively.

Restructuring of INCAP (CD29.R27)

To PASB PASB

Requests it to continue to administer INCAP and re- Continued to administer the Institute.structure it. Evaluated INCAP's program and functions. As a result of the

evaluation, adjustments were made to the Institute's adminis-trative and operational structure and its program was reori-ented toward more effective cooperation with the countriesof the Isthmus on the basis of their national priorities.

Drug abuse prevention (CD29.R17)


Urges them to conduct ongoing epidemiological as- The countries designed a master plan for epidemiological as-sessments of the drug abuse problem and formulate sessments. Colombia and Peru, with UNFDAC support, for-and implement appropriate programs. mulated plans including epidemiological components.

To PASB PASB

Requests it to give priority to this program and obtain Conducted negotiations with UNFDAC on drug dependencyadditional financial resources. control and epidemiology in Barbados, Belize, and Jamaica.

Supported programs being started or in progress in Barba-dos, Belize, Brazil, Dominica. Grenada. Haiti, Jamaica.Peru, Trinidad and Tobago. and Venezuela.

106 Annual Report


Resolutions Action

Development of Health Promotion and Disease Control Programs (Cont.)

Expanded Program on Immunization (EPI)(CD29.R16)


Urges them to set biennial targets; to use immuniza- 20 Latin American and 7 English-speaking Caribbean coun-tion coverage in children under 1 year of age and tries reviewed their programs and set biennial targets.pregnant women as an indicator; and to use morbid- The countries are gradually using the coverage and evalua-ity and mortality data for measles, poliomyelitis, and tion indicators recommended in the resolution.tetanus as evaluation indicators.

Six countries conducted follow-up evaluations after the firstevaluation. Ten have scheduled specific oversight activities.

To PASB PASB

Requests it to study vaccine production capacity and Continued to monitor vaccine efficacy and safety. Supportedavailability and strengthen the EPI Revolving Fund. national laboratories of Brazil, Chile, and Mexico in the pro-

duction of vaccines.

Strengthened the EPI Revolving Fund. increasing its capitalto US$4.5 million.

Pan American Center for Human Ecology and Health(CD29.R28)


Requests them to identify and support national insti- In an initial stage, the countries have sought to identify na-tutions to form. with ECO, a Network of Collaborat- tional programs and units that, in the course of seeking solu-ing Centers. tions to environmental problems. engaged in activities in the

areas of epidemiology and toxicology.

To PASB PASB

Requests it to focus ECO's technical program on the ECO has given priority to epidemiological and toxicologicalepidemiological and toxicological aspects of the ef- aspects in special studies. dissemination of information. train-fects of health of chemical pollutants and to comple- ing, and technical cooperation with governments.ment ECO's work with that of CEPIS. ECO and CEPIS have worked together in Peru on a project

involving research on water source pollution.

Report on the III Inter-American Meeting, at the Min-isterial Level, on Animal Health (CD29.R26)

To PASB PASB

Requests it to negotiate an agreement between IICA Signed the IICA/PAHO agreement based on the study of theand PAHO on the Pan American Foot-and-Mouth possibility of a transfer of the Center.Disease Center. Presented a report to the XXX Meeting of the Directing

Council in October 1984.

Women in health and development (CD29.R22)

To the Governments Governments and PASB

Urges them to strengthen national policies for the Took action on the points in resolution CD29.R22 and PASBprotection of women; strengthen cancer prevention prepared a report (Document CD30/8) that was consideredprograms: and enact legislation to guarantee equal by the Directing Council at its XXX Meeting in October 1984.rights for women.

To PASB

Requests it to support the Five-Year Plan forWomen.



Resolutions Action


PAHO Advisory Committee on Medical Research(ACMR) (CD29.R29)

To PASB PASBRequests it to implement the recommendations of The Committee broadened its functions and changed itsthe Committee on expanding (ACMR Report, Doc. name to Advisory Committee on Health Research (ACHR).CD29.14) ACMR's areas of responsibility, research Will serve as an instrument for mobilization of national techni-areas and information exchange, and enlarging the cal resources and development of networks of research cen-cooperative networks. ters. New areas of study pertaining to health services and

auxiliary personnel will be taken on.

Secretariat Activities-PASB Managerial Strategy

Functions of the Area Offices of PASB (CD29.R2)

To PASB PASBApproves the Director's recommendation that the Eliminated the Area Offices effective 1 January 1984. Con-Area Offices be eliminated with effect from 1 January currently initiated a process aimed at administrative strength-1984. ening of the PAHO/WHO Country Offices.Is requested to evaluate the extent and effectiveness As of the end of 1984, PASB has entered into new basicof the proposed measures and report to the Directing agreements with Argentina, Brazil, Guatemala, and Peru;Council at its XXXI Meeting in 1985. negotiations were nearing completion with Mexico and

Venezuela.

Executive Committee andDirecting Council (1984)

5.4 Analysis of the discussions and deci-sions in 1984 reveals that PAHO's GoverningBodies were instrumental in promotingactions directed to the development of specificcomponents of the Region's priority programareas.

5.5 92nd Meeting of the ExecutiveCommittee. The Committee met in June1984 to consider an agenda of 23 items-some purely administrative and statutory, oth-ers relating to health policies and programs,including technical cooperation. Special im-portance was given to the studies done by theSubcommittee on Long-Term Planning andProgramming on PAHO's Managerial Strat-egy, the common framework for evaluatingRegional Strategies, the economic crisis andits repercussions on the health sector, TCDC,and the Subcommittee's own functions. Other

significant Executive Committee actions in1984 were its recommendations to the XXXMeeting of the Directing Council concerning aprovisional draft of the WHO American Re-gion Program Budget for 1986-1987 (in theamount of US$58.6 million), the basis for aPAHO population policy, and the Interna-tional Program on Chemical Safety.

5.6 The resolutions of the ExecutiveCommittee of PAHO calling for specific actionby the governments and Secretariat are listedin table 17.

5.7 XXX Meeting of the DirectingCouncil. At its XXX Meeting, held in October1984, the Council considered 22 matters andadopted 18 resolutions. Table 17 lists 10 ofthe resolutions by priority program area, to-gether with the recommendations to the gov-ernments and PAHO. An examination of thisanalysis reveals the Council's concern overthe economic crisis which the countries of theAmericas are going through and its repercus-

108 Annual Report

Table 17. Resolutions of the PAHO Governing Bodies, 1984

Resolutions of the 92nd Meeting Recommendations to the Governmentsof the Executive Committee, 1984 and to PASB

Common framework and format for evalu- Governmentsating the strategies for health for all by the Cooperate with PASB in the field tests of the evaluation in-year 2000 (CE92.R13) strument and use it subsequently to adjust the national infor-

mation and evaluation processes.

PASB

Adjust the evaluation instrument on the basis of the fieldtests. Provide support to the countries in improving theirprocesses and in preparing the regional contribution to theSeventh Report on the World Health Situation.

Managerial Strategy for the Optimum Use Governmentsof PAHO/WHO Resources in Direct Sup- Examine the possibility of redeploying resources in the na-port of Member Countries (CE92.R15) tional budgets to respond to the priorities adopted by them

in PAHO's Governing Bodies.

PASB

Examine the "Managerial Strategy" continuously to adapt itto the various factors that influence development and healthconditions in the Member Countries.

Resolutions of the XXX Meeting Recommendations to the Governmentsof the Directinq Council, 1984 and to PASB

Development of the Health Services Infrastructure

The economic crisis in Latin America and Governmentsthe Caribbean and its repercussions on the Undertake studies on the impact of new approaches andhealth sector (CD30.R2) technologies, including human resources, on health costs.

Review the financing of the health sector with the objectiveof moving toward the fulfillment of the principles of efficacy,efficiency, and quality, and examine the impact of the crisison health sector resources and on their distribution and use.

PASB

Continue to examine and report to the Governing Bodieson the international economic environment and assist theMember Countries in examining their own situation.

Coordination of social security and public Gouernmentshealth institutions (CD30.R15) Formulate strategies for the progressive development of

linkages to ensure better use of resources for the extensionof health care services to population groups lacking accessto them. Define the sectoral framework and intersectoral re-lationships, and examine the possibilities of complementaryroles for sectoral institutions in providing health care. In-clude social security in the planning and implementation oftechnical cooperation for the health sector.

PASB

Establish a program of technical cooperation with nationaland international social security agencies.

Operational capacity of the health services(CD30.R18)

Gouernments

Introduce managerial and technological innovations de-signed to make the health services more equitable and effec-


Table 17. Resolutions of the PAHO Governing Bodies, 1984 (Cont.)

Resolutions of the XXX Meeting Recommendations to the Governmentsof the Directing Council, 1984 and to PASB

Development of the Health Services Infrastructure (Cont.)

tive, with emphasis on the groups at greatest risk. Reviewthe financing structure of the services, establish the actualcomposition of health expenditure, and provide opportuni-ties for community participation in decisions relating tohealth.

PASB

Foster and support an exchange of views and promote thedevelopment of arrangements for increasing the operationalcapacity of health services.

Health Promotion and Disease Control Programs

Basis for the definition of the Organization's Governmentsaction policy with respect to populationaction policy with respect fo population Strengthen maternal and child health programs taking intomatters (CD3.R8) aaccount the close relationship to population dynamics prob-

lems. Promote multisectoral participation in the formulationand implementation of population policies. Ensure the useof demographic data to identify high-risk and other prioritygroups.

PASB

Promote the participation of the health sector in formulatingpopulation and development policies, and strengthen theOrganization's coordination with multilateral, bilateral, andnongovernmental bodies.

Final Report of the Seminar on Uses and GovernmentsPerspectives in Epidemiology (CD30.R16) On the basis of the recommendations of the Seminar

(Buenos Aires, November 1983), reinforce the practice ofepidemiology, expanding its application to all areas of thesector. Promote coordination of epidemiological services,research, and teaching.

PASB

Develop a program of support for the countries and seekextrabudgetary funds for implementing it.

Health of disabled persons (CD30.R7) Governments

Adopt policies and implement programs of comprehensivecare, giving special emphasis to the development of family-and community-based rehabilitation technologies.

PASB

Cooperate with the governments in the adoption of suchpolicies and strengthen PAHO's regional program in thisfield.

International Program on Chemical Safety Gouernments(IPCS) (CD30.R14) Participate in the International Program on Chemical Safety

(IPCS) at both the regional and the national levels, pro-mote chemical safety studies, and foster intersectoralcoordination.

PASB

Carry out an evaluation of the status of chemical safety inthe Region and formulate proposals for medium-term(1984-1989) programs on the subject.

110 Annual Report

Table 17. Resolutions of the PAHO Governing Bodies, 1984 (Cont.)

Resolutions of the XXX Meeting Recommendations to the Governmentsof the Directing Council, 1984 and to PASB

SDecial Program Areas

Priority Health Needs in Central America Gouernmentsand Panama (CD330.R117) Jointly and severally support the efforts of the countries of

Central America, including Belize, and Panama.

PASB

Support the initiative within the limits of available budgetaryallotments and of extrabudgetary funds that may beobtained, and seek to establish closer coordination withUNICEF and other technical cooperation agencies.

Women, health, and development (WHD) Gouernments(CD30.R6) Intensify their efforts to provide more educational opportu-

nities for women, including opportunities for occupationaldevelopment. Strengthen country WHD focal points andenforce their laws on the protection of women's rights.

PASB

Continue supporting regional WHD activities. Provide spe-cial training in key areas so as to enable women to competeon an equal footing for senior positions. Support the Execu-tive Committee's Special Subcommittee on Women.


Guidelines for the promotion of Technical Governments

Cooperation Among Developing Countries Take legal, financial, administrative, and institutional steps(TCDC)/Economic Cooperation Among to promote, facilitate, and undertake actions using theDeveloping Countries (ECDC) in the health mechanisms of TCDC/ECDC.sector with the collaboration of PAHO(CD30.R3) PASB

Collaborate with Member Countries in TCDC/ECDCactions.


sions on the health sector. In the discussion ofthe topic of intersectoral linkage and in the rel-evant resolution (CD30.R18), the Councilunderscored the urgent need for the govern-ments to combine and make better use of thesector's resources by coordinating the work ofministries of health and social security institu-tions more effectively. The Council also calledfor strengthening the operational capacity ofhealth services as a means of increasing theirproductivity. In reviewing the Organization'shealth promotion and disease control pro-grams, the Council requested the govern-ments to formulate population policies, utilizeepidemiology as a basic tool in the analysis ofhealth problems and services, and considerthe growing problem of chemical pollutants.

5.8 The other eight resolutions involveadministrative or statutory matters.

Preliminary Draft Program andBudget of the World HealthOrganization for the Region ofthe Americas for the Biennium1986-1987

5.9 In fulfillment of its constitutional re-sponsibilities, at its XXX Meeting, the Direct-ing Council adopted resolution CD30.R13recommending to the Director-Generalof WHO a proposed allocation ofUS$58,076,000 for the American RegionProgram and Budget for the Biennium 1986-1987 (table 18). The Director-General wasfurther requested to approve a US$484,000increase in the funds earmarked for the coun-try activities development program under theOffice of the Director of PASB.

112 Annual Report

Table 18. Draft Program and Budget of the World Health Organization for the Region of theAmericas for 1986-1987 (in USA dollars)

WHO Regular Budget

Program Amount Total Percent

Direction, Coordination, and ManagementGoverning Bodies

Regional committeesGeneral Program Development and Management

Executive managementDirector-General's and Regional Director's development program'General program developmentExternal coordination for health and social development

Health Systems InfrastructureHealth Systems Development

Health situation and trend assessmentManagerial process for national health developmentHealth systems research

Organization of Health Systems Based on Primary Health CareHealth ManpowerPublic Information and Education for Health

Health Science and Technology-Health Promotion and CareResearch Promotion and DevelopmentGeneral Health Protection and Promotion

NutritionOral health

Protection and Promotion of the Health of Specific Population GroupsMaternal and child health, including family planningWorkers' healthHealth of the elderly

Protection and Promotion of Mental HealthPsychosocial factors in the promotion of health and human developmentPrevention and control of alcohol and drug abusePrevention and treatment of mental and neurological disorders

Promotion of Environmental HealthCommunity water supply and sanitationFood safety

Diagnostic, Therapeutic, and Rehabilitative TechnologyClinical, laboratory, and radiological technology for health systems based on

primary health careDrug and vaccine quality, safety, and efficacy

Health Science and Technology-Disease Prevention and ControlDisease Prevention and Control

ImmunizationDisease vector controlMalariaParasitic diseasesTropical disease researchDiarrheal diseasesTuberculosisLeprosyZoonosesSexually transmitted diseasesOther communicable diseases

Prevention and control activitiesBlindnessCancerOther noncommunicable diseases

Prevention and control activitiesProgram Support

Health Information SupportSupport Services

PersonnelGeneral administration and servicesBudget and financeEquipment and supplies for Member States

Total Program Budget

271,900

260,200207,000

1,896,20068,200

3,013,3004,505,300

63,300

1,856,700444,500

869,700539,500193,800

383,300231,100156,800

4,818,800499,900

437,900595,400

1,096,0003,505,9001,082,300

329,400112,800522,100351,600291,100

1,961,00036,500

1,662,20045,90094,600

77,200

731,6002,631,4001,550,200

295,400

2,703,500 4.7271,900 .5

.52,431,600 4.2

.4

.43.3.1

24,992,800 43.07,581,900 13.1

5.27.8.1

11,206,800 19.35,358,900 9.2

845,200 1.411,200,700 19.3

173,300 .32,301,200 4.0

3.2.8

1,603,000 2.71.5.9.3

771,200 1.3.6.4.3

5,318,700 9.28.3.9

1,033,300 1.8

.81.0

11,168,600 19.211,168,600 19.2

1.96.01.8.6.2.9'.6.5

3.4.1

2.8.1.2

.18,010,400 13.82,801,800 4.85,208,600 9.0

1.34.52.7.5

58,076,000 100.0

Reserved for country activities.

Part IVActivities of the PAHO Secretariat

Chapter 6. Managerial Strategy

6.1 In 1983, PAHO adopted the "Mana-gerial Strategy for Optimum Use of PAHO/WHO Resources in Direct Support of MemberCountries" for the purpose of ensuring that thelimited resources available to PAHO/WHO forcooperation with Member Governments areused as efficiently and effectively as possible.The Executive Committee's Long-Term Plan-ning Subcommittee examined and supportedthe overall Strategy. Based on the Subcom-mittee's report, the Executive Committee, atits 92nd meeting, adopted a resolution(CE92.R15) urging the Secretariat to expeditethe implementation of the Strategy and adapt itto the countries' changing needs.

Implementation of the ManagerialStrategy

6.2 The basic principles of the Strategy arethat a country is both the subject and object ofPAHO/WHO cooperation, that the MemberGovernments participate in the setting of pri-orities and the formulation of technical coop-eration programs, and that the mobilization ofnational and international resources to meetrequirements in priority areas is a continuingresponsibility of the Organization and the Sec-retariat. Within this framework, adjustmentsand changes were made in 1984 to strengthen

the managerial and operational capacity of theCountry Offices. Thus, the former Area Of-fices were replaced by Country Offices, and a"Plan for Decentralized Administrative Devel-opment" was launched. This Plan includes, inthe first stage, a review of administrative sys-tems at the various levels of the Pan AmericanSanitary Bureau (PASB), an analysis of theoperating capacity of PAHO/WHO's CountryOffices and Centers, and feasibility studies onpotential areas for decentralizing Headquar-ters functions to the field. These analysesserved as a basis for the design of modules formanaging and monitoring technical coopera-tion programs (AMPES) and the budgeting, fi-nancial, and accounting subsystems; decen-tralized administration of personnel, travel,fellowships, seminars, and courses; and infor-mation systems for monitoring programs andbudget performance. A start was made on uti-lizing microcomputers to facilitate these func-tions. The process was under way at thePAHO/WHO Country Offices in Argentina,Bolivia, Guatemala, and Panama and atPANAFTOSA, CEPANZO, CAREC, CEPIS,and INCAP. In addition, work proceeded onthe organization of documentation and infor-mation centers in Bolivia, Brazil, Chile, Cuba,Dominican Republic, Guatemala, Jamaica.Mexico, Nicaragua, Panama, and Paraguay.

6.3 The Organization intensified its pro-

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116 Annual Report

gram to train field personnel, especially Coun-try Representatives, for the delegated author-ity and new responsibilities assigned to themas a result of the review of their Offices' oper-ating capacity.

6.4 With regard to the Strategy's basicprinciple of active participation by MemberCountries in the conduct of the Organization,the record for 1984 shows that the govern-ments played a far wider role than ever beforein determining the type of cooperation to beprovided by PAHO/WHO at national level.Joint Government/PAHO/WHO reviews ofpolicies and programs continued to go for-ward in a number of countries, resulting in thedefinition of national priorities and require-ments for PAHO/WHO cooperation which inaddition served as a basis for developingPAHO's Program and Budget for 1986-1987.

6.5 Regarding the mobilization of nationaland international resources, the Strategy'sthird basic principle, the Secretariat's effortswere directed to strengthening national andinstitutional capacities and to the optimum useof resources. Examples of this process includeutilization of the experience and technicalskills of national officials in their own countryand, by means of TCDC, in other countries aswell, together with the development of net-works of national collaborating centers; theseefforts are examined in chapter 3 of thepresent Report. Moreover, PAHO's extensivecontacts and joint undertakings with donoragencies, bilateral and multilateral, providebetter prospects for the flow of resources to

governments and an increase in extrabudge-tary funds for PAHO/WHO. Perhaps themost significant development in this respectwas the Secretariat's promotion and supportof the joint action undertaken by CentralAmerica and Panama in 1984 to mobilize na-tional capacities and wills and coordinatethem so as to arrive at a joint analysis of prior-ity health requirements. This led to the formu-lation of national and subregional project pro-posals requiring complementary financingfrom outside sources. By the end of 1984,some of this funding had been obtained. De-tails on this initiative are found in chapter 2 ofthis Report.

American Region Programmingand Evaluation System (AMPES)

6.6 The system was adjusted for consis-tency with the new budgetary classification. Inkeeping with the basic principles of the Mana-gerial Strategy, procedures were further sim-plified to make AMPES an efficient and effec-tive managerial tool for PAHO/WHOtechnical programming and optimal resourcemobilization. AMPES is now in the process ofbecoming the central management mecha-nism for short- and medium-term program-ming of technical cooperation. Once the Sys-tem has been consolidated, the methodologyfor monitoring and evaluating PAHO/WHOtechnical cooperation will be gradually incor-porated into it.

Chapter 7. Support Services

7.1 The Organization's support serviceunits are grouped in two functional areas. Thefirst, basically technical, includes the Publica-tions Program, Translations, the PASB Infor-mation Systems, the Public Information Office,and the Office of the Legal Counsel. The sec-ond area is essentially administrative and in-cludes the Offices of General and ConferenceServices, Personnel, and Procurement.

Technical Support

Publications

7.2 The publications program featuredsignificant changes during the year. In addi-tion to the program's traditional objectives, forthe first time it targeted direct technical coop-eration with the countries in editorial matters.A General Committee on PAHO PublicationsPolicy was established and met regularlythroughout the year. The program also wasrestructured and the Organization's main edi-torial units were centralized at Headquarters,resulting in the transfer of the PublicationsService (SEPU) from Mexico City to Head-quarters. The agreement with the AmericanPublic Health Association regarding PAHO'stranslation and publication into Spanish andPortuguese of Control of Communicable Dis-

eases in Man continued to bear fruit. Stepswere taken to assure closer collaboration be-tween the PAHO publications program andthe Publications Service of the Spanish Minis-try of Health. Close coordination continuedbetween PAHO and WHO in activities relatedto health and biomedical publications, infor-mation, and documentation. PAHO hostedthe annual meeting of the PAHO/WHO Pub-lications Policy Coordination Committee,which included representation of the EURO,SEARO, and EMRO publications programs.

7.3 Scientific publications. Despite a se-vere shortage of staff, the Editorial Service is-sued 35 Scientific Publications during 1984(see table 19), an unprecedented number forthe program. The Editorial Service provideddirect support to 14 of PAHO's technical pro-grams by means of these publications, whichcovered the subjects of health technology de-velopment, health services delivery, healthsystems personnel, health systems develop-ment, epidemiology, health of adults, envi-ronmental health, maternal and child health,food and nutrition, tropical diseases, veteri-nary public health, emergency preparednessand disaster relief, health statistics, and thewomen, health, and development program.Each of these 35 publications represented animportant contribution to the promotion andexchange of health and biomedical informa-

118 Annual Report

Table 19. Publications issued by the PAHO Editorial Service in 1984

Serial No. Title Serial No. Title

Scientific Publications Scientific Publications

438 Suministros médicos con posterioridad a los desastresnaturales

442 Controle das doencas transmissíveis no homem, 13a.ed.

445 Terapia de rehidratación oral. Una bibliografía ano-tada

447 Epilepsia-manual para trabalhadores de saúde452 Diagnostic of Animal Health in the Americas452 Diagnóstico de la salud animal en las Américas456 Compéndio codificado da classificajáo de tumores457 Pautas para adiestrar en nutrición a trabajadores de

salud en la comunidad458 Trastornos depresivos en diferentes culturas459 Experiencia nacional en el empleo de trabajadores

comunitarios en salud460 Prevention and Control of Genetic Diseases and

Congenital Defects460 Prevención y control de las enfermedades genéticas y

los defectos genéticos460 Preveniao e controle de enfermidades genéticas e os

defeitos congénitos461 Salud materno-infantil en las Américas: hechos y ten-

dencias462 Policies for the Production and Marketing of Essential

Drugs: Technical Discussions of the XXIX Meetingof the PAHO Directing Council, 1983

462 Políticas de producción y comercialización de medi-camentos esenciales: Discusiones Técnicas de laXXIX Reunión del Consejo Directivo de la OPS,1983

463 Certificados de vacunación requeridos para los viajesinternacionales y advertencias a los viajeros, 1984

464 Women, Health and Development in the Americas.An Annotated Bibliography

464 La mujer, la salud y el desarrollo en las Américas.Una bibliografía anotada

465 Quimioterapia da lepra para programas de controle466 Criterios de salud ambiental 14-Radiación ultra-

violeta467 Criterios de salud ambiental 15-Estaño y compues-

tos orgánicos de estaño468 Criterios de salud ambiental 16-Radiofrecuencias y

microondas469 Seguridad en la calidad en radiología de diagnóstico

470471

471

472473

473

474

474

475476

476

Seguridad en la calidad en medicina nuclearEpidemiology and Control of Falciparum Malaria in

the AmericasEpidemiología y control de malaria causada por Plas-

modium falciparum en las AméricasInmunizaciones: Información para la acciónCommunity Participation in Health and Development

in the AmericasLa participación de la comunidad en la salud y el de-

sarrollo en las AméricasDevelopment and Implementation of Drug Formula-

riesElaboración y utilización de formularios de medica-

mentosLas drogas, el conductor y la seguridad en el tránsitoIII Inter-American Meeting on Animal Health at the

Ministerial LevelIII Reunión Interamericana de Salud Animal al Nivel

Ministerial

Official Documents

192 Final Report of the PAHO Directing Council, XXIXMeeting/Informe Final del Consejo Directivo de laOPS, XXIX Reunión

193 Précis Minutes of the XXIX Meeting of the DirectingCouncil of PAHO/Actas Resumidas de la XXIXReunión del Consejo Directivo de la OPS

195 Précis Minutes and Final Report of the 91st and 92ndExecutive Committee Meetings of PAHO/ActasResumidas de la 91a y 92a Reuniones del ComitéEjecutivo de la OPS.

Periodicals

Boletín de la Organización Panamericana de la Salud(12 numbers)

Bulletin of the Pan American Health Organization(4 numbers)

Educación médica y salud (4 numbers)Epidemiological Bulletin (6 numbers)Boletín Epidemiológico (6 numbers)

tion in the Americas. The Organizationbrought together special expert groups whosedeliberations resulted in numerous originalpublications, included in table 19.

7.4 Official documents. In 1984 threeofficial documents were issued: Final Reportof the XXIX Meeting of the PAHO DirectingCouncil (bilingual, English and Spanish edi-tions), Précis Minutes of the XXIX Meeting ofthe PAHO Directing Council, and Précis Min-

utes and Final Report of the 91st and 92ndExecutive Committee Meetings of PAHO(multilingual) .

7.519.

Other publications are listed in table

7.6 Periodicals. Changes affecting theoverall publications program likewise affectedits various aspects. The production of the Bo-letín de la Oficina Sanitaria Panamericana,

Support Services 119

which issued 12 monthly numbers as usual,was transferred towards year end from MexicoCity to Washington, D.C. The Bulletin of thePan American Health Organization was thesubject of both a redesign and a major promo-tional campaign aimed at enhancing aware-ness of PAHO among English-speaking read-ers. Educación médica y salud issued its fourregular numbers; and the EpidemiologicalBulletin/Boletín epidemiológico published sixissues in both English and Spanish.

7.7 Distribution and sales. During 1984,PAHO presented its publications in 11 na-tional and international conferences. The fol-lowing promotional projects were imple-mented: improvement of the complimentarydistribution of the Scientific Publications by of-fering recipients a choice of subjects, expan-sion of booksellers, and preparation of lists forshipment of promotional copies of the Scien-tific Publications. A review was carried out ofpaid subscriptions to the Boletín de la OficinaSanitaria Panamericana with the offer of re-newal. Another review was done of compli-mentary lists of subscribers to the Boletín andEducación médica y salud. As a result of thepromotional efforts, during 1984, the distribu-tion and sales of PAHO publications exceeded1983 figures by 68%. The Revolving SalesFund for Publications collected US$136,302and totaled US$337,496 at the end of 1984.

7.8 Visual aids. The visual aids programseeks to identify national technology centersand promote joint PAHO/WHO activitieswith them. The filmstrip on infant diarrhealdiseases was completed and distributed to allmaternal and child care centers. Three newsets of slides with descriptive narratives wereissued on the following subjects: "Hand-Com-pression Sprayer," vector control in the wakeof a natural disaster (English and Spanish),and "The Natural History, Epidemiology, andControl of Chagas' Disease." The Spanishversion of the latter is being prepared underthe title La historia natural, epidemiología ycontrol de Chagas. The following materialswere distributed in response to MemberCountry requests: 1,900 copies of filmstrips,

271 sets of slides with a printed narrative,1,631 color graphs, and 4,450 half-framemounts for converting filmstrips to slides.

Translations

7.9 Translation services were providedfor technical units and programs. The materialtranslated included operational and adminis-trative reports, working papers for meetings ofthe Governing Bodies and other groups con-vened by the Organization, documents issuedby the Office of the Director, technical articles,and regulations. In addition, translation ser-vices were provided at meetings of the Gov-erning Bodies and PAHO/WHO-sponsoredtechnical conferences and seminars. Morethan 30,000 pages were translated into En-glish, Spanish, Portuguese, and French.

7.10 Machine translation. SPANAMcompleted 5 years of service translating Span-ish into English for users at PAHO Headquar-ters, centers in the field, and WHO/Geneva.At the same time, ENGSPAN, a new systemfor translating from English into Spanish, be-gan to produce large-scale output in two ma-jor pilot projects. Both systems are wholly de-veloped and owned by PAHO.

7.11 At year's end, ENGSPAN had pro-duced a total of 641 pages for publication.SPANAM, in the meantime, continued toprove its utility and cost-effectiveness, pro-ducing a total of 3,152 pages under 267 as-signments during 1984.

7.12 The SPANAM and ENGSPAN dic-tionaries expanded in the course of interactionwith the terminology function carried out bythe same office. At year's end, SPANAM hada database of 61,240 terms and ENGSPANhad 43,825.

PASB Information Systems

7.13 The office in charge of these systemshas been structured into four functional areas:

120 Annual Report

user support, computer systems, systems de-velopment, and special projects. Accomplish-ments in 1984 included the following: asmooth transition was made to the new struc-ture; the several alternatives in hardware andsystems software were studied for the futureoperating environments; development of awide range of standards was started includingdocumentation standards; a comprehensivetraining plan for technicians and end userswas prepared and the initial course offeringswere presented; the large number of requestsfor programming support was organized andsteps were initiated which will lead to a reduc-tion of the backlog in this area; and all basicsoftware installed in PAHO's computationalequipment was updated. In addition, a list ofapproved products was developed to be usedas the basis for purchasing microcomputerequipment and a microcomputer laboratorywas created for testing new products, devel-oping applications, and training users.

Public Information

7.14 In 1984, a bimonthly newsletter,PAHO in Action, began publication with theobjective of keeping employees in the fieldand at Headquarters informed of PAHO's ac-tivities. PAHO/WHO continued to respondto growing numbers of inquiries, from boththe press and the public, about the Organiza-tion and its programs. To help increase publicawareness of PAHO/WHO, the Office pre-pared slide shows and videotapes (in Spanishand English) describing the Organization andits activities and new pamphlets and brochuresdescribing the Organization and its programswere designed and printed in both languages.The Office coordinated the design and publi-cation of several special booklets using colorphotographs, including one on the CentralAmerican "Bridge for Peace" health plan andanother on children's health in the Americasissued for World Health Day. Material onWorld Health Day, including articles, black-and-white photographs, and color slides, wasdistributed throughout Latin America and the

Caribbean. A collaborative effort betweenPAHO and the American Association forWorld Health generated several hundred ob-servances of World Health Day throughoutthe United States of America.

Legal Matters

7.15 The Organization continued to pro-vide advisory services for the solution of spe-cific problems at the request of Member Gov-ernments. Chile received assistance to solvinga problem encountered in the purchase of flu-oride for a dental caries prevention program,and Guatemala in defining the bases for therelationship among its Government, INCAP,and PAHO/WHO. Two studies were subse-quently begun in this field-one on legislationgoverning production and marketing of drugs,and the other on medical equipment technol-ogy.

7.16 In the course of the year, the Orga-nization signed seven Basic Agreements onPrivileges and Immunities-with Argentina,Belize, Guyana, Haiti, Mexico, Paraguay,and Peru-along with an addendum to theBasic Agreement with Brazil, a Basic Techni-cal Cooperation Agreement with Mexico, andnine General Agreements for Cooperationwith other institutions. In addition, PAHO en-tered into five agreements for the conduct ofenvironmental health programs with Bolivia,Colombia (2), Costa Rica, and the DominicanRepublic; an agreement with Costa Rica onmaintenance of health facilities; and an agree-ment with Peru on educational technology inhealth.

7.17 Finally, 12 interagency agreementswere signed with UNDP (4), UNICEF (3), IDB(1), and GTZ (4) for joint technical coopera-tion programs in Colombia, Cuba, the CentralAmerican countries and Panama, DominicanRepublic, Peru, Trinidad and Tobago, andtwo regional programs.

7.18 A reference center on health legisla-tion and the legal aspects of health was estab-lished in PAHO's Legal Affairs Unit. The Unit

Support Services 121

provided support services to the Director,technical units, PAHO/WHO Country Of-fices, and the Regional Centers in connectionwith internal legal matters.

Administrative Support

General and Conference Services

7.19 General services. To implementthe decision to eliminate the Area Offices, thePAHO/WHO Country Representatives of Ar-gentina, Guatemala, Mexico, Peru, and Ven-ezuela developed proposals for discussionwith the governments regarding operatingcosts and office space for the new Country Of-fices. At the same time, studies were begun todetermine the future use of the physical facili-ties of the former Area buildings, all of which,except for the Mexico office, are owned byPAHO. As instructed by the PAHO ExecutiveCommittee, an agreement was signed with aWashington developer which will allowPAHO to proceed with the necessary arrange-ments for the construction of the addition tothe Headquarters office building on the Gov-ernor Shepherd and adjacent sites. The nextsteps for PAHO will be to review the proposedarchitectural plan and to develop a compre-hensive study of space and functional require-ments for the Washington office.

7.20 Conference services. Conferencepersonnel participated in the organization of410 meetings held at Headquarters orthroughout the Hemisphere which were con-voked by the Organization or the MemberCountries. Major efforts were focused on theXXX Meeting of the Directing Council, andthe 92nd, 93rd, and 94th Meetings of the Ex-ecutive Committee. The Word ProcessingUnit offered support for meetings as well as forthe technical departments at Headquarters.

Personnel

7.21 During the period under review,several major activities were carried out in the

areas of post classification, staffing, and staffdevelopment and training, in order to supportthe policy of administrative decentralization,the conversion from Area to PAHO/WHOCountry Offices, and strengthening of overallmanagerial capabilities at Headquarters and inthe field.

7.22 The Master Standard of the Interna-tional Civil Service Commission was formallyadopted for the grading of posts in the profes-sional and higher categories. Implementationprogressed with a series of briefings for profes-sional staff at the executive and manage-ment-supervisory levels, as well as for allother professional staff.

7.23 Work was completed for the devel-opment of an orientation program for profes-sional staff at senior levels, designed to facili-tate the integration of newly recruited staff intothe Organization and their subsequent reori-entation to the changing needs of the Organi-zation.

7.24 The use of special service agree-ments was expanded for hiring national ex-perts on PAHO/WHO projects in order tomaximize the scope of cooperation availablefrom national resources. The term "temporaryadvisers" was extended to include those per-sons recruited under the concept of TechnicalCooperation Among Developing Countries.

7.25 Equally important was the plannedinstitution of an integrated approach to theclassification, recruitment, training and devel-opment, and evaluation of general servicesstaff at Headquarters. The-structure, now inpreparation, has as its ultimate aim staffing ofthe Secretariat that fully meets the basic crite-ria of efficency, competence, and integrity.

7.26 Likewise under study is the Organi-zation's performance appraisal policy, theneed for revising the existing arrangements,and development of a proposed design.

7.27 Staff strength at the end of 1984 was1,165 (and 41 short-term employees). Ofthese, 57% were assigned to the field. In1984, PAHO's permanent staff decreased by

122 Annual Report

4%, continuing the trend observed in the pre-vious year. The number of consultants andtemporary advisers contracted was 1,570 in1984, as compared to 1,632 experts in 1983.The proportion of female staff in the profes-sional and higher categories remained stableat 22% throughout the Organization.

Procurement

7.28 The Organization purchased sup-plies, equipment, and services to supportPAHO Headquarters, PAHO/WHO proj-

ects, and Member Countries under the Reim-bursable Procurement Program and the Ex-panded Program on Immunization. Total pro-curement by the Organization for MemberCountries was US$3,796,000 for the Ex-panded Program on Immunization andUS$6,433,500 for other programs. Theseother programs included US$1.7 million fordrug purchases. In addition to responding toincreasing numbers of requests for drug pro-curement, the Procurement Office provideddrug price and source information to MemberCountries. Purchases for goods and servicesfor PAHO/WHO-funded projects totaledUS$11,340,500.

Part VCountries' Activities with

PAHO/WHO Cooperation

Chapter 8. Summary of Each Country's Activitieswith PAHO/WHO Cooperation

8.1 Based on the information receivedfrom the countries on the activities carried outin 1984, within the joint programming Govern-ment/PAHO/WHO, individual country sum-maries have been elaborated which appear inthis chapter. In these summaries, emphasis isplaced on the efforts of each Member Govern-ment to solve its priority problems, in accor-dance with the national and regional objec-tives.

8.2 Furthermore, basic information is be-

ing provided regarding the state of health andthe socioeconomic situation, with the aim ofdeveloping a simplified country profile.

8.3 Also, some substantive data regardingresource mobilization is presented in this chap-ter. This information is not exhaustive, it needsmore in-depth verification and only tries toshow the extent of the external financial re-sources that the Government has negotiatedwith donor or lending institutions.

125

Antigua and BarbudaBasic Data

Demographic Indicators

Estimated population (in thousands)Percentage of urban population

(as nationally defined)Birth rate/1,000 inhabitantsMortality rate/ 1,000 inhabitants

YEAR NUMBERCoverage IndicatorsPercentage of children under 1 year

1983 78,000 immunized against:-diphtheria-whooping cough-tetanus

1980 32.61977 20.4

State of Health Indicators

Life expectancy at birthInfant mortality/1,000 live birthsMaternal deaths/1,000 live birthsDeath rate 1-4 years/ 1,000 childrenPercentage of newborn with a weight of

less than 2,500 gramsAvailability of calories

per capita/dayAvailability of proteins (grams)

per capita/day

Percentage of deaths due to:infectious and parasitic diseasestumorsheart diseasesmotor vehicle traffic accidents

19831983

70.011.1

(triple vaccine)-poliomyelitis-measles-tuberculosis

Percentage of population served withpotable water

Percentage of population served bysanitary waste disposal

Consultations per inhabitant per year1983 0.2 Number of discharges per 100 inhabitants

0.1 Number of beds per 1,000 inhabitants

1982 8.2 RHuman Resource IndicatorsPhysicians per 10,000 inhabitants

1979-81 1,979 Nurses per 10,000 inhabitantsNursing auxiliaries per

1979-81 55.0 10,000inhabitants17- 55.0

1978197819781978

2.016.017.6

Health ExpenditureHealth Expenditure per capita (in US$)Total health expenditure as a percentage

of the GDPPercentage of the National Budget

dedicated to health

YEAR NUMBER

1983 100.01983 100.0

1983 95.0

1983

1984

100.0

6.9

1984 4.51984 16.0

1984 19.0

1983 184

1983 6.2

1983 11.8

... Data not available.- None.

Activities with PAHO/WHOCooperation

Development of the health serviceinfrastructure

8.4 A national health policy was ap-proved that reflects Antigua and Barbuda's ac-ceptance of the primary health care strategy asthe principal means to achieve health for all bythe year 2000. A health planner was ap-pointed to the Ministry of Health's headquar-ters' staff. The Health Planning Committee,organized in 1983, began functioning in 1984and is expected to present a health plan earlyin 1985.

8.5 In human resources, senior nurseswere oriented on Caribbean standards ofnursing care, permitting the development ofguidelines for personnel performance ap-praisal. A community health nursing coursefor public health nurses and inservice educa-tion in management for ward sisters at Holber-ton Hospital were instituted and are continu-ing. The Organization supported and hostedtwo subregional workshops in Antigua, oneon community participation and the other onhealth systems development.

8.6 For most of the year, the problems ofdrought dominated the environmental healthprogram; accompanying concerns about wa-ter quality emerged during the months of wa-

127

128 Annual Report

ter importation, storage, and vehicular trans-portation. The Government considered aPAHO/WHO sewerage system proposal forSt. John's.

Health promotion and diseasecontrol

8.7 In collaboration with the CaribbeanFood and Nutrition Institute (CFNI), the Na-tional Nutrition Committee prepared a foodand nutritional policy for the country. Antiguacontinues to promote breastfeeding and im-proving management of dietary proceduresfor diabetes, hypertension, and obesity.

8.8 A new pediatric ward at the Holber-ton Hospital is almost completed; it promisesto enhance the quality and range of secondarycare in Antigua. The Maternal and ChildHealth Committee remains active, and inte-gration with family planning and primaryhealth care is progressing satisfactorily. A newproject proposal directed to family life educa-tion and family planning specifically for ado-lescents has been approved by UNFPA forfunding over a 3-year period. PAHO/WHOhas provided administrative and technicalsupport to new UNFPA-funded projects.

8.9 The Government continues to stresssurveillance and control of communicable dis-eases. The implementation of the ExpandedProgram on Immunization (EPI) has beenvery satisfactory. The Caribbean Epidemiol-ogy Center (CAREC) is assisting the Govern-ment in developing and strengthening thecountry's epidemiological surveillance and isproviding opportunities for health personnelto participate in workshops and other trainingactivities. A national workshop on primaryhealth care and surveillance was developed.Antigua and Barbuda received assistancefrom the Pan Caribbean Disaster Prepared-ness Health Team, which is stationed in Anti-gua.

Mobilization of Technical andFinancial Resources

8.10 International cooperation: WHO/IPPF gave US$53,000 for a population anddevelopment project (1983-1986); WFP/FAO, US$79,000 for supplemental feeding tovulnerable groups (October 1984-December1986); and UNFPA, US$14,500 for familylife education-family planning services for ad-olescents (1984).

8.11 Bilateral cooperation: USAID pro-vided US$25,000 for the construction of ahospital pediatric unit, USAID/Caribbean De-velopment Bank gave US$78,000 for a basicneeds trust fund; the Republic of Korea andVenezuela gave US$87,000 and US$30,000for garbage collectors, respectively.

8.12 Foundations: the Mellon Founda-tion provided US$40,000 for a laboratory andmortuary.

Cooperation Provided byPAHO/WHO

8.13 Professional staff assigned to thecountry: 2 full-time consultants, one in nurs-ing and the other in statistics and information.A regional adviser and the Pan Caribbean Di-saster Preparedness Health Team are based inthe country. Most cooperation is provided bythe Organization's staff in other parts of theCaribbean and from Headquarters, CAREC,CFNI, and other Centers of the Organization.Consultants were provided to collaborate withthe Government in its efforts in health systemsdevelopment, disaster preparedness, diseasecontrol, environmental health services, nutri-tion, vector control, maternal and childhealth, and veterinary public health.

8.14 Fellowships: 7, in: statistics, pri-mary health care, food analysis, alcoholism,hepatitis, and laboratory technology. PAHO/WHO funding was US$40,982. The Euro-pean Economic Community (EEC)-Carib-bean Community (CARICOM) funds

Summary of Each Country's Activities

supported additional training for three nation-als in ward management (Barbados), commu-nity nutrition (Barbados), and laboratorymanagement.

General Appraisal and FutureTrends

8.15 In response to the hardships suf-fered because of the long drought, the Gov-ernment has proposed increased develop-ment of the water supply (with externalassistance). Attention also will be paid to envi-ronmental health operations at the field level,utilizing primary health care strategies whenfeasible.

8.16 Following up on the introduction offamily life education within the Teacher'sTraining College and strengthening nursingmidwifery and neonatal care are importantprogram activities which have been given pri-ority in 1984.

8.17 With the support of the Organiza-tion, a thorough analysis of the health situa-tion will be conducted early in 1985 as thestarting point for the managerial process. Thepresence of resident PAHO staff membersand the establishment of a country PAHO/WHO office will ensure the continuity ofPAHO/WHO's cooperation to the country,mainly in the areas of planning and informa-tion.

129

130 Annual Report

ArgentinaBasic Data



(as nationally defined)Birth rate/ 1,000 inhabitantsMortality rate/1,000 inhabitants


Life expectancy at birthInfant mortality/1,000 live birthsMaternal deaths/1,000 live birthsDeath rate 1-4 years/1,000 childrenPercentage of newborn with a weight of



per capita/day


YEAR NUMBER

Coverage IndicatorsPercentage of children under 1 year

1984 30,097,000 immunized against:-diphtheria-whooping cough-tetanus

1980 83.0 (triple vaccine)1982 23.4 -poliomyelitis1981 8.4 -measles

-tuberculosisPercentage of population served with

potable waterPercentage of population served by

1980-85 69.7a sanitary waste disposal1982 30.1 Consultations per inhabitant per year1981 0.7 Number of discharges per 100 inhabitants1981 1.5 Number of beds per 1,000 inhabitants

Human Resource IndicatorsPhysicians per 10,000 inhabitants

1979-81 3,380 Nurses per 10,000inhabitantsNursing auxiliaries per

1979-81 112.7 10,000inhabitants17- 112.7

1980198019801980

4.016.745.1

1.5



dedicated to health

YEAR NUMBER

1983198319831983

62.091.060.061.0

1980 6 9.0b

1980198019801980

79.26.2'6.6'5.4

1980 2 4 .8d1980 5 .8d

1980 8 .9d

1983 US$2,972

1984 3.0

... Data not available.a Age for men, 65.4; for women, 72.1. b Urban population; ruralpopulation,17%. c Metropolitan area of Buenos Aires. dDoes notinclude personnel working only in private practice.

Activities with PAHO/WHO was restructured, priority work areas were de-fined, and closer coordination with the prov-inces and territories was sought through theFederal Health Council (CONFESA). In an ef-

Development of the health service fort to bring the public and private subsectorsinfrastructure and social agencies into a unified system, leg-

islation was drafted providing for the creation8.18 In 1984, the Government adopted a of a system of National Health Insurancegeneral health policy under which the overall based on linking the installed capacity of socialresponsibility for health sector activities-in- agencies with that of private sector and pre-cluding the integration of health programs payment systems with the aim of increasingwith other social priorities such as nutrition, the coverage of services. As part of thishousing, community development, and cop- scheme, a survey of operating capacity, ar-ing with emergency situations-was central- ranged by politico-administrative jurisdictionized in the Ministry of Health and Social and by area of knowledge, is being made forAction. To implement this policy, the Ministry the purpose of defining the needs for human


resources and for technical cooperation be-tween the central and provincial governmentsand among provinces. In addition, efforts arebeing made to obtain better coordinationamong the information system of the Depart-ment of Health of the Province of Buenos Ai-res, the Municipal Government of Buenos Ai-res, and the National Institute of Social Work.In administrative reform and institutional de-velopment, a joint training program involvingthe participation of the Department of Healthand the University of Buenos Aires (School ofPublic Health and Faculty of Economics) wasformulated. A survey to obtain information onhealth sector financing and expenditures-anessential input for the implementation of thenational health plan and the national healthinsurance proposal-was prepared and wasbeing implemented.

8.19 In human resources, emphasis wasplaced on developing provincial courses andseminars for existing staff. The deans of medi-cine and dentistry of nine universities and di-rectors of schools of nursing examined theirinstitutions' curriculum structures, teaching-learning process, and instrumental resourcesfor the purpose of adjusting them to the uni-versities' new approach to academic mecha-nisms and administrative structures. Activitiesunder the textbook program increased as aresult of a wider dissemination of its purposesand improved accessibility by the program'sintended beneficiaries.

8.20 The following activities stand out inenvironmental health: development of waste-water treatment technology (Central Univer-sity, National Water Supply Service, andCEPIS); re-equipping for occupational hy-giene and radiation health programs; and pre-sentation of courses on basic rural sanitation,urban sanitation, solid waste management,and radiation health.


8.21 Following approved policies and pri-

orities and directing emphasis to groups re-garded as vulnerable, the national, provincial,and municipal health authorities intensifiedthe services within programs for maternal andchild health, control of diarrheal and acuterespiratory diseases, the Expanded Programon Immunization (EPI), cardiovascular prob-lems, and the health of workers and the el-derly. A course on maternal and child healthwas conducted, and a survey on delivery ofservices to that group was initiated.

8.22 The National Congress enacted leg-islation establishing a National Food Plan(PAN) and a Drug Assistance Fund (FAM)based on proposals developed by the Ministryof Health and Social Action and approved bythe Executive Branch. These instruments rep-resent an attempt to ameliorate two pressingdeficiency problems-food and drugs.

8.23 In epidemiology, a working groupheaded by the Ministry of Health and SocialAction and the School of Public Health wasestablished to conduct surveillance operationsas well as service, teaching, and research pro-grams. In the area of noncommunicable dis-eases, studies continued on arterial hyperten-sion, with emphasis on the prevalence ofcardiovascular risk factors.

8.24 Work in the laboratory utilizationfield included a survey of the institutes at-tached to the Under-Secretariat for HealthPrograms and the food control program, car-ried out with the cooperation of CEPANZO.


8.25 International cooperation: UNDPprovided US$22,000 for development of avaccine against hemorrhagic fever, and IDBallocated US$7 million for control of leprosy,Chagas' disease, and malaria in rural zones.

8.26 Bilateral cooperation: The Gov-ernments of Germany, Italy, Japan, and the

131

132 Annual Report

Netherlands supplied fellowships for thehealth sector, with no specific amount offunds allocated. Approximately 208 privatefoundations invest nearly US$2 million in dis-ease prevention and control and medical careactivities.

8.27 Foundations: The W. K. KelloggFoundation donated US$300,000 for the de-velopment of physical resources, andUS$50,000 for a maternal and child healthprogram.


8.28 Professional staff assigned to thecountry: 4, the PAHO/WHO Country Rep-resentative and advisers in health systems,laboratory services, and sanitary engineering.

8.29 Regional and intercountry advis-ers: 3, for a total of 510 days, in: epidemiol-ogy, nursing, and information systems; 54 re-gional, intercountry, and Center advisers, for192 days, in: epidemiology, nursing, informa-tion systems, rehabilitation, maternal andchild health, cancer, sanitary engineering, vi-ral and bacterial respiratory infections, medi-cal education, planning, and drugs.

8.30 Short-term consultants (STC):134, for a total of 694 days, in: nursing ser-vices, mental health, medical care, health sys-tems, nutrition, maternal and child health,drugs, epidemiology, chronic diseases, theExpanded Program on Immunization, phar-macology, laboratory services, health re-search, sanitary engineering, hospital archi-tecture, occupational therapy, informationsystems, health legislation, neonatology, den-tistry, administration of health services, andanimal health.

8.31 Fellowships: 47, for a total of 33months, for studies abroad in: maternal andchild health, cancer, epidemiology, medical li-brary science, laboratories, veterinary medi-

cine, and physical medicine. Total cost wasUS$46,775. In addition, 88 fellows fromother countries came to Argentina to pursuestudies in various health-related fields.

8.32 Courses, seminars, and work-shops: 34 workshops and seminars, with 476participants, on information systems, plan-ning, primary care, dentistry, epidemiology,occupational health, sanitary engineering,mental health, human communications, ma-ternal and child health, and chronic diseases;and 10 courses on tuberculosis bacteriology,environmental sanitation, planning, adminis-tration of health services, and information sys-tems. PAHO/WHO's financial participation inthese activities came to US$183,747.


8.33 In the course of the year, the Gov-ernment gave special priority to health pro-grams addressed to the neediest segments ofthe population. Regrettably, economic con-straints prevented a more effective expressionof this political decision.

8.34 The strengthening of the Ministry ofHealth and Social Action provides a favorableopportunity to improve coordination and inte-gration within the health system in such a wayas to ensure effective sector-wide leadership.While the Government has little leeway to re-allocate funds in line with priorities, the socialcompact mechanism and the National HealthInsurance proposal may be helpful in over-coming this constraint. The strengthening ofthe Ministry of Health and Social Action is ex-pected to be completed fairly soon, enablingthe Ministry to assume its function of guidingnational health policy. The National HealthInsurance proposal should help to producenew and positive changes. The formulation ofnational short- and medium-term policies (forthe constitutional term of the Government),based on the electoral platform, as well as the


formulation and implementation of the rele-vant programs, will confer consistency andcredibility onto the health sector.

8.35 The demand for technical coopera-tion will increase considerably, as already evi-

denced by developments in the latter monthsof 1984. Advisory services and cooperation intraining, research, and the distribution andproduction of instructional materials will cen-ter around the formulation of projects and theconducting of studies.

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134 Annual Report

BahamasBasic Data



(as nationally defined)Birth rate/ 1,000 inhabitantsMortality rate/l 1,000 inhabitants


Life expectancy at birthInfant mortality/ 1,000 live birthsMaternal deaths/ 1,000 live birthsDeath rate 1-4 years/1,000 childrenPercentage of newborn with a weight of



per capita/day

Percentage of deaths due to:infectious and parasitic diseasestumorsheart diseasesmotor vehicle traff ic accidents






1980 69.3 sanitary waste disposal1980 27.7 Consultations per inhabitant per year1982 0.8 Number of discharges per 100 inhabitants1982 1.0 Number of beds per 1,000 inhabitants

Human Resource IndicatorsPhysicians per 10,000inhabitants

1979-81 2,200 Nursesper 10,000inhabitantsNursing auxiliaries per

1979-81 62.2 10,000inhabitants17- 62.2

1982198219821982

1.620.115.93.7



dedicated to health

YEAR NUMBER

198319831983

1983198319831983

65.065.067.0

2.5 a

11.64.3

1983 9.81983 42.9

1983 7.9

1982 207

1982 5.9

1982 14.7

... Data not available.a Includes primary health and general practice, accident and emergency, and specialized clinics.



8.36 Priorities in 1984 included develop-ing and strengthening the administrative struc-ture in order to function effectively within aframework of evolving policy adjustments, in-cluding the decentralization of the health caredelivery system. The health policy documentis being revised as a prerequisite to the devel-opment of a written health plan. Concomi-tantly, the health information system is being

strengthened. Intersectoral deliberations havecommenced to determine alternative methodsof health financing; one possibility being con-sidered is some form of health insurance, per-haps a national insurance.

8.37 In human resources, training ofhealth personnel-through fellowships, atten-dance at seminars, workshops abroad, and in-country training-continued apace with bothnational and PAHO/WHO funding. Signifi-cant areas of training included biostatistics,dental public health, nutrition, disaster man-agement, oncology, environmental health,health systems development and manage-ment (including supply management), andcontrol of communicable diseases.


8.38 In environmental health, the dis-posal and management of solid waste deterio-rated to unsatisfactory levels during this re-porting period. This has been attributed tostaff turnover, problems with equipment andstaff expertise, and the increased generationof solid waste resulting from an upturn in tour-ism. The Organization provided prompt short-term assistance. The Government has alsomoved rapidly to upgrade equipment andidentify personnel for further training. Withthe return of a qualified government analyst,there was a significant renewal of activities inoccupational health. It is expected this willcontribute to the upgrading of the services ofthe government laboratory, as well as stimu-late renewed input from the Pan AmericanCenter for Human Ecology and Health (ECO)in Mexico.


8.39 Increased emphasis is being given tothe development of a nutrition policy, startingwith the establishment of a nutrition surveil-lance system with technical input from CFNI.Training in communicable disease controlcontinues to be an important and effective ac-tivity in PAHO/WHO's overall program oftechnical cooperation. Training is receivedthrough numerous courses and workshops atthe Trinidad headquarters of CAREC, as wellas incountry training.

8.40 A nation-wide problem of drugabuse surfaced in 1984, resulting in the crea-tion of a national level task force on drugabuse.


8.41 Professional staff assigned to thecountry: 2, a PAHO/WHO Program Coordi-nator and a statistician.

8.42 Regional and intercountry advis-ers: In addition to the resident PAHO/WHOstaff members, other advisers located in vari-ous parts of the Caribbean, as well as fromHeadquarters, CAREC, and CFNI, providedassistance in disease prevention and control,environmental health, nutrition, nursing edu-cation, veterinary public health, sexuallytransmitted diseases, drug abuse, health sys-tems development, manpower, andoncology.

8.43 Short-term consultants (STC): 6,for 127 days, in: sexually transmitted dis-eases, environmental health, oncology, andhealth legislation.

8.44 Fellowships: 7, in: health serviceadministration, community nutrition, environ-mental health, disaster management, medicalrecords, laboratory management, and com-municable disease control, at an estimatedcost of US$34,000.


8.45 All levels of PAHO/WHO re-sponded promptly whenever there was aneed for their cooperation. This was exempli-fied in the case of the solid waste disposal andmanagement problem; timely PAHO/WHOconsultation contributed to solving this prob-lem. With PAHO/WHO's full-time statisti-cian, posted in late 1983, and the imminentaddition of a trained national biostatistician tohead the Health Information Unit, the interna-tional assistance should be even more effec-tive. Development of a health plan will neces-sitate technical input from PAHO/WHO, andsubregional and possibly regional resourceslikely will be required. The Organization's re-sources at various levels also may be tapped inassisting the Government in the area of drugabuse. The prerequisites are being defined forthe establishment of a cancer registry; how-ever, further technical input from PAHO/WHO will be required, including a workshopto be held in the second quarter of 1985.

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136 Annual Report

BarbadosBasic Data





Life expectancy at birthInfant mortality/1.000 live birthsMaternal deaths/ 1,000 live birthsDeath rate 1-4 years/1,000 childrenPercentage of newborn with a weight of



per capita/day







1983 69.8 sanitary waste disposal1983 24.5 Consultations per inhabitant per year... ... Number of discharges per 100 inhabitants

1983 0.5 Number of beds per 1,000 inhabitants


1979-81 3,020 Nurses per 10.000 inhabitants1979-81 3,020 Nursing auxiliaries per

1979-81 86.3 10,000 inhabitants17- 86.3

1982198219821982

2.317.120.5

1.1



dedicated to health

YEAR NUMBER

198319831983

73.066.066.0

1983 100.0

1983198319831983

90.03.08.38.0

1983 8.51983 30.0

1983 12.0

1983 310.7

1983 4.0

1983 15.1

... Data not available.a Not given routinely to children less than 1 year of age.



8.46 As part of a national developmentplan, the country has developed a health sec-tor plan whose primary goal is the establish-ment of a national health service, the firstphase of which-the Barbados Drug Ser-vice-is already in existence. The next phase,the general practitioner service for the over 65and under 5 age groups, is now being intro-duced. The Barbados Drug Service and theMental Hospital are WHO Collaborating Cen-

ters. The Inter-American Development Bank(IDB) is funding projects for the improvementof the Queen Elizabeth Hospital and PAHO/WHO is providing technical cooperation inthis endeavor. The Organization has contin-ued to support specific nursing services man-agement and organization of health care activ-ities.

8.47 In human resources, PAHO/WHOsupported a 6-week course for public healthstudents and served as external examiner atthe Barbados Community College; 16 stu-dents participated in the course.

8.48 In environmental health, thestrengthening of water and sanitation agenciescontinued as part of the national environmen-


tal health program. In the management of theWater Authority, attention was directed to-ward the computerization of water and sewer-age records, while staff of the EnvironmentalEngineering Unit received professional train-ing abroad. Preliminary investigations werecarried out on the environmental health as-pects of tourism, and building control proce-dures were reviewed. In an effort to developthe occupational health and safety program,special training and sensitization activitieswere carried out.


8.49 The national family planning pro-gram is in the process of development. Atraining program for nurses and teachers infamily life education and family planning hasbeen implemented.

8.50 With support from the CaribbeanFood and Nutrition Institute (CFNI), the Na-tional Food and Nutrition Committee pre-pared a food and nutrition policy proposal forBarbados. Disease prevention and controlactions continued to stress the Expanded Pro-gram on Immunization. Emphasis in noncom-municable diseases is on hypertension, diabe-tes, and cancer, as well as the prevention oftraffic accidents and alcoholism.

8.51 Development of improved relation-ships and functions between the Ministries ofAgriculture and Health for food protectionwas discussed during Government andPAHO/WHO officials' meetings in Bridge-town.


8.52 Technical Cooperation AmongDeveloping Countries (TCDC): Barbados isin the forefront of TCDC arrangements withthe East Caribbean territories.

8.53 International cooperation:UNICEF assisted in programs of research inchild care; and IDB donated US$190,000 forconstruction of health care facilities (1984-1989), extension of the sewerage system, andfor a small projects program.

8.54 Bilateral cooperation: Assistancewas received for health development andmanagement from USAID, from the Univer-sity of the West Indies, and from the AmericanPublic Health Association. Also assistancewas received from USAID, for maintenance ofequipment; from the International PlannedParenthood Foundation, for family planningservices; and from the European EconomicCommunity, for construction of a child devel-opment center (1984-1985).


8.55 Professional staff assigned to thecountry: 10, including the Caribbean Pro-gram Coordinator (CPC), who is also thePAHO/WHO Country Representative forBarbados, medical officers, a scientist, a sani-tary engineer, a nurse, health educators, atechnical officer, and an administrative officer.

8.56 Short-term consultants (STC): 5,in: environmental health aspects of tourism,building control, occupational health andsafety, and computerization of water and sew-erage records.

8.57 Fellowships: 26, in: laboratorymanagement, vector control, meat process-ing, geriatric medicine, occupational safetyand health, public health administration,pharmacy, primary health care, communitynutrition, nursing education, alcoholism, in-dustrial hygiene, management systems, den-tal auxiliary, tuberculosis, veterinary publichealth, nursing administration, and health sci-ences. The cost was US$104,750.

8.58 Courses, seminars, and work-shops: 4, in: environmental health aspects of

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138 Annual Report

tourism, occupational health and safety, andsolid waste management planning in the Car-ibbean.

8.59 Grants: US$5,000 was provided forsurveying the health needs of the elderly andUS$15,000 for studying drug utilization in thecountry.


8.60 Barbados subscribes fully to theAlma-Ata Declaration on primary health care,and PAHO will continue supporting Govern-ment efforts to expand national health ser-vices. A major and urgent need is the reorgan-ization of the Ministry's central level. Althoughweekly meetings are held between Govern-ment health authorities and PAHO/WHO of-ficials, more systematized dialogue is neededon infrastructure and program development.

8.61 The recent introduction of family

planning and family life education within theMinistries of Health and Education calls forcontinued follow-up and support in these ar-eas when requested by the Government.

8.62 In Barbados and throughout theCaribbean, there is a need to evolve the legis-lative and practical means to improve the or-ganization and coordination of the Ministriesof Health and Agriculture to ensure a safe andwholesome supply of food, especially meat.Developments in this regard are consideredcrucial in Barbados and Jamaica.

8.63 In environmental health, the author-ities channeled PAHO/WHO cooperation tostrengthen the institutional resources andmanagement. Traditional program activitieswere reviewed and possible new program ar-eas were explored with the aim of striking abalance between the two. This approach islikely to continue, especially because Barba-dos will be increasingly used as a "donor"country to achieve TCDC in the Eastern Car-ibbean.


BelizeBasic Data



(as nationally defined)Birth rate/ 1,000 inhabitantsMortality rate/ 1,000 inhabitants





per capita/day








Human Resource Indicators'... ... Physicians per 10,000 inhabitants


1979-81 67.7 10,000inhabitants17- 67.7

1982198219821982

8.87.6

21.21.7



dedicated to health

YEAR NUMBER

1982198219821982

61.265.250.784.9

1983 70.0

1983198319831983

70.01.9

10.32.5

1983 5.11983 17.2

1983 7.0

1983 30.0

1983 3.0

1983 10.0

... Data not available.



8.64 The Five-Year National Health Planwas completed and presented for circulationin final form. Specific projects were formu-lated for health infrastructure development,based on the general objectives and strategiesidentified in the Plan. Planning capabilitieswere strengthened at the central ministeriallevel, and the programming and supervisory

skills of mid-level managers were developedthrough national training workshops. TheGovernment is institutionalizing mechanismsfor achieving integrated planning and devel-opment of the public sector-includinghealth, education, agriculture, and economicdevelopment-at both the central and periph-eral levels.

8.65 A long-term strategy was developedfor strengthening and extending primaryhealth care (PHC) services. For this purpose,the pilot Toledo District PHC project was eval-uated, and specific project proposals for im-proving the health care delivery infrastructure

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140 Annual Report

and support services were channeled throughPAHO for external funding. The Governmentexpects to extend the PHC program through-out the country over the next 5 years, utilizingvillage-level community health workers.

8.66 With reference to human resources,a 1-week workshop was held for senior offi-cials of the Ministry of Health, Labour, andSports and representatives from the Ministryof Education and the Belize College of Arts,Science, and Technology to formulate poli-cies and strategies for health personnel plan-ning and development. This workshop waspresented jointly with the CARICOM HealthDesk. The Belize School of Nursing revised itsprofessional, practical, and nursing midwiferycurricula.

8.67 In environmental health, the Minis-try of Health, Labour, and Sports conducted areview of existing environmental health legis-lation. Cooperation also is taking place in thedevelopment of a local training program forenvironmental health officers. The food sani-tation program is being strengthened throughtraining and updated legislation. Recentagreements with USAID, UNICEF, CARECand the Canadian Government will providethe funding necessary for implementing therural water and sanitation projects prepared in1983.


8.68 An updated report of the food andnutrition situation in Belize was prepared, aswell as project proposals for external fundingfor the development of a nutrition unit and anutrition surveillance program. The Ministryof Health, Labour, and Sports has introducedthe use of the home growth chart in all healthcenters and is preparing a country-wide sur-vey on hemoglobin levels in pregnant women,with CFNI and UNICEF support. A 3-year,UNFPA-funded project for maternal and childhealth (MCH) and family planning started in1984 with an evaluation of the efficiency of

MCH programs at health centers and hospi-tals. This evaluation served as the basis for ad-justing programs and procedures and identify-ing priority needs in physical facilities andequipment. The Ministry of Health, Labour,and Sports is developing a program to providecommunity-based rehabilitation services. Oralhealth programs were evaluated, and localprogram staff received training.

8.69 In epidemiology, CAREC providedsupport for the development of the epidemio-logical surveillance program, including on-sitetechnical assistance in the investigation of ahepatitis outbreak. An extensive evaluation ofthe Expanded Program on Immunization(EPI) was conducted, and a project proposalfor strengthening EPI activities has been ap-proved for funding by Rotary International.EPI coverage continued to improve in 1984.The Ministry of Health has improved the mon-itoring and supervision of EPI activities at thedistrict and national levels. Both UNICEF andPAHO/WHO provided cold chain equipmentfor the program. All EPI vaccines were ob-tained through the regional Revolving Fund.

8.70 The intensive efforts of the 1983malaria program have arrested the progres-sive deterioration noted in recent years. Thepercentage of increase in 1984 was smallerthan in the previous period. For the first timein many years, spraying operations obtained100% coverage of all dwellings in the attackarea in both spray cycles. PAHO/WHO alsoprovided support in carrying out a country-wide entomological assessment and in prepar-ing a plan of operations on which a USAID-funded project for malaria eradication will bebased. This US$500,000 program will pro-vide supplies, equipment, training, technicalassistance, and facilities to strengthen malariacontrol over the next 3 years.

8.71 The tuberculosis control programwas evaluated and specific recommendationswere made concerning its organization. Fewercases were reported than in the previous year.However, case control and management atthe district level continued to be deficient.



8.72 In 1984, local investigators initiatedor completed five national research activitieswith technical or material support fromPAHO/WHO: infant morbimortality survey;KAP (knowledge, aptitude, and practice) sur-vey on fertility and related issues; communityparticipation in two health projects; malariaand migration; and ethnic attitudes and prac-tices regarding diarrheal diseases.

8.73 Technical Cooperation AmongDeveloping Countries (TCDC): The Gov-ernments of Mexico and Belize signed anagreement of technical cooperation to im-prove health conditions in their common bor-der area. PAHO/WHO was requested to pro-vide support for the implementation of theagreement. Mexico will provide technical as-sistance in vector control, malaria, MCH, andhealth education, as well as training of healthworkers in different fields. Also, at the requestof the Ministry of Health, PAHO/WHO is fa-cilitating the cooperation of the Governmentof Brazil in providing technical and financialassistance to Belize for hospital construction.

8.74 International cooperation:UNICEF provided US$600,000 for theToledo District rural water supply and sanita-tion project, US$200,000 for a health educa-tion school, and US$15,000 for the primaryhealth care Cayo project; and UNFPA con-tributed with US$190,000 for maternal andchild health and family planning services.

8.75 Bilateral cooperation: USAID allo-cated US$500,000 for a malaria and Aedesaegypti program and US$300,000 for the Be-lize/Cayo rural water and sanitation projects;and the British Overseas Development Ad-ministration donated US$150,000 for reno-vation of hospital and health center equip-ment and US$100,000 for a health centerrenovation.

8.76 Nongovernmental organizationsand foundations: Project Concern Interna-

tional gave US$100,000 for the Toledo PHCproject; and Rotary International, US$50,000for strengthening EPI.


8.77 Professional staff assigned to thecountry: The PAHO/WHO Country Repre-sentative.

8.78 Regional and intercountry advis-ers: 22 for 372 days, in the following fields:primary health care and health service infra-structure, nutrition, maternal and child health,diarrheal diseases, epidemiology, immuniza-tion, entomology, and vector control.

8.79 Short-term consultants (STC): 15,for 314 days, in the following fields: healthplanning, nursing education, environmentalhealth, research methodology, mental health,oral health, immunization, maternal and childhealth, health legislation, tuberculosis, ma-laria, and sexually transmitted diseases.

8.80 Fellowships: 20, in the followingfields of study: primary health care, nursingadministration, health research, clinical medi-cine, nutrition, dental auxiliary, laboratorymanagement, food sanitation, and vectorcontrol. PAHO/WHO's contribution wasUS$100,000.

8.81 Courses, seminars, and work-shops: 8, with 280 participants and PAHO/WHO's contribution of US$126,000, in thefollowing areas: supervisory course for thecontrol of diarrheal diseases, health personnelplanning, services for the handicapped, ma-laria voluntary collaborators, malaria micros-copists, and international disease classifica-tion.


8.82 PAHO/WHO's involvement in thedevelopment of the health sector in Belize has

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142 Annual Report

been growing and has contributed significantlyto improving the quality and accessibility ofhealth services. Technical cooperation wasprovided in more areas; new fields of devel-opment such as mental health, oral health,health education, services for the handi-capped, health research, allied health train-ing, and others are demanding the Organiza-tion's support. Current efforts to introduceand develop rational planning and program-ming methodologies need to be strengthenedwithin the framework of the Government'scommitment to the PHC strategy. It remains

important to support the development ofqualified national leaders and managers inhealth, as well as the country's commitment toachieving a greater self-sufficiency in humanresources.

8.83 Finally, as other agencies begin toprovide more material and technical assis-tance in developing the health sector in Belize,there is a rising need to achieve interagencycoordination to avoid unnecessary duplicationof efforts and lighten the burden of over-worked government officials.


BoliviaBasic Data



(as nationally defined)Birth rate/ 1.000 inhabitantsMortality rate/ 1.000 inhabitants

YEAR NUMBER

1984 6,253,000

19841980-851980-85

46.844.015.9


Life expectancy at birthInfant mortality/ 1,000 live birthsMaternal deaths/1,000 live birthsDeath rate 1-4 years/1,000 childrenPercentage of newborn with a weight of



per capita/day


1980-851980-851980-85

50.7129.048.0


immunized against:-diphtheria-whooping cough-tetanus




Consultations per inhabitant per yearNumber of discharges per 100 inhabitantsNumber of beds per 1,000 inhabitants

1981 10.0 Human Resource IndicatorsPhysicians per 10,000 inhabitants


1979-81 54.6 10,000 inhabitants17- 54.6

1980 16.6



dedicated to health

1983198419841983

1980 36.0

1980 18.0

1981

1982 5.11980 1.7

1980 4.5

1982 2.0

1981 6.0

1980 18.3




8.84 The Ministry of Social Welfare andPublic Health undertook a functional reorgan-ization in which the central structures andhealth units were grouped together into nucleiforming a chain of command reporting even-tually to the Office of the Minister. Itwas hoped that this arrangement wouldstrengthen the Ministry's role in the govern-ance of the health sector. In addition, an effort

was made to strengthen relations between theinstitutional sector and the organized commu-nity by placing the operation of the People'sHealth Council and Committees on a formalbasis and instituting a strategy of people's mo-bilizations.

8.85 Within the context of the nationalhealth policy, the grouping of the functionalunits and the definition of eight lines of strate-gic strength made it possible to develop an ef-fective type of planning by means of whichmanagement was improved substantially inthe face of resource constraints, traditional redtape, and a complex national situation. A be-ginning was made on integrating and develop-

YEAR NUMBER

16.680.062.046.4

1.8

143

144 Annual Report

ing a system of services at the local level(health areas) by implementing the Compre-hensive Health Area Activities Plan (PIAAS).The Plan was applied initially in 50 areas, andfunding was provided for extending it to 150of the country's 800 urban and rural areas bythe end of the year. This institutional coverageprocess is supplemented by the coverage pro-vided by the people's mobilizations.

8.86 Various programs of disease con-trol, sanitation, and social communication arebeing integrated into the operational structureas their vertical organization is graduallyphased out. The major participants in the Planare the Ministry of Social Welfare and PublicHealth and the organized social sector, con-sisting of the People's Health Council and thePeople's Departmental and Local Commit-tees-these consisting, in turn, of representa-tives of the Bolivian Labor Federation, thePeasants Confederation, the NeighborhoodBoards, universities, students, the MedicalCollege, an so on. These organizations, to-gether with the Ministry and its regional struc-tures, have held five congresses of People'sHealth Committees in each department forthe purpose of reviewing health policy, publicneeds, possibilities, and community participa-tion.

8.87 A number of developments in 1984were conducive to progress in the linkage ofsocial security with the Ministry of Health andother sectoral components. These includedthe arrangement for centralized procurementof drugs through the National Institute of Med-ical Supplies (INASME), the determination ofa salary policy for the health professions, andthe impetus given to priority areas such as hu-man resource development, control of diar-rheal diseases, and the implementation ofPIAAS.

8.88 In the field of human resources, theauthority of the Ministry of Social Welfare andPublic Health was strengthened in matterspertaining to the regulation, planning, and uti-lization of health personnel on a nationalscale. This led to the creation of a National

Commission on Teaching-Service Integra-tion, which, acting in conjunction with the uni-versities, delineated national intersectoral pol-icies and promoted changes in the institutionsinvolved. In addition, a national human re-source system involving the participation ofthe Schools of Public Health in La Paz andCochabamba, the Multiprofessional TrainingInstitute, and the medical care agencies of thenational service network was launched. AMaster of Public Health course was estab-lished for the first time in Bolivia. A continuingeducation program is already in operation,and a National Center for Educational Tech-nology in Health has been established.

8.89 In the implementation of programs,particular emphasis was placed on adequateutilization of existing human resources. An ex-ample of this was the decision to organize all800 health areas of the PIAAS coverage-ex-tension program using available physiciansand professional nurses.

8.90 Participation by the organized com-munity is a priority of Bolivia's health policy.This involvement was encouraged by con-ducting orientation courses; the first result wasthe development of the People's Health Mobi-lizations, which contributed substantially tothe progress made in certain programs. Thus,in the Expanded Program on Immunization,the coverage of the poliomyelitis and measlesvaccination drives was increased from 20% to80% and oral rehydration salts were used ona massive scale.

8.91 Outstanding developments in envi-ronmental health were the construction of wa-ter and sanitation infrastructure in the Depart-ments of Cochabamba and Tarija and thedevelopment of works based on appropriatetechnologies in rural areas and marginal urbancommunities, as well as the training of person-nel. A number of projects for investments inurban and rural water and sanitation facilitieswere formulated. A solid waste managementprogram was undertaken with the support ofthe People's Mobilizations, and a pilot pro-gram was initiated at El Alto de La Paz.



8.92 In view of the seriousness of Boliv-ia's food and nutrition situation, various rapid-response plans were prepared in addition tosupplemental food programs. A project for in-creasing the supply of milk under socially af-fordable conditions was formulated. Also, anational plan was instituted for establishingpeople's child care centers to provide foodand comprehensive care to preschoolers atnutritional risk. The production and mass con-sumption of iodized salt was encouraged as ameans of combating endemic goiter. The ini-tiatives on behalf of preschoolers are linkedwith the PIAAS, which is the focus of all ma-ternal and child and worker's health care ef-forts. A new drug policy, aimed at supplyingthe needs of the population in a socially affor-dable manner, is a fundamental step in ex-tending the coverage of services.

8.93 Organized community participationmade it possible to take measures of far-reach-ing importance for the prevention of poliomy-elitis and measles (80%) and of diphtheriaand tetanus, yellow fever, and tuberculosis.New malaria control strategies were being ap-plied in the northern part of the country, andthe campaign against Chagas' disease was ini-tiated with a People's Mobilization against thevinchuca and introduction of housing im-provements. In addition, integrated vectorcontrol programs were considered and the tu-berculosis control program was being revised.A diarrheal disease control program waslaunched with the mass distribution of oral re-hydration salts.


8.94 In the area of generation and dis-semination of knowledge, a Department ofResearch was established within the Ministry

of Social Welfare and Public Health with theaim of defining a joint research policy with theSan Andrés University, the Academy of Sci-ences, and the Ministry of Planning.

8.95 Technical Cooperation AmongDeveloping Countries (TCDC): Bolivia andBrazil entered into a technical cooperationagreement including a section on develop-ment of human resources in the public healthsector by the Ministry of Social Welfare andPublic Health of Bolivia and the School ofPublic Health of Rio de Janeiro, an agency ofthe Oswaldo Cruz Foundation. The agree-ment covers the areas of research, services,administration, planning, epidemiology, so-cial sciences, occupational health, and humanresource research. Negotiations were under-taken with Argentina, Cuba, and Brazil in aneffort to encourage TCDC programs.

8.96 International cooperation: Interna-tional Concern donated US$675,000 for im-plementation and development of an exten-sion coverage plan, and UNICEF, US$1.8million for the rural integrated development ofthe Departments of Oruro, Chuquisaca, Po-tosí, and Tarija.

8.97 Bilateral cooperation: JICA (Ja-pan) donated US$16.8 million (2 years) forthe Santa Cruz General Hospital; GTZ andKfW (Germany), US$1,612,903 for a basichealth program in Oruro; Dan Church Aid(Denmark), US$290,000 (3rd phase) for theprovision of integrated primary health care inLos Andes Province, La Paz; Andean RuralHealth Corporation, US$300,000 for ruralAndean development; Government of GreatBritain, US$1 million for administration anddelivery of health services and developmentof human resources; Technical Cooperationof Switzerland, US$400,000 (1980-1986)for the health project of Chuquisaca, andUS$1 million for the health project of Izozog,Santa Cruz; and USAID, US$310,000 for ru-ral health, US$1 million for the control of con-tagious diseases, and US$1.2 million for recu-peration in case of emergencies.

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146 Annual Report


8.98 Professional staff assigned to thecountry: 8, including the PAHO/WHOCountry Representative; advisers in planningof health programs, nutrition, nursing and ad-ministrative methods, health administration,human resources and research; and two sani-tary engineers.

8.99 Regional and intercountry advis-ers: 27, for a total of 206 days, in: nutrition,systems engineering, textbook program, ac-counting, development of health services,nursing, animal health, medical records, ma-ternal and child health, sanitary engineering,supplies, epidemiology, and malariology.

8.100 Short-term consultants (STC):16, for a total of 463 days, in: epidemiology(Chagas' disease), human resources, diar-rheal diseases, sanitary engineering, environ-mental pollution, information systems, plaguecontrol, malaria, mental health, and statistics.

8.101 Fellowships: 12, for a total of 56.5months, at a cost of US$79,100, in: leproder-matology, malariology, occupational health,immunology, hemorrhagic fever, tuberculo-sis, parasitology, planning, and vaccine con-trol.

8.102 Courses, seminars, and work-shops: 57, for approximately 1,500 to 2,000participants. These events received a totalPAHO/WHO contribution of US$118,631.


action and, while advances were evident,progress-especially in institutional develop-ment-was impeded by a number of prob-lems. The requirements of a dynamic plan ofaction, together with the seriousness of the cri-sis, constitute an incentive to improve themeans for achieving better internal coordina-tion and a better combination of domestic ef-forts with the cooperation provided by inter-national, bilateral, and nongovernmentalagencies. The mechanisms for programming,implementing, and monitoring PAHO's coop-eration with the Government are character-ized by frequent workshops, analysis, contin-uous reprogramming and adjustment, andstandardization of requests for assistance. Ef-forts also are being made to increase the coun-try's capacity for programming and utilizingexternal resources and for negotiation. TheGovernment improved its procedures for theformulation and management of projects,thereby speeding up their development andincreasing the levels of implementation, in-cluding budget execution. Other items worthyof note were the compilation of an inventoryof nongovernmental cooperative agenciesand the holding of a national meeting of inter-national and nongovernmental organizationsattended by delegations from 70 agencies ac-tive in the country.

8.104 The manner in which the Organi-zation is providing its cooperation, as well asthe manner in which the Government and thesocial sector are utilizing it, warrant the expec-tation that the cooperation will continue evenif adjustments are made to the new Govern-ment's plans.

8.103 The health sector stepped up its


BrazilBasic Data



(as nationally defined)Birth rate/ 1.000 inhabitantsMortality rate/ 1.000 inhabitants





per capita/day







1980-85 63.5 sanitary waste disposal1980 87.3 Consultations per inhabitant per year1980 1.3 Number of discharges per 100 inhabitants1980 3.8 Number of beds per 1,000 inhabitants

Human Resource Indicators*... ... Physicians per 10,000 inhabitants


1979-81 59.4 10,000 inhabitants17- 59.4

1980198019801980

14.89.5

29.43.4



dedicated to health

... Data not available.a Urban population; the rate for the rural population was 67.2% in 1983. b Urban population; the rate for the rural population was only6.5% in 1983. ' Ambulatory consultations through the National Institute of Medical Care of the Social Security (INAMPS).



8.105 Better coordination at the Stateand Municipal levels, achieved with the helpof the Interministerial Planning Commission,contributed to implementing the strategy of in-tegrated health actions. As part of this strat-egy, and to bring together the service efforts atall three levels, a methodology was designedto facilitate linkage and harmonious develop-ment. This linkage fell short of the goal be-cause of a sharp reduction in Federal funds,

especially for Social Security. These con-straints and other factors of a political naturealso affected the negotiations with the WorldBank (IBRD) on the Sao Paulo and Northwesthealth programs.

8.106 In human resources, the essentialactivities were harmonized and integratedwithin the framework of the health actionsstrategy. Steps were taken to continue inser-vice training for middle-level staff in fiveStates, and instructor-supervisors in maternaland child health and communicable diseaseswere retrained. In medical education, the sur-vey of the country's schools of medicine wascompleted, its results were analyzed. andstrategies for the adjustment and updating of

YEAR NUMBER

1984198419841980

65.095.087.559.4

1983 93.7

19831980

1980

60.4b

1.5'

4.3

1980 8.61980 1.0

1980 25.2

147

148 Annual Report

curricula were redefined. A review of practice,education, and research in the nursing field,conducted with the participation of the Minis-tries of Education, Social Security, andHealth, provided the basis for the formulationof a joint plan of action to be initiated in 1985.The Brazilian Institute of Geography and Sta-tistics, the National School of Public Health,and PAHO/WHO conducted a survey ofavailable health sector personnel with a viewto improving their utilization.

8.107 In environmental health, the mag-nitude and complexity of existing problemsand the large number of Federal agencies andorganizations involved made it necessary todevelop linkage mechanisms, such as the unitestablished to coordinate the formulation andimplementation of the basic sanitation pro-grams being conducted in the Northwest andin Rio Grande do Sul with the assistance ofIBRD. In addition, greater impetus was givento the National Sanitation Plan (PLANASA);in addition to providing the means for makingbetter use of resources, PLANASA has madeit possible to harmonize national goals withthose of State governments and to ensure aneffective contribution by the National HousingBank (BNH). The Secretariat for the Environ-ment carried out an intensive program of tech-nology development and staff training, espe-cially in the area of water quality and controllaboratories.

8.108 The Brazilian portion of the PanAmerican Network of Information and Docu-mentation in Sanitary Engineering and Envi-ronmental Sciences (REPIDISCA) was ex-panded to include 28 national technicalinformation centers.


8.109 Salient activities in food and nutri-tion included the supplementary feeding forundernourished pregnant women and pre-schoolers, the formulation of a policy for in-cluding nutrition in maternal and child health

programs, the evaluation of the basic foodtraining program in low-income areas, and theiodized salt distribution program for the con-trol of goiter.

8.110 The integrated health care pro-gram for women and children was instituted in10 States and the Federal District. Its initial ac-tivities included the strengthening of manage-rial capacity, review of techniques and proce-dures, and training of personnel. A substantialreduction in the number of cases of poliomye-litis (from 2,400 in 1980 to 33 in 1984) wasobserved. Poliomyelitis vaccination coverageof newborn infants increased to 87 %. Measlesand DPT vaccination remained at the 1983levels of protection. Cold chain improvementswere made as a result of revised proceduresand the training of personnel.

8.111 The program for control of majorendemic diseases-a priority activity beingconducted through the Superintendency ofPublic Health Campaigns (SUCAM)-intensi-fied its linkage with health sector institutionsand other sectors, especially in the interest ofstrengthening programs against malaria andother tropical diseases. Malaria continued tobe a serious problem, although restricted tothe Amazon Region. Transmission was re-duced, however, in Mato Grosso, Amazonas,Acre, and Goias. A number of research activi-ties were stepped up to find solutions to thisproblem, notably the inventory of researchprojects, which was completed during theyear; the setting of priorities; and tests to de-termine the efficacy and feasibility of usingmefloquine. As for Chagas' disease, attackphase operations involving the use ofpyrethroids in the control of triatomides wereextended to new areas (Ceará, Piauí, and RioGrande do Norte). The program of Aedesaegypti surveillance was continued in 3,960strategic localities throughout the country.This vector was eradicated in the State of RioGrande do Norte and in Roraima. Schistoso-miasis control, based on early case detectionand treatment and the destruction of foci of in-fected mollusks, continued to be carried out in16 Federal entities. The studies on the im-


munoprophylactic elements produced by theUniversity of Minas Gerais for the control ofleishmaniasis were expanded, and reportingsystems were improved.

8.112 The National Institute for QualityControl in Health consolidated its food anddrug control operations. The National Com-mission on Revision of the Brazilian Pharma-copeia completed and published the first vol-ume of the revision. The program for theproduction of reference chemicals advancedand was being coordinated with similar pro-grams of other Latin American countries (suchas Argentina and Mexico).


8.113 Technical Cooperation AmongDeveloping Countries (TCDC): Intranationalhorizontal cooperation in environmentalhealth was strengthened and expanded withthe inclusion of organizations that have at-tained an exceptional capacity in terms oftechnical, scientific, and administrative-insti-tutional infrastructure. These agencies havecollaborated with other national, state, and lo-cal entities in the planning and execution ofprojects. In intercountry cooperation, the Su-perintendency of Campaigns (SUCAM) ex-tended technical cooperation to Bolivia, Para-guay, and Uruguay in the structuring ofChagas' disease control programs. It also col-laborated with Bolivia in a review of the prob-lems presented by other tropical diseases.

8.114 International cooperation:UNFPA provided US$15 million for inte-grated maternal and child health care and IDBgave. US$450,000 for studies to improve pri-mary care for low-income groups.


8.115 Professional staff assigned to the

country: 19, including the PAHO/WHOCountry Representative and advisers in sani-tary engineering, epidemiology, institutionaldevelopment, development of health ser-vices, drug control, malaria eradication, ma-ternal and child health, and human resources.

8.116 Short-term consultants (STC):48, for a total of 1,253 days, in: sanitary engi-neering, dentistry, health services, serology,leprosy, disease research, biomedical engi-neering, occupational health, pneumology,maternal and child health, laboratories, tuber-culosis, pharmacology, health facilities archi-tecture, thoracic surgery, alcoholism, reha-bilitation, cancer, radiology, hospitaladministration, vaccines (BCG), veterinarymedicine, food quality control, perinatology,and hemotherapy.

8.117 Fellowships: 129, for a total of148 months, in: mental health, veterinarypublic health, sanitary engineering, immunol-ogy, maternal and child health, food and drugcontrol, epidemiology, leprosy, chronic dis-eases, human resources, nursing, nutrition,cancer, vector control, health services, labora-tories, medical library science, dentistry, sexeducation, toxicology, pneumology, andother areas. PAHO/WHO contributedUS$380,668.

8.118 Courses, seminars, and work-shops: 32, with 2,419 participants, in: envi-ronmental health, water quality control, birthcontrol, breastfeeding, instructor training,health technology, social communication, ep-idemiology, toxic product surveillance, toxi-cological analysis, international healthactions, interdisciplinary research, hospitaladministration, pneumology, cold chain, ro-dent control, hospital medical care, interna-tional classification of diseases, essentialdrugs, basic sanitation, floods, water supply,health systems development, communicablediseases, human resource development,nursing, auxiliary health services, and hospitalcosts. The cost of these events for PAHO/WHO was US$243,777.

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150 Annual Report

8.119 Grants: PAHO/WHO providedgrants at a cost of US$229,108 in: malariaand yellow fever control and eradication, hos-pital infections, health information, interna-tional health systems, diarrheal disease infec-tions, acute respiratory infections, mentalhealth, primary care, environmental health,nursing, a traveling seminar on scientific coop-eration in health, and supply of drugs at themeeting of the National Research Commis-sion.


8.120 Health conditions in Brazil gener-

ally reflect those in the Region, and the Gov-ernment's priorities are consistent withPAHO/WHO Regional Strategies. Action bythe national authorities was subject to con-straints deriving from the political transition in1984. Such constraints have also negative re-percussions on PAHO/WHO technical coop-eration. Consequently, it is necessary to re-view with the new authorities the strategiesand priorities of PAHO/WHO cooperationand adjust them within the framework of theGovernment's overall and health policies.Given the limited availability of resources, ef-forts should focus on the areas of strongest im-pact, particularly new approaches, more ef-fective technology, and the development ofhuman resources. An evaluation of the na-tional health system also is advisable.


British West IndiesBasic Data (for British Virgin Islands only)



(as nationally defined)Birth rate/ 1.000 inhabitantsMortality rate/ 1,000 inhabitants


Life expectancy at birthInfant mortality/ 1,000 live birthsMaternal deaths/1,000 iive birthsDeath rate 1-4 years/1,000 childrenPercentage of newborn with a weight of



per capita/day

Percentage of deaths dueto:infectious and parasitic diseasestumorsheart diseasesmotor vehicle traffic accidents



... ... (triple vaccine)1982 18.0 -poliomyelitis1982 5.4 -measles



... ... sanitary waste disposal

1982 41.0 Consultations per inhabitant per year1983 - Number of discharges per 100 inhabitants1983 2.0 Number of beds per 1,000 inhabitants

Human Resource IndicatorsPhysicians per 10,000 inhabitantsNurses per 10,000 inhabitantsNursing auxiliaries per

10,000 inhabitants

1983198319831983

1.20.30.2



dedicated to health

YEAR NUMBER

198319831983. . .

89.074.089.0

1984 90.0

1983 85.01983 50.01983 7.41983 4.7

1983 8.01983 31.7

1983 22.5

1981 135

1981 5.5

1980 11.2




8.121 This report includes the followingcountries: Anguilla, British Virgin Islands, andMontserrat. These Governments are continu-ing to strengthen their human resources bymeans of training through workshops or fel-lowships. PAHO/WHO has supported theorientation of senior nursing personnel to Car-ibbean standards of nursing care.

8.122 National environmental healthprograms proceeded satisfactorily in these

countries without major events or develop-ments. Due to limited resources, assistancewas minimal, but water (Anguilla) and health(Montserrat) agencies were represented at asubregional workshop on water quality con-trol.


8.123 Regarding Anguilla, family plan-ning (FP) and family life education (FLE) wereincorporated into the maternal and childhealth program. FLE activities within theschool system and out of school declinedsomewhat because the three family life educa-

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152 Annual Report

tors trained under the UNFPA-funded andFLE project entered the Ministry of Educationas full-time teachers. This was compoundedby a delay in selecting and appointing a healtheducator to commence in the third quarter ofthe year. The new Government expressed theneed to reactivate health/FLE, and funding isbeing sought from UNFPA for a project di-rected to FLE. The basic child health services,including immunization, maintained good lev-els of coverage.

8.124 In the British Virgin Islands, FP andFLE were incorporated into the maternal andchild health services. The main objectives ofthe FLE and FP program are to introduce FLEwithin the school system, make FP available inhealth clinics, and provide FP services for ad-olescents. The FLE curriculum was completedand placed within the health sciences courseof the high school. FP services are now avail-able in six clinics scattered throughout the is-lands. The parent effectiveness training pro-gram in FLE, including sex education formembers of the Parent/Teachers' Associa-tion, was carried out successfully in fourschools.

8.125 The British Virgin Islands joinedthe Caribbean Family Planning Association,which provides educational material tostrengthen FLE and FP activities. To keepabreast of changes, the FP nurse receivedtraining in FP and the family life educator at-tended an international conference on FLE inMexico. Policies and procedures for the ma-ternity ward are being developed in order toimprove services by maintaining standards.

8.126 In Montserrat, the FLE programcomes under the Ministry of Education. FP ac-tivities continued to be the main responsibilityof the Montserrat FP Association. A healthand FLE manual to be used by teachers wasdeveloped, and it will serve as one way of pro-moting and strengthening FLE within theschool system.

8.127 Surveillance and control of com-municable diseases continued to have a high

national priority in all of the territories. Theyparticipated in the immunization programand, with CAREC's assistance, are develop-ing and strengthening their surveillance andlaboratory capabilities. Collaboration fromCFNI continued in 1984.


8.128 International cooperation:UNFPA donated US$30,120 for family plan-ning/FLE distributed as follows: AnguillaUS$2,600, British Virgin Islands US$15,820,and Montserrat US$11,700.

8.129 Bilateral cooperation: USAID/IPPF gave technical cooperation for FamilyPlanning Services in Montserrat.


8.130 Professional staff assigned to theislands: Although no full-time professionalstaff were assigned to any of these islands,considerable cooperation was provided by theOrganization's staff located in other parts ofthe Caribbean, Headquarters, CAREC, andCFNI. Consultants from the CPC's Officewere provided to collaborate with govern-mental efforts in health systems development,personnel, disaster preparedness, diseasecontrol, environmental health, zoonoses andvector control.

8.131 Fellowships: 11, in: health educa-tion techniques, midwifery, hepatitis, meatand other foods, middle management, alco-holism, public health administration, and lab-oratory services. PAHO/WHO funding wasUS$27,040. In addition, training was pro-vided for three nationals of Montserrat in labo-ratory management (Saint Lucia), ward man-agement (Barbados), and communitynutrition (Barbados), utilizing European Eco-


nomic Community-Caribbean Community(EEC-CARICOM) Secretariat funding.


8.132 PAHO/WHO collaboration withthe Governments is expected to continuealong the same lines in the years to come.PAHO/WHO will support a thorough healthsituation analysis in 1985 as the first step topromote the managerial process.

8.133 In Anguilla, a new project proposalto UNFPA for funding of FLE/FP activities

should restore momentum to the maternaland child health aspect of the health services.In the British Virgin Islands, FLE in secondaryschools progressed; however, there is a needto introduce this subject in primary schools.The parent effectiveness training programshould be further developed in the four mainislands. Continued support should be given tothe development of the maternal and childhealth manual and the policy and proceduremanual. In Montserrat, PAHO/WHO willprovide continued support in FLE, perinatalcare, and updating knowledge and skills inmaternal and child health care with referenceto postnatal care.

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154 Annual Report

CanadaBasic Data

YEAR NUMBER




1984 25,]

1984. . .





per capita/day


1981198219821982


128,000 immunized against:-diphtheria-whooping cough-tetanus

75.5 (triple vaccine)-poliomyelitis

·.. . -measles-tuberculosis


Percentage of population served by90.01 sanitary waste disposal

9.1 Consultations per inhabitant per year0.2 Number of discharges per 100 inhabitants0.5 Number of beds per 1,000 inhabitants

1982 58.b Human Resource IndicatorsPhysicians per 10,000 inhabitants


1979-81 98.2 10,000 inhabitants

Health ExpenditureHealth Expenditure per capita (in C$)

1982 0.5 Total health expenditure as a percentage1982 24.3 of the GDP1982 34.4 Percentage of the National Budget1982 0.9 dedicated to health

YEAR NUMBER

19831983

80.080.0

1982 97.0

1982198219801983

60.0550.0

16.116.2

1984 19.51984 86.9

1984 32.8

1982 1,220

1982 8.4

1982 13.5

... Data not available.a Age for women; for men, 72.0. b Excluding Newfoundland.

Analysis of the Steps Taken in1984 to Implement RegionalStrategies


8.134 The major Canadian initiative in1984 with respect to the health service infra-structure was the adoption of new Federal leg-islation in support of the national health insur-ance program (The Canada Health Act,1984), and the consequent repeal andamendment of existing legislation. The newact does not change the nature of the existing

health insurance program in Canada; rather,it consolidates the provisions of earlier legisla-tion into a single act and, by clarifying andstrengthening the program conditions and cri-teria, it reaffirms Canada's commitment to auniversal, prepaid national health insuranceprogram.


8.135 The new Government, elected in1984, confirmed that health promotion andillness prevention activities would be a particu-lar priority and that the current health system,


designed primarily to deal with sickness,would be supplemented by a policy frame-work designed to promote health, with em-phasis on such areas as new models of healthcare for the elderly and changes in personal

lifestyles to reduce use of tobacco, abuse of al-cohol, neglect of exercise, carelessness withdiet, and other lifestyle characteristics destruc-tive to health.

Technical and FinancialResources Provided to OtherPAHO Member Governments

Total DisbursementProgram Area or country (Canadian dollars) 1983/1984

Regional drug testing lab. Caribbean 231,500 2.1Occupational health Colombia 134,900Nursing education Colombia 159,500Continuing education in

health Latin America 960,000Rural water and health

education Nicaragua 2,310,900Radiotherapy Brazil 140,000Bone marrow transplants Brazil 50,000

8.136 The figures above should be readwith the following factors in mind:

(a) Most of the projects noted came onstream in Fiscal Year 1984-1985 orwere completed in 1982-1983,hence no disbursement figures for1983-1984.

(b) The list covers only projects fundedfrom the bilateral allocation. Signifi-cant disbursements in the health sec-tor through nongovernmental orga-nizations and institutions andthrough Mission Administered Funds(MAF) are not noted.

(c) Only projects specifically underhealth delivery and health educationhave been listed. Not included aremajor disbursements in health-re-lated fields such as potable water,sewage, and nutrition.

8.137 With reference to (b), for example,the MAF inventory for 1983-1984 showsover US$2,500,000 in small (between

US$1,000 and US$50,000) health and nutri-tion activities with local nongovernmental or-ganizations and communities in the Caribbeanand Latin America.

Future Trends in ProvidingTechnical and FinancialResources to PAHO MemberGovernments

8.138 The various governments establishthe orientations of future programs within thebilateral agreements to which Canada is aparty. The specialized sectors themselves aredefined by the governments according to theirindividual priorities. The governments, mem-bers to these agreements with Canada, tendto favor the planning, development, and eco-nomic sectors rather than the health sector. Itis, therefore, difficult to predict or define Can-ada's future trends in health; they depend onthe priorities of the other Member Govern-ments.

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156 Annual Report

ChileBasic Data




YEAR NUMBER

1983 11,682,000

1983 82.61983 22.71983 6.4





per capita/day


1983198319831983

67.121.8

0.41.1


immunized against:- diphtheria-whooping cough-tetanus

(triple vaccine)

-poliomyelitis-measles-tuberculosis




Human Resoaurce IndicatorsPhysicians per 10,000 inhabitants


1979-81 75.7 10,000 inhabitants1979-81 75.7

1983198319831983

3.616.127.612.4



dedicated to health

YEAR NUMBER

1984 92.31984 97.81984 90.81984 96.2

1985 99.0

.1985 80.01983 125.01983 8.91983 2.9

1982 10.01983 4.0

1980 20.7

1981 95

1983 6.0

1982 12.4



8.139 Pursuant to its medium-term strat-egies, the Ministry of Health designed a pro-gramming module for the national health ser-vice system to enable each service to define itsgoals and formulate its own programs. Vari-ous studies were undertaken to evaluate theoperational and implementing the capacity offacilities in the health care delivery system.The results should make it possible to identify

critical areas and adjust the system as needed.Community participation in the effort toachieve better levels of health facilitatedthe transfer of primary level health establish-ments to Municipal authorities with a view toextending the coverage of services and mak-ing them more accessible. The Ministry ofHealth retains responsibility for regulating, su-pervising, and evaluating the work of facilitiestransferred.

8.140 In the human resource area, a totalof 16 training courses, seminars, and work-shops on priority health areas, primary care,hospital administration, and the decision-making process were conducted for national


personnel. The Ministry also instituted a con-tinuing education scheme.

8.141 In environmental health, a sympo-sium on water supply and excreta disposal inunderserved urban areas and a seminar onenvironmental health planning were held.Equipment was provided for a water qualitycontrol laboratory operated by the Ministry.The Chilean portion of the Pan American Net-work of Information and Documentation inSanitary Engineering and Environmental Sci-ences (REPIDISCA) was consolidated.


8.142 The program of primary healthcare for mothers and children in rural areaswas evaluated and reformulated. Significantprogress was made in the immunization pro-gram: vaccination coverage rates increased to84% for DPT, 86% for poliomyelitis, 77% formeasles, and 87% for tuberculosis. The pro-grams for control of typhoid fever, hepatitis,and hospital infections were continued.

8.143 A seminar on mental health care atthe primary level was held, as was a course onbasic psychiatry for general practitioners. Withregard to cancer, a course was conducted onstatistical methods in cancer studies, researchon cancer chemotherapy was carried forward,and a subcenter was established at the Na-tional University as part of the Latin AmericanCancer Research Information Program (LA-CRIP). A survey on the needs of the elderlywas conducted to obtain basic information forthe design of a policy for the care of thisgroup. The national tuberculosis and acuterespiratory infections control program wasevaluated with a view to restructuring andstrengthening it. Further field tests of the oraltyphoid fever vaccine were conducted, and vi-rological techniques were improved. Addi-tional training courses were conducted andeducational materials were prepared andscheduled under the patient rehabilitationprogram.


8.144 In the area of generation and dis-semination of knowledge, the national priorityorder for research topics in the health sectorwas revised. High on the list are studies onhealth trends in health services, profile studieson physicians in the primary care field, andbirthweight trends.

8.145 International cooperation:UNICEF donated US$60,000 for a health ed-ucation program (3 years); UNDP,US$43,906 for the expansion and improve-ment of the Institute of Public Health (projectended in 1984); UNFPA, US$16,150 forfamily planning (project to end in 1985); andIDB, US$2.5 million for water and air pollu-tion control.


8.146 Professional staff assigned to thecountry: The PAHO/WHO Country Repre-sentative.

8.147 Regional and intercountry advis-ers: 53, for a total of 377 days, in: nursing,auditing, health of the elderly, Chagas' dis-ease, nutrition, essential drugs, human re-sources, occupational health, cancer control,Expanded Program on Immunization (EPI),radiology, and human reproduction.

8.148 Short-term consultants (STC):32, for a total of 625 days, in: hemotherapy,EPI, dentistry, health of the elderly, sexuallytransmitted diseases, disaster preparedness,solid waste management, health programs,water fluoridation, food control, leprosy, drugcontrol, teaching-service integration, and di-arrheal diseases.

8.149 Fellowships: 48, in: cancer epide-miology, WHO Special Program for Researchand Training in Tropical Diseases (WHO/

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158 Annual Report

TDR), animal health, Chagas' disease, para-sitic diseases, epidemiological surveillance,pediatric dentistry, human anatomy, nursing,public health, adult education, rural health,vector control, urban sanitation, intrahospitalinfections, psychiatry in chronic and acute dis-eases, respiratory diseases, and congenitalmalformations. PAHO/WHO contributedUS$113,080.

8.150 Courses, seminars, and work-shops: 13 courses in social communication,rehabilitation, public health, mental health,family planning, information, environmentalhealth, pediatric oncology, primary care andchild health, epidemiology, and women'sgeneral care; 9 seminars in environmentalhealth, social anthropology and research, tu-berculosis, diarrheal diseases, maternal andchild health, primary care, and epidemiology;and a workshop on information and docu-mentation (REPIDISCA). In addition, specialmeetings were carried out in human re-sources, disease control, and environmentalhealth. PAHO/WHO contribution to theseareas was US$58,200.

8.151 Grants: PAHO/WHO awardedUS$8,000 for public health workshops;US$12,680 for preparing the professionalprofile of physicians in the primary care field inChile; US$44,174 for a bronchial asthmastudy; US$1,200 for a study of birthweighttrends; US$1,000 for the first primary careworkshop at the Bío-Bío health service;US$2,000 for a study of decision-making au-thority at the various levels of care; andUS$2,500 for a survey on needs of the el-derly.


8.152 Chile has attained a high level ofmaturity in the definition and implementationof health policies, especially those pertainingto expansion of health service coverage, infra-structure development, rural services, mater-nal and child care, and diseases preventableby vaccination. Nonetheless, the health au-thorities have reaffirmed the Government'scommitment to the goal of health for all by theyear 2000. With this in view, the Ministry ofHealth periodically reviews priorities and ac-complishments to ensure that actions are re-sponsive to the real needs of the population.

8.153 The Ministry of Health believes thatthe improvement of a country's levels ofhealth is essentially a politicosocial processwhich must be triggered by a broad accep-tance of the role of the health sector andwhich, accordingly, requires close relationswith other development sectors. Its principalrelationship is with the Ministry of Education,which advises on food and nutrition matterspertaining to the lunch programs at schoolsand child care centers. It has also establishedcommittees for the study and control of alco-holism and drug addiction. The Ministry ofHealth conducts joint programs for childrenand adolescents in conjunction with the Gen-eral Directorate for Sports (Ministry of De-fense) and collaborates with the Ministry ofAgriculture on problems of pollution in farm-ing areas and on residual insecticide control. Italso collaborates with the commission for thestudy of milk problems.


ColombiaBasic Data





Life expectancy at birthInfant mortality/1.000 live birthsMaternal deaths/1,000 live birthsDeath rate 1-4 years/1,000 childrenPercentage of newborn with a weight of



per capita/day







1981 62.1 sanitary waste disposal1983 52.0 Consultations per inhabitant per year19791977

1.84.5

Number of discharges per 100 inhabitantsNumber of beds per 1,000 inhabitants

1977-81 3.4 Human Resource IndicatorsPhysicians per 10,000 inhabitants


1979-81 55.3 10,000inhabitants17- 55.3

1977197719771977

16.310.217.9

2.8



dedicated to health

YEAR NUMBER

1984198419841983

60.060.052.079.4

1983 64.6

1983 47.71983 50.019831982

6.11.7

1983 7.91983 1.8

1982 8.2

1982 50.0

1980 5.4

1980 7.7



8.154 Five major objectives were estab-lished within the framework of the 1983-1986 national health plan: reduction of mor-bidity and mortality rates, health educationand community participation, expansion ofthe coverage of primary health care, adminis-trative development and modernization, andtechnical and scientific modernization of thehealth sector. In order to continue strengthen-ing the national health system, the Ministry ofHealth undertook an analysis of regional andlocal approaches to the programming of ser-

vices in order to integrate them within a set ofunified technical and administrative stan-dards.

8.155 To implement on the sectoral reor-ganization, the Government completed a sur-vey of health conditions and health sector re-sources in all 106 regional units in order toobtain information for the subsequent stage oflinkage among the various subsectors com-posing the national health system. With a viewto establishing linkage between Social Secu-rity and the Ministry of Health, a joint determi-nation was made of potential areas for the co-ordination of activities. Action was also takento extend the Ministry's agreement with theNational Institutes of Health (USA) andPAHO/WHO for technical and administrativedevelopment. The Government's priority of

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160 Annual Report

integrated development in underserved urbanand rural areas facilitated health sector coordi-nation with the economic and social sectors.Relationships among the Integrated Rural De-velopment Program, the Integrated Develop-ment Plan for the Pacific Coast, and the Minis-try of Health were thereby strengthened. Inkeeping with this approach, integrated pro-grams were being promoted in marginal dis-tricts of Bogotá and Cúcuta and in zones inwhich armed conflicts were taking place.

8.156 The health information system isregarded as a useful tool for promoting devel-opment in other components of the sector.Special emphasis was placed on strengthen-ing epidemiological surveillance as an effec-tive instrument for the control of infectious dis-eases and on evaluation of the activities ofhealth services.

8.157 The Ministry of Health's HumanResource Directorate, together with the Na-tional Institutes of Health, designed a compre-hensive human resource development pro-gram for the training of high-level personnel inareas of present and future priority interest forthe country. The Colombian Association ofSchools of Medicine collaborated with othercountries' schools of medicine in the establish-ment of subregional organizations, leading tothe establishment of the Central American As-sociation of Schools of Medicine. In nursingeducation, PAHO/WHO cooperated with theColombian Association of Schools of Nursing(ACOFAEN) on a study concerning the prac-tice of nursing in the health services.

8.158 The National School of PublicHealth of the University of Antioquia contin-ued to conduct training programs in planningand in strategic management of health pro-grams.

8.159 In environmental health, activitiesrelated to the International Drinking WaterSupply and Sanitation Decade were pro-moted, specifically the following national pri-ority programs: a program for improvement,surveillance, and monitoring of water quality

and solid waste management based on theadoption of health code regulations and theconducting of two workshops on treatmentplant operation and maintenance to enableColombia's six largest cities (with a combinedpopulation of approximately 10 million) to im-prove water quality without enlarging treat-ment plans; and a leak detection and elimina-tion program (PRONCOPE), under whichworkshops on pitometry, macrometering, andwater losses were held in Cali, Bucaramanga,and Barranquilla. The Government's environ-mental sanitation strategy is to promote hori-zontal technical cooperation so that firms witha higher level of technical and administrativedevelopment may extend support to less de-veloped enterprises.

8.160 In the area of environmental haz-ards and pollution, four workshops on envi-ronmental impact studies, evaluation ofchemical environmental hazards, and envi-ronmental health and the use of pesticideswere held.

8.161 The National Institute of Health or-ganized a national committee of experts to ad-vise the Ministry of Health and the Presidencyof the Republic on the consequences to hu-man health of the use of herbicides to destroycoca and marijuana fields.


8.162 The National Planning Office andthe Ministry of Health, with cooperation fromUNDP and PAHO/WHO, organized an in-terinstitutional workshop to coordinate thepolicies of the various food and nutrition insti-tutions and determine lines of action for theyears ahead, notably the establishment of anadequate nutrition surveillance system. Thesurvey on nutrition in primary care, carriedout at the School of Interdisciplinary Studiesof Javeriana University, was completed.

8.163 The Ministry of Health has adoptedan intensive scheme of specific actions for in-


fant survival. To this end, activities aimed atcontrolling acute diarrheal diseases throughoral rehydration were intensified. The Na-tional Institute of Health increased the produc-tion of salts and conducted an intensive edu-cational drive through the media. TheGovernment defined its family planning policyand decided to concentrate on those geo-graphic areas with the highest rates of infantmorbidity and mortality. In conjunction withthe Latin American Center for Perinatologyand Human Development (CLAP), a studywas carried out on the care of the prematureinfant.

8.164 In the oral health field, training wasprovided to technicians in charge of a salt fluo-ridation program, and a dental caries surveywas continued in Antioquia. Upon comple-tion of the first stage of the drug addiction con-trol program, it was found that its objectives inthe areas of prevention, epidemiology, andtraining were achieved, leading to the formu-lation of a second stage. A program and a fi-nancing proposal were prepared with a viewto improving the central laboratory at the Na-tional Institute of Health to convert it into a ref-erence center for quality control, staff training,and development of regional and local cen-ters. The four sets of simplified radiologyequipment installed in the Department ofAntioquia continued in service; auxiliary per-sonnel were trained in the operation of thisequipment; and a protocol on evaluation ofthe quality and efficiency of this equipmentwas defined. In the area of essential drugs, theUniversity of Antioquia, with PAHO/WHOcooperation, updated and modernized a basiclist of such drugs and initiated operational re-search.

8.165 The Expanded Program on Immu-nization (EPI) was strengthened with the sup-port of the Executive Branch. In 1984, vacci-nation coverage (poliomyelitis and measles)of infants less than 1 year of age increased inColombia from 43% to nearly 80%. Antima-laria operations were redirected toward spe-cific areas, including training and research. In

Antioquia, malaria control was integrated intothe local health service. In food protection,personnel were trained, information systemswere organized, and procedures and tech-niques of the laboratory network were stan-dardized.

8.166 With respect to foot-and-mouthdisease, priority aspects and reporting systemswere worked out. The first Latin Americanmeeting on women and health, which washeld during the year, formulated basic lines ofaction for governments and private organiza-tions. In the emergency relief and disaster pre-paredness program, the experience ofPopayán was examined and a program toprepare hospitals for disaster situations wasinitiated.


8.167 Technical Cooperation AmongDeveloping Countries (TCDC): Cooperationand the exchange of knowledge and experi-ence with other countries were accomplishedmainly through international resources. Spe-cial mention should be made of the meeting ofministers of health and social security authori-ties held in Medellín in July, in which 14 coun-tries participated; the meeting of faculties ofschools of medicine for Central America andthe Andean Pact countries, organized by thePan American Federation of Associations ofFaculties (Schools) of Medicine (FEPAFEM)and the Colombian Association of Faculties ofMedicine (ASCOFAME); the internationalgroup on health prospects; and the PanAmerican Conference on Medical Education(FEPAFEM-ASCOFAME). Work went for-ward on an assessment of the country's poten-tial for providing technical cooperation, andan expanded development program was de-signed for 1985.

8.168 International cooperation: FAOprovided US$900,000 for an African feverprogram; UNFDAC, US$360,000 for a drug

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addiction control program; IDB, US$200 mil-lion for water supply and basic sanitation forMedellín and rural communities (5 years-RioGrande project); IICA, US$100,000 for ani-mal health; and TDR/WHO, US$7,500 forvector control (2 years) and US$70,000 formalaria control (2 years).

8.169 Bilateral cooperation: USAIDprovided US$900,000 for a foot-and-mouthdisease program; the Gouernment of theNetherlands, US$350,000 for tropical dis-eases; and the National Academy of Sciences(USA), US$117,000 for Anopheles albi-manus research (3 years).


8.170 Professional staff assigned to thecountry: 9, including the PAHO/WHOCountry Representative and advisers in: de-velopment of health services and planning,sanitary engineering, veterinary public health,malaria (3), immunizations, and maternal andchild health. In addition, a veterinary medicalofficer assigned to the food control programand a technician assigned to the diarrheal dis-ease control program are stationed in Colom-bia.

8.171 Regional and intercountry advis-ers: 83, for a total of 333 days, in: maternaland child health, nutrition, mental health,tropical diseases, intrahospital infections, tu-berculosis, noncommunicable diseases, vene-real diseases, veterinary public health, adulthealth, workers' health, drugs, textbooks,drug dependency, disaster emergencies, envi-ronmental health, urban sanitation, epidemi-ology, planning, health services, and technol-ogy.

8.172 Short-term consultants (STC):63, for a total of 793 days, in: planning,health services, hospital administration andaccidents, drugs, sanitary engineering, tuber-culosis, pesticides, veterinary public health,

textbook program, basic radiology, EPI, ag-ing, virology, and hemorrhagic fever.

8.173 Fellowships: 46, for 107 monthsand at a cost of US$188,706. The areas ofstudy were: environmental health, veterinarypublic health, Master of Public Health, re-search, epidemiology, cancer,.malaria, genet-ics, preparation of vaccines, library science,drugs, dentistry, and accidents.

8.174 Courses, seminars and work-shops: 65, with 1,485 participants, for a totalof 372 days and at a cost to PAHO/WHO ofUS$38,526. The subjects were: emergencypreparedness; health, women, and develop-ment; human resources; environmentalhealth; veterinary public health; food and nu-trition; maternal and child health; chronic dis-eases; occupational health; epidemiology andpreventable diseases; malaria; dengue; men-tal health; and drug dependency.

8.175 Grants: 3, for a total ofUS$74,000. The entities receiving the grantswere the National School of Public Health ofMedellín (Meeting of Ministers of Health)ASCOFAME (Carta médica), and Pan Ameri-can Conference on Medical Education.


8.176 The Government gave high prior-ity to action in the health sector. The Presidentof the Republic personally stressed the impor-tance of the sector within the policy of peace,solidarity, and social justice. The Ministry ofHealth is committed to revitalizing and reor-ganizing the sector on the basis of the primarycare strategy. National policies and strategiesemphasize the need to direct resources towardinitiatives exerting an impact on priority healthproblems. Within this overall framework,technical cooperation is aimed at providingsupport to priority activities within the sector.Interagency coordination was encouragedand supported.


Costa RicaBasic Data





Life expectancy at birthInfant mortality/1,000 live birthsMaternal deaths/ 1,000 live birthsDeath rate 1-4 years/ 1,000 childrenPercentage of newborn with a weight of



per capita/day









1983 3,056 Nurses per 10,000 inhabitantsNursing auxiliaries per

1985 64.0 10,000 inhabitants195 64.0

1983198319831981

4.419.828.0



dedicated to health

YEAR NUMBER

1984198419841983

77.9 a

74.2a

79.2a81.4

1983 92.8

1983198219821982

94.82.6

11.63.3

1983 10.01983 9.6

1983 22.8

1983 71.3

1983 5.7

1983 28.0

... Data not available.First semester 1984.



8.177 The Government has undertaken anew effort aimed at sectoral development andintegration of the health services. A situationalanalysis was carried out and alternative ar-rangements for a functional integration of thenational health system were examined. As aresult, the Ministry of Health and the Costa Ri-can Social Security Agency entered into anintegration agreement establishing comple-

mentary functions, responsibilities, andmechanisms for the joint administration ofavailable infrastructure and resources. As afirst step toward integration of health servicesin the regions, the Ministry and the Social Se-curity Agency jointly conducted a survey ofhealth conditions in the Huetar Atlántica re-gion. Progress was also achieved in integrat-ing the operation of health services of theCosta Rican Social Security Agency and theMinistry of Health in 34 of the country's citiesand towns. Highlights of these joint operationswere an evaluation of programs and the train-ing of staff on new national and internationalstrategies, and the development of mecha-nisms for regional participation in the process

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164 Annual Report

of sectoral linkage. The risk approach hasgradually been incorporated into local pro-gramming.

8.178 As a result of the critical economiccondition, the Ministry and the Social SecurityAgency focused their attention on the supply,management, and financial and accountingareas, achieving significant gains in the effec-tive use of institutional funds.

8.179 Given the need to renew and ad-just the infrastructure for the programs to ex-tend the coverage of primary health care ser-vices and to develop sector-wide planning,management, and evaluation systems, proj-ects in each of these areas were developed aspart of the Plan for Priority Health Needs inCentral America and Panama (including in-fant survival and environmental sanitation).

8.180 National activities in human re-source development were directed to linkingtraining institutions with users of human re-sources to align occupational and educationalprofiles more closely with national policies andpopulation needs. The following activitieswere conducted for this purpose: a workshopreviewing the curriculum of the School ofMedicine; a seminar-workshop on teaching-service integration in nursing, medicine, den-tistry, and nutrition; design of a family nursingcare curriculum; courses on the risk approachfor faculty of the School of Nursing and fornursing auxiliaries; a preliminary draft of a hu-man resource development project for thecountry; and training of multidisciplinary staffat the regulatory and regional office levels andof instructors in educational technology.

8.181 The Ministry of Health, through itsEnvironmental Sanitation Division, continuedits programs in food control, environmentalpollution control, industrial safety, and solidwaste management. Working through thehealth regions, it promoted the preparationand implementation of urban sanitation pro-grams for 11 communities with populationsof more than 15,000, including portions ofthe metropolitan area of San José. A

US$2,068,000, 4-year program of rural sani-tation was prepared for scattered populationsof three health regions.

8.182 The Costa Rican Water and Sew-age Institute continued its programs to expandthe water supply coverage and strengthen ex-isting networks. The Institute currently haswell-advanced projects amounting to a total ofUS$59 million, of which US$40 million is vir-tually financed. Technical strengthening andstaff training aimed at improving the Institute'soperating capacity continued during the year.


8.183 The analysis of data from the na-tional nutrition survey, including the review ofstandards for the assessment of growth andnutritional status, was completed in 1984.The new procedures were scheduled to be im-plemented in 1985. Pursuant to the decisionto implement uniform maternal and childhealth care standards in all facilities of the Min-istry of Health and the Costa Rican Social Se-curity Agency, a unified maternal and childclinical history form was adopted for use in allhealth centers, posts, and clinics in the servicearea of one of the country's principal hospitalcenters (Hospital Mexico). In addition, con-siderable effort was given to the preliminarywork on developing a nation-wide prenatalprogram, and the risk approach was widelydisseminated as the new basis for new plan-ning and programming services. Lastly, ap-proval was given to a PAHO/Kellogg projectto be carried out by the Ministry of Health, theUniversity of Costa Rica, and the Social Secu-rity Agency to foster nation-wide progress inmaternal and child care.

8.184 In the preventive oral health pro-gram, coverage was further increased andstaff training continued. Studies were beingmade to determine the feasibility of distribut-ing fluoridated table salt. In mental health, aNational Mental Health Commission was es-


tablished and was developing a modular na-tional program in this field. Drug addictionsurveys and workshops were conducted.Training in the detection and referral of peo-ple with psychiatric problems was provided tocommunity personnel in one region of thecountry. Staff training in disaster prepared-ness continued.

8.185 The country's current health policyemphasizes disease prevention. Accordingly,the Ministry of Health and the Social SecurityAgency continued their efforts to strengthenprograms extending the coverage of preven-tive services-especially immunization andcontrol of diarrheal diseases and acute respira-tory infections-and developing preventiveschemes for priority chronic diseases preva-lent in the country, such as diabetes, hyper-tension, chronic rheumatic diseases, and dis-eases of the elderly. In the course of the year,a number of training workshops and seminarswere conducted for health personnel at everylevel and from both institutions for the pur-pose of fostering the inclusion of these newschemes in the health services. It was plannedto assign new graduates in public health to thehealth regions in order to give more impetusto the development of these programs.

8.186 The Epidemiology Division of theMinistry of Health is responsible for programsfor the control of tuberculosis, sexually trans-mitted diseases, public health dermatology(leprosy), epidemiological surveillance ofother communicable diseases, malaria, andcancer. Successful outcomes of these pro-grams have influenced a shift in the patterns ofmorbidity and mortality, leading to the open-ing of new action fronts (such as perinatal careand congenital diseases).


8.187 Technical Cooperation AmongDeveloping Countries (TCDC): Costa Ricaentered into agreements with Panama (border

health) and Belize. An agreement with Nicara-gua was being prepared.

8.188 International cooperation: IDBgave US$741,000 for health service mainte-nance, US$28.3 million for expansion of thewater supply systems of middle-sized towns,including Puntarenas, and rural areas, andUS$414,000 for a study on housing andhealth problems; WFP gave US$1 million forcommunity development.

8.189 Bilateral cooperation: USAIDgave US$760,000 for administrative reorgan-ization of the Costa Rican Social SecurityAgency.

8.190 Foundations: The W. K. KelloggFoundation donated US$650,500 for mater-nal and child health and teaching-service link-age.


8.191 Professional staff assigned to thecountry: 5, including the PAHO/WHOCountry Representative and advisers in:health services, engineering, administration,nursing, and maternal and child health.

8.192 In addition, several locally re-cruited contractors provided technical cooper-ation in areas such as supplies, mental health,financial management, computers, and re-search.

8.193 Regional and intercountry advis-ers: A number of advisers rendered servicesin: nursing, epidemiology, maternal and childhealth, administration, sanitary engineering,radiology, information systems, and bloodbanks.

8.194 Short-term consultants (STC):10, for a total of approximately 600 days, in:supplies, diarrheal diseases, administration, fi-nancial management, nutrition, mentalhealth, and radiodiagnosis.

Fellowships: 35, for a total of

155

8.195

166 Annual Report

US$119,325, in the following study areas:.public health, ophthalmology, vascular sur-gery, administration, maternal and childhealth, environmental sanitation, and alco-holism and drug addiction. Recipients of thefellowships were employees of institutionssuch as the Ministry of Health, the Social Se-curity Agency, the University of Costa Rica,the National University, the Costa Rican Insti-tute for Research and Training in Nutritionand Health (INCIENSA), and the National In-stitute of Alcoholism (INSA).

8.196 The country hosted 55 fellowshipsfrom other Latin American countries, in thefollowing areas: nursing, maternal and childhealth, primary care, dentistry, medical re-cords, demography, cancer, equipmentmaintenance, and oral rehydration.

8.197 Courses, seminars, and work-shops: 60, with the participation of 3,312 em-ployees of the Ministry of Health, the SocialSecurity Agency, the University of Costa Rica,and the National Autonomous Univer-sity. PAHO/WHO's financial contributionamounted to US$3,525,184. These eventswere concerned primarily with primary care,administration, the risk approach, the mater-nal and child clinical history form, nursing,oral health, mental health, and environmentalsanitation. In addition, 70 Costa Rican em-ployees participated in international meetingsat a cost of US$34,112.

8.198 Grants: 7, totaling US$155,415,were awarded to the Ministry of Health, theSocial Security Agency, and the University ofCosta Rica for: activities under the Plan forPriority Health Needs in Central America andPanama, development of the Health SectorSecretariat, development of epidemiologicalsurveillance (needs of the elderly), a study onthe feasibility of salt fluoridation, malaria sur-veillance and control, a study of angiostrongy-losis, and preparation of audiovisual materialsfor the School of Nursing of the University ofCosta Rica.

General Appraisal and FutureTrends8.199 The year was marked by significantprogress in restructuring of the health sector,integration of Ministry of Health and Costa Ri-can Social Security Agency services in variousparts of the country, the continuing educationprogram, and the evaluation and reformulat-ion of primary care programs of major na-tional importance. Progress also was made inshaping the national health system. These ac-tivities imply a structuring of Costa Rica'shealth services along more modern, dynamic,and administratively rational lines better at-tuned to the country's health conditions andavailable health resources.

8.200 PAHO/WHO provided technicalcooperation to both the Ministry of Health andthe Costa Rican Social Security Agency invarious priority areas. It also collaborated withthe Costa Rican Water and Sewage Institute,the universities, and other health-related insti-tutions.

8.201 The process of transformation aswell as the technical cooperation made avail-able for that purpose were hampered by anumber of constraints, notably the persistenceof critical conditions in the domestic economyand budgetary constraints on the program.Considerable importance therefore is attachedto the formulation and negotiation of projectsprepared within the Plan for Priority HealthNeeds in Central America and Panama and tothe implementation of resource-mobilizationmechanisms.

8.202 Costa Rica's health authoritieshave reaffirmed the political commitment tospeeding up the integration and broadeningthe provision of health services, strengtheningthe mechanisms for an expanded primaryhealth strategy, increasing the operating ca-pacity of the sector (organized and managedas a national health system), and developing anew model of integrated health care.


CubaBasic Data

YEAR NUMBERDemographic Indicators


(as nationally defined)Birth rate/ 1000 inhabitantsMortality rate/1.000 inhabitants


Life expectancy at birthInfant mortality/1.000 live birthsMaternal deaths/ 1.000 live birthsDeath rate 1-4 years/ 1,000 childrenPercentage of newborn with a weight of



per capita/day


1







1983 8.5 Human Resonrce IndicatorsPhysicians per 10,000 inhabitants

1983 2,929 Nurses per 10,000 inhabitantsNursing auxiliaries per

1983 77.0 10,000 inhabitants193 77.0

1983198319831981

2.019.129.1

2.9



dedicated to health

1983198319831983

1982 61.2

1982198319831983

1983 19.11983 26.5

1983 9.0

1984 21.0c

... Data not available.a Admissions. b Includesprivateservicebeds. C Education and health budget.



8.203 Activities focused on upgrading theeffectiveness of primary services providedthrough polyclinics, hospitals, and rural healthposts on the basis of the community medicinemodel. With the same objective, improve-ments were made to physical plants and prior-ity was given to the integration of teaching-service facilities for training health personnel

in the application of the primary care strategy.An analytical study of the network of primarycare services, prepared during the year,should make it possible to develop quantita-tive information on investments, operatingcosts, productivity, and the impact of the ser-vices on the health and well-being of the pop-ulation.

8.204 In human resources, highlights in-cluded the analysis and improvement of infor-mation systems for use in personnel planningand the performance of a study on the utiliza-tion of middle-level technicians in health, par-ticularly those in the nursing profession. Theuse of appropriate teaching methods and pro-

YEAR NUMBER

86.193.672.195.9

31.05.2

14.6a6. lb

167

168 Annual Report

cedures was encouraged, training in moderntechnology was provided, and improvementswere instituted in the teaching-learning pro-cess for the benefit of medical, dental, andveterinary students and of middle-level tech-nical staff of the health services.

8.205 Within the context of the Interna-tional Drinking Water Supply and SanitationDecade, the Government, together withECLA, CEPIS, and PAHO/WHO, prepareda proposal on the provision of technical andfinancial cooperation for improvements to thewater and sewage facilities of the city of Ha-vana; the proposal was submitted to UNDPand other financing agencies. A study on thepollution of Havana Bay and alternative solu-tions to this problem also was made. Cuba'saffiliation with the Pan American Network ofInformation and Documentation in Engineer-ing and Environmental Sciences (REPI-DISCA) provided an effective means ofstrengthening the national system of informa-tion on sanitary engineering through the train-ing of librarians responsible for the manage-ment of such data.


8.206 Studies were conducted on prob-lems related to eating habits-obesity, diabe-tes, arteriosclerosis, and arterial hypertension.In addition, the Government and the WorldFood Program (WFP) signed an agreementfor a new project entitled "Development of theDairy Sector" that will support the country'sprograms in health, rural development, com-munity participation, and food production.

8.207 To strengthen the maternal andchild health services and activities related topopulation dynamics, further work was doneon operations research and the developmentof statistical research methods, and those ac-tivities were intensified and expanded in theareas of sex education and information on fer-tility regulation. An adolescent health pro-

gram was being organized for the purpose ofproviding comprehensive attention to thegrowing problems of this group. A programfor epidemiological monitoring of the health ofworkers was formulated, as was a study ondesignation of the Institute of Labor Medicineas a PAHO/WHO Collaborating Center. Ingerontology and geriatics, a refresher coursewas conducted and a study on the health ofthe elderly was carried out. In oral health, thedental care services for children were strength-ened, as was the fluoride utilization program.

8.208 Disease prevention and controlactions within the Expanded Program on Im-munization (EPI) included improvements tothe cold chain and to the quality of vaccinesproduced and used in the country. Cuba con-tinued to produce measles and antimeningo-coccal vaccines and initiated the production ofviral vaccines against mumps and rubella. Theuse of oral rehydration was further expandedas a means of controlling diarrheal diseases.

8.209 In epidemiological surveillance,the educational program in epidemiology wasstrengthened with the aim of providing stu-dents with a greater ability to analyze healthproblems, prescribe solutions, formulate andevaluate schemes for the prevention and con-trol of diseases of national importance, and di-agnose the health situation and its trends as aprerequisite to planning.

8.210 In regard to noncommunicable dis-eases, an integrated program was developedthat will make possible the design of innova-tive strategies in this field. The Project for Re-gional Monitoring of Integrated Chronic Dis-ease Control Programs (MORE) was beingimplemented in two of the country's munici-palities.

8.211 Activities in priority areas includeda Latin American and Caribbean meeting onpreparations for the World Conference to beheld in 1985 to review and assess the achieve-ments of the United Nations Women's Dec-ade. The Federation of Cuban Women partic-ipated actively in these preparations.



8.212 A total of 2,030 researchers in 219units were engaged in health research. Initialsteps were taken to integrate these activitieswithin a system; with this in view, a scienceand technology area was established withinthe Ministry of Health to assist in concentrat-ing projects according to subject and focusingavailable resources on priority problems. Intechnology, new prenatal and postnatalhealth care procedures were developed, astudy on factors posing a risk to the centralnervous system in the first year of life was car-ried out, and biotechnology activities werepursued. Policy definition and the evaluation,development, adaptation, transfer, and utili-zation of technologies were identified as basicpriorities.

8.213 Technical Cooperation AmongDeveloping Countries (TCDC): The Gov-ernment designated 3,044 health workers toprovide service in 27 African, Asian, andLatin American countries: 1,675 physicians,58 oral health specialists, 742 nurses, 516technicians, and 53 support workers. Alsowithin the TCDC concept, the Governmentmaintains a fellowship program at the disposalof the 71 Third World countries; by the end ofthe year, more than 700 physicians and oralspecialists from other countries had graduatedin Cuba. Cuba reformulated its strategy of sci-entific and technical cooperation to collabo-rate more effectively with other countries inthe Region. As a result, the program of bilat-eral cooperation with Nicaragua was strength-ened, and significant gains were made in thecoordination of joint efforts with Bolivia andMexico.

8.214 International cooperation: UNDPgave US$188,000 for the production of bio-logicals and neurophysiological developmentof infants; UNFPA provided US$800,500 forprograms on maternal and child health andpopulation dynamics, demographic studies,and training; and UNICEF gave US$82,000

for a project on water supply and sanitationservices and nutritional surveillance.


8.215 Professional staff assigned to thecountry: A medical officer in charge of coordi-nating programs (the PAHO/WHO CountryRepresentative) and a medical officer whoacts as technical coordinator and is responsi-ble for TCDC.

8.216 Regional and intercountry advis-ers: 158, for a total of 1,495 days, in the fol-lowing areas: development of health systems,coverage extension and planning of healthprograms, human resources, infectious andparasitic diseases, oral health, essential drugsand vaccines, veterinary medicine, food hy-giene, new technologies, environmentalhealth, information and documentation sys-tems, gerontology and geriatrics, occupa-tional health, and sex education.

8.217 Short-term consultants (STC):31, for a total of 510 consultant days, in: ma-ternal and child health and population dy-namics, human resources, infectious and par-asitic diseases, hospital administration,science and technology organization, environ-mental health, chronic diseases, oral health,sex education, health education, educationaltechnology, and gerontology.

8.218 Fellowships: 138, for a total ofUS$224,553, in: human resources, healtheducation, environmental health, maternaland child health, primary care, production ofbiologicals, disease prevention and control,essential drugs, gerontology, chronic dis-eases, scientific and technical information,oral health, and veterinary medicine.

8.219 Courses, seminars, and work-shops: 15, dealing with pesticides, immuniza-tion, adolescence and youth, breastfeeding,childhood accidents, oral rehydration, growthand development, health research, the Codex

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170 Annual Report

Alimentarius, chronic diseases, REPIDISCA,rapid diagnosis of tuberculosis, parasitic infec-tions, medical education, and natural disas-ters. PAHO/WHO's contributions for coursesand seminars came to US$9,600 for local ex-penses. The assistance of 30 regional and 36temporary consultants was also available forthese events at an estimated cost ofUS$93,852.


8.220 The national health system contin-ued to place high priority on developing andstrengthening the community medicine ap-proach at the level of all polyclinics, hospitals,and rural medical posts, which together con-stitute the regionalized network of primaryhealth services for the entire population. Es-pecially noteworthy were the institution ofnew technologies for the diagnosis and treat-ment of disease, the theoretical and practicaltraining provided to health personnel at vari-ous levels and in various program areas, thedevelopment and strengthening of the system

of epidemiological surveillance, and the im-proved utilization of the scientific and techni-cal information system.

8.221 The country's undeniable ad-vances in health led to increased technical co-operation requests from other developingcountries. To meet this commitment, the na-tional health system sends medical and techni-cal contingents overseas and receives fellowsand visitors from other countries to exchangeexperience as to the models best suited forachieving universal primary health care cover-age.

8.222 In regard to PAHO/WHO techni-cal cooperation, the Government imple-mented 17 projects resulting from the identifi-cation of priority areas. This analysis, carriedout in 1983 by multidisciplinary teams consist-ing of national officials and PAHO/WHOstaff, was aimed at strengthening the capacityof the Ministry of Public Health and providingfor optimal use of international technical co-operation. Similar joint analyses have sincebeen made in order to improve the program-ming of cooperation between the country andPAHO/WHO and to maximize the utilizationof resources.


DominicaBasic Data



(as nationally defined)Birth rate/ 1.000 inhabitantsMortality rate/1,000 inhabitants





per capita/day







·.. . 74. 0a sanitary waste disposal1983 13.9 Consultations per inhabitant per year1983 0.0 Number of discharges per 100 inhabitants1983 0.4 Number of beds per 1,000 inhabitants



1979-81 55.4 10,000inhabitants1979-81 55.4

198319831983

Health ExpenditureHealth Expenditure per capita (in US$)

·.. . Total health expenditure as a percentage21.0 of the GDP23.0 Percentage of the National Budget·.. . dedicated to health

YEAR NUMBER

1983198319831983

86.085.062.077.0

1983 77.0

1980 86.0

1983 3.0

1983 3.61983 16.0

1980 4.1

1978 4.3

1978 21.0

1978 15.0


a Age for women. Age for men, 68.0 years.



8.223 Dominica has experienced impor-tant administrative changes, the most strikingbeing the decentralized organization and man-agement of the community-based services.Also of importance was the implementation ofthe National Health Plan, the development ofnursing services, the implementation of theprimary care nurse program, and the planning

and realization of a workshop to orient nursesin Caribbean standards of nursing care.

8.224 In human resource development,health personnel data collected during 1983received a critical review, and planning wasunder way for a national workshop to be heldduring 1985 on organizational support, strat-egy, and policy formulation for health person-nel development.

8.225 In the continuing development ofprimary health care throughout the country.activities in environmental health were aimedat program management, solid waste disposalfor Roseau, vector control, and the develop-

171

172 Annual Report

ment of a water and sanitation sectorial reportto assist in setting priorities for national needsand projects. The water and health agencieswere represented at a subregional workshopin water quality control, and an environmentalhealth officer received training overseas invector control.

8.226 Dominica is the headquarters ofthe PAHO/WHO Caribbean Health Labora-tory Project which provides services to all ofthe Caribbean area in the examination and re-porting of histology, cytology, and bone mar-row specimens. It also provides active pathol-ogy consultation in patient care, assists in theestablishment of rural laboratories, and givestraining courses in laboratory managementand hepatitis testing.


8.227 Maternal and child health is incor-porated into the country's primary health caresystem. There has been a progressive restruc-turing of the delivery of the health services ac-companied by relevant training and place-ment of staff. To this end, the healthinformation system has been geared to pro-vide the necessary information, particularly inmaternal and child health, such as coverageby the various service components. Progresswas made in promoting family life educationin schools and in implementing programs inthe Adolescent Center.

8.228 Progress was achieved in the fol-low-up of the family nurse practitioner pro-gram and continued guidance was providedto its graduates. Progress also was made in theanalysis of perinatal survey results. PAHO/WHO provided administrative and technicalsupport for UNFPA projects-including re-ports, fellowships, and procurement of sup-plies-and cooperation in carrying out twofamily life education workshops for teachers.

8.229 A revised food and nutrition policyfor Dominica was prepared with CFNI assis-tance. The nutrition strategy continues to pro-

mote breastfeeding. Activities of the PAHO/WHO-UNICEF Joint Nutrition Support Pro-gram (JNSP) were in progress at year's end.In the country's immunization program, theGovernment, with CAREC's assistance, de-veloped and strengthened its surveillance andlaboratory capabilities. Progress also wasachieved in developing the leprosy controlprogram.

8.230 PAHO/WHO's Disaster Prepared-ness Team continued to support Dominica'sactivities in this area. The Organization collab-orated by reinforcing zoonoses surveillanceand by monitoring the development of theveterinary diagnostic laboratory.


8.231 International cooperation: Assis-tance was received from UNICEF for a jointnutrition program and for child care; fromUNDP for laboratory services for the EasternCaribbean health services; from UNFPA,US$89,435 for a maternal and child healthand family planning program; from Interna-tional Planned Parenthood Federation(IPPF), for family planning; and from CARI-COM, for training in community health ad-ministration.

8.232 Bilateral cooperation: the Inter-national Development Research Center ofCanada (IDRC) assisted in the evaluation of aprimary care nurse program; USAID gaveUS$203,703 for a program of drug supply (2years; technical cooperation only) and for aprogram on primary health care; the OverseasDevelopment Administration of Britain pro-vided for training of personnel (technical co-operation); the Government of Holland gaveUS$444,444 to upgrade the Princess Marga-ret Hospital; the Gouernment of Belgium pro-vided US$80,000 to upgrade the majorhealth center in Roseau; and the Governmentof France gave for hospital and primary carefacilities.



8.233 Professional staff assigned to thecountry: 2, a pathologist and the manager ofthe Caribbean Laboratory Project.

8.234 Regional and intercountry advis-ers: Considerable cooperation comes fromthe Organization's staff located in various partsof the Caribbean as well as from Headquar-ters, CAREC, and CFNI. A team of consul-tants from the Caribbean Program Coordina-tion's (CPC) Office collaborated with theGovernment in health systems development,disaster preparedness, disease control, envi-ronmental health, zoonoses, and vector con-trol.

8.235 Fellowships: 7, in: management,science education, community health, hepati-tis, medical records, nursing education, meatand other foods. PAHO/WHO's contributionwas US$32,670. In addition, training wasprovided for six nationals in laboratory man-agement (Saint Lucia), ward management(Barbados), community health nursing (Ba-hamas), and meat and food inspection(Jamaica), utilizing European EconomicCommunity-Caribbean Community (EEC-CARICOM) Secretariat funding.

8.236 Grants: PAHO/WHO providedUS$3,000 for a study on women's groups.


8.237 The Government is fully commit-ted to primary health care, and the expecta-

tion is that PAHO/WHO's cooperation willcontinue. PAHO/WHO will promote thebuilding of professional competence and self-sufficiency within the maternal and childhealth team in Dominica, using the UNFPAproject as its focus. A review of the maternaland child health manual and an assessment ofpostnatal services should be carried out. Localtraining in neonatal care, with the assistanceof CLAP, is also planned.

8.238 PAHO/WHO's assistance in envi-ronmental health had greater impact than inprevious years, allowing a marked progress tobe made in the two priority areas of solidwaste management and vector control. Thefull implementation of primary health care atthe district level, to which the Government re-mains committed, will require further assis-tance in field operations.

8.239 As a collaborative effort with theCaribbean Center for Development Adminis-tration (CARICAD) and the CARICOM Sec-retariat, an outline proposal was prepared fora 2-year inservice program in communityhealth management to be implemented underthe University of the West Indies (UWI) Chal-lenge Outreach Scheme. The program is in-tended to meet the needs of Dominica (andother developing countries) for training healthstaff in health services management. The pro-posal is acceptable to the Ministry of Health ofDominica and has been approved by theBoard of the Faculty of Medicine of the UWI.Implementation has been deferred, however,until 1985 to permit further consultationsamong staff of the Ministry of Health. Thisprogram and other inservice training activitieswill receive financial support from the EEC-CARICOM Secretariat grant.

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174 Annual Report

Dominican RepublicBasic Data








per capita/day








Human Resource Indicators' ... Physicians per 10,000 inhabitants


1979-81 47.3 10,000 inhabitants1979-81 47.3

1982198219821982

10.96.6

12.62.1



dedicated to health

YEAR NUMBER

1983198319831983

24.422.4a23.440.8

1983 65.0

1983198319831983

27.50.94.91.2

1983 5.91983 1.0

1983 10.2

1983 7

1983 3.7

1983 11.8

... Data not available.a Immunization campaign data (children 0-3 years old).



8.240 Regional health programming wasprepared, the information system was organ-ized, and the comprehensive care model wasadopted within the framework of the healthpolicy for 1983-1986. These activities werefacilitated by the establishment of a GeneralDirectorate for Primary Health Care and itslinkage with the Planning Center. Training of

personnel in health planning and hospital ad-ministration proceeded concurrently.

8.241 Further progress was made on theimplementation of the project, financed withthe help of an IDB loan, for expansion ofhealth services, institutional development ofthe Ministry of Public Health and SocialWelfare (SESPAS), and improvement of itsoperating capacity, especially in the areas ofinformation, supplies, maintenance, transpor-tation, and drugs.

8.242 In view of the increase in installedcapacity, and considering the changes and in-creased requirements likely to result from theinflux of new external resources, surveys were


made to determine the supply and demandfor health services and requirements in humanresources. An operational survey of healthservices in the Santiago area was also carriedout with a view to improving their productivityand the use of resources.

8.243 A noteworthy event was the estab-lishment of the essential drug program (PRO-MESE), under which some 300 generic drugswill be made available at cost to communities.The drug laboratory of the Autonomous Uni-versity of Santo Domingo (UASD) continuedto produce approximately 40 drugs.

8.244 Human resource planning was in-stituted, together with a staff training programat an interinstitutional level (health, social se-curity, universities). Teaching-service integra-tion activities continued. A Master of PublicHealth program was inaugurated, with con-centrations in administration and epidemiol-ogy (41 students with fellowships provided bythe Ministry of Health and UASD). In San-tiago, the project on administration of healthservices was carried forward as part of the Re-gional Program on Advanced Training inHealth Services Administration (PROASA).The National Health Communication Center(CENACES) was strengthened as nucleus forpriority programs implemented by SESPAS,especially those related to disease preventionand control.

8.245 In environmental health, the Ten-Year Plan continued to be developed with thecooperation of other sectors. Activities in thisarea included programs to supply water toscattered rural communities, the rehabilitationand expansion of 16 systems, and the com-pletion of training of Dominican personnel ondrinking water supply systems. A start wasmade on the project for institutional develop-ment of the National Water Supply and Sew-erage Institute (INAPA) in the areas of pro-gramming, technical assistance, operationsand maintenance; employees of the water flu-oridation program and staff responsible for theoperation of Santo Domingo's two sanitarylandfills received training.


8.246 With the collaboration of the Ma-ternal and Child Health Division and the Au-tonomous University of Santo Domingo, thestudy on infant mortality was continued, aproposal for a diarrheal disease control pro-gram was prepared, and criteria were estab-lished for an extensive food and nutrition pro-gram.

8.247 Hospital activities in the mentalhealth area were examined, and the occupa-tional therapy program was continued at boththe service and teaching levels. In oral health,coverage was expanded by extending preven-tive activities to 600,000 schoolchildren, anda public information program was carried out.Dental care began to be provided in rural ar-eas, and epidemiological and operational re-search was continued.

8.248 In regard to disease control, anevaluation of the Expanded Program on Im-munization (EPI) showed that during the pe-riod from January to June the country hadachieved a DPT vaccination coverage (thirddose) of 18% and a significant coverage of94% for poliomyelitis vaccination (first dose).The antiparasite campaign conducted duringthe year covered more than 90% of the popu-lation. In addition, arrangements were com-pleted for mass-scale activities in oral rehydra-tion, malaria, and tuberculosis.

8.249 The epidemiological surveillanceprogram was reformulated and implementedin the health regions. Work proceeded on theimplementation of a joint Dominican-Haitianmalaria control program, with the cooperationof the IDB and PAHO/WHO.

8.250 In veterinary public health, an as-sessment of the animal health project wasmade, a rabies control training center was es-tablished, and a proposal for improvements tothe Biologicals Production and Control Labo-ratory was formulated.

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176 Annual Report


8.251 Technical Cooperation AmongDeveloping Countries (TCDC): The countrybegan to mobilize its resources for the purposeof cooperating with other countries in the ar-eas of planning, human resources, oralhealth, and operations research.

8.252 Technical cooperation was ob-tained from other countries in the form of theservices of national experts in planning, ad-ministration, public health training, research,malaria, epidemiology, oral health, veterinarypublic health, environmental health, andother areas. These were funded directly by thegovernments concerned or by PAHO/WHO.

8.253 International cooperation: UNDPprovided US$90,000 for oral health andUS$47,161 for mass training; UNFPA gaveUS$73,589 for a family planning program;IDB assisted with US$335,000 for the institu-tional development of INAPA and withUS$308,039 for the extension and strength-ening of health services; WHO and its TDRProgram gave US$13,600 for bilharzia re-search and US$10,000 for malaria research.

8.254 Foundations: The W. K. KelloggFoundation donated US$111,443 for an ad-ministration and family health program.


8.255 Professional staff assigned to thecountry: 5, including the PAHO/WHOCountry Representative, who serves as thecoordinating medical officer, and advisers inpublic health administration, environmentalhealth, oral health, and mass training. In addi-tion, three professionals-two environmentalhealth advisers (IDB/INAPA project) and amedical officer (IDB/SESPAS project) -wereassigned to extrabudgetary projects in thecourse of the year.

8.256 Regional and intercountry advis-ers: 34, for a total of 262 days, in: maternaland child health, malaria, oral health, waterfluoridation, parasitology, operations re-search, administration, nutrition, urban sani-tation, EPI, population and family health ser-vices, human resources, medical care,veterinary public health, nursing, mainte-nance, scientific-technical information, andenvironmental health.

8.257 Short-term consultants (STC):66, for a total of 1,140 days, in: occupationalhealth, environmental health, informationsystems, malaria, health services, oral health,laboratories, veterinary public health, humanresources, mental health, health administra-tion, epidemiology, pharmacy, occupationaltherapy, maternal and child health, animalhealth, EPI, disaster preparedness, nutrition,and hematology.

8.258 Fellowships: 67, providing a totalof approximately 84 fellowship months, at acost of US$106,205, in the areas of: publichealth administration, epidemiology and dis-ease control, maternal and child health, oralhealth, health planning, animal health, envi-ronmental health, library science, laborato-ries, human resources, hospital administra-tion, social medicine, malaria, tuberculosis,health research, veterinary public health,nursing, occupational health, and immunol-ogy.

8.259 In addition, PAHO/WHO spon-sored the participation of 23 Dominicans inseminars, workshops, and congresses heldabroad on cancer of the cervix uteri, maternaland child health, disaster preparedness, den-tistry/UDUAL, pediatrics, environmentalhealth, breastfeeding, health education, andleprosy control.

8.260 Courses, seminars, and work-shops: 34 events, with a total of 3,245 partici-pants, involving a financial contribution ofUS$56,119. The areas of study were malaria,epidemiology, health services, maternal andchild health, human resources, environmental


health, nutrition, social welfare, nursing,mental health, and oral health.

8.261 Grants: In the course of the year,PAHO/WHO, at the request of national au-thorities, administered WHO grants totalingUS$23,600 for research on malaria and bil-harzia.


8.262 Activities during the year centeredaround regional health programming and theorganization and initial operation of the infor-mation system. Priority was given to the for-mulation of a model for providing compre-hensive health care at the primary level, a

basic element of the Government's plan forimplementing its health policy. The Govern-ment assigned special importance to environ-mental health, the essential drug program,and an intersectoral veterinary public healthprogram. Intersectoral linkage was promoted,as was community involvement in health pro-grams. The high coverage percentagesachieved in the poliomyelitis vaccination drive(first dose) and the antiparasite campaign areworthy of note.

8.263 The result of research carried outand in execution is opening up increasinglybroader horizons for health work. Along withthis, the training of specialized personnel toadminister the expanding structure of thehealth services represents a new element ofprogress within the system.

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178 Annual Report

EcuadorBasic Data








per capita/day







1984 65.2a sanitary waste disposal1980 63.9 Consultations per inhabitant per year1980 1.9 Number of discharges per 100 inhabitants1980 8.6 Number of beds per 1,000 inhabitants

Human Resource IndicatorsPhysicians per 10,000inhabitants


1979-81 50.1 10,000 inhabitants17- 50.1

1980198019801980

17.46.1

12.43.7



dedicated to health

YEAR NUMBER

1983 31.51983 32.51983 35.11983 87.1

1983 38.2

1983 42.91983 80.01983 2.51982 1.9

1984 13.91984 3.4

1983 13.4

1982 34

1982 6.0

1983 6.9

... Data not available.a Age for women. Age for men, 62.8 years.



8.264 In the process of extending thecoverage of health services to disadvantagedurban dwellers and the rural population, thenational strategies, objectives, and goals werefocused on two of the basic areas consideredessential to achieving that objective: improve-ment in the efficiency, effectiveness, andstructure of health services, and delivery ofprimary health care with community participa-tion. Major activities within this process in-

cluded: the development and improvement ofsectoral planning systems; establishment of anintegrated local programming methodologybased on the diagnosis of community healthconditions and operating within a frameworkof functional regionalization of health servicesand a decentralized national administration;revision of the system for the monitoring, su-pervision, and control of health activities andtheir administrative support processes; anddefinition of the national health system.

8.265 A short- and medium-term admin-istrative development scheme was formulatedfor use in the improvement of operations atcentral and regional levels, health areas, andlocal services. A computerized information


system developed under the health servicemaintenance program should soon make itpossible to monitor the operation of installa-tions and equipment. An activity responsiveto a high priority in health care is the essentialdrug program, under which consideration isbeing given to supplying medications and bio-logical substances free of charge for mothersand for children under age 5.

8.266 In human resources, measures arebeing taken to adapt the study plans to the re-quirements of health programs. There is ashortage of specialists; efforts are being madeto solve this problem by means of a programof residencies financed by local fellowshipsand a plan under which graduates of a pro-gram can be stationed where the need forthem is greatest. Inservice training courses fornursing auxiliaries continued to be offered, re-sulting in the reduction of the shortage in thispersonnel category. Improvements weremade in the national postgraduate course inhealth administration and research, as well asin the continuing education program con-ducted for technical, administrative, andmaintenance staff of the health services. Fur-ther progress was made in the development ofthe Educational Technology Center and its in-tegration into the Institute of Pedagogy of theCentral University.

8.267 In environmental health, the proj-ect for institutional development of the Munic-ipal Sewerage Company of Guayaquil wascompleted, the master sewage plan was beingimplemented, and sanitary landfills were be-ing established in outlying areas of that city. Aresearch study on low-cost, substitute meth-ods of excreta disposal was completed. TheNational Congress approved legislation on thefinancing of rural sanitation works. Work wentforward on the rehabilitation of water supplyand sewage systems in the areas affected bythe 1982-1983 floods. Institutional and hu-man resource development continued at theEcuadorian Institute of Sanitary Works(IEOS), and significant progress was achievedin improving the Institute's linkage with theMinistry of Public Health.


8.268 The consultation coverage levelsachieved were 49% for pregnant women and54.7% for infants under age 1. These per-centages are low in relation to the relevantsupply capacity, and the hope is to raise themonce the system of integrated local program-ming has been implemented nation-wide. Astep in that direction was the formulation of anintegrated infant mortality reduction programincluding vaccinations, food systems, breast-feeding, the monitoring of growth, and thedevelopment of a program for the control ofacute respiratory infections.

8.269 The vaccination coverage ratesachieved to September (1984) by the Ex-panded Program on Immunization (EPI) were36% for DPT/poliomyelitis (third dose) vac-cine, 40% for measles vaccine, and 79% forBCG. Five national workshops were con-ducted for the training of EPI personnel. Theguide for epidemiological surveillance of theEPI diseases was approved, and the standardsand training modules for technical profession-als were updated.

8.270 The food supplement program wasextended to undernourished children underage 4. Education and prevention activities es-pecially designed for mothers, infants, andschoolchildren were conducted in the field oforal health. Of the Ministry of Public Health'soperational units, 48% have facilities andequipment for the provision of dental services.A 5-year diarrheal disease control programwas formulated, and 12 hospital oral rehydra-tion units were set up in six provinces.

8.271 The procurement of a significantquantity of insecticides made possible the ex-pansion of vector control activities in malariacontrol programs. In addition, a project wasformulated that would provide US$9 millionfor the procurement of equipment and sup-plies for use in malaria control in the Provinceof Esmeraldas. The serological survey onChagas' disease continued, as did the studies

179

180 Annual Report

on the biology and taxonomy of the vectors ofonchocerciasis, which is present in a limitedarea of the Province of Esmeraldas. Trainingwas provided in leprosy and plague controland the handling of disaster emergencies.

8.272 In keeping with commitments tothe South American Commission for the Con-trol of Foot-and-Mouth Disease, Ecuador car-ried out a macro-characterization of the localforms of the disease with a view to deciding onstrategies for its control. A pilot foot-and-mouth disease control program was con-ducted in the Santo Domingo de los Colo-rados area, where 300,000 doses ofoil-adjuvanted vaccine were administered.The technical standards of the rabies controlprogram were redesigned, its information sys-tem was revised, and a program was preparedfor Guayaquil.


8.273 International cooperation:UNFPA donated US$2.1 million for maternaland child health and family planning programin the Provinces of Guayas and Chimborazo(4 years); UNICEF, US$303,390 for primaryhealth care in the underserved urban area ofGuayaquil (program started in 1983 and ap-proved for 2 years, 6 months); IDB, US$12.2million for a 4-year program (in operation) forwater supply for various localities in El Oro,US$17 million for a 4-year program (in opera-tion) for sanitary landfills and sewage servicein Guayaquil, US$12.2 million for a 4-yearprogram (in operation) to consolidate theQuito water supply system, US$28 million fora 4-year program (approved in 1984) for theQuito water supply system and first stage ofMico-Tambo project, US$400,000 for a 2-year program (in operation) for the institu-tional development of EMAG, US$260,000for a study on marginal costs of water rates(technical cooperation funds), US$710,000for a 2-year program (in operation) for theGuayaquil sanitary sewage and storm drains,

US$530,000 for reduction of maternal and in-fant mortality (program started in November1984 and approved for 1 year), and US$9million for a 5-year program (in operation) forstrengthening the physical infrastructure ofhealth services in rural areas. WFP providedUS$11.2 million for food for mothers and in-fants (5 years) and US$7 million for agrarianreform and rural development.

8.274 Bilateral cooperation: USAIDdonated for two malaria control projects:US$500,000 for 1984 and US$10 million for5 years; US$11.8 million for two programs forthe development of integrated rural healthservices (both for 5 years), and US$400,000for teaching-service integration in maternaland child health (4 years). AGFUND providedUS$216,000 for the control of rabies in Gua-yaquil (2 years).

8.275 Foundations: The W. K. KelloggFoundation donated US$284,000 for teach-ing-service integration for expansion of thecoverage of maternal and child health services(4 years).

8.276 In order to provide for more effec-tive coordination among the agencies collabo-rating in the health field, the Ministry is plan-ning to prepare a unified program ofcooperation.


8.277 Professional staff assigned to thecountry: 11, including the PAHO/WHOCountry Representative, a regional consul-tant, and advisers in: health service adminis-tration, nursing, epidemiology, administrativemethods, veterinary public health, malariaand other vector-borne diseases, sanitary en-gineering, EPI, and administrative assistance.

8.278 Regional and intercountry advis-ers: 42, for a total of 251 days, in: veterinarymedicine, chronic and degenerative diseases,vector-borne diseases, diarrheal diseases, ed-


ucational technology, maternal and childhealth, dentistry, disaster preparedness, lep-rosy, nutrition, information, sanitary engi-neering, production of biological substances,development of services, EPI, rehabilitation,women in health and development, and es-sential drugs.

8.279 Short-term consultants (STC):40, for a total of 832 days, in the followingspecialties: drug pricing, rehabilitation, medi-cal sociology, parasitology laboratory, mainte-nance of services, information and monitor-ing, physical resources in health, planning,mental health, perinatal health, acute respira-tory infections, veterinary epidemiologicalsurveillance, control of diarrheal diseases, ra-diology, sanitary engineering, oral health, di-saster preparedness, leprosy control, diagno-sis of vesicular diseases, teaching-serviceintegration, and research in the field of health.

8.280 Fellowships: 37, for a total of 125months at an actual cost of US$93,975, in:Master of Public Health, epidemiology, publichealth nursing, teaching methodology, socialcommunication, diagnosis of Chagas' disease,health planning, environmental sanitation,physical resources in health, toxicology, med-ical library science, diarrheal disease control,production of biological substances, medicalrecords, hospital maintenance, respiratorydiseases, management of animal colonies,laboratory techniques, diagnosis of encephali-tis, and community participation.

8.281 Courses, seminars, and work-shops: 24 courses and 3 seminars, with 748

participants, in: epidemiological surveillance,educational communication, teacher training,sanitation in disaster situations, techniques ofsupervision, control of leprosy and leishma-niasis, maternal and child health, disaster pre-paredness, control of rabies and otherzoonoses. In addition, an interregional meet-ing on primary care in underserved urbanareas and an international pharmacologycongress were held. These events received atotal contribution from PAHO/WHO ofUS$38,762.

8.282 Grants: Under its Special Programfor Research and Training in Tropical Diseases(TDR), WHO awarded a grant of US$32,000(1983-1985) for the control of Chagas' dis-ease and a grant of US$6,000 for the controlof onchocerciasis. PAHO also granted a sumof US$15,000 (1983-1985) for the control ofonchocerciasis.


8.283 Because 1984 was an electoralyear, difficulties and delays occurred in thehealth program. This situation continued untilAugust, when the new authorities took office.A period followed in which a health programwas being defined and structural changeswere being made to the units of the Ministry ofPublic Health, all of which led to a redefinitionof PAHO/WHO's technical cooperationwithin the framework of the Plan of Actionand Strategies for health for all by the year2000.

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182 Annual Report

El SalvadorBasic Data






... ... (triple vaccine)1983 30.51982 7.0





per capita/day

Percentage of deaths dueto:infectious and parasitic diseasestumorsheart diseasesmotor vehicle traffic accidents

1980-85198219821982

64.642.2

0.74.9

-poliomyelitis-measles-tuberculosis






1979-81 55.8 10,000inhabitants17- 55.8

1982198219821982

11.02.98.12.0



dedicated to health

YEAR NUMBER

1983 45.01983 44.91983 41.31983 47.5

1983 58.8

1983 50.81984 1.11983 4.51983 1.3

1983 3.41983 2.8

1983 5.9

1981 14

1983 8.7




8.284 By the end of 1984, 363 healthservice facilities were in operation in 234 of ElSalvador's 261 municipalities. Another 55 fa-cilities had been damaged and were out of ser-vice. With the aim of rehabilitating the coun-try's system of service establishments, twonational projects have been formulated underthe Plan for Priority Health Needs in CentralAmerica and Panama. The first project (forUS$66 million), designed to strengthen the

coverage-extension effort, called for the re-modeling of 21 health posts, 15 health cen-ters, and a number of hospitals, as well as con-struction of 40 rural nutrition centers andpromotion of training for research activities.The second, a maintenance-systems projectwith a cost of approximately US$1 million, isaimed at increasing the operational capacity ofthe Ministry of Public Health and Social Wel-fare and strengthening its administrative man-agement systems.

8.285 A total of 13 courses on medicalequipment and hospital administrative man-agement were conducted with a view tostrengthening the facilities maintenancesystem.


8.286 To improve the planning and eval-uation processes, the national informationsystem was evaluated and was being restruc-tured. A start was made on preparing hospi-tals for coping with disasters.

8.287 The curricula of three nursingschools continued under review. A total of896 health officials attended courses andorientation workshops on medical care,epidemiology, malaria, and environmentalsanitation.

8.288 The national plan for the Interna-tional Water Supply and Sanitation Decadewas formulated and a plan was developed forthe operation and maintenance of water sup-ply systems, with emphasis on the control ofleaks.


8.289 Highlights in the area of maternaland child health included the integration offamily planning activities into the health ser-vices and the revision of the program's policiesand procedures on the basis of risk criteria.Five projects-on breastfeeding, monitoringof growth, oral rehydration, immunization,training of practical midwives, and communityeducation-were formulated as part of thePlan for Priority Health Needs in CentralAmerica and Panama. In nutrition 11 projectswere formulated, with a major focus on foodproduction, processing, marketing and distri-bution, also under the same Plan for PriorityHealth Needs. Research protocols were de-signed for a survey to determine the popula-tion's levels of oral health, and the teaching-service component was evaluated with a viewto improving the delivery of dental servicesby using auxiliary personnel and simplifiedmodules.

8.290 To strengthen the epidemiologicalsurveillance system, two additional physicianswere assigned to the program, and staff (phy-sicians, nurses, and auxiliaries) were trained in

modular courses. Three more hospitals werebrought into the diarrheal disease program,which is operational in five regions of thecountry. The Expanded Program on Immuni-zation (EPI) covered only 45% of the infantsunder age 1. Cold chain improvements weremade, and training continued to be offered toEPI-related staff.

8.291 The number of malaria cases dur-ing the year was 53,000, up 5,000 from1983. The malaria program was seriouslyhampered by anopheline resistance to insecti-cides, human migratory flows, and adminis-trative constraints, particularly inadequatefunding. Research on malaria control meth-ods was intensified, and four feasibility studieswere carried out with the aim of improving thesituation. The projects included in the Plan forPriority Health Needs were formulated duringthe year. In view of the growing problem ofhuman rabies (32 deaths reported), morethan 24,000 dog bite victims were vaccinatedand a laboratory was converted from the pro-duction of Semple-type rabies vaccine to theproduct based on unweaned mice brain.


8.292 International cooperation:UNICEF aided in the preparation of the sub-projects in the infant survival area under thePlan for Priority Health Needs in CentralAmerica and Panama; supplementary fundswere allocated for 1983-1984 in the amountof US$654,000. UNDP provided US$83,554for rural water supply programs, includingcourses, seminars, and hiring of consultants;UNFPA, US$99,851 for family planning pro-grams; and IDB, US$18,652 for financing offour courses in equipment maintenance.

8.293 Bilateral cooperation: USAID al-located US$1,144 for a VISISA (Vitalizationof Health Systems) program andUS$102,000 for a breastfeeding program;CIDA, US$20,705 for equipment and sup-

183

184 Annual Report

plies for the El Rosales Hospital andUS$1,000 for equipment for the MaternityHospital Milk Bank.


8.294 Professional staff assigned to thecountry: 5 staff members, including thePAHO/WHO Country Representative andadvisers in: medical care, epidemiology, ma-laria, and environmental sanitation. The latter(a sanitary engineer) assumed his duties inAugust.

8.295 Regional and intercountry advis-ers: 42, for a total of 283 days, in 15 areas:maternal and child health, oral health, epide-miology, zoonoses, malaria, environmentalhealth, health systems, disaster preparedness,essential drugs, mental health, service admin-istration, human resources, nursing, statistics,and nutrition.

8.296 Short-term consultants (STC):38, for a total of 1,628 days, in: maternal andchild health, oral health, zoonoses, environ-mental health, health systems, disaster pre-paredness, essential drugs, mental health,human resources, laboratories, adulthealth, nursing, statistics, maintenance, andnutrition.

8.297 Fellowships: 44, totalingUS$118,549 were awarded to national offi-cials for studies in: hospital administration, in-formation systems, human resources, foodand nutrition education, oral health, epidemi-ology, tuberculosis control, drug registration,leprosy, and production of rabies vaccine.Governmental regulations do not allow publicemployees receiving fellowships to continueon the payroll while receiving fellowshippayments.

8.298 Courses, seminars, and work-shops: 8 courses, 1 seminar, and 5 work-shops with a total of 896 participants. Thecourses dealt with malaria, wastewater treat-

ment plants, training for community pipe lay-ers, street cleaning, potable water treatment,statistical and medical records clerks, commu-nity development, and hospital disaster pre-paredness. The seminar dealt with mentalhealth. The workshops covered the provisionof refresher training to personnel working intuberculosis clinics, preparation for the na-tional vaccination drives, health for all by theyear 2000, the children's dental care cam-paign, and development of the occupationalprofile for statistical assistants. PAHO/WHO'sfinancial participation in these activities cameto US$38,819.


8.299 El Salvador, in common with theother Central American countries, is con-fronted by a serious economic and social crisiswhich is affecting every sector, including thehealth sector. Service delivery is often inhib-ited by obstacles inherent in the current situa-tion and compounded by budgetary con-straints. A new Government has presented anopportunity to work for the improvement ofeconomic and social conditions. The newhealth authorities pledged their unconditionalsupport for the Plan for Priority Health Needsin Central America and Panama, includingsubregional projects as well as two nationalprojects designed to meet the health require-ments of El Salvador. It is hoped that jointaction by the countries of the Isthmus willmake it possible to obtain the resources for im-plementing the Plan, thereby helping to bringabout improved levels of well-being in the sub-region.

8.300 Some of the profiles contemplatedin the health priorities began to be reflected inthe projects for 1985, especially in the areas ofinfant survival and tropical disease control. Ifthe internal conditions of the country im-prove, a number of deferred activities mightbe carried out in 1985.


French Antilles and Guiana



8.301 Epidemiological analysis at the lo-cal level has been an important objective. Ineach Department, seminars were organizedon principles of epidemiology for disease con-trol, using the PAHO/WHO modular course.A first seminar to train moderators was fol-lowed by multiplier courses. PAHO/WHOprovided fellowships in the field of epidemiol-ogy and community health to senior staff oftwo Departments.

8.302 In the program of scientific ex-change and cooperation between the Frenchdepartments and their neighbors in the Re-gion, participants went to CAREC-organizedsubregional workshops-seminars, to the Car-ibbean Veterinary Public Health Seminar, andto a control of diarrheal diseases (CDD) mid-level supervisory skills course in Haiti.


8.303 In French Guiana, malaria remainsa special concern. At the request of theFrench authorities, a border meeting was or-ganized with Suriname to discuss the malariaproblem and control strategies on the Marowi-jne River. Participants attended from theHealth Department (including primary health

care staff) and the Pasteur Institute. A micro-computer provided by PAHO/WHO for useby the Cancer Registry in Martinique enteredits first year of operation.


8.304 Professional staff assigned to thecountry: A PAHO/WHO epidemiologist vis-ited each Department for 1 week to conductthe first PAHO/WHO course on principles ofepidemiology for disease control.

8.305 Fellowships: 2, one in epidemiol-ogy and the other in community health.

8.306 Courses, seminars, and work-shops: For the three courses mentioned andthe corresponding multiplier courses, PAHO/WHO provided the modules (500 sets).


8.307 Relations with the French Depart-ments continued to be good. A major weak-ness identified in the delivery of health ser-vices was the absence of an adequateinformation base and the ability to interpretdata at the local level. Attitudes toward under-standing the regional neighbors and exchang-ing information with them have remainedgood.

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186 Annual Report

GrenadaBasic Data



(as nationally defined)Birth rate/1,000 inhabitantsMortality rate/1,000 inhabitants



1983 26.31983 7.3


Life expectancy at birthInfant mortality/1,000 live birthsMaternal deaths/1.000 live birthsDeath rate 1-4 years/ 1.000 childrenPercentage of newborn with a weight of



per capita/day


198219831983

67.0a21.2

1.4

(triple vaccine)-poliomyelitis-measles



sanitary waste disposalConsultations per inhabitant per yearNumber of discharges per 100 inhabitantsNumber of beds per 1,000 inhabitants



1979-81 61.9 10,000 inhabitants1979-81 61.9

1983198319831983

1.07.0

21.00.5

YEAR NUMBER

1983 68.01983 78.01983 7.0

1983 85.0

1983 7.11983 3.2

1982 3.81982 33.7

1982 15.7



dedicated to health

... Data not available.a Age for women. Age for men,64.0 years.



8.308 The country is developing a healthplan with the assistance of PAHO/WHO andthe Caribbean Community (CARICOM). Pro-gramming workshops were held at the districtlevel, but there was a major loss of momen-tum in program development during 1984, aperiod of political and economic uncertainty.A follow-up was done of the programmingprocess at the district level, and PAHO/WHO

made recommendations for improving nurs-ing services at St. George's General Hospital.

8.309 In human resources, along with therest of the country, the Ministry of Health hasbeen undergoing a rebuilding phase. This hasbeen reflected in an emphasis on planningand personnel development, carried out withthe assistance of several agencies includingPAHO/WHO, USAID, and Project HOPE.Senior nurses received orientation on Carib-bean standards of nursing care.

8.310 In environmental health, becauseof the unsettled political situation, the environ-mental health program continued at a modestpace, leaning heavily on bilateral assistance.


Attention was given to human resource devel-opment and to an OAS study of a seweragesystem for the southwest area of the island.Also, a representative of the Central WaterCommission attended a subregional work-shop on water quality control. PAHO/WHOsupported the reporting of histopathologicalspecimens, the training of laboratory technol-ogists in laboratory management, testing forhepatitis B, and the setting up of rural labora-tories.


8.311 Strategies in nutrition continued todevelop breastfeeding and feeding of theweaning age group. Official priority wasplaced on health education.

8.312 Maternal and child health and fam-ily planning services were somewhat weak-ened by diminished staffing and uncertaintyabout funding; female sterilization has not yetbecome an established procedure. Two staffmembers completed courses in family nursingpractice and community nutrition as part ofthe process of developing maternal and childhealth within a primary health care context.Some outstanding activities were as follows:development of a project proposal on familyplanning and family life education, which isawaiting funding from UNFPA; follow-up ofdiarrheal disease control activities; and provi-sion of oral rehydration salts.

8.313 Grenada participates in the Ex-panded Program on Immunization (EPI) and,with the assistance of the Caribbean Epidemi-ology Center (CAREC), is developing andstrengthening its surveillance of laboratory ca-pabilities. In animal health, emphasis con-tinues to be placed on zoonoses surveillanceand improving the rabies control program.


8.314 Bilateral cooperation: USAID

provided technical cooperation for commu-nity sanitation and the European EconomicCommunity (EEC), funds for fellowships.

8.315 Foundations: Project HOPE as-sisted in health personnel and Radda Barnendonated US$833,333 for maternal and childhealth.


8.316 Professional staff assigned to thecountry: Although no full-time professionalstaff are assigned to Grenada, considerablecooperation comes from the Organization'sHeadquarters staff as well as from CARECand CFNI. Consultants in health systems, per-sonnel development, disaster preparedness,disease control, environmental health, veteri-nary public health, vector control, nutrition,and maternal and child health were providedto collaborate with Government efforts.

8.317 Fellowships: 5, in: vector control,community nutrition, hepatitis, dental auxil-iary, and public health inspection. Traininghas been provided for 5 nationals in: labora-tory management (Saint Lucia), communitynutrition (Barbados), radiography (Jamaica),and community health nursing (Jamaica), uti-lizing EEC-CARICOM Secretariat funding.PAHO/WHO's total contribution for fellow-ships was US$33,650.


8.318 A major programming effort willhave to be deferred until the newly electedGovernment is settled. The UNFPA-fundedproject should be a key element in future ma-ternal and child health activities and should beimplemented fully. The long-delayed revisionof the maternal and child health manualshould proceed with PAHO/WHO technicalcooperation. Provision is being made to in-

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188 Annual Report

clude Grenada in the proposed development development is likely to occur in all sectors,of perinatal care services in collaboration with and the environmental health program willCLAP. have to be accelerated to meet the needs of a

new tourist trade and a more demanding pub-8.319 If political difficulties can be settled lic. Continued development of primary healthin the coming year, as expected, increased care in rural districts is expected.


GuatemalaBasic Data

YEAR NUMBER








per capita/day


1'






980-85 60.7 sanitary waste disposal1984 67.7 Consultations per inhabitant per year19831983

1.215.6




1979-81 58.2 10,000inhabitants17- 58.2

1983198319831983

29.63.24.10.4



dedicated to health

1983198319831983

1982 49.8

1982 33.61982 40.01983 2.51982 1.7

1983 6.01983 2.6

1983 10.8

1984 21.8

1984 3.7

1984 13.5



8.320 The structural reorganization of theMinistry of Public Health and Social Welfarewas the outstanding action taken by the healthauthorities in 1984. Immediate outcomes ofthe change were an administrative and func-tional rearrangement of the units of the Gen-eral Directorate and Subdirectorate for HealthServices and the performance of an institu-tional analysis of the health sector by a na-tional multi-institutional Government team.

The portion of the analysis pertaining to theGuatemalan Institute of Social Security wascompleted and those parts relating to the Min-istry of Public Health and Social Welfare andthe Secretariat for Social Welfare were welladvanced at year's end. Studies also were ini-tiated on the Municipal Government of Gua-temala City, universities, and private sectoragencies.

8.321 In the strategic planning and localprogramming process, the Government's ob-jectives are to make optimal use of resourcesand increase the operational capacity of thesystem, thereby achieving qualitative andquantitative improvements in the delivery ofhealth services. Moreover, the health authori-

YEAR NUMBER

55.055.038.040.0

189

190 Annual Report

ties, with the aim of achieving the goals ofHFA/2000, have decided to institute an oper-ational system based on the primary healthcare strategy to improve the quality of careprovided to underserved urban communities.A model based on that operational system be-gan to be applied in May 1983 in the Depart-ment of Escuintla. Its major findings indicatethat vaccination coverage within the Ex-panded Program on Immunization (EPI),which was formerly 10% is now at 73%. An-other salient fact is that institutional vaccina-tion is now an ongoing function in this depart-ment. The oral rehydration program, whichdid not exist formerly, is now functioning con-tinuously with a preventive approach at allhealth facilities and on the basis of coordi-nated actions by the health teams and com-munity leaders in more than 600 localities.Preliminary results indicate that overall mor-tality due to diarrheal diseases has declined bymore than 50%.

8.322 The Government decided to ex-tend the operational primary care model to allhealth areas and took initial actions to imple-ment it in the Departments of Santa Rosa, ElProgreso, and Sacatepéquez. A total of 14seminar-workshops were conducted in the lat-ter areas for approximately 500 people, in-cluding hospital physicians and auxiliary staff.As the year ended, the Departments of Ju-tiapa, Jalapa, Zacapa, and Chiquimula werepreparing to apply the model in 1985.

8.323 In order to strengthen the health in-stitution maintenance program, a responsibleunit was established and 4 regional centersand 10 local maintenance units were organ-ized.

8.324 Salient developments in the hu-man resource field were the definition of a hu-man resource policy, the taking of a census ofpersonnel available at institutional and com-munity level, the holding of interinstitutionalseminar-workshops on human resource pol-icy, and the conducting of a course-workshopon methodology for research on health per-sonnel.

8.325 Among the most significant accom-plishments in the protection of environmentalhealth were the following: formulation of amodel information system for the water sup-ply and sanitation subsector; formulation,through the Permanent Coordination Com-mittee for Water Supply and Sanitation (CO-PECAS), of a project to strengthen the watersupply and sanitation sector; development ofprofiles for water supply and sanitation proj-ects as Guatemala's contribution to the Planfor Priority Health Needs in Central Americaand Panama; and the planning and imple-mentation of a program for including basicsanitation components in the operationalmodel for primary health care in the Escuintlaarea, with a view to constructing 27,000 la-trines and 50 wells with manually operatedpumps and establishing simple systems forsolid waste management. In addition, threeworkshops on the manufacture of latrine tilesand slabs were conducted. Work went for-ward on monitoring and measuring arsenicand boron pollution levels in the Paz River,near the border with El Salvador, as a result ofdischarges from a geothermal plant in thatcountry.


8.326 In the food and nutrition area, thesupply of food, especially basic grains, was in-creased and improved. Further technical im-provements were made to the "Nutricta" cornseed, and work proceeded in the fields of agri-business, food fortification, and agriculturaldevelopment along the east-west corridor innorthern Guatemala.

8.327 In maternal and child health, oper-ational health care models were put into prac-tice and a structure of health services wasworked out, ranging from the basic units tothe levels of greatest complexity. In oralhealth, PAHO/WHO cooperation was pro-vided in teaching-service integration, espe-cially to the University of San Carlos in Guate-mala City. A significant development was the


training of personnel in intrahospital infectionsat the country's two largest hospitals-SanJuan de Dios and Roosevelt. A manual ofstandards and procedures for epidemiologicalsurveillance of intrahospital infections wasclose to completion. In the malaria eradicationprogram, efforts were focused mainly on epi-demiological and entomological aspects, in-cluding a follow-up survey to determine thesusceptibility of Plasmodium falciparum to thefour aminoquinolines; on field testing of newtherapeutic regimens; on entoepidemiologicalstudies in a locality with persistent transmis-sion; and on monitoring the susceptibility ofanophelines to various insecticides.

8.328 To strengthen the tuberculosis con-trol program, now entirely integrated into theregular service network, a seminar was con-ducted to evaluate and analyze the programcomprehensively and identify the major prob-lems and their possible solutions.

8.329 Zoonoses control was carried outin coordinated fashion by the ministries ofhealth and agriculture. The major develop-ment was the relocation of the rabies vaccineproduction plant and the solution of problemswhich had reduced its output. A committee ofhigh-level representatives of the ministries ofhealth and agriculture established during theyear was making arrangements for the prelim-inary phase of the plan for controlling humanrabies.

8.330 An emergency preparedness planwas completed and was being revised. A sem-inar was conducted to prepare a national planfor governing hospital performance in theevent of a disaster necessitating medical careon a massive scale. The seminar was later re-peated in five regions of the country.


8.331 Technical Cooperation AmongDeveloping Countries (TCDC): Of salientimportance was Guatemala's cooperation

with El Salvador to collaborate in the techno-logical shift from the production of Sample-type Fuenzalida vaccine.

8.332 International cooperation:UNICEF provided US$593,131 for watersupply, development of rural health units,maternal and child health (breastfeeding, oralrehydration, comprehensive care of childrenbelow age 6), and immunization; UNFPAgave US$486,132 for family planning; Cen-tral American Bank for Economic Integration(CABEI), US$4,049,100 for construction of100 health posts; CIDA, US$2,870,000 forrural waterworks; CARE, US$300,000 forconstruction of 20 health posts and training ofvolunteers, US$5,116,000 for maternal andchild health (food supplements), andUS$250,000 for rural water systems; UNDP,US$350,000 for drug control (program in op-eration) and for development of the manage-rial capacity of water supply institutions (proj-ect approved); IDB, for the following projectsin operation: design of a national water supplyand sewage program for urban centers(US$850,000), water supply and sewage forGuatemala City (US$35.5 million), construc-tion of water and sewage systems for second-ary cities (US$22.5 million), construction of55 rural health centers (US$28 million), con-struction of 3 departmental hospitals (US$51million); and for approved projects to con-struct 140 municipal works in the amount ofUS$18 million and US$1,326,000 for opera-tion and maintenance of a water supply sys-tem jointly with GTZ.

8.333 Bilateral cooperation: USAIDprovided US$600,000 for a comprehensivefamily planning system and US$4.7 millionfor health and nutrition and environmentalsanitation.


8.334 Professional staff assigned to thecountry: 8, including the PAHO/WHO

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192 Annual Report

Country Representative and professionals, in:health administration, laboratory procedures,epidemiology, environmental health, andnursing.

8.335 Regional and intercountry advis-ers: 38, for a total of 247 days, in: health pro-gramming and administration, hospital ad-ministration, statistics, maternal and childhealth and family planning, tropical and para-sitic diseases, vaccine production, human re-sources, essential drugs, and disaster pre-paredness.

8.336 Short-term consultants (STC):22, for a total of 1,483 days, in: hospital archi-tecture, primary care, information systems,environmental health, maintenance, epidemi-ology, diarrheal diseases, respiratory dis-eases, maternal and child health, malaria, ne-phrology, and communications sciences.

8.337 Fellowships: 46, for a total of 112months of study, at a cost of US$132,640, in:public health, hospital administration, envi-ronmental health, design of health establish-ments, workers' health, communicable dis-eases, tuberculosis, human resources,epidemiology, maternal and child health,drug control, and bacteriology.

8.338 Courses, seminars, and work-shops: 132, with a contribution from PAHO/WHO of US$268,469. The participants inthese events totaled 4,367 national officials,and these events were conducted in the fol-lowing areas: maternal and child health, hos-pital maintenance, primary care, communityhealth, methodology for education in the fieldof health, environmental sanitation, publichealth, planning and administration, para-sitology, pesticides, tuberculosis, human re-sources, diarrheal diseases, disaster emergen-cies, supervision, programming, and borderhealth meetings.

8.339sionalscost of

Local contracts: 18 local profes-were contracted for specific jobs at aUS$32,951 to supplement resources

provided under the technical cooperation pro-gram.


8.340 The basic policy adopted by thehealth authorities calls for intensification ofactions directed to attaining the HFA/2000goals, curtailment of investment programs,and concentration of efforts on achieving opti-mal use of resources by rationalization of themanagement process and increasing opera-tional capacity. Specific gains in the improve-ment of intra- and intersectoral linkages werethe improvement of coordination between theGuatemalan Institute of Social Security andthe Secretariat for Social Welfare and thecloser relations of the General Secretariat forEconomic Planning institutions like the Munic-ipality of Guatemala and universities.

8.341 An outstanding event in 1984 wasthe XIV Meeting of Directors General ofHealth and the XXIX Meeting of Ministers ofHealth of Central America and Panama,which was also attended by the managers ofthe social security agencies of the countries inthe subregion.

8.342 The Government has supportedthe Plan for Priority Health Needs in CentralAmerica and Panama and carried out an in-tensive multisectoral program of activities withPAHO/WHO. One product of this joint effortwas an analysis of health conditions, in whichthe major problems were identified and prior-ity areas established. The study gave rise tothe preparation of a document containing theprofiles of 33 projects requiring an externalcontribution of US$181 million over a 5-yearperiod. In addition, the study served as a basisfor upgrading the country's capacity to assesshealth conditions and formulate projects, aswell as a vehicle for. improving interinstitu-tional and intersectoral coordination.

Sumrnmary of Each Country's Activities

GuyanaBasic Data





Life expectancy at birthInfant mortality/1,000 live birthsMaternal deaths/ 1,000 live birthsDeath rate 1-4 years/1,000 childrenPercentage of newborn with a weight of



per capita/day










1979-81 57.5 10,000 inhabitants


1979 8.5 Total health expenditure as a percentage1979 4.9 oftheGDP1979 20.4 Percentage of the National Budget.:. .... dedicated to health

YEAR NUMBER

1983198319831983

58.361.626.175.9

1984 98.0

1983 17.51982 4.5

1980 1.21980 6.5

1980 9.2

1983 70

1982 5.0

1983 6.3




8.343 Planning, programming, and eval-uation activities were formalized, including theparticipation of all interested and responsibleentities, and the establishment of timetables.Regionalization was accelerated by the initia-tion of the regional health services directorate.At the same time, the large and the small re-gions were reappraised realistically in terms of

population density. The large regions havefour levels of care (health posts, health cen-ters, district hospitals, and a regional hospital)and are led by a regional health team leader.The small regions, lightly populated, have atypical representation of health service institu-tions and the team leader may be a medex(rural health technician), a public healthnurse, or even a nurse assistant. Decentraliza-tion also progressed along with the regionaladministrative machinery, which is becomingmore and more a partner of the Ministry ofHealth in the administration of the health ser-vices. These actions, coupled with the im-provement of the referral system, willstrengthen the primary health care network.

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194 Annual Report

8.344 A good number of graduates frommedical schools and other health serviceteaching institutions abroad have returned. Anumber of medex, various categories ofnurses and technicians, and communityhealth workers have graduated locally; thesegraduates are being hired to open new districthospitals, health centers, and health posts, orto fill long-awaited vacancies in the health sec-tor, thereby increasing the health service cov-erage substantially.

8.345 In human resources, a large effortwas invested in training health staff to preparethem for their new role in primary health care.Seminars, workshops, courses, and inservicedemonstrations were carried out at both theinstitutional and community levels. The nextphase of this exercise will focus on the public:training individuals, families, and communi-ties for their role in primary health care. Aninnovative medical education program is be-ing developed and it is hoped that the medicalschool will open its doors for the first time in1985 or in 1986 at the latest. The establish-ment of a national center for health educationtechnology also is being discussed. The centeris scheduled to be inaugurated before theopening of the new medical school.

8.346 The UNDP/PAHO study of the1970's is still being utilized as a reference inenvironmental health. Water and sanitationactivities are concentrated mainly on watersupply and sanitation for urban as well as ruralareas through the Guyana Water Authority(GUYWA). The IDB has studied the possibil-ity of institutional strengthening of GUYWA,and consideration is being given to the majorcomponents of this subproject. In conjunctionwith the water project, a fluoridation schemeusing Fluorospar from Brazilian sand is beingelaborated.


8.347 Health centers, clinics, and homevisits of public health nurses continued to pro-

vide maternal and child health services.The oral rehydration salt program is an inte-gral part of this service. The immunizationprogram has progressed to a creditable level.World Food Program (WFP) and UNICEF in-puts were sought in support of the Cerex-weaning food program. The Government hasrequested CFNI to evaluate the impact ofCerex as supplementary infant food and thenutritional adequacy of rice flour as a substi-tute for wheat flour.

8.348 Malaria is still endemic in thesparsely populated areas of the NorthwestDistrict and Rupununi. The number of malariacases in 1984 was more than 2,000. Techni-cal problems such as identification of particu-lar vectors in specific areas, susceptibility to in-secticides, resistance to drugs, and the like,are being studied as support to the malariacontrol program. This program is being inte-grated into the health services, rather than be-ing run as a vertical program.

Mobilization of Technical andFinancial Resources8.349 Technical Cooperation AmongDeveloping Countries (TCDC): The countryparticipated in TCDC activities throughPAHO/WHO, the Caribbean Community(CARICOM), and the Regional EducationProgram for Animal Health and VeterinaryPublic Health Assistants (REPAHA) in theCaribbean border meetings for malaria, Uni-versity of the West Indies (UWI), and the Car-ibbean Development Bank (CDB). There isalso a joint human resources program withCuba. DDT for the malaria program was re-ceived from Trinidad and Tobago on a TCDCbasis.

8.350 International cooperation:UNICEF provided US$544,000 for provisionof water supplies for small communities andvillages (1983-1985), US$58,000 for pri-mary health care, US$78,000 for a nurseryschool project (1981-1984), US$24,500 forthe National Rehabilitation Committee


(1981-1984), and US$92,000 for women'sappropriate technology (1981-1984).

8.351 Bilateral cooperation: The Gov-ernments of Korea (People's Republic) andCuba provided assistance, respectively, for areferral hospital (400 beds) in Georgetownand for human resource development, includ-ing the school of medicine; CIDA gave assis-tance for improvement of the health services.


8.352 Professional staff assigned to thecountry: 6, the PAHO/WHO Country Rep-resentative and advisers, in: malaria, sanitaryengineering, dental health, pathology, andveterinary education.

8.353 Regional and intercountry advis-ers: Several, in: epidemiology, medical edu-cation, environmental health, and water fluo-ridation.

8.354 Short-term consultants (STC):Several, in: occupational health, medical edu-cation, and diarrheal diseases control.

8.355 Fellowships: 23, in the followingareas: primary health care, health statistics,nurse education-administration, laboratoryservices, hospital maintenance, vector con-trol, health education, public health adminis-tration, and project management. A total ofUS$127,320 was obligated.

8.356 Courses, seminars, and work-shops: These training activities were for com-munity health workers, tutors in educationmethods, health science teachers, nurses, andregional health managers and clerks. Work-shops were also held in occupational health,dental health, and information systems forwater and sanitation.

8.357 Grants: PAHO/WHO providedUS$5,000 for a survey on the needs of the el-derly, US$2,200 for collection of informationon trends in health services research in Latin

America and the Caribbean, and US$1,000for research studies in psychological testing inchildren.


8.358 With regard to health for all by theyear 2000, the crisis affecting the countryshould be seen as an opportunity to arouse anational drive to foster self-sufficiency andconsequently to encourage appropriate tech-nology. The health sector could become aninstrument in this drive. Within the health sec-tor itself, a number of innovations are beingintroduced which would not have been ac-ceptable in past years, such as the followingconcepts: regionalization; decentralization; in-tegration of team-based health care, with fivelevels of care and with the community healthworker as the base of the pyramid and a veryimportant entry point to it; and using eco-nomic analyses to make decisions about proj-ects and programs.

8.359 These new approaches, arising inresponse to the present economic disadvan-tage, accentuate the value of mobilizing na-tional resources. The community, organizedby the local democratic organs at various lev-els, is a force for developing local potential.The Ministry of Health is devising ways of in-corporating the input of the private and semi-private health sectors into a national health ef-fort. Since the private and semi-private sectorsadminister almost as many hospital beds andoutpatient facilities as the Ministry, this coordi-nated effort should have a salutary effect onthe overall health service.

8.360 The Ministry has come to the real-ization that the cooperation of the teaching in-stitutions and professional societies is indis-pensable in the administration of the healthinstitutions and especially in the developmentof medical education in the country. The na-tional insurance scheme, which only recentlyhas begun to make financial contributions to

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196 Annual Report

health services through fee-for-service reim-bursement, will eventually play an even moreactive role.

8.361 The unfavorable economic situa-tion has also made the Government acutelyaware of the potential of external resourcemobilization. Hence, the Department of Inter-national Cooperation has been established inthe Ministry of Economic Planning and Fi-nance for mobilizing and coordinating exter-nal inputs.

8.362 The future depends on a capabilityfor coping with a difficult economic situationwhich does not seem to disappear quickly. Asone of the lowest priority areas under theseeconomic circumstances, the health sector,will have to learn-even more so than othersectors-to be dynamic, flexible, and innova-tive with regard to both the software and hard-ware of health technology development.PAHO/WHO's support will certainly be athand.


HaitiBasic Data








percapita/day










1979-81 45.5 10,000inhabitants17- 45.5

1982198219821982

19.42.14.40.5



dedicated to health

YEAR NUMBER

19831983

1983

8.76.0

69.0

1984 32.0O

1984198319841984

19.0b

20.01.00.8

1983 1.41983 1.9

1983 3.6

1984 9.0

1984 3.0

1984 10.0

- None.a 54% urban and 25% rural. b Urban population; the figure fortheruralpopulation is 12%.



8.363 The Government remained com-mitted to the primary health care strategythrough the sequential attack on six priorityprograms identified in its "Nouvelle Orienta-tion." Within this framework, late in 1983, theMinistry of Health stepped up its efforts to de-centralize authority for health services deliveryto four regional directorships: North, South,West, and Transversal. In 1984, special ef-forts were made to expedite the establishment

of new regional offices in the West and Trans-versal Regions. Developments in the West Re-gion, headquartered in Port-au-Prince, haveproceeded smoothly; in the Transversal Re-gion, headquartered in Gonaives, major orga-nizational challenges emerged. In general, sig-nificant administrative and programmaticautonomy has been turned over to regionaladministrations. Financial planning, however,has remained more centralized, and this im-portant division of authority has now createdspecial needs for more uniformity of reportingprocedures and information systems so thatcentral planners can accurately track the ex-tent of activities and results achieved in the re-gions.

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8.364 The rural health delivery programfeatured a substantial increase in the numberof health institutions (341 at the beginning ofthe year to 389 at the end) as well as renova-tion and reequipment. However, the results oftraining and deployment of health inspectorssuggested the need to reassess the program.In the development of secondary and tertiarycare, the recommendations made in 1983 bya PAHO/WHO consulting team at the Uni-versity Hospital produced positive effects inachieving better sanitation measures at thehospital and availability of water supply.

8.365 In environmental health, relevantactivities included the implementation by theNational Committee for the Water and Sanita-tion Decade (CONADEPA) of the formulationof the sectoral national plan and the masterplan for the capital's water system. In addi-tion, 10 water systems of the principal citieswere strengthened and studies were com-pleted for seven other intermediate cities. Ru-ral water supplies and latrine construction withinnovative technology have progressed.


8.366 As stated in the "Nouvelle Orienta-tion," primary health care strategy should beimplemented by focusing on six priority healthproblems: diarrheal disease, immunizable dis-ease, tuberculosis, nutrition, maternal andchild health, and malaria.

8.367 In food and nutrition, although nu-tritional problems continue to be serious, awell-focused Government strategy has not yetbeen identified; it is estimated that the prob-lem is linked primarily to shortages in availablefood stocks. In maternal and child health andfamily planning, program productivity waslow because of administrative and organiza-tional problems. To strengthen those services,a functional reorganization was adopted at theend of the year.

8.368 Immunization activities remained

low in 1984. The coverage for children ofages 0-4 in the first 6 months of 1984 wasabout 8.5% for DPT, 7.4% for polio, and38.7% for BCG. Measles vaccine also wasgiven sporadically.

8.369 In 1983, planning began for amultisectorally supported project, the "Na-tional Program for the Control of DiarrhealDiseases and the Promotion of Breast-feed-ing," which became fully operational in 1984.As of mid-1984, over 2,000 health workersand almost 4,000 nonhealth workers hadbeen trained in the program. Almost 1 millionoral rehydration salt (ORS) packets were dis-tributed in public and private sector commer-cial institutions, and 2,000 commercial outletsfor ORS also were established. Althoughproblems were encountered in the operation,overall progress in this program was encour-aging.

8.370 Tuberculosis is the third priority inthe country. Grace Children's Hospital andthe Crusade against Tuberculosis (CAT-ICC)continued to support most diagnostic andtreatment programs in the country, as well asmaintaining BCG immunization. Their suc-cess with BCG was a modest 38.7 % coverageof children less than 1 year.

8.371 The national malaria eradicationservice had a difficult year operationally be-cause of Government and departmental prob-lems with budgets and availability of externalfinancial resources. On the positive side, co-operation between the National Service forMajor Endemic Diseases (SNEM) of Haiti andits counterpart in the Dominican Republiccontinued at a brisk pace. The two SNEMsnow coordinate activities along border areas,and the SNEM-Haiti has agreed to give pre-ventive malaria treatment to all contractualHaitian cane cutters who travel to the Domini-can Republic for work. The single most impor-tant event in 1984 was a mid-term evaluationof the SNEM Malaria Program emphasizingthe need for improvements in technical qualityand administrative program support, such asturning the surveillance system over primarily


to the regular health services and greatly ex-panding the responsibility of the SNEM collab-orating volunteers.

8.372 In epidemiological services, tech-niques and methods were improved. Two im-portant epidemic outbreaks, dengue and diar-rheal diseases, were investigated during theyear which served to help build an apprecia-tion for the need of epidemic surveillance.

8.373 With regard to disaster prepared-ness, a seminar on disaster planning for 30health workers in the South Region was de-veloped. In advance of the Caribbean hurri-cane season, PAHO/WHO also supportedthe design and printing of 20,000 posters ad-vising the population on advance precautions.


8.374 International cooperation:UNICEF provided US$644,000 for primaryhealth care, medicaments, immunization, nu-trition, and water supply; UNDP, US$81,000for water supply; UNFPA, US$400,000 formaternal and child health and family plan-ning; the World Bank, US$1.7 million for wa-ter supply; IDB, US$9,873,000 for four proj-ects in health services and water supplysystems, in progress; OPEC, US$750,000 forthe sewerage system; WFP, US$2,616,000for primary health and nutrition; and EEC,US$1,435,000 for water supply.

8.375 Bilateral cooperation: USAIDgave US$6,632,000 for malaria, health ser-vices, family planning, and rural water supply;Government of France, US$3,170,000 forrural water supply and training in publichealth; Federal Republic of Germany,US$1,887,000 for nutrition and water supplyin seven towns; CARE, US$343,000 for nu-trition; and Government of Japan, US$2.5million for malaria.


8.376 Professional staff assigned to thecountry: 12, including the PAHO/WHOCountry Representative and advisers in epi-demiology, administrative methods, nursing,sanitary engineering, entomology, medical of-ficer, and sanitarians.

8.377 Short-term consultants (STC):18, for a total of 175 days in several healthservices areas.

8.378 Fellowships: 44, in the followingfields: public health administration, sanitation,maternal and child health, health education,health statistics, dental health, malaria, tuber-culosis, laboratory services, and communica-ble diseases.


8.379 Progress was made in the imple-mentation of maternal and child health poli-cies and plans, as stated in the "Nouvelle Ori-entation." Other positive features were theattempts to strengthen and expand the infra-structure of health services, together with apromising water supply program, as well assubstantial progress in the national diarrhealprogram. However, these efforts and the sub-stantial amount of financial resources involved(mainly from external sources) did not keeppace with expected target achievements.Since Haiti is one of the major recipients ofconcessionary funds and external donations,it is hoped that the Government could devisenew approaches to manage international co-operation (legal, administrative, and opera-tional) to achieve greater impacts with avail-able resources.

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200 Annual Report

HondurasBasic Data








percapita/day










1979-81 52.1 10,000inhabitants17- 52.1

1980198019801984

27.45.6

11.81.2



dedicated to health

YEAR NUMBER

1983198319831983

70.069.066.075.0

1983 69.0

1983198319831983

.44.0100.0

2.70.8

1984 3.81984 1.5

1984 14.8

1983 43

1983 7.0

1983 13.0



8.380 The Ministry of Public Health andSocial Welfare (MSP) concluded the arrange-ments for the local programming process,which was instituted in three health regions.The information system (both intra- and extra-hospital) was redesigned in terms of the healthprograms to be carried out, as were the equip-ment, occupation, and education profiles forthe peripheral levels. A determination wasmade of the population to be covered by theMSP. In sectoral planning, the current situa-

tion and its conditioning factors were analyzedand planning functions were identified. Con-tact was made at the highest level with theEconomic Planning Council (CONSU-PLANE) with a view to coordinating sectoralplanning. The organization of groups to for-mulate profiles for projects included in thePlan for Priority Health Needs in CentralAmerica and Panama, together with the per-formance of feasibility studies on each of thoseprojects, constituted a significant effort coordi-nated at the political level through the Plan-ning Division, culminating in the establish-ment of a Projects and Investments Unit in theMSP.

8.381 Under the guidance of a politico-technical commission, MSP coordination with


the Honduran Social Security Institute pro-gressed along two work fronts: the prepara-tion of valid options for integration and asearch for areas of common interest for jointshort-term activities. A cost manual adoptedto improve the efficiency of the country'shealth establishments was expected to facili-tate the management and improve the main-tenance and adequacy of the information sys-tem. Nearly 500 urban and rural healthcenters were re-equipped with financial sup-port from the Government of the Netherlandsand UNDP.

8.382 Following a decision to reorganizeambulatory care services in the MetropolitanHealth Region, the MSP defined a methodol-ogy for extending the coverage of servicesthrough referrals from peripheral centers andcoordinating operations with those of othersectors. To complete the ambulatory carescheme, the Ministry also began to prepare aprotocol for a study on the demand for outpa-tient services in the country's hospitals.

8.383 Human resource activities were fo-cused primarily on definition of a national pol-icy; planning, development, and utilization ofinstructional staff; and strengthening of train-ing centers. Courses were conducted formembers of the faculty of the School of Medi-cal Sciences in order to upgrade their aca-demic level in the areas of learning evaluation,systematization of instruction, applied didac-tics, and research methodology.

8.384 PAHO/WHO contributed to thedevelopment of the National Medical Libraryby helping to improve its equipment, train itsstaff, and increase its collection of books andperiodicals. Equipment was provided to theSchool of Medical Science's EducationalTechnology in Health Unit, which was to as-sume responsibility for the organization of in-structional resources, production of educa-tional materials, and educational research.

8.385 In the area of environmentalhealth, a national water supply and sanitationcommittee was established by presidential de-

cree, in connection with the InternationalDrinking Water Supply and Sanitation Dec-ade (IDWSSD), and the first stage of the infor-mation system for monitoring and evaluatingthe national water and sanitation plan was de-signed. In addition, a study was carried out forthe purpose of evaluating the institutions inthe subsector and determining the status ofbasic sanitation in underserved urban areas ofthe Central District and the municipality ofSan Pedro Sula. Water supply systems werecompleted for three cities (at an investmentcost of US$23.5 million), and projects wereformulated for another four cities for whichIDB financing was to be made available(US$20 million). With respect to the environ-mental impact of economic developmentprojects, the Ministry coordinated the effortsto minimize the health hazards posed by eco-logical changes in new human settlement andhydroproject construction areas.

8.386 Regional health laboratories werestrengthened to increase their technical andadministrative capacity; a total of 26 periph-eral laboratories were equipped during 1984with funds provided by a grant from the Gov-ernment of the Netherlands.


8.387 In the nutrition area, four nationalprojects were formulated within the Plan forPriority Health Needs in Central America andPanama. The projects covered the followingfields: increased production, preservation,and consumption of food; fortification offoodstuffs with basic nutrients; nutritional stateof displaced populations; and strengtheningof the Ministry's Department of Nutrition.

8.388 In maternal and child health,1,200 traditional midwives and 600 healthprotectors received training, along with healthpersonnel, in demography, administration offamily planning programs, and equipmentmaintenance. UNFPA-funded equipment

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202 Annual Report

was provided for use in ambulatory servicesand hospitals and by traditional midwives.

8.389 The oral health program received26 complete sets of dental equipment fi-nanced by a grant from the Government ofthe Netherlands. A study was made to deter-mine the fluoride content of water supplied bythe waterworks of the country's departmentalcapitals.

8.390 In mental health, a course was con-ducted in family therapy and prevention of al-coholism and drug dependency, and work be-gan on the centralization of psychiatry andpsychology activities and their integration intothe health services.

8.391 The Expanded Program on Immu-nization was evaluated. The diarrheal diseasecontrol program continued to promote andutilize oral rehydration treatment by commu-nity and institutional personnel and con-ducted seminars for pediatricians. A controlprogram for acute respiratory infections wasinaugurated in 1984 with a number of re-gional seminars and workshops to acquaintparticipants with the program regulations. Inthe vector control program, a study was madewith a view to pointing out the various prob-lems appropriately on the basis of an im-proved information system and better epide-miological analysis. As a result of thisprogram, the number of cases of malaria wasreduced from 57,500 in 1982 to 17,500 in1984. An epidemiological survey on the prev-alence of Chagas' disease, conducted withTDR/WHO support, revealed a prevalencerate of 6%. The tuberculosis control programwas evaluated against its goals at a seminar at-tended by regional directors.

8.392 The animal health program of theMinistry of Natural Resources continued to becoordinated with the MSP rabies program inareas related to laboratory diagnosis and theproduction of canine rabies vaccine.

8.393 The MSP organized a nationalteam to develop a national disaster prepared-ness plan.

Mobilization of Technical andFinancial Resources8.394 International cooperation:UNICEF donated US$250,000 for integratedrural development (1981-1984) and for ma-ternal and child health; UNFPA, US$496,846for family planning (198i-1984); ILO,US$11,000 for actuarial evaluation of theHonduran Social Security Institute; IDB,US$7.3 million for rural waterworks and sani-tation (1981-1984), US$27 million for con-struction of water supply systems for threecities (1981-1984), US$14 million for devel-opment of the physical infrastructure (1981-1984), US$9 million for improvement of ruralwaterworks (3 years), US$24 million for con-solidation and extension of water distributionlines in four cities (approved in 1984), andUS$380,000 for studies on hygienic condi-tions of housing; and IBRD, US$31.4 millionfor urban sanitation (6 years).

8.395 Bilateral cooperation: USAIDprovided US$11,242,000 for basic sanitation(1982-1987), US$70,200 for maternal andchild health (1980-1984), US$15,391,000for administrative systems (1981-1984),US$101,500 for immunization, US$157,500for tuberculosis control, US$15,141,000 forcontinuing education for health workers,US$10,350,000 for water and sewage facili-ties (1982-1985), US$1.4 million for watersupply services for the Metropolitan District(2 years), and US$31,100 for urban rabiescontrol (1980-1984); EEC providedUS$4,576,000 for basic sanitation (1982-1985); the Government of France,US$15,750,000 for hospital equipment(1984-1985); the Gouernment of Japan,US$2.5 million for hospital equipment(1 year); and the Government of Switzerland,US$1,033,300 for rural sanitation.

8.396 Foundations: Project Hope pro-vided US$3 million for staff training (1983-1986); Pathfinder, US$57,348 for familyhealth (1983-1986) for 1 year; and JohnsHopkins, US$13,500 for health education(2 years).



8.397 Professional staff assigned to thecountry: 6, including the PAHO/WHOCountry Representative and advisers in: epi-demiology, maternal and child health, envi-ronmental sanitation, and health service de-velopment. The Institute of Nutrition ofCentral America and Panama provided tech-nical support in the nutrition area.

8.398 Regional and intercountry ad-visers: 56, for a total of 351 days, in: epide-miology techniques, veterinary public health,ecology, human resources, dentistry, devel-opment of health services, administration,sanitary engineering, computing, vector con-trol, drugs, nutrition, maternal and childhealth, and social security.

8.399 Short-term consultants (STC):41, for a total of 504 days, in: sanitary engi-neering, epidemiology, information systems,drugs, vector control, health planning and ad-ministration, biomedical equipment mainte-nance, risk approach, maternal and childhealth, human resource development, mentalhealth, social security, and development ofhealth projects.

8.400 Fellowships: 234, at an actual costof US$128,630, in: health planning, Masterof Public Health, medical statistics and re-cords, basic demography, various topics inepidemiology and disease control, maternaland child health, cancer, hematology, publichealth dentistry, serological diagnosis of para-sitic diseases, pesticide toxicology, mentalhealth and community psychiatry, educa-tional technology and the development of hu-man resources, nutrition in primary healthcare, and drug registration.

8.401 Courses, seminars, and work-shops: 175 courses with 2,802 participants,representing a contribution of US$101,609,in: training of health science instructors, medi-cal statistics and records, biomedical equip-ment maintenance, pesticide toxicology,

mental health, vector control, epidemiology,sanitary engineering, training of traditionalmidwives and health protectors, maternal andchild health, risk approach, public health labo-ratory procedures, disaster preparedness,health education, public health dentistry, andvarious aspects of public health administra-tion.

8.402 Grants: 7, totaling US$131,000,were awarded for studies on: the health of theelderly, the use of drugs in health services, ananalysis of the status of professional practice innursing, activities under the Plan for PriorityHealth Needs in Central America and Pan-ama, the epidemiology of visceral leishma-niasis, and a seroepidemiological survey ofthe prevalence of Chagas' disease. In addi-tion, funds were made available for the pur-chase of equipment and supplies for the Edu-cational Health Technology Unit (UTES) ofthe School of Medical Sciences and for re-equipping a number of maternity clinics in theinterior of the country.


8.403 In 1984, significant efforts weremade in the health sector. These resulted inthe definition of a structure for the MSPthat has enabled the Ministry to conduct basichealth programs, coordinate activities with theHonduran Social Security Institute (HSSI),formulate a human resource developmentpolicy, institute a local programming process,create a national water and sanitation com-mission to promote the implementation of thenational plan defined in 1983, and improvethe Ministry's managerial capacity.

8.404 The implementation of programsto extend the coverage of health services tounderserved regions and priority groups hasbeen hindered by the persistence of criticaleconomic conditions within the country. Todeal with this situation, the MSP has devel-

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204 Annual Report

oped the following criteria for making the bestpossible use of resources: examine and adjuststrategies and set medium-term objectives; re-late the implementation of local health pro-grams to priority problems, human groups,and geographic areas in order to allow optimaluse of resources and extend the coverage ofservices; undertake joint actions and pro-grams with HSSI to achieve short-term econo-mies of scale; involve the community in the fi-nancing of services; bring health workers andtraining centers into the work-study strategy;

and develop the ability to manage external co-operation and improve its utilization on thebasis of priority needs.

8.405 There is an overall policy commit-ment reflected in the specific actions men-tioned above, to initiate a process which is ad-equately and rationally structured yet flexibleenough to accommodate the necessarychanges in the years ahead, and to theachievement of more efficiency and effective-ness in the delivery of health services.


JamaicaBasic Data



(as nationally defined)Birth rate/ 1,000 inhabitantsMortality rate/1,000 in habitants





per capita/day




1982 46.3 (triple vaccine)1983 28.8 -poliomyelitis1983 5.9 a -measles




Human Resource Indicators... ... Physicians per 10,000 inhabitants


1979-81 63.5 10,000 inhabitants


... ... Total health expenditure as a percentage

... ... of the GDP1978 83.3 Percentage of the National Budget1978 34.9 dedicated to health

YEAR NUMBER

1983198319831983

54.051.047.044.8

1984 90.0

19771983

1983

94.51.6b

2.6

1983 1.91983 8.0

1983 4.6

1983 46.0

1983 3.6

1982-83 8.9

... Data not available.a It is believed that a significant number of infant mortality is not being reported. b Public hospitals and health centers. Data from privatesources are not available.



8.406 Despite substantial constraints,actions were carried out to strengthen the ca-pability of the health service infrastructure inthe country. Guidelines for strengthening theoperational level of primary health care werecompleted, which were the result of the expe-rience gained in selected pilot health districts;the roles and functions of secondary and ter-tiary levels of health care were reviewed; andthe linkage between these levels was sur-

veyed. Also, a structural analysis of the inter-mediate and distributive level of primaryhealth care of the parish health departmentswas completed; the results were fed back tothe central level of the Ministry of Health andto all parishes. With reference to the nationalinformation system, steps were taken to im-prove the information available on secondaryand tertiary services, and preliminary investi-gations examined the feasibility of using hospi-tal computers to support the system.

8.407 In the area of human resources,the implementation of standards for nursingeducation continued through 1984, andgrants, fellowships, and teaching assistancewere given to programs in the national and re-

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206 Annual Report

gional teaching institutions (University of theWest Indies, College of Arts, Science, andTechnology, and the West Indies School ofPublic Health).

8.408 Inservice training activities havebeen implemented through the Ministry ofHealth Training Branch and should continueto receive priority as part of the strengtheningof the Ministry of Health's training capability.

8.409 In environmental health, contin-ued progress has been made in the priority ar-eas of water quality and supply and environ-mental pollution control. Activities involved anumber of government agencies and, throughthe efforts of the National Action Committee,funding has been identified for the develop-ment of a Decade Water Plan.


8.410 Specific projects on family plan-ning and family life for eight communities re-ceived support through government ministriesand national agencies, UNFPA, UNICEF, andthe Government of Norway. The proposal tofluoridate water supplies was reviewed during1984, and investigations into salt fluoridationwere begun.

8.411 Epidemiological surveillance anddisease control, sexually transmitted diseases,and veterinary public health have shown asubstantial progress.

8.412 In conjunction with the Pan Carib-bean Disaster Preparedness and PreventionProject, the Government took definite steps incurriculum development and in environmen-tal planning and hospital preparedness in caseof disasters.


8.413 Technical Cooperation AmongDeveloping Countries (TCDC): Jamaica

continued to be a source of recruitment forshort-term consultants and temporary advis-ers to serve in other countries in the Carib-bean. Staff from the Unversity of the West In-dies and from government ministriesundertook these assignments. Efforts to pro-mote TCDC between Jamaica .and Haiti con-tinued.

8.414 International cooperation:UNICEF assisted in an urban upgrading pro-ject and in the construction of health centers;UNFPA gave support to the Duhaney ParkHealth Center and for the purchase of contra-ceptives; IDB gave US$1,948,529 for theGreater Mandeville Water Supply project;and FAO/UNDP gave US$16,176 for soilconservation.

8.415 Bilateral cooperation: USAIDgave US$790,441 for improvement of ahealth management project, US$24,448 forfamily life education, and US$90,073 for a ru-ral agricultural project; European EconomicCommunity assisted a public health laboratoryand gave US$215,808 for delivery of veteri-nary services; the Government of the Nether-lands gave US$687,500 to improve commu-nity health centers and US$93,933 for the"Hague Meylersfield" agricultural project; andthe Government of Italy aided a major ruralwater supply scheme.


8.416 Professional staff assigned to thecountry: 7, the PAHO/WHO Country Rep-resentative and advisers in: health statistics,health management, sanitary engineering,community development, project manage-ment, and nursing education (who is also theregional adviser in nursing education).

8.417 Regional and intercountry advis-ers: Several, in: veterinary public health,health planning, health systems development,disaster preparedness, mental health, dentalhealth, and maternal and child health.


8.418 Short-term consultants (STC):Several, in: nursing, medical records, andmental health.

8.419 Fellowships: 56, in: meat inspec-tion, environmental health, food inspection,public health planning, health care adminis-tration, laboratory services, techniques in re-agent production, epidemiology, dentalhealth, medical records, community health,drug abuse, dairy cattle production, commu-nity nutrition, sexually transmitted diseases,maternal and child health, neonatology, radi-ology, and health management. The total costwas approximately US$208,000.

8.420 Courses, seminars, and work-shops: 27, for over 500 participants, coveredthe subjects of hospital administration, publichealth inspection, water supply, environmen-tal sanitation, drug abuse, Hansen's disease,immunization, perinatal, and geriatric care.PAHO/WHO's financial contribution was ap-proximately US$41,000.

8.421 Grants: PAHO/WHO providedgrants to the University of the West Indies

(medical faculty), a community rehabilitationprogram, and a community education projecttotaling approximately US$14,000.


8.422 In 1984, PAHO/WHO supportedthe same number of programs as in 1983,with a reduced number of professional staff.

8.423 The national economic crisis madea severe impact on the Ministry of Health andits programs during 1984. The Ministry beganimplementing a program of administrative ra-tionalization of its hospital services during thesecond half of the year; a major effect of this islikely to be an increased emphasis on devel-oping linkages among levels of care, an areain which PAHO/WHO has given and shouldcontinue to give assistance. In addition, re-vised and increased fees for hospital serviceswere introduced in November. These in-creases are likely to place an additional strainon primary care services.

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208 Annual Report

MexicoBasic Data





Life expectancy at birthInfant mortality/1,000 live birthsMaternal deaths/1,000 livebirthsDeath rate 1-4 years/ 1,000 childrenPercentage of newborn with a weight of



per capita/day










1979-81 74.9 10,000 inhabitants17- 74.9

1976197619761976

20.35.8

11.82.8



dedicated to health

YEAR NUMBER

1983 53.7

1980 71.0

1980198219821982

50.7140.0

3.70.8

1981 8.21981 4.9

1981 6.1

1983 5

1984 5.7

1983 0.7




8.424 A new general health law, reap-portioning responsibilities among the central,State, and municipal levels, went into effect.The year also saw the adoption of the nationalhealth plan for 1984-1988, which includesprovisions for reorganizing the Ministry ofHealth and Welfare (SSA) and integrating itssocial welfare programs into the National Sys-tem for Comprehensive Family Development(DIF System). Pursuant to these policies, re-sponsibilities for programs and services in the

Ministry's central units were being decentral-ized and shifted to the coordinated publichealth services for individual States and terri-tories. Programs affected were in the areas ofmaternal and child health and family planningand infectious and chronic diseases. In addi-tion, 18 units of the Federal hospital network(now abolished), 8 psychiatric hospitals, and16 psychiatric services were transferred to theState or municipal level.

8.425 In health planning, a number ofState health plans were designed and localprogramming was intensified; workshops andseminars were held for training State healthemployees involved in the proposed decen-tralization; and a national workshop on de-centralization of services and local administra-


tion was conducted for SSA, DIF, HealthCabinet, and coordinated services staff re-sponsible for directing the decentralization. Anumber of foreign experts also participated. Inthe rural health program, health care, rehabili-tation, education, and community participa-tion activities conducted in marginal urbanand rural areas by the SSA, DIF, and certainuniversity institutions were gradually beingstrengthened.

8.426 In the human resources area,health planning courses were offered at theSchool of Public Health, and primary care,epidemiology, and information systems areaswere strengthened. The establishment of anUndersecretariat for Human Resources andResearch gave impetus to the preparation ofcurriculum designs for the training of physi-cians, nurses, and nursing auxiliaries.

8.427 In environmental health, leakagecontrol received priority attention under thenational plan for the International DrinkingWater Supply and Sanitation Decade(IDWSSD). It is estimated that over 50% ofthe water produced is lost through leakage.Controlling this problem would help to meetthe needs of a larger number of people (by in-creasing coverage) and to lower costs(through operational efficiency). Air, water,and soil pollution control operations and re-search and training projects in the field wereaffected to varying degrees by the transfer ofadministrative units, programs, and resourcesto the Ministry of Urban Development andEcology.


8.428 The training of primary level staffwas stressed in the maternal and child careand family planning program. In epidemiol-ogy, a national epidemiological surveillanceprogram, to be implemented by stagesthroughout the country, was designed. In or-der to determine the effectiveness of the coun-try's immunization programs and the adjust-

ments needed, a seroepidemiological surveywas carried out in one State. The most impor-tant activity in disease control was the designand implementation of a national diarrhealdisease control program, launched at a high-level workshop conducted at the Children'sHospital of Mexico.

8.429 The Organization cooperated inthe design of a model for decentralizing Mexi-co's malaria programs from the central level tothe States. Of particular interest in tuberculosiscontrol were the training courses in tuberculo-sis, bacteriology, epidemiology, and controlprogramming. A national plan for the preven-tion of diabetes and hypertension was formu-lated. Professional staff of the national labora-tory system received training in six nationaland two international courses as part of theongoing effort to strengthen the system.


8.430 Technical Cooperation AmongDeveloping Countries (TCDC): Mexico isone of the focal points for the development ofTCDC. An inventory was made of potentialnational capacities for technical cooperation insome 150 Mexican institutions in the healthand other sectors involved in activities thatlend themselves to this type of cooperation.The inventory provided data on some 600specific lines of cooperation that can be of-fered to other countries.

8.431 International cooperation: UNDPprovided US$91,987 for laboratory pro-grams; UNFPA, US$983,166 for mater-nal and child health and family planning;UNICEF, US$1.4 million for multisectoralprograms for the benefit of underserved ruraland urban groups; and IDB, US$1.4 millionfor the Cutzamala project, US$23 million forthe Monterrey project, and US$8 million forthe Municipal development project.

8.432 Foundations: The W. K. Kellogg

209

210 Annual Report

Foundation donated US$138,000 for the Ti-juana family health program.


8.433 Professional staff assigned to thecountry: 12, including the PAHO/WHOCountry Representative and advisers, in:health service administration, planning, ma-ternal and child health, child growth and de-velopment, community health, epidemiologyof chronic and communicable diseases, statis-tics, environmental sanitation, nursing admin-istration, veterinary medicine, sanitary engi-neering, and public health laboratories.

8.434 Regional and intercountry advis-ers: 26, at a cost of approximatelyUS$26,550.

8.435 Short-term consultants (STC):32, at a cost of approximately US$95,848.

8.436 Fellowships: 98, for a cost ofUS$32,500. The studies covered all healthdisciplines.

8.437 Courses, seminars, and work-shops: 42, with the participation of 1,242 na-tional officials, in: chronic disease control; ad-ministrative decentralization; women, health,and development; medical coding and biosta-tistical information system; nursing education;trends in health service research; human re-source planning; diarrheal diseases and oralrehydration; epidemiology; bacteriology; vet-erinary medicine; leishmaniasis; rabies; mor-tality; disaster emergency measures; environ-mental sanitation; malaria; laboratories;textbooks; vaccines; nutrition; and dentistry.PAHO/WHO's contribution came toUS$142,985.

8.438 Grants: PAHO/WHO awardedUS$115,000 for the decentralization of SSAprograms and services, US$40,000 to theSchool of Public Health for a health planningcourse, US$40,000 to the School of PublicHealth for a workshop on health service re-search, and US$20,000 for studies on thenursing profession.


8.439 The performance of Ministry ofHealth and Welfare programs in 1984 was un-even in terms of the achievement of goals,with some programs exceeding their targetsand others unable to reach them. This wasdue to problems in particular programs and avariety of general factors stemming from thesector's reorganization, the application of thedecentralization policy, and the repercussionsof the economic crisis, especially the increasein operating costs.

8.440 Problems in obtaining spare parts,spraying and laboratory equipment, insecti-cides, chemicals and other inputs, becausethey had risen in price, were difficult to im-port, or were scarce on the domestic market,affected the control programs for malaria, on-chocerciasis, and other diseases.

8.441 In Mexico, PAHO/WHO's techni-cal cooperation program was closely linked toa health sector reorganization based on thestrategies of sectorization, modernization, anddecentralization. The studies conducted bythe country and PAHO/WHO for the pur-pose of gaining better knowledge of the sectorshould be helpful in identifying potentiallyfruitful areas of technical cooperation.


Netherlands AntillesBasic Data








per capita/day

Percentage of deaths due to:infectious and parasitic diseasestumorsheart diseasesmotor vehicle traffic accidents'






1980 72.8 a sanitary waste disposal1983 15.8 Consultations per inhabitant per year

1983 0.8bNumber of discharges per 100 inhabitantsNumber of beds per 1,000 inhabitants



1979-81 81.2 10,000inhabitants17- 81.2

1983198319831983

3.6b

22.7 b

18.5a1.8b



dedicated to health

YEAR NUMBER

198219821982

85.8b

85.8b

30.0 b

1981 81.8b

1984 100.0b

1983 10.4

1983 10.81983 19.4

1983 16.5

1982 690b

1981 8. 5b

... Data not available.- None.a Only Curaçao and Aruba. b Only Curaçao.



8.442 Six islands make up the Nether-lands Antilles: Aruba, Bonaire, Curacao, St.Eustatius, St. Maarten, and Saba. The Minis-try of Public Health and Environmental Hy-giene of the Netherlands Antilles is responsiblefor providing overall health care for the popu-lation of these islands.

8.443 In the Netherlands Antilles, thereare 35 health installations that have 2,477 in-patient beds; of these beds, 50.5% are in gen-eral hospitals, 24.7% in geriatric care, and18.2% in psychiatric care. Hospital facilities inthe islands of St. Maarten, Saba, and St. Eus-tatius have been under review simultaneouslywith those of CuraQao and Bonaire.

8.444 , It is proposed that, as of 1986,Aruba will have a "status apparatus" in rela-tion to the Netherlands Antilles, so that em-phasis is now placed on the decentralization ofservices. PAHO/WHO consultants have pro-

211

212 Annual Report

vided technical advice on the administrativeaspects in the early phases of decentralization.A crucial component in this endeavor will bethe development of a health information sys-tem. The legal implications relating to decen-tralization are also of considerable impor-tance.

8.445 The Ministry of Education hasstarted work on the total personnel require-ments for the Netherlands Antilles, and theMinistry of Health is preparing an assessmentof health personnel requirements. Concomi-tantly, the standards and legal requirementsgoverning all levels of health personnel are be-ing developed.

8.446 The main areas of concern in envi-ronmental health are: improvement of thequantity and quality of potable water supply,solid waste disposal control, control of oil con-tamination of the sea, air pollution control,and radiation hazards control. The program isdirected toward the prevention of pollution ofthe sea, land, and air.


8.447 The Expanded Program on Immu-nization (EPI) has continued to receive closeattention. However, no decision is as yetforthcoming on joining the PAHO/WHO Re-volving Fund. There was a minor outbreak ofpertussis which has led to discussions aboutthe delivery of the national program.

8.448 Occupational health is a priorityarea, principally due to the large petrochemi-cal complexes in Aruba and Curaçao, the drydock facilities in Curacao, and the airline per-sonnel. With regard to mental health care, theprincipal hospital admissions are for schizo-phrenia, other psychoses, and personality dis-orders. Excessive alcohol consumption posesa problem in all the islands, while hard drugstend to be used principally in St. Maarten,Aruba, and CuraQao. Dengue and yellow fe-ver continue to pose a threat to the Nether-lands Antilles because of the presence of the

vector Aedes aegypti. However, no cases ofthese diseases were reported in 1984.PAHO/WHO cooperated in evaluating theAedes aegypti control programs in St. Eusta-tius, Bonaire, St. Maarten, and Saba. Yellowfever vaccine also was obtained for the au-thorities of Curacao.

8.449 The health authorities of the is-lands are being especially vigilant to preventthe importation of rabies. No cases of foot-and-mouth disease were reported in 1984.The health authorities, with PAHO/WHOcollaboration, carried out an evaluation in Oc-tober of the rodent control program.


8.450 Professional staff assigned to thecountry: There are no PAHO/WHO staffbased in the Netherlands Antilles. The Cara-cas PAHO/WHO Office is the Country Officeresponsible for the delivery of the PAHO/WHO cooperation program.

8.451 Regional and intercountry advis-ers: 5, for a period of 35 days, in: health plan-ning, information systems, Aedes aegypti, ro-dent control, and radiation hazards.

8.452 Short-term consultants (STC): 2,for 60 days, in: hospital architecture and vet-erinary public health.

8.453 Courses, seminars, and work-shops: Inservice training was provided to per-sonnel of the Ministry of Health and Environ-mental Hygiene of the Netherlands Antilles byPAHO/WHO, as well as to the VeterinaryPublic Health Laboratory staff of Aruba. Nofellowships were awarded to health personnelof the Netherlands Antilles.


The economy of the Netherlands8.454


Antilles has been severely affected by the de-cline of tourism and the reduction of the oilsupply to the refineries in Aruba and Curacao.The continuing decline in oil revenues and thepossibility that the Aruba oil refinery may closedown is causing concern in the islands; as aconsequence, an increase in demand is ex-pected for outside cooperation, notwithstand-ing the additional help that Holland is ex-pected to provide.

8.455 Political instability surfaced during1984 and there was a change of government

in September, due to a rearrangement of theparliamentary coalition which governs the is-lands. Aruba is expected to leave the group ofsix islands to have its own "status apparatus"in 1986. Decentralization of health services,therefore, will continue to be an area of con-siderable interest for the local authorities.

8.456 For 1985, it is expected that themain programs to receive PAHO/WHO col-laboration will be: health services develop-ment, environmental health, and veterinarypublic health.

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214 Annual Report

NicaraguaBasic Data

YEAR NUMBERDemographic Indicators







per capita/day

Percentage of deaths due to:infectious and parasitic diseasestumors

heart diseasesmotor vehicle traffic accidents






980-85 59.8 sanitary waste disposal1983 75.2 Consultations per inhabitant per year... ... Number of discharges per 100 inhabitants... ... Number of beds per 1,000 inhabitants



1979-81 58.7 10,000 inhabitants


... ... Total health expenditure as a percentage

... ... of the GDP

... ... Percentage of the National Budget

... ... dedicated to health




8.457 The regionally structured UnifiedNational Health System consolidated the or-ganization and operation of 80% of the healthareas and sectors as a basis for extending cov-erage and upgrading the quality of care pro-vided to the country's population, with specialemphasis on mothers, children below age 5,and workers. The following activities contrib-uted to this goal: review and adjustment of the

regionalization criteria; definition of health ar-eas and sectors; strengthening of the NationalHealth Planning Division and reorganizationof the Ministry of Health; support for the re-gional planning units; improvement of the op-erational capacity of the National Division andRegional Units for Health Statistics and Infor-mation; and broadening of intersectoral coor-dination. The advances made in 1984 in thenational health service maintenance programand the national essential drugs and critical in-puts system are also appropriately consideredunder this heading.

8.458 Human resource developmentcontinued to be an area of intensive activity,

YEAR NUMBER

1983198319831983

23.988.023.088.5

1984 43.8

19841983

. . .

19.6210.0

. . .

1984 0.5

1


emcompassing the training of auxiliary, tech-nical, and undergraduate and graduate pro-fessional personnel, as well as the training ofmembers of health brigades and practical mid-wives. A total of 2,267 auxiliary and technicalpersonnel were enrolled in three PolytechnicInstitutes (Managua, León, and Carazo) andeight departmental training units. The clinicalresidencies program was continued (134 phy-sicians), as was the Master's program in epide-miology and health administration (30 profes-sionals). The continuing education programwas carried forward, and additional certifica-tion programs were conducted for empiricaland auxiliary personnel.

8.459 With the cooperation of the Na-tional Council of Higher Education, the Nica-raguan Water and Sewage Institute, the Minis-try of Health, and the Institute of NaturalResources, a graduate program in environ-mental and sanitary engineering was preparedduring the year. The program was scheduledto begin in 1985.

8.460 Substantial numbers of textbooksand supplies were distributed under the Ex-panded Textbook and Instructional MaterialsProgram to the following entities: Schools ofMedicine of León and Managua; CentralAmerican University; Polytechnic University;Health Polytechnical Schools of Managua,León, and Carazo; School of Nursing of Es-telí; Center for Health Organization of Nicara-gua (CENIDOS)-Ministry of Health; NationalWater and Sewage Institute; and PAHO/WHO Documentation Center. A total of11,728 volumes of textbooks and 1,393 diag-nostic instruments, with a total cost ofUS$239,842.09 were distributed.

8.461 In environmental health, advanceswere made in strengthening the Directoratefor Rural Water Supply Systems, the ratestudy was completed, and the medium-termdevelopment plan for construction of waterand sewage facilities was adjusted on the basisof proposals in the Plan for Priority HealthNeeds in Central America and Panama.


8.462 Coverage of maternal and childcare services was at 80% for infant care, 84%for prenatal care, 42% for institutional deliv-ery, 37% for postpartum control, and 58%for the care of children suffering from diar-rheal diseases. The national immunizationprogram was strengthened and had a signifi-cant impact. No cases of poliomyelitis were re-ported, and the measles vaccination programcovered 100% of the infants under age 1. Theepidemiological surveillance program wasstrengthened with the addition of a nationalreference center at the Pediatric Hospital. TheMinistry of Agricultural Development initiatedthe first stage of the Five-Year Food and Nu-trition Plan under its Food and Nutrition Pro-gram.


8.463 Technical Cooperation AmongDeveloping Countries (TCDC): TCDC activ-ities in the field of human resources and tech-nology were undertaken with Canada, Cuba,and Mexico.

8.464 International cooperation:UNICEF provided US$1,205,000 for eightprogram areas: analysis of Nicaragua's eco-nomic and social situation, primary care strat-egy, maternal and child health, communica-ble disease control, essential drugs, healthequipment and facilities maintenance, watersupply, and environmental hygiene, andUS$4,672,000 for the Five-Year Food andNutrition Plan; IDB, US$1.5 million for envi-ronmental health; International Atomic En-ergy Agency, US$50,000 for a radiology pro-gram; WFP, US$3 million for supplementalfood; and OAS, US$1,000 for staff training.

8.465 Bilateral cooperation: CIDA as-sisted with US$320,000 for training in nutri-tion; the Gouernment of Mexico. with

215

216 Annual Report

US$14,000 for mental health (2 years); theGovernment of Cuba, US$600,000 for auxil-iary, technical, and postbasic training; and theGovernment of Italy, US$698,000 for familyplanning through UNFPA.


8.466 Professional staff assigned to thecountry: 4, including the PAHO/WHOCountry Representative, a medical officer, anadministrative assistant, and an officer incharge of the Documentation Center and theTextbook and Medical Equipment Program.

8.467 Regional and intercountry advis-ers: 62, in the areas of: health service plan-ning, epidemiology, nutrition, oral health,maternal and child health, medical education,construction of health facilities, administra-tion, drugs, x-ray diagnosis, environmentalhealth, and sanitary engineering.

8.468 Short-term consultants (STC):The Organization, at the request of the coun-try, provided the services of 51 consultants forvarious program areas.

8.469 Fellowships: 90, with a cost ofUS$204,641, in the following study areas:postbasic diversified training in nursing, nutri-tion, health planning, administration, epide-miology, environmental sanitation, rehabilita-tion, malaria, clinical laboratory procedures,food quality control, and specialized diagnosisof tropical diseases.


8.470 The destruction of 50 health postsand centers has impaired the ability to provide

regular health care to 225,000 people. In ad-dition, malaria control and related special ac-tivities have deteriorated in the conflict-stricken regions, with a consequent increase inmalaria indicators.

8.471 Despite the critical situation in thecountry, it was possible, with assistance pro-vided by PAHO/WHO from regular, re-gional, and extrabudgetary funds, to accom-plish a high percentage of the activitiesprogrammed (80%), while also inauguratingnew programs relating to the institutional de-velopment of the Unified National Health Ser-vice, the health for all strategy, the Five-YearFood and Nutrition Plan, and the National Es-sential Drugs and Critical Inputs System.

8.472 After 5 years of applying a broadand highly flexible approach, it will be neces-sary to review with the national authorities theprojected lines of PAHO/WHO collaborationin order to systematize the provision of me-dium-term external funds and coordinatethem more effectively.

8.473 Important progress has been madein interagency and intercountry coordinationwith the IDB, UNFPA, UNDP, and UNICEF;however, joint working procedures need fur-ther improvement. This approach also shouldbe extended to working relations with otheragencies of the United Nations system.

8.474 Also, if the guidelines for PAHO/WHO cooperation for the medium-term aredefined to reflect additional responsibilitiesstemming from the Plan for Priority HealthNeeds in Central America and Panama, it willbe necessary to review the administrativestructure and the complement of technicaland professional staff to ensure that the neces-sary resources are available for continuedmonitoring of the managerial process atthe PAHO/WHO Country Office and Head-quarters.


PanamaBasic Data







percapita/dayAvailability of proteins (grams)

per capita/day








1982 8.2 Human Resource IndicatorsPhysiciansper 10,000 inhabitants

1982 3, 044 Nurses per 10,000 inhabitantsNursing auxiliaries per

1982 69.1 10,000inhabitants192 69.1

1982198219821982

6.713.116.64.6



dedicated to health

YEAR NUMBER

1983198319831983

56.055.657.078.0

.1985 90.0

1982198319831983

80.8150.0

9.13.2

1983 10.41983 10.4

1983 15.8

1983 98

1983 10.1

1983 14.1



8.475 Work began on implementingthe Government/IDB-financed project forstrengthening the National Network of HealthServices. In carrying out this work, Panama isapplying the strategic planning approach in-volving the analysis of proposals and changesat three levels to ensure that resources will beused efficiently and with the greatest social im-pact. The plan encompasses three areas:planning the network, developing the system,

and developing the infrastructure. A nation-wide learn-by-doing effort instituted under thisscheme resulted in the training of more than300 national employees. Underserved groupswere identified, and the population's access tovarious levels of care was analyzed. The out-put and productivity of health care deliveryunits and their problem solving capacity wereevaluated. Finally, a study of health sector fi-nancing was carried out. With regard to theservice network, its organization was analyzedand preliminary studies on specific projectswere performed. Along with this, architecturaland functional studies of essential hospitalswere made, including new hospitals at SanMiguelito and La Chorrera; hospitals being re-modeled at Ocú, Las Tablas, and Santo To-

217

218 Annual Report

más; and hospitals under construction in Co-lón and Soná.

8.476 In the development of the opera-tional capacity of institutions and services, ad-ministrative procedures of the Ministry and ofthe integrated health services were strength-ened in keeping with the strategies of decen-tralization and integration. A drug control andconsumption model was instituted for use inthe integrated health services. Of special im-portance in the area of nursing service admin-istration were the measures taken to ensureoptimal utilization of available resources, aspart of the process for developing the servicesnetwork and the unified health system.

8.477 In human resources, priority wasgiven to the following training activities forhealth service nurses and auxiliaries: a plan-ning course for 13 participants, three pro-gramming workshops for public health andcommunity nurses, and a seminar on primarycare. Also, the teaching-service approach wasstrengthened, and arrangements were madefor student practice at the initial level of care inrural facilities.

8.478 In environmental health, despitebudget constraints in the Ministry of Health,the Ministry's Department of Basic Sanitationconstructed 35 water supply systems, 157wells, and 5,522 latrines. The training of sani-tation inspectors through seminars on stabili-zation ponds, water quality control, pollutioncontrol, and silk traps was intensified. Sanita-tion projects with an estimated cost of US$81million were prepared under the Plan for Pri-ority Health Needs in Central America andPanama.


8.479 A survey of human resources infood and nutrition was taken, and a proposalfor the establishment of a school of nutrition atthe University of Panama was prepared.

Other noteworthy events were an analysis ofseminars on hospital nutrition, the training ofinstructors for food and nutrition educationprograms, and the revision and reformulationof food aid programs. A study of risk factors inmaternal and child health made it possible toredirect efforts toward the areas and groups atgreatest risk. As a result, more emphasis wasplaced on the promotion of breastfeeding bymeans of training, broad-scale publicity,mother's milk banks, and the organization ofinformation centers. Finally, an infant survivalproject was prepared for submittal to prospec-tive financing organizations. Dental healthcare standards were developed for the Minis-try of Health and the Social Security Agency.

8.480 In epidemiology, emphasis wasplaced on training, especially in control of sex-ually transmitted diseases, epidemiological re-search on noncommunicable diseases, andtuberculosis control. A workshop on the coldchain was held, and the Expanded Programon Immunization (EPI) was evaluated. Thenumber of malaria cases declined signifi-cantly, from 341 cases in 1983 to 121 in1984. A proposal for funding the malaria andAedes aegypti eradication programs was for-mulated within the context of the Plan for Pri-ority Health Needs in Central America andPanama. The amount of the proposal wasUS$30 million.


8.481 Technical Cooperation AmongDeveloping Countries (TCDC): Technicalpersonnel were made available to the coun-tries of the Central American Isthmus for pre-paring profiles of subregional projects underthe Plan for Priority Health Needs in CentralAmerica and Panama.

8.482UNFPAplanning

International cooperation:donated US$300,000 for family(1979-1986) and US$150,000 for


nursing education (1984-1986); IDB gaveUS$240,000 as a preliminary investmentfund for the National Network of Health Ser-vices.

8.483 Bilateral cooperation:AID/INCAP provided US$776,857 for pro-motion of breastfeeding (1984-1986).


8.484 Professional staff assigned to thecountry: 5, including the PAHO/WHOCountry Representative and four advisers, in:planning, hospital administration, nursing,and veterinary medicine (uhtil August). A re-gional vector control team consisting of an en-tomologist, an Aedes aegypti specialist, andan educator was stationed in Panama frommid-year. In addition, a medical officer for thebreastfeeding, maternal and child health, andnutrition project was added to the staff.

8.485 Regional and intercountry advis-ers: 107, for a total of 730 days, in: serviceadministration and development, nursing, hu-man resources, environmental health, com-puter programs, maternal and child health,nutrition, dentistry, epidemiology, immuniza-tion (cold chain), respiratory diseases, vectorcontrol, zoonoses and foot-and-mouth dis-ease, food protection, drugs, and entomol-ogy.

8.486 Short-term consultants (STC):42, for a total of 1,004 days, in: service plan-ning and administration, hospital administra-tion, human resources, clinical psychologyand sociocultural studies, maternal and childhealth, dental health, mental health, immuni-zation, and acute respiratory diseases.

8.487 Fellowships: 42, for a total of 233months of studies at a cost of US$194,000, inthe following fields: organization of health ser-vices, nursing, maternal and child health, en-

vironmental health, health education, nutri-tion, and statistics.

8.488 Courses, seminars, and work-shops: 40 events, with a combined participa-tion of 1,490 national officials, in the followingfields: planning, organization, and administra-tion of health systems; planning at the primarylevel; supervision and administration; contin-uing education for primary level workers; hu-man resource planning; environmentalhealth; the risk approach to maternal andchild health care; breastfeeding; medical re-cords; food and nutrition; dental health; drugdependency; epidemiological evaluation;drugs; and disaster preparedness.


8.489 A study coordinated by the Plan-ning Directorate provides evidence that thecountry is earnestly seeking full developmentof its resources to meet the needs of the entirepopulation, with emphasis on the satisfactionof social as well as health needs.

8.490 The chief purpose of the Ministry isto expand the coverage of the network ofhealth services, making them more accessibleto underserved groups through programs ofindividual and community care and environ-mental protection. The health service networkproject was the central core of these actions.

8.491 In 1984, Panama took an impor-tant initiative with respect to the Plan for Prior-ity Health Needs in Central America and Pan-ama. Availing itself of its status as host to theContadora Group, Panama organized andconducted an important meeting of the mem-bers of that group with cabinet ministers fromthe subregion at which the Director of PASBexplained the objectives of the Plan to the for-eign ministers of the Group.

Future developments in the subre-

219

8.492

220 Annual Report

gional projects will provide additional oppor-tunities for exchange of national experiences,for the utilization of TCDC, and for decisionsto concentrate limited resources in critical ar-eas where the impact is greatest. The policystrategies formulated for the development of

the health system in the areas of primary care,comprehensive care and service integration,community involvement, and the strategic ap-proach to the planning and administration ofhealth services will facilitate equitable and effi-cient achievement of the expected goals.


ParaguayBasic Data





Life expectancy at birthInfant mortality/1,000 live birthsMaternal deaths/1,000 live birthsDeath rate 1 -4 years/1,000 childrenPercentage of newborn with a weight of

less than 2,500 gramsAvailability of calones


per capita/day








Human Resource IndicatorsPhysiciansper 10,000 inhabitants


1979-81 79.9 10,000inhabitants17- 79.9

1981198119811981

12.57.7

11.61.7



dedicated to health

YEAR NUMBER

1984 67.01984 68.01984 62.01984 80.0

1983 25.0

1983 87.81982 70.01982 4.01982 1.4

1980 6.01980 2.0

1980 9.0

1983 12

1979 4.9

1985 5.2



8.493 Efforts continued to center aroundthe development of the 1983-1988 nationalhealth plan, which directs resources andactions toward the goal of health for all. Em-phasis during the year was on regional pro-gramming.

8.494 Under a program designed to pro-vide additional facilities at the basic level(health posts) and at the intermediate level(local and regional health centers), work wentforward on the construction, equipping, and

initial operation of six new health posts andfour health centers being built with local fundsand with loans and grants provided by inter-national and bilateral cooperation agencies. Anumber of specialized health centers also wereinaugurated, including the Central Laboratoryand Institute of Tropical Medicine, both re-cently organized; the National Cancer andBurn Institute, a 200-bed facility constructedat a cost of US$25 million; and the newly in-augurated Greater National Hospital, with570 beds and a cost of US$63 million. Thisdevelopment of physical infrastructure wascomplemented by the strengthening of techni-cal and administrative systems and proce-dures. Other significant events were the im-provement of institutional performance, thereview of the information system, and the

221

222 Annual Report

analysis of the progress of programs, espe-cially the Expanded Program on Immuniza-tion. The results of the analysis reflected im-provements in the physical accessibility offacilities to their target population and an in-crease in operating capacity, particularly in ge-ographic areas formerly unserved or under-served.

8.495 In human resource development,the personnel information, planning, and de-velopment system was redesigned and the re-vised system was used to take a sector-widehealth personnel census. Staff training in pri-ority areas continued to be provided throughlocal courses and seminars and the awardingof fellowships for training abroad. The HealthPersonnel Training Center was reorganized toadjust its programs to the requirements of thenational health plan.

8.496 In environmental health, prioritywas given to water supplies for rural com-munities. In an initial program, 47 water sup-ply systems were constructed, with IBRD(World Bank) financing, for rural communitieswith 500 to 4,000 inhabitants; of these sys-tems, 31 were being operated by sanitationboards and the other 11, also in full operation,were awaiting transfer to the appropriateboards. A second program providing for 49water systems was under way, and 5 of thesystems were already in operation. Along thesame line of action, projects were preparedwith a view to requesting a third IBRD creditfor providing water supply facilities to all com-munities with 500 to 4,000 inhabitants andconstructing 12 sewage systems.

8.497 For communities with 150 to 500inhabitants, 16 basic water systems con-structed were completed with the cooperationof the Federal Republic of Germany (GTZ)and were scheduled to go into operation inthe near future, and 42 wells with hand-oper-ated pumps were constructed with UNICEFassistance. For communities with fewer than150 inhabitants and scattered population, aguideline was prepared containing informa-tion on the construction and analysis of

models and the testing of prototypes of manu-ally operated pumps involving the use of low-cost technology. General guidelines weredrawn up for the solid waste program, and therelevant requests for IBRD financing were re-viewed.


8.498 Comprehensive care services,which continued to emphasize maternal andchild care, extended their coverage to unpro-tected geographic areas. Within these ser-vices, priority was given to prenatal care, ob-stetrical care, postpartum care, and themonitoring of infant growth and develop-ment. The coverage of partum and postpar-tum care was increased by using auxiliary per-sonnel and trained practical midwives.Vaccination coverage against the principal im-munopreventable diseases continued to ex-pand at a rapid pace and achieved levels closeto 50%, compatible with endemoepidemicrates, especially for tuberculosis, measles,pertussis, and tetanus.

8.499 The diarrheal disease control pro-gram moved forward slowly. With regard tourban yellow fever, Aedes aegypti control op-erations were intensified at the country's prin-cipal ports of entry, yellow fever vaccinationof the population at greatest risk was steppedup, and an ambitious Aedes aegypti eradica-tion project was prepared and submitted tothe IDB with a request for financing. The ma-laria eradication program moved forward in asatisfactory way despite a number of local out-breaks, which received preferential attention.The Chagas' disease survey continued to becarried out in 27 districts; the Trypanosomacruzi human infection rate was 22.5%.


International cooperation:8.500


UNICEF allocated US$1,420,000 for ruralwater supply services; UNFPA, US$984,159for the extension of the maternal and childhealth program in rural areas; IDB, US$14.4million for the second stage of the project forextending the coverage of health services, aswell as US$507,000 for institutional strength-ening of the Ministry of Health; and IBRD,US$11.8 million and US$6 million, respec-tively, for two 4-year water supply projectsand US$22.4 million and US$98,000, re-spectively, for a program of integrated ruraldevelopment (health component) and a hy-drogeologic study (3 years).

8.501 Bilateral cooperation: the Fed-eral Republic of Germany donated US$4 mil-lion for the extension of health service cover-age in health regions III and IV which includes28 posts, 10 centers, and 2 regional centersand for their construction and equipping;US$1.5 million for water supply systems inSan Pedro Department (German Develop-ment Bank); US$400,000 for water systemsin communities with fewer than 500 inhabit-ants (GTZ grant); and US$700,000 for stud-ies of the health service network in Misionesand Neembucú (GTZ grant); construction, ex-pansion and equipping of health posts andcenters (GTZ grant); Government of Brazil,US$20 million for construction and equippingof the 200-bed National Cancer and Burn In-stitute (credit from Banco do Brasil); Govern-ment of France, US$63 million for construc-tion and equipping of the 560-bed GreaterNational Hospital (SGE credit); Governmentof Japan, US$8 million for construction andequipping of the Central Laboratory and Insti-tute of Tropical Medicine and equipping of the70-bed Pedro Juan Caballero Health Center;and GTZ, US$1.2 million for water supplysystems (4 years) and US$90 million for a 10-year sanitary works plan; and KfW gave US$4million for water supply systems (4 years).

8.502 Foundations: the W. K. KelloggFoundation donated US$260,425 for perina-tology and maternal and child health.


8.503 Professional staff assigned to thecountry: 9, including the PAHO/WHOCountry Representative and advisers in: plan-ning, administration, nursing, environmentalhealth, maternal and child health, and veteri-nary public health.

8.504 Regional and intercountry advis-ers: 13, for a total of 80 days, in: health ad-ministration, nursing, environmental health,maternal and child health, systems analysis,health education, statistics, serology, tropicaldiseases, and zoonoses.

8.505 Short-term consultants (STC):14, for a total of 526 days, in: health facilityarchitecture, plant and equipment mainte-nance, environmental health, supplies, re-search, maternal and child health, health edu-cation, dentistry, community health, andChagas' disease.

8.506 Fellowships: 45, with an aggre-gate cost of US$100,000, in the following ar-eas of study: public health, malaria and envi-ronmental sanitation, cancer epidemiology,risk in maternal and child health, perinato-logy, technology for the construction of deeptubular wells, tuberculosis control, populationpolicy and maternal and child health, tubercu-losis diagnosis, intensive nursing, and so-cioperiodontics.

8.507 Courses, seminars, and work-shops: 6, with 560 participants, with aPAHO/WHO contribution of US$32,878, inthe following fields: training of volunteers andhealth promoters at community level, andmaintenance of water supply systems.

8.508 Grants: PAHO/WHO awardedUS$9,000 to finance research on the applica-tion of educational models for oral rehydra-tion therapy in the family and the community;US$17,656.25 to finance a health promo-tion, nutrition, and family welfare project un-der the responsibility of the Division of Social

223

224 Annual Report

Welfare; and US$112,399 to defray local ex-penses of the support project for extendingthe coverage of the maternal and child healthprogram in rural areas.


8.509 The health sector has reached astage of intensive dynamism, one that couldaptly be termed the stage of take-off towardthe goal of health for all. This assessment isbased on the impressive number of facilitiesunder construction at every level; their opera-tion in the future will bring a substantial in-crease in the volume of services being sup-

plied and, for reasons of geographicdistribution, an expanded area of coverage.Nevertheless, the economic crisis which thecountry is facing has necessitated a policy offiscal austerity that limits the allocation offunds required for the operation of health fa-cilities.

8.510 Increased requirements for localfunding and technical and financial coopera-tion have created incentives for better coordi-nation in the planning and implementation ofassistance provided by the various interna-tional and bilateral agencies and for intensifiedcommunity involvement. To a lesser degree,such requirements also have strengthenedmovements toward intersectoral coordinationand technical cooperation among developingcountries.


PeruBasic Data

YEAR NUMBER




1983 18,707,000

19811980-851980-85

64.937.011.0


Life expectancy at birthInfant mortality/1,000 live birthsMaternal deaths/1,000 live birthsDeath rate 1-4 years/ 1,000 childrenPercentage of newborn with a weight of

less than 2,500gramsAvailability of calories


per capita/day


1982198219791982

59.099.0

3.210.0







1982 9.0 Human Resource IndicatorsPhysicians per 10,000inhabitants


1979-81 58.7 10,000 inhabitants17- 58.7

1980198019801980

45.95.8

11.35.0



dedicated to health

YEAR NUMBER

1984198419841984

27.827.834.762.7

1983 49.0

1983 36.01982 60.0

1982 1.7

1982 8.11982 6.4

1979 4.4

1982 15

1983 4.5

1983 4.1




8.511 Within the operational plan of thesector for 1984-1985, the objectives of theextension of health services coverage projectfor the Eastern Region were attained, as werethe goals for the establishment of a nationalhospital architecture and maintenance systemand those of the relevant national trainingplan. To support the linkage of the sector's re-sources, a proposal was drawn up for cooper-ation between the Ministry of Health and the

Peruvian Social Security Institute in the im-provement of physical infrastructure and de-velopment of programs. The nursing compo-nent of the basic health services wasstrengthened through the training of person-nel and the upgrading of community and hos-pital nursing standards.

8.512 In the priority area of human re-source development, the training of primarylevel health personnel stands out, despite thefact that only 60% of the objectives werereached. A multidisciplinary short- and me-dium-term plan developed during the year onthe basis of an evaluation of the School ofPublic Health provided for continuing educa-tion of staff of the Ministry of Health. An eval-

225

226 Annual Report

uation of the educational technology beingutilized by institutional and community per-sonnel yielded highly useful results, includingnew teaching approaches and techniques andthe preparation of self-instruction modules forMinistry staff. A related development in thisarea was the strengthening of the National Ed-ucational Technology in Health Center(CENTES), which is now related to San Mar-cos University, the Ministry of Health andPAHO/WHO. A plan was drawn up with theaim of organizing a national network of healthscience libraries. An academic program inhealth administration, covering both theMaster's and residency levels, was estab-lished under the Regional Program onAdvanced Training in Health Administration(PROASA).

8.513 In the area of environmentalhealth, a highlight was the formulation, inconnection with the International DrinkingWater Supply and Sanitation Decade, of a na-tional basic sanitation plan setting prioritiesand providing for coordinated use of nationaland external resources. The progressive im-plementation of the national water qualitycontrol program in three regions of the coun-try was a highly important development in thisfield. Water pollution studies also were carriedout, and mechanisms were developed formonitoring the quality of water in the riversand along the coast.


8.514 Of importance in the food and nu-trition area was the development of a joint nu-trition support program, whose activities innutrition and in maternal and child healthwere integrated with those of other develop-ment sectors involving community participa-tion. Endemic goiter and cretinism control, amajor component of this program, wasstrengthened with the establishment of a goi-ter control unit and an evaluation and refor-mulation of the program.

8.515 The maternal and child health andfamily planning program, which failed to yieldthe expected results, was analyzed and newproposals were submitted to UNFPA for1985. The plan of operations for the Soca-baya-Arequipa maternal and child health andperinatology program began to be imple-mented. Vaccination coverages under the Ex-panded Program on Immunization (EPI) werevery low and did not result in any reduction inthe incidence of the target diseases, leading toan evaluation of the program and a proposalfor new solutions for 1985.

8.516 As an outcome of the assessmentof the malaria situation (late 1983), the pro-gram was reactivated at two levels: emer-gency actions and long-term activities. Malariahas nonetheless continued to spread to newareas, including some that had been free oftransmission for 20 years.

8.517 Highlights in veterinary publichealth-one of the areas of greatest activity-included advances in urban and suburban ra-bies control, food inspection, foot-and-mouthdisease vaccination, and the Iquitos primatereproduction station.


8.518 Technical Cooperation AmongDeveloping Countries (TCDC): In an effortto provide systematic encouragement in thisfield, initial contacts were made with the em-bassies of countries in a position to participatein this type of cooperation, including Brazil,Colombia, Cuba, Mexico, and Venezuela.Brazil expressed interest in taking actionthrough UNFPA.

8.519 International cooperation:UNICEF provided US$415,000 for extensionand development of health services andUS$2,167,000 for comprehensive child andfamily care (in operation, initiated in 1983);UNDP, US$922,000 for development and


extension of the coverage of health services inthe Eastern Region, US$450,000 for the de-velopment of the physical infrastructure ofhealth services, US$750,000 for develop-ment of a biotechnology research and devel-opment center (1983-1986), US$56,854 fora drug abuse monitoring program (in opera-tion, initiated in 1984), US$4.2 million formaternal and child care and family planning,and US$73,280 for the Amazon hospital-Pucallpa (in operation, initiated in 1980);IDB, US$23 million for projects under way inthe following fields: development of technol-ogy for water and sewage systems, waterquality control, wastewater recycling, trainingfor the primary care level, and training in ani-mal health; IBRD, US$33.5 million for pri-mary care and basic health services (in opera-tion and initiated prior to 1984); and WFP,US$900,000 for nutritional assistance tomothers and children (in operation, initiatedin 1982).

8.520 Bilateral cooperation: USAIDprovided US$30 million for programs in oper-ation initiated prior to 1984: water qualitycontrol laboratories, design standards for wa-ter and sewerage systems, and an immuniza-tion program; and US$1.2 million to carry outa study of the health sector. The Governmentof Czechoslovakia, US$207,920 for genera-tor sets and dental and oral health equipment;Government of Denmark, US$381,444 forprimary care at Pucallpa (in operation, initi-ated in 1979); Government of France,US$5.3 million for hospital equipment-Iquitos and Juliaca; Federal Republic of Ger-many donated approximately US$24 millionfor projects in operation initiated prior to 1984in the areas of: strengthening of the hospitalsystem, primary care and health services, lab-oratory services, nutrition, and environmen-tal health; Gouernment of Hungary,US$612,669 for supplies; Government of It-aly, US$42,522 for extension of rural medicalcare; Government of Japan, US$2.05 millionfor malaria control (in operation, initiated in1981); IICA, US$769,230 for physical infra-structure (in operation, initiated in 1980);

Government of Norway, US$34.7 million forextension of medical care in rural areas-Puno (in operation, initiated in 1981); Gov-ernment of the Netherlands, US$6.7 millionfor a rural hospital network and US$4.2 mil-lion for support for health sectors; Govern-ment of Sweden, US$106,400 for integratedhealth care (in operation, initiated in 1980);and Switzerland's Swiss Technical Coopera-tion, US$609,278 for extension of rural medi-cal care.

8.521 Foundations: the Amazon Foun-dation donated US$192,830 for devel-opment of health services in ApurímacRiver Valley; W. K. Kellogg Foundation,US$149,775 for development of the maternaland child health program in the Hunter-Soca-baya area (1984-1985); and Save the Chil-dren Fund, US$19,220 for development andextension of health services (Tambo and EneRiver area) (in operation, initiated in 1982).


8.522 Professional staff assigned to thecountry: 5, including the PAHO/WHOCountry Representative and advisers, in:health administration, nursing, comprehen-sive medical care, and environmental health.

8.523 Regional and intercountry advis-ers: 33, for a total of 268 days, in the follow-ing fields: health services and primary care, in-formation systems, nursing, medical records,laboratories, environmental health, maternaland child health, food and nutrition, immuni-zation, epidemiology, dentistry, tropical medi-cine, cancer, plague, veterinary medicine,public health, and primate stations.

8.524 Short-term consultants (STC):49, for a total of 658 days, in the followingfields: planning and organization of services,hospital architecture, human resources, envi-ronmental health, maternal and child healthand the nutritional risk approach, mentalhealth, occupational health, production of

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228 Annual Report

drugs, immunization, meningitis, leishma-niasis, Chagas' disease, plague, and tropicaldiseases.

8.525 Fellowships: 98, for a total of 167months and at a cost of US$270,205, in thefollowing areas of study: human resources,maternal and child health, administration andorganization of services, environmentalhealth, malaria and vector control, immuniza-tion, drug control, nutrition, dentistry, tuber-culosis, veterinary health, tropical medicine,pharmacology, serology, and social commu-nication.

8.526 Courses, seminars, and work-shops: 46, with a participation of 1,872 na-tional officials and at a cost of US$72,829, inthe following fields: Master's of Public Health,health administration, training of promoters,training of health service staff, training in thefirst level of care, maintenance of health facili-ties, dentistry, immunization, maternal andchild health, supervision, and emergency anddisaster preparedness.

8.527 Grants: PAHO/WHO awardedUS$139,700 in grants for the following: eval-uation of the School of Public Health(US$30,000); primary care study and pro-ject (US$17,000); Cayetano Heredia Univer-sity (US$10,000); San Marcos University

(US$10,000); training of researchers(US$13,500); drug research and policies(Hipólito Unanue Agreement, US$40,000);cancer research (US$2,000); study of respira-tory problems in children (US$14,700); andmedical education (US$2,500).


8.528 Peru experienced the same effectsof the economic crisis as the other LatinAmerican countries. These were com-pounded by a number of political and socialfactors peculiar to Peru. As a result, the healthsector was faced with serious constraints inreal financial resource availability and, conse-quently, serious limitations on the operatingcapacity of health services and on human re-source productivity. The situation also af-fected the Organization's technical coopera-tion activities, as the funding provided forpriority Government action areas was onlypartially used. The imminence of elections fora new Government suggests a need to adjustcooperative actions to new health policies andplans, with a view to focusing currently scat-tered efforts on critical areas and designing in-novative approaches and procedures.


St. Christopher and NevisBasic Data





Life expectancy at birthInfant mortality/1,000 live birthsMaternal deaths/ 1,000 ive birthsDeath rate 1-4 years/1,000 childrenPercentage of newborn with a weight of



per capita/day








2.32.5




1979-81 52.8 10,000 inhabitants17- 52.8

1982198319831982

6.211.117.00.2



dedicated to health

YEAR NUMBER

19831983

1983

89.593.0

69.0

1983 75.0

1985 96.01977 106.01980 12.21981 5.6

1983 5.81981 56.7

1981 0.9

1984 12.3




8.529 An assessment of PAHO/WHO'stechnical cooperation with the newest Mem-ber Country of the Organization was made inNovember 1984. The Government is imple-menting a national development plan, andPAHO/WHO has supported the follow-up ofthe health planning process and the identifica-tion of technical inputs needed. Orientation toCaribbean standards of nursing care was pro-vided for senior nursing personnel.

8.530 In environmental health, emphasiswas placed on integrating the primary healthcare strategy into the day-to-day operations ofthe national program, and the first steps weretaken towards drafting an environmentalhealth field operations manual. A 5-day semi-nar on operational definitions of primaryhealth care strategies in environmental healthprograms and a 3-day workshop on emer-gency operations planning for water supplyand environmental health personnel were de-veloped as part of this scheme. In the light ofrecent hotel and tourism developments, theGovernment is becoming increasingly con-cerned with liquid and solid waste disposal.

8.531 The Organization supported the re-

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230 Annual Report

porting of histopathology and cytology speci-mens and the provision of training for labora-tory technologists in the testing of hepatitisand in laboratory management.


8.532 Family planning and family life ed-ucation, which are integrated into maternaland child health services, are priority pro-grams within the national health policy and inthe overall development plan of the country.In strengthening health and family life educa-tion and family planning within primary healthcare (PHC), activities have included the plan-ning of a health education unit, integration ofhealth and family life education into theTeachers' Training College, and establish-ment of adolescent health and family planningcenters in Sandy Point and Cayon.

8.533 Efforts have been made to improvethe status of maternal and child health by pre-senting findings of the perinatal risk study andplanning for training of health personnel inperinatal care. The implementation and fol-low-up of the oral rehydration program hasimproved the management of gastroenteritisin children. However, there have been delaysin the strengthening of nursing midwifery ser-vices through the revision of the maternal andchild health manual and the updating of thenursing midwifery curriculum. Three familynurse practitioners (FNP) have been trainedand are working in PHC settings. Laws andlegislation are being revised to incorporate theroles and functions of the FNP.

8.534 Surveillance and control of com-municable diseases continues to have a highnational priority. St. Christopher and Nevisreceived collaboration from the ExpandedProgram on Immunization (EPI), and CARECcontinued to develop and strengthen its labo-ratory diagnostic capability. Progress is alsobeing made in developing the leprosy controlprogram. The country also received assis-tance from the Pan Caribbean Disaster Pre-

paredness and Prevention Project health teamlocated in Antigua.


8.535 International cooperation:UNFPA provided US$8,420 for a program onmaternal and child health and familyplanning.


8.536 Professional staff assigned to thecountry: Cooperation comes from the Orga-nization's staff located in various parts of theCaribbean, as well as from Headquarters,CAREC, and CFNI. Additionally, a team ofconsultants from the Caribbean Program Co-ordinator's (CPC) Office collaborated withGovernment efforts in health systems devel-opment, manpower, health statistics, disasterpreparedness, disease control, environmentalhealth, nutrition, maternal and child health,veterinary public health, zoonoses, and vectorcontrol.

8.537 Fellowships: 3 fellowships wereawarded in vector control, hepatitis, and alco-holism, and training was provided for 4nationals in laboratory management (SaintLucia), ward management (Barbados), radi-ography (Jamaica), and meat-foods inspec-tion (Jamaica), utilizing the European Eco-nomic Community-Caribbean CommunitySecretariat funds.


8.538 The Government has agreed toconduct a thorough analysis of the health situ-ation early in 1985 with the support of the Or-ganization. PAHO/WHO will provide assis-


tance when priority areas have been identifiedand will work consistently in those areas. Fur-ther assistance will be provided to fertility pro-grams directed at adolescents in and out ofschool, to strengthening maternal and childhealth services to decrease infant morbidityand mortality, and to training health person-nel in specific areas of concern in maternaland child health.

8.539 Despite the limited resources avail-able, assistance in environmental health hasbeen stepped up, and a review of the nationalprogram is expected to assist the Governmentin strengthening this component of primaryhealth care. A national workshop in solidwaste management is anticipated.

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232 Annual Report

Saint LuciaBasic Data






1980 40.01983 31.01983 6.3





per capita/day


1985198319831983

70.027.0

0.257.2







1979-81 64.3 10,000 inhabitants17- 64.3

1979197919781978

10.012.019.0



dedicated to health

YEAR NUMBER

1981 63.61981 65.3

1985 100.0

1985 100.0

1979 2.81979 4.4

1982 4.01980 22.7

1980 9.3

1978 29

1981 4.0

1985 13.6




8.540 Assistance was received in the de-velopment of a planning unit in the Ministry ofHealth and in strengthening the planning ap-proach to delivery of health services. Also im-portant has been the study for strengtheningthe physical infrastructure; the results are nowbeing implemented.

8.541 A critical review of health person-nel data collected during 1983 was done, andpreparation is under way for a national work-shop to be held during 1985 on organizationalsupport and management issues in health per-sonnel, as a basis to policy formulation. Aworkshop on standards of nursing care for se-nior nursing personnel was carried out. Thecountry was the site for two important envi-ronmental health workshops, one on waterquality control and emergency operationsplanning for water supply, and the other onenvironmental health personnel. Discussionscommenced on continuing education in pri-


mary health care for environmental health of-ficers. The national environmental health pro-grams continued without major change tosurveillance activities.

8.542 Assistance was provided in the co-ordination of all laboratory services and re-lated activities, the reporting of histopathologyspecimens, a training exercise in testing forhepatitis, and the hosting of a 2-week work-shop in laboratory management.


8.543 Progress has been principally in theintegration of related services. The most nota-ble examples are the integration of familyplanning into maternal and child health andfamily life education into the school system.Local training to match these objectives is be-ing actively pursued with the help of externalagencies. However, inadequacies in thepresent physical facilities impose limitationson the efficacy of both the primary and sec-ondary levels of perinatal health care. Thefamily program is progressing along with theintegration of family life education into theTeachers College curriculum. A revised ma-ternal and child health manual is now in oper-ation.

8.544 Surveillance and control of com-municable diseases continue to be a high na-tional priority. Saint Lucia participates in theExpanded Program on Immunization and,with the Caribbean Epidemiology Center(CAREC) assistance, is developing andstrengthening its surveillance and laboratorycapabilities.


8.545 International cooperation:UNFPA provided US$101,600 for maternaland child health and family planning.

8.546 Foundations: The Kellogg Foun-dation provided US$789,000 for primaryhealth care development (1985-1989).


8.547 Professional staff assigned to thecountry: 2, in health planning and manage-ment. Additional cooperation comes throughthe Organization's staff located in various partsof the Caribbean, as well as from Headquar-ters, CAREC, CFNI, and other PAHO/WHOCenters. A team from the PAHO/WHO Ca-ribbean Program Coordination Office collabo-rated closely with Government efforts inhealth systems development, personnel, di-saster preparedness, disease control, mater-nal and child health, environmental health,nutrition, and veterinary public health.

8.548 Fellowships: 6, in: communityhealth, alcoholism, hepatitis, and obstetrics.PAHO/WHO funding was US$21,030.Training also was provided for five nationals incommunity nutrition (Barbados) and in meatand other foods inspection (Jamaica), utilizingEuropean Economic Community and Carib-bean Community Secretariat funding.


8.549 Political commitment to primaryhealth care, the national authorities' enthusi-asm, and dedication of the national technicalstaff constitute favorable factors in deliveringtechnical cooperation.

8.550 Since the Government is turning itsattention to the implementation of the na-tional health plan, the Organization shall assistwith program review and execution at all lev-els. Further health personnel development to

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234 Annual Report

increase their operational capacity is pro-posed. A need continues for the services of apathologist and for assistance in the develop-ment of the laboratory services. Steps shouldbe taken to accelerate the strengthening of theBureau of Health Education (within the UN-FPA project). The various maternal and childhealth and family life education-related proj-

ects need to be coordinated even more closelyin the future.

8.551 A situation analysis, to be carriedout as a first step in the managerial process,was discussed with and approved by the na-tional authorities. The study will be conductedin 1985, with PAHO/WHO's support.


St. Vincent and the GrenadinesBasic Data








per capita/day







1980 68.5 sanitary waste disposal1982 40.6 Consultations per inhabitant per year1980 1.3 Number of discharges per 100 inhabitants1980 3.7 Number of bedsper 1,000 inhabitants



1979-81 50.7 10,000 inhabitants1979-81 50.7

1980198219821982


1.8 Total health expenditure as a percentage7.4 oftheGDP

19.5 Percentage of the National Budget-- dedicated to health

YEAR NUMBER

198319831983

82.085.052.0

1981 75.0

1981 88.0

1980 2.4

1980 2.91980 10.4

1980 9.7

1981 10

1979 5.3

1982 14.2




8.552 As part of the development of thenational health plan, workshops were held onprimary health care surveillance and on thestrengthening of health districts. Also impor-tant were the implementation and the follow-up of nursing care standards in hospital andcommunity services and of the guidelineson developing a patient classification system

and staffing pattern for Kingstown GeneralHospital.

8.553 In human resources, a critical re-view of health personnel data collected during1983 was done, and preparation is under wayfor a national workshop to be held during1985 on organizational support and manage-ment issues in health personnel, as an intro-duction to policy formulation.

8.554 Environmental health does not ap-pear to enjoy a high priority in the nationalhealth program, and surveillance activitiescontinued routinely without any major newdevelopment.

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236 Annual Report


8.555 A review of nutritional surveillancein St. Vincent, its information system, and ba-seline data on children and pregnant womenwas prepared with the CFNI assistance and aspart of the PAHO/WHO-UNICEF Joint Nu-trition Support Program. An altogether satis-factory level of progress in maternal and childhealth has been maintained in St. Vincent andthe Grenadines.

8.556 Conditions for technical coopera-tion are now more favorable with the returnfrom professional courses of a senior healtheducator, two family nurse practitioners, anda community nutrition officer. In addition,there is significant potential for more effectiveplanning and implementation of maternal andchild health and primary health care activitiesnow that vacant positions in the district andhospital services have been filled and traininghas been established in family planning andfamily life education and related subjectsthrough continuing education programs.

8.557 Other related activities were: thefollow-up of postnatal services, the overall ad-ministrative and technical operations for theUNFPA project, the presentation of perinatalsurvey results, the development of a nationalmedical policy on contraception, and the pro-vision of two fellowships in audiovisual tech-niques and three fellowships for observationalstudy in family life education.

8.558 The country continues to developand strengthen its surveillance and laboratorydiagnostic capability; these efforts were sup-ported by CAREC. Animal health and veteri-nary public health activities progressed satis-factorily.


8.559 International

UNFPA gave US$54,200 for family planningand family life education.


8.560 Professional staff assigned to thecountry: Although no full-time professionalstaff are assigned to St. Vincent and the Gren-adines, considerable cooperation came fromthe Organization's staff located in various partsof the Caribbean, as well as from Headquar-ters and the PAHO/WHO Centers. A team ofconsultants from the PAHO/WHO 'CaribbeanProgram Coordinator's Office collaboratedwith Government efforts in health systems de-velopment, personnel, disaster preparedness,disease control, environmental health,zoonoses, and vector control.

8.561 Fellowships: 10, in: rainwater sys-tems, hepatitis, community nutrition, audiovi-sual techniques, and family life education.Additionally, training was provided for 9 na-tionals in laboratory management (Saint Lu-cia), ward management (Barbados), commu-nity health nursing (Bahamas), pharmacy(Barbados), medical laboratory technology(Barbados), and rodent control (Barbados),utilizing European Economic Community-Caribbean Community funding. PAHO/WHO cooperation for fellowships wasUS$7,630.


8.562 The installation of a new Govern-ment in July provided some freshness to theoverall process of health development. Thenew Government is fully committed to pri-mary health care, and PAHO/WHO cooper-ation is anticipated to continue. The full com-plement of family nurse practitioners shouldbe thoughtfully deployed in the developmentand expansion of primary health care. A newUNFPA-funded project proposal should becooperation:


prepared for strenghthening the family plan-ning and family life education components ofmaternal and child health. St. Vincent shouldbenefit from the subregional program in peri-natal care, planned to be developed in collab-oration with CLAP in 1985.

8.563 The modest environmental healthprogram likely will pay increased attention topersonnel development through continuingeducation programs and PAHO/WHO tech-nical cooperation.

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238 Annual Report

SurinameBasic Data

Demographic lndicators


(as nationally defined)Birth rate/1.000 inhabitantsMortality rate/1,000 inhabitants


Life expectancy at birthInfant mortality/ 1,000 live birthsMaternal deaths/1.000 live birthsDeath rate 1-4 years/ 1000 childrenPercentage of newborn with a weight of



per capita/day










1979-81 62.2 10,000 inhabitants17- 62.2

19811981

7.18.9



dedicated to health

YEAR NUMBER

198319831983

85.085.055.0

1983 95.0

1983 80.0

1982 5.8

1984 8.41984 20.8

1984 16.7

1983 54

1983 5.0




8.564 The primary health services werereviewed by the Regional Health Service (re-sponsible for the coastal area-90% of popu-lation) and the Medical Mission (responsiblefor the interior of the country); a new healthpolicy document for 1985-1990 was pre-pared; nursing standards were implemented(developed for the Caribbean in 1983); and aworking group to develop national health in-

formation systems was organized in mid-1984. Its first priority is to develop informationsystems for primary health care.

8.565 In human resources, the strategycontinued to strengthen national health per-sonnel training institutions while facilitatingthe access of health personnel to higher tech-nical and professional training and continuingeducation. Two key public health staff arepresently obtaining their Master of PublicHealth degrees-in epidemiology and mater-nal and child health, respectively; this willgreatly enhance the existing staff and the Min-istry of Public Health infrastructure.

A new Environmental Health Divi-8.566

Summary of Each Country's Activities 239

sion is being established. This process will beaccelerated with the posting of a PAHO/WHO sanitary engineer in the country late in1984. The Public Health Inspectorate wasstrengthened through a 5-month trainingcourse in environmental health. A new teamof food inspectors also participated in thiscourse.


8.567 A nutrition survey, which also cov-ered diarrheal diseases, was conducted in thecoastal area. The data were being analyzed atthe Caribbean Food and Nutrition Institute(CFNI). A public health nurse was trained at acommunity nutrition course (CFNI) to intro-duce and supervise nutrition activities at theprimary health care level.

8.568 The training program for the youthdental program continued to train dental aux-iliaries. PAHO/WHO provided equipmentthat contributed to the improvement of out-reach services for this expanding program. Afirst assessment of needs and priorities wasconducted in the field of workers' health, inwhich no activities presently are deployedother than accident prevention. At year's end,negotiations were under way for PAHO/WHO and UNICEF to assist in the procure-ment of a large part of the essential drugs onthe national formulary.

8.569 In the third year since its reviewand reorientation, the national immunizationprogram now fully immunizes more than 90%of children by age 1, in all regions in the coun-try. After thorough evaluation and planning,the diarrheal disease control program waslaunched in mid-June with a series of work-shops for all levels of health personnel. Oralrehydration is now available nation-widethrough the primary health care services. Alongitudinal study on the epidemiology of eti-ological agents in diarrheal diseases was

started in an underprivileged area close to thecapital.

8.570 Epidemiological surveillance hasbeen strengthened and epidemiological analy-sis is now being applied to programs for thecontrol of major diseases as well as to healthservices delivery and utilization. The Surin-ame epidemiological bulletin is an importantmeans for distribution of information. CARECcontinues to be the main referral laboratory fordiagnostic and epidemic services, mainly in vi-rology; it also organizes training courses andon-the-bench assistance in this field, as well asin epidemiology.

8.571 The integration of malaria controland eradication into primary health carethrough the Medical Mission was evaluated.The review commented very positively on thetransfer and drew attention to the excellentnetwork of services provided by the MedicalMission. Border meetings between Surinameand French Guiana in October-November dis-cussed possible control measures and agreedon a common strategy regarding the deterio-rating malaria situation along the MarowijneRiver border. An emergency campaign to re-duce the estimated 40% infestation with Ae-des aegypti in Paramaribo prevented the in-troduction of derigue outbreaks reported inother countries of the Caribbean.

8.572 In 1984, there was the first follow-up to the WHO Special Program for Researchand Training in Tropical Diseases (TDR)workshop in the epidemiology of schistoso-miasis held in 1983. Results are being ana-lyzed. Following the evaluation of sexuallytransmitted diseases, treatment at the primarylevel is being standardized and laboratory sup-port for diagnosis is being improved.

8.573 While Suriname is not extremelydisaster-prone, the possibility of man-madedisaster (e.g., air crash, industrial accidents)prompted a review of preparedness in thehospital sector. The hospital board is presentlyreviewing the results of this assessment.

240 Annual Report


8.574 International cooperation: In1984, IDB opened an office in Suriname tofacilitate project preparation and monitoring.Two health-related projects are being pre-pared: construction-renovation of a hospitalin the Regional Health Services of Nickerie,and water and sewage supply in Paramaribo.

8.575 Bilateral cooperation: Since theabrupt termination of Dutch development aid,several projects in development of the healthservice infrastructure have been curtailed se-verely. Projects funded by the European Eco-nomic Community (EEC) to consolidate infra-structure in the interior have continued.


8.576 Professional staff assigned to thecountry: 2, the PAHO/WHO Country Rep-resentative (who also advises in epidemiol-ogy) and a sanitary engineer assigned to thecountry in December 1984.

8.577 Regional and intercountry advis-ers: 12, for a total of 110 days, in: health in-formation systems development, nutrition,epidemiology, occupational health, nutritionsurvey procedures, malaria, vector control,virology training, REPAHA review, food es-tablishment inspection, health education, andregional health service.

8.578 Short-term consultants (STC):14, for a total of 290 days, in: environmentalhealth, training, nursing services, epidemiol-ogy, radiation safety, malaria, brucellosis,sexually transmitted diseases, schistosomiasis,and epidemiology research.

8.579 Fellowships: 16, in: health plan-ning, primary health care in nursing, nursingservices management, hospital nursing ser-

vices, community nutrition, immunologytechniques, orthopedic shoe making, com-prehensive vector control, environmentalhealth, methods in special medical bacteriol-ogy, epidemiology, skin pathology, bacteriol-ogy of tuberculosis, water purification, publichealth, and epidemiology. PAHO/WHO'sfunding was US$57,400.

8.580 In addition, 23 nationals partici-pated, with PAHO/WHO support, in 14courses carried out in the Caribbean area andin the Region.

8.581 Courses, seminars, and work-shops: 4, with 200 participants.in diarrhealdiseases. PAHO/WHO's funding wasUS$5,000.

8.582 Grants: 4, for dental equipmentfor the Youth Dental Foundation(US$30,000); drugs-malaria chemopro-phylaxis and test kits (US$8,751); administra-tion of EPI program and cold chain equipment(US$2,680); and oral rehydration salts (ORS)(US$5,294).


8.583 The political and socioeconomicsituation remained difficult in 1984 with con-sequent repercussions on national programsand activities and on PAHO/WHO technicalcooperation. Still a number of major develop-ments were noted, including the emphasisplaced on the development of a health policyand plan for 1985-1990 and of adequatehealth information systems. Cooperation withdisease control programs remained strong.Family health programs received a concentra-tion of technical cooperation with excellentresults in strengthening of the national capac-ity. More involvement was noted in the deliv-ery of health services based on primary healthcare, and the 1985 program will be based onthis concept.


8.584 Several activities were noted in en-vironmental health, while the further develop-ment of technical cooperation awaited thefull-time assignment of a sanitary engineer tothe country.

8.585 Cooperation for 1985 will focus onthe areas of health policy, disease control,family health and health services, as well as onthe development of planning and informationsystems in support of these areas.

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242 Annual Report

Trinidad and TobagoBasic Data








per capita/day








Human Resource Indicators*... ... Physicians per 10,000 inhabitants


1979-81 75.5 10,000 inhabitants17- 75.5

197819781978

4.710.625.5



dedicated to health

YEAR NUMBER

1983 60.01983 61.01983 60.0

1984 95.0

1984 100.0

1980 12.11980 4.1

1983 10.51983 28.3

1983 245

1980 1.6

·. Data not available.



8.586 The increasing need to reempha-size the crucial importance of health planninghas been recognized not only by the Ministryof Health and Environment but also by theother Government departments and in partic-ular by the Ministry of Finance and Planning.In the draft development plan prepared by anational task force, health planning had beeninterwoven into the general plan; now thehighest levels of Government accept that so-

cial sector ministries, such as health, have animportant role in the overall planning process.The state of the national economy has made iteven more important to institutionalize plan-ning in order to use limited resources effec-tively. During 1984, the Ministry made a de-termined effort to sensitize senior managers tothe planning process and completed the initialspade work necessary to develop a nationalhealth plan.

8.587 Because of these commitments,the Ministry of Health and Environment hasfound it necessary to review and reorganize itsorganizational structure and to streamline andstrengthen systems. The Ministry is now insti-tutionalizing planning and management in the


records, finance, transport, and supply sys-tems.

8.588 However, unless administrationand decision-making are decentralized, therewill be no noticeable improvement in manage-ment functions, efficiency, and effectiveness,regardless of the structures created. Opera-tional guidelines for financial managers are be-ing developed. This work entails reviewing allexisting financial regulations, instructions, andcirculars and compiling this information into asingle document for the use of county healthofficers, administrators, and accounting per-sonnel. Such actions will strengthen primaryhealth care services based on the concept of acounty health team headed by the countymedical officer of health. In this approach,county health teams have greater responsibil-ity for planning programs and more authorityfor making decisions locally.

8.589 The commitment to the healthplanning process requires the support of an ef-ficient and reliable information system. In thisregard, the Ministry of Health and Environ-ment requested assistance in the introductionof modern technology to strengthen the infor-mation system. It is important to stress that anoutline of the national plan of action for theyears 1985-2000 was prepared, consisting ofbroad program areas with suggested priorityactivities.

8.590 In human resources, outstandingactivities included: the continuous process ofteaching basic principles of health planningand the methodology to be used for nationalhealth development in Trinidad and Tobago;the preparation and completion of the curricu-lum for medical laboratory technicians to beused at the College of Allied Health Sciences;'and CAREC collaboration with the Universityof the West Indies (UWI) in the training ofmedical students. An important innovation in1984 was the attachment of medical gradu-ates of UWI to the health centers as part of thesecond year of their internship program. Thiscompulsory attachment was for a period of 3months, but many found this orientation to

community health so interesting that they ex-tended the duration to 6 months.

8.591 An orientation seminar on healthplanning for national health development wascarried out. This seminar was attended byover 50 senior Government executives andofficials from the Ministry of Health and Envi-ronment and other ministries whose dutieshave a direct impact upon the health of thepopulation. Primary health care workshopsheld in six counties were an unqualified suc-cess. Two counties are yet to host these work-shops-Caroni and Tobago.

8.592 Preparations are being made to-ward a national consultation on environmen-tal health which will bring together the policyand decision makers of the various ministries,Government agencies, and interested publicbodies involved in the management, monitor-ing, control, and use of the environment. Theoverall objective of the consultation is to for-mulate a national policy and a plan of actionto develop and strengthen programs for themanagement of the environment.

8.593 The objectives of two projectsfunded by UNDP and IDB were: strengthen-ing the training unit at the Water and Sewer-age Authority (WASA) and improving certaintechnical areas at the Authority, respectively.The first project achieved its objective in themain, but there was need for a comprehensiveapproach to the Authority's personnel needs.The second project was less successful, andthe objectives of achieving significant im-provements in pollution control, water distri-bution, and the maintenance of sewage treat-ment plants were not attained. UNDP fundeda new project to improve the Authority's orga-nizational and functional performance. Along-term training program in public healthengineering for public health inspectors andpreliminary preparations for a suitable trainingprogram to correct deficiencies in supervisoryskills and knowledge are under way. Assis-tance has also been provided to public healthinspectors for improving their information sys-tems.

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244 Annual Report


8.594 At county level, training in familylife education and family planning wasstrengthened, as well as in infant feeding withemphasis on breastfeeding. Workshops alsowere developed on maintenance of the coldchain in the Expanded Program on Immuniza-tion. Oral rehydration therapy now is prac-ticed at all health centers. Preliminary evalua-tion has suggested that its use in hospitals hasreduced infant deaths due to gastroenteritis.

8.595 During the year, the Ministry ofHealth and Environment decided to seek acomplete appraisal of the progress made in itscommunity mental health program with aview toward improving the program's effi-ciency and maximizing the use of resources.The extent of drug use and abuse in Trinidadand Tobago has galvanized the Ministry andthe Government into action. It is generallyagreed that alcohol is the major problem, butmarijuana and cocaine are often used. A sur-vey conducted at Port-of-Spain General Hos-pital in Trinidad revealed that 47% of admis-sions resulted from the use of alcohol. Theprogram of providing special attention tochronic diseases (diabetes mellitus and hyper-tension) at selected health centers continued.

8.596 The Aedes aegypti eradicationcampaign continued throughout 1984 and re-corded steady progress. Routine operationscontinued in Trinidad while a special cam-paign was mounted in Tobago to contain anderadicate foci of reinfectations discovered dur-ing the second quarter of the year.


8.597 Bilateral cooperation: USAID as-sisted in a health development planning andmanagement project (technical cooperation),and the EEC gave US$965,000 for a trainingprogram in the health sector (3 years).


8.598 Professional staff assigned to thecountry: 4, the PAHO/WHO Country Rep-resentative and advisers in: health services de-velopment, institutional management, andAedes aegypti eradication.

8.599 Fellowships: 15, for a total of 43months, in: public health administration, per-sonnel management, community nutrition,tuberculosis bacteriology, and water and sew-age systems. PAHO/WHO's estimated costwas US$108,770.

8.600 Grants: PAHO/WHO providedUS$20,000 for CAREC reconstruction andUS$5,000 for laboratory equipment.


8.601 The Government continued to em-phasize the importance of health planning inorder to promote optimum use of the coun-try's available resources. This emphasis wastranslated into the formulation of the nationalhealth plan. The health plan demonstrates acommitment to implementing the primaryhealth care approach, including decentraliza-tion of administrative responsibility, encour-agement of community participation, andprovision of comprehensive services at healthcenters. The Government also is mindful ofthe important role of women in health and de-velopment and the priority health care needsof the elderly.

8.602 During the year, meetings wereheld with the technical cooperation division ofthe Ministry of Finance and Planning, the Min-istry of Health and Environment, and PAHO/WHO. These meetings are a valuable mecha-nism for planning future cooperation, moni-toring programs, discussing problems, solvingdifficulties, and obtaining expeditious govern-mental approval.


United States of AmericaBasic Data




YEAR NUMBER

1984 236,158,000





per capita/day


1982198219821982

74.611.50.90.6









1979-81 105.6 10,000 inhabitants17- 105.6

1982198219821982

1.022.338.3

2.3



dedicated to health

1983 37.41983 24.01983 7.11984

1984 b

1980 98.2

1983 16.71982 5.7

1982 19.01982 59.0

1983 33.0

1983 1,459

1983 10.9

1983 29.7

... Data not available.a Almost none. b Almostthe entire population.

Analysis of the Steps Taken in1984 to Implement RegionalStrategies


8.603 Considering that many of the ma-jor health problems confronting Americans to-day are rooted in lifestyle or environmentalfactors that are amenable to change, healthpromotion and disease prevention appear tohold the key to further improvements in thehealth status of the United States of America'spopulation. Since 1980, the Department of

Health and Human Services has been pursu-ing the goals set out in a report entitled "Pro-moting Health/Preventing Disease: Objec-tives for the Nation." This volume representsthe Federal Government's plans for achievingbetter health for Americans by 1990. Goalsare aimed at the five major life stages: infant,child, adolescent and young adults (15-24years), adults (25-64 years), and older adults(65 and older). For each of the first fourgroups, the goals are to improve health andreduce mortality; and for the last group, theelderly, to improve health and the quality oflife and reduce the average annual number ofdays of restricted activity due to acute andchronic conditions. These goals are to be im-

YEAR NUMBER

245

246 Annual Report

plemented in 11 priority areas: high bloodpressure control, family planning, toxic agentcontrol, occupational safety and health, acci-dent prevention and injury control, fluorida-tion and dental health, surveillance and con-trol of infectious diseases, smoking andhealth, abuses of alcohol and drugs, physicalfitness and exercise, and control of stress andviolent behavior. Specific and quantifiable ob-jectives, 227 in all, and implementation planshave been developed for each priority area.More than 500 individuals and organizationalrepresentatives from the public and privatesectors were brought together to participate inthis process, recognizing that achievementof the goals requires the participation of insti-tutions and individuals from every sector ofsociety.

8.604 In February 1984, representativesfrom more than 60 national groups from thepublic and private sectors met to discuss thestatus of health promotion in the schools,business and industry, voluntary organiza-tions, health professions, and health care set-tings. The range of ongoing health promotionfor each of the sectors was defined and possi-ble areas for action identified. In addition,each sector identified the barriers to actionand recommendations for action were made.The overall success of the conference is re-flected in the fact that all of the groups notedthe importance of the objectives in their mis-sions and made specific suggestions aboutways in which the Federal Government andthe private sector could cooperate in achiev-ing the Nation's health promotion goals.

8.605 The Department has been provid-ing financial support to institutions which tar-get resources to areas of high national priority,such as disease prevention, health promotion,increasing the supply of primary care practi-tioners, and improving the distribution ofhealth professionals. Area health educationprojects have provided training settings whichemphasize health promotion at the commu-nity level. Regional resource centers assist intraining allied health professionals and multi-

disciplinary training in geriatric care. The sup-ply of allopathic physicians in the four groupsof medical specialties comprising primary care(general practice, family practice, internalmedicine, and pediatrics) increased 47.5%from 1970 to 1982. The number of first-yearresidents in family medicine increased from190 in 1970 to 2,584 in the 1984-1985 aca-demic year. Data on location of family prac-tice graduates suggest amelioration of geo-graphic distribution problems. Registerednurses working as nurse practitioners/mid-wives increased 73.98% between 1977 and1980.

8.606 Health planning, evaluation, andbudgeting activities occur in both the publicand private sectors as part of sound manage-ment practices. At the Federal level this pro-cess has recently brought about a majorchange in Medicare financing, a programwhich in 1983 covered over 30 million peo-ple, 90% of whom are 65 years old or over.The impact of past health care spending forthe Medicare program on the Nation's re-sources has led to a change from the highlyinflationary, cost-based reimbursement sys-tem for hospitals to a "prospective payment"system based on patient diagnostic groupings.The expectation is that an effective exercise ofthe prospective payment system will yieldgreater returns in the form of improved healthcare at more reasonable cost. Given the in-creasing percentage of the United States ofAmerica's population that the elderly repre-sent, the method of financing the Medicareprogram will have a progressively larger im-pact on health care delivery in this country.


8.607 The United States of America hasalready reached several of the 1990 objectivesin health promotion and disease prevention.Examples include: the goal of less than 10cases of paralytic polio and congenital ru-bella-only seven cases of each occurred in


1982; the goal of less than 60% of 9-year-olds with cavities in any of their permanentteeth-in 1982, only about 51% of 9-year-olds had cavities; the goal to reduce the an-nual rate of work-disabling injuries to 83 per1,000 full-time workers-current data fromthe Bureau of Labor Statistics indicate that therate has already come down to 81 per 1,000.

8.608 Major strides have been made inthe area of immunizations. For the 1981-1982 school year, at least 95% of children en-tering first grade or kindergarten had been im-munized against measles, rubella, mumps,polio and diphtheria, tetanus and pertussis.The number of reported cases of measlesdropped from 13,597 in 1979 to 1,697 in1982. Surveillance, including epidemiologicalinvestigations, is basic and essential to infec-tious disease control. Accordingly, our objec-tives emphasize the continued developmentand application of effective surveillance tech-niques; improvements in sanitation; case find-ing and control; rapid and accurate diagnosisand reporting; appropriate therapy; and thedevelopment and use of new drugs and vac-cines, such as the vaccine for hepatitis B. Inaddition, the country gives priority to the sur-veillance and control of infectious diseasesthrough the increased use of molecular biol-ogy to improve the detection of new reservoirsof infection, the definition of populations atrisk, the understanding of patterns of diseasecontraction, and the evaluation of controlmeasures. In 1983, three demonstration com-puter-based telecommunications systemswere established for routine collection, analy-sis, and dissemination of surveillance data;rapid communication of messages; and inves-tigation of epidemics.

8.609 Major emphasis is placed on mak-ing people aware of their own role in theirhealth status. For example, cigarette smokershave a 70% higher overall death rate thannonsmokers, and tobacco is associated withan estimated 300,000 premature deaths ayear. The Surgeon General of the PublicHealth Service has called for a smoke-free so-

ciety by the year 2000, to increase emphasison the anti-smoking campaigns already underway. The Environmental Protection Agency(EPA) has been investigating the extent andeffects of indoor air pollution and has recentlymade some estimation of the extent to whichpassive smoking contributes to lung cancermortality.

8.610 Significant progress has been madein recent years in improving the already highlevels of quality in sanitation and safe drinkingwater achieved earlier in this century. A fore-most concern continues to be the protection ofpublic water systems from contamination bybacteria and viruses. Increasingly, efforts arebeing placed on monitoring chemical contam-inants and reducing their concentrationswhere they are found to exceed safe levels.EPA is gradually increasing the number ofsuch chemicals for which legally enforceablestandards have been established.

8.611 Continuing activities include moni-toring levels of man-made toxic agents in theenvironment, assessing their health signifi-cance, and establishing control programs toreduce environmental concentrations of thetoxic agents found to threaten the publichealth. New data show greater health effectsat lower blood-lead levels in both children andadults than previously reported. Based onthis, in August 1984, EPA proposed to furtherreduce the amount of lead allowed in gasolineto 0.1 grams per gallon by January 1986, witha possible total ban by 1995. EPA and theCenters for Disease Control (Atlanta, Geor-gia) recently established a close associationbetween blood lead and hypertension-relatedmortality.

8.612 In 1984, a new group working onrisk assessment and risk management andcontrol was established within the President'sCabinet Council on National Resources andthe Environment. Members of the Council in-clude the five principal regulatory agenciesthat deal with public health and the environ-ment: Food and Drug Administration, Occu-pational Safety and Health Administration,

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248 Annual Report

EPA, Food and Safety Inspection Service ofthe Department of Agriculture, and the Con-sumer Product Safety Commission. The pur-pose of the new group is to develop consis-tent, Government-wide approaches toassessing and managing risks to public healthand the environment.

8.613 By 1980, at least 50% of the largeremployers had established one or more "well-ness" programs. Today, worksite wellnessprograms are expanding in prevalence, incomprehensiveness, and in sophistication.Smaller employers, public sector employers,unions, nonprofit sector employers, and hos-pitals also are offering wellness programs orfacilitating access to community services. Thisphenomenon mirrors the growth in the gen-eral public's commitment to healthier life-styles, concern for the escalation of medicalcare costs, acceptance of the changing natureof illness, understanding of the medical sys-tem's limitations and awareness that healthcan be promoted through behavioral and en-vironmental changes.

Technical and FinancialResources Provided to OtherPAHO Member Governments

8.614 The Agency for International De-velopment (AID) is the principal Governmentagency providing financial support to PAHOMember Governments in the health sector.Approximately 40% of AID's health accountis allocated to bilateral and regional projects inapproximately 20 PAHO Member Countries.These projects, in the form of grants andloans, support activities consistent with the ob-jectives articulated in AID's 1982 Health Pol-icy and Strategy: "to assist countries to be-come self-sufficient in providing broad accessto cost-effective, preventive, and curativehealth services...AID-financed health projectsfocus on those health problems which contrib-ute most significantly to infant, child and ma-ternal mortality and morbidity."

8.615 AID's health strategy focuses onselective primary health care (PHC) interven-tions, including: oral rehydration therapy, im-munizations, growth monitoring and nutritioneducation, family planning, and provision ofessential drugs.

8.616 Resources for PHC programs arechanneled primarily to those countries withthe highest infant mortality rates. Programs inother countries emphasize improved manage-ment, productivity, and financial viability ofpublic sector health services; and promotionof alternatively financed and organized healthservices. Resources provided by AID are usedto support technical assistance; incountry andoffshore training; commodities; and, in somecases, construction and renovation. Localcurrencies generated by balance of paymentsupport programs and concessional sales offood also are used to support the local costs ofhealth programs.

8.617 Resources available for program-ming in the health sector have increased anaverage of 30% per year since 1981 to thecurrent level of approximately $60 million(not including funds for family planning) in1985. The increases in 1984 and 1985 are at-tributable to the priority accorded to CentralAmerica. Funding for health will level off andperhaps be reduced in 1986 because of over-all Government budget constraints not relatedto the relative priority of health or of LatinAmerican and Caribbean countries.

8.618 3ecause of its legislative mandateas a domestic health agency, the Departmentof Health and Human Services' internationalcooperation is more limited in scope than thatof AID. However, the Department has about30 bilateral health agreements-some carriedout within the terms of science and technologyagreements entered into by the Department ofState; agreements between governments; andagreements between components of the Pub-lic Health Service, such as the National Insti-tutes of Health and the Food and Drug Ad-ministration, and their technical counterpartsin other countries.


8.619 The Public Health Service, particu-larly the National Institutes of Health and theCenters for Disease Control, has long con-ducted research on health issues and prob-lems of importance to developing countries.For example, tropical medicine research in-cludes studies on filariasis, leishmaniasis, lep-rosy, malaria, schistosomiasis, and trypanoso-miasis-the diseases targeted by theWHO/UNDP Special Program on Researchand Training in Tropical Diseases. Other im-portant diseases receiving attention includegastroenteritis other than cholera, hepatitis,acute respiratory illness, and sexually trans-mitted diseases. The Government has shownnew interest in the development of new andimproved drugs and vaccines for the controlof diseases more prevalent in developingcountries, better techniques for control of dis-ease vectors, improved epidemiology, simpleand effective diagnostic methods, and im-

proved mechanisms for cost-effective servicedelivery. In addition, the Public Health Ser-vice provides substantial technical assistanceto AID in the form of expert consultants forboth bilateral and regional development proj-ects.

Future Trends in ProvidingTechnical and FinancialResources to PAHO MemberGovernments

8.620 The United States of America doesnot anticipate any change in priorities in thetype of assistance provided to other PAHOMember Governments. Technical and finan-cial resources will be made available consistentwith the resources the principal agencies re-ceive through the budgetary process of theGovernment.

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250 Annual Report

UruguayBasic Data





Life expectancy at birthInfant mortality/ 1.000 live birthsMaternal deaths/ 1,000 live birthsDeath rate 1-4 years/1,000 childrenPercentage of newborn with a weight of



per capita/day




1984 84.8 (triple vaccine)... ... -poliomyelitis... ... -measles






1979-81 86.6 10,000 inhabitants1979-81 86.6

1981198119811980

2.621.423.0

1.2



dedicated to health

YEAR NUMBER

1981198119811981

55.058.090.074.0

1981 75.0

1981198119811981

40.0350.0

11.55.2

1982 20.11981 4.4

1981 51.8

1979 7.8

.. Data not available.



8.621 The study of the health service sys-tem begun in 1982 was completed, as was theanalysis of the technical framework for inter-sectoral coordination and external coopera-tion. The resultant information and a numberof policy definitions led to adjustments in na-tional programs and to more rational utiliza-tion of financial resources. They were alsohelpful in defining the role and degree of com-

plexity to be assigned to each type of healthfacility and, consequently, in defining a ser-vice network based on a hierarchy of levels ofcare. This was an important step toward bring-ing all levels of the system within the reach ofthe population.

8.622 Operational capacity was im-proved in selected priority areas. First, mana-gerial procedures were strengthened by devel-oping a simplified information system anddefining indicators for hospital administration,training staff in the managerial systems. andlinking such staff with the budget system. As asecond step, drug management procedureswere improved by standardizing the informa-


tion on patterns of drug use, adjusting policiesgradually to make them more rational, andadjusting the system of procurement.

8.623 In human resources, the leadingactions were in the area of nursing auxiliaries.The occupational profile for nursing auxiliarieswas revised, and the curriculum (which alsoincludes the training of instructors) was evalu-ated and adjusted. The Ministry's Health Aux-iliary School conducted courses on pharma-cology, mental health, clinical histories, andpathological anatomy.

8.624 In environmental health, the tech-nical cooperation program was revised to fo-cus on critical areas, including institutional de-velopment of the State Sanitary Works(OSE), in which cost systems, laboratory ser-vices, and staff training were strengthened. Inaddition, a social involvement program wasformulated. Legislation on water fluoridationbased on the use of simple, low-cost technol-ogy was adopted during the year.


8.625 In maternal and child health, ef-forts were aimed at providing for the examina-tion of pregnant women from the early stagesof pregnancy to reduce the risk to the new-born. With the cooperation of CLAP, the peri-natal information system was implemented informulating the first assessment of perinatalhealth systems at the Pereira Rossell Hospital.The Expanded Program on Immunization(EPI) was evaluated, and the cold chain wasstrengthened with new equipment and instru-ments. A plan instituted during the year willprovide computerized birth records to facili-tate keeping track of children susceptible topreventable diseases.


8.626 Technical Cooperation Among

Developing Countries (TCDC): Close rela-tions were maintained with neighboring coun-tries in the areas of fellowships and short-termconsultants.


8.627 Professional staff assigned to thecountry: 4, including the PAHO/WHOCountry Representative and advisers in medi-cal care and administration.

8.628 Regional and intercountry advis-ers: 37, for a total of 360 days, in: health ser-vice systems, human resources, medicalrecords, maternal and child health,epidemiology, information systems, immuni-zation, environmental health, water and saltfluoridation, chronic diseases, toxicology, andanimal health.

8.629 Short-term consultants (STC):22, for a total of 393 days, in: research,chronic diseases, chemical and biologicalwastes, EPI evaluation, viral hepatitis, ortho-pedics, EPI computerization, textbooks, andhealth surveys.

8.630 Fellowships: 28, for a total of 38months at a cost of US$22,650, in the follow-ing fields: health services, human resources,sanitation, disaster preparedness, disease pre-vention and control, and animal health.

8.631 Courses, seminars, and work-shops: A total of 15 events involving the par-ticipation of 290 officials were held during theyear at a cost to PAHO/WHO of US$36,567.The subjects were: primary care, hospital sta-tistics, EPI evaluation, nursing, productionand costs, health programming, mentalhealth, pathological anatomy, pharmacy, ma-ternal and child health programming, congen-ital malformations, and biosafety in the labora-tory.

8.632 Grants: PAHO/WHO awardedUS$25,000 for the environmental sanitation

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252 Annual Report

programs and US$85,000 for a study ofchronic diseases; 1983 funds were availablefor both programs.


8.633 Significant problems were ad-dressed, particularly those concerning thestructure and operation of services. Progresswas slow, partly because of economic condi-tions and the political process, both of which

affected the pace of programs in general. Be-cause a change in administration was immi-nent, the most useful data were obtained andsystematized so that the new authorities wouldhave the necessary information available onwhich to base estimates of service require-ments and demand and of the capacity andinfrastructure of the national health servicenetwork, and would accordingly be able to de-fine policies, introduce structural and strategychanges, and prepare the appropriate pro-grams and set them in motion. This approachalso applied to environmental health.


VenezuelaBasic Data








per capita/day








0.51.7




1979-81 71.2 10,000inhabitants17- 71.2

1983198319831983

8.210.316.46.2



dedicated to health

YEAR NUMBER

1983198319831982

71.891.645.073.5

1982 90.3

1982 78.21981 180.01981 5.51982 2.7

1982 12.11982 8.1

1982 23.4

1982 130.0

1984 3.0

1982 9.1



8.634 The dominant features were theGovernment's efforts to integrate the sector'scomponents and shape the national healthsystem. With this in view, a System SteeringCommittee was established to evaluate, regu-late, and coordinate sectoral activities. In1984, the Ministry of Health and Social Wel-fare (MSAS) was operating 154 hospitals and3,282 ambulatory health care facilities. TheVenezuelan Social Security Institute had 17

hospitals and its beneficiaries numbered 4.7million, out of an economically active popula-tion of 5.5 million.

8.635 A number of technical committeeswere established in the health sector to defineparticular problems and to determine the sta-tus, objectives, and limitations of stratégicprojects and of 60 proposed operations, aswell as the strategic effects and the operations-actions matrix. This research and analysis pro-cess has created intensive activity in the healthsector. At the first stage of restructuring, theMSAS presented a proposed program andbudget for 1985 which reallocated fund allot-ments in keeping with the following priorities:expansion of primary health care services; ex-

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panded coverage and greater effectiveness inmaternal and child care; improvement of nu-trition levels; and delivery of health services,with emphasis on preventive measures.

8.636 In support of this initiative, prelimi-nary studies were begun on the financing ofambulatory treatment based on the primaryhealth care strategy. In addition, a nationalworkshop on strategic planning in health wasconducted with the participation of theMSAS, Central Office of Coordination andPlanning of the Presidency (CORDIPLAN),preventive medicine staff of the schools ofmedicine, the Central University of Venezue-la's Development Center (CENDES), and theVenezuelan Social Security Institute.

8.637 Significant events in human re-sources were the development of a computer-ized information system to provide data onhuman resources in the health sector and theimplementation of the first stage of the sys-tem, which will make it possible to do studiesand projections on the training and adminis-tration of health personnel and to develop acontinuing education program for health staff,as well as design and institute a program ofpublications on human resources and thehealth sector. Teaching-service integration inthe faculties of health science schools wasevaluated, and the programs were adjusted.In addition, a study was carried out on curric-ular change and continuing education at theSchool of Public Health.

8.638 In environmental health, the exec-utive branch decided to extend the CaracasMetropolitan Water Supply System to coverthe entire metropolitan area and to enlargethe water systems in the northwestern andcentral regions of the country and the State ofZulia. Work went forward on the constructionof 12,000 housing units per year within therural housing program. Comprehensive eval-uations of air pollution (especially from indus-trial sources) were carried out in the metropol-itan area of Caracas and in the areas of LakeMaracaibo and Lake Valencia.


8.639 An evaluation of the family plan-ning component of the maternal and childhealth program financed by UNFPA was be-gun. Special attention also was paid to thehealth of adolescents and schoolchildren. Inmental health, priority was given to training.An evaluation of the teaching and practice ofepidemiology was carried out to lay thegroundwork for comprehensive improve-ments in epidemiological activities. The Ex-panded Program on Immunization (EPI) wasevaluated nation-wide, and proposals weremade to improve its performance.

8.640 Following the resurgence of ma-laria in Venezuela, a study and a Govern-ment/PAHO/WHO agreement were beingprepared with a view to establishing a unit toconduct research on the diagnosis, epidemiol-ogy, and control of rural endemic diseases.

8.641 Leprosy research and the testing ofa leprosy vaccine continued. The RafaelRangel National Institute of Hygiene im-proved its quality control procedures for medi-cations, drugs, and cosmetics and producedrabies vaccine for human and canine use.


8.642 Technical Cooperation AmongDeveloping Countries (TCDC): PAHO/WHO and the Latin American Economic Sys-tem (SELA) entered into an agreement forjoint promotion of TCDC activities in the fieldof health. A preliminary review was carriedout of opportunities and possibilities for tech-nical cooperation in health in Venezuela, withspecial emphasis on the country's participa-tion in Central American peace and develop-ment efforts. Also worthy of note were: thepreliminary studies on a project for producingraw materials to be used in the manufacture ofwidely consumed medications; the design of a


project to strengthen capabilities for manufac-turing and maintaining laboratory equipment;and the cooperation among Venezuelan, Car-ibbean, and Central American institutions inthe areas of research, training, and productionof generic drugs, as well as in the provision ofadvisory services on the clinical and toxicolog-ical aspects of drugs.

8.643 International cooperation: UNDPprovided US$115,974 for a study on the con-trol of tropical diseases; UNFPA, US$16,210for family planning; UNDP/UNESCO,US$80,000 for human resource develop-ment; and IDB, US$10 million for ambulatorycare and US$2 million for production of foot-and-mouth disease vaccine.


8.644 Professional staff assigned to thecountry: 6, including the PAHO/WHOCountry Representative and advisers in:strengthening of health systems, productionof rabies vaccine, human resource develop-ment, international classification of diseases,and veterinary public health.

8.645 In addition, 4 intercountry profes-sionals rendered services in Venezuela during1984 in the fields of immunology, epidemiol-ogy, nursing, and rodent control.

8.646 Regional and intercountry advis-ers: 42, for a total of 327 days, in: tropical re-search and training, maternal and childhealth, human resources, oncology, produc-tion of biologicals, tuberculosis, disease classi-fication, mental health, nursing, EPI, familyplanning, oral health, health infrastructure,leprosy, epidemiology, environmental sanita-tion, medical records, technology in the fieldof health, strengthening of health servicesplanning, chronic diseases (blindness), essen-tial drugs, and occupational health.

8.647 Short-term consultants (STC):44, for a total of 413 days, in: laboratory ser-

vices, strengthening of health services, tuber-culosis, maternal and child health, diseaseclassification, occupational health, tropicaldisease research and training, leprosy, medi-cal records, family planning, blindness pre-vention, assistance to School of Public Health,food hygiene, and scientific and technologicaldevelopment in the field of health.

8.648 Fellowships: 52, for a total ofUS$154,240, in the following fields: diseasecontrol, tropical diseases, environmentalmanagement, laboratory services, strengthen-ing of the health system, foot-and-mouth dis-ease control, food hygiene, human resourcedevelopment, mental health, family health,oncology, tuberculosis, oral health, nursing,and vaccine production.

8.649 Courses, seminars, and worl-shops: 6, in: malariology and environmentalsanitation, dermatoleprology, oral health, dis-ease classification, drug dependency, and oc-cupational health. In addition, an Inter-Amer-ican working group on bacterial resistancesurveillance met during the year.

8.650 Grants: A US$15,000 grant wasawarded to the Venezuelan Center for Dis-ease Classification (CEVECE) for the perfor-mance of national studies on the applicationof ICD-9 (International Classification of Dis-eases-9th Revision).


8.651 In February 1984, following theelections, a new Government was inaugu-rated and a new Minister of Health and SocialWelfare was sworn in. Priorities underwent anumber of changes which also were influ-enced by the economic crisis in the country.The new authorities began to prepare the VIINational Plan (1984- 1989) to orient the Gov-ernment's work in health and other fields dur-ing its constitutional term of office.

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256 Annual Report

8.652 Prominent among the priorities es-tablished for the health sector was creating asteering committee to implement the nationalhealth system as a vehicle for the eventual un-ification of the sector's various components.Adjustments were made to give high priorityto promoting primary health care, rehabilitat-ing secondary and tertiary health care centers,increasing the operating capacity of all ser-vices, and encouraging community participa-tion in relevant activities and a district-basedpublic health organization.

8.653 Economic conditions made it nec-essary to reduce budgets sharply and utilizeavailable resources more productively. Con-sequently, preliminary contacts and studieswere made with the IDB with a view to financ-ing inter alia a project to strengthen ambula-tory care on the basis of the new primary carestrategies. An additional indication of the na-tional authorities' growing interest in using re-sources available through international techni-cal cooperation was the grant request toUNFPA for activities under the family plan-ning program.

Index

Accident prevention and controlin children, 2.66traffic accidents, 2.65

Acquired immune deficiency syndrome (AIDS), 2.171Acute respiratory infections, 2.161-2.162Addiction Research Foundation, 2.63Aedes Aegypti, eradication, 2.149, 2.155, 2.170Agency for International Development, USA (see under

United States of America)Agency for Technical Cooperation (see under Germany,

Federal Republic of)Alcoholism, 2.62, 2.63American Association of Cancer Research, 2.186American Association for World Health, 7.14American Cancer Society, 2.252American Public Health Association, 7.2American Region Programming and Evaluation System

(AMPES). 6.2, 6.6American Society of Clinical Oncology, 2.186Andean Pact, 1.14, 1.20, 1.72, 3.25, 3.26Anguilla, 2.64, 2.134, 2.169Antibiotics, 1.65Antigua and Barbuda, 1.6, 1.25, 2.40, 2.68, 2.85,

2.134, 2.169, 2.225summary of activities, 8.4-8.17

Anthology of Experiences, 2.48Arab Gulf Fund (AGFUND), 2.161, 2.164, 2.182Argentina, 1.2, 1.6, 1.7, 1.9, 1.11, 1.12, 1.15, 1.17,

1.22, 1.38, 1.41, 1.44, 1.46, 1.63, 1.64, 1.65,1.68, 1.69, 1.71, 1.73, 1.79, 1.88, 2.32, 2.33,2.36, 2.52, 2.55, 2.58, 2.64, 2.82, 2.83, 2.98,2.100, 2.101, 2.106, 2.112, 2.140, 2.151, 2.156,2.162, 2.166, 2.174, 2.175, 2.179, 2.183, 2.195,2.197, 2.199, 2.201, 2.206, 2.207, 2.208, 2.210,2.212, 2.215-2.220, 2.223, 2.226-2.228, 3.8,3.14, 3.15, 3.19, 3.27, 7.16

Animal Virology Center, 2.222National Institute of Microbiology, 2.208National Institute of Social Services, 1.17, 2.52Veterinary Diagnosis and Research Center, 2.211

summary of activities, 8.18-8.35Autonomous Metropolitan University (Mexico), 1.35,

2.111

Bahamas, 2.78, 2.108, 2.125, 2.169, 2.180, 2.189summary of activities, 8.36-8.45

Barbados, 1.3, 1.8, 1.24, 1.26, 1.68, 1.74, 1.88, 2.29,2.52,

summary of activities, 8.46-8.63Basic Agreements on Privileges and Immunities, 7.16-

7.17BCG vaccine, 2.133, 2.134, 2.165, 2.166, 2.208,

2.216Belize, 1.6, 1.86, 1.88, 2.61, 2.85, 2.123, 2.142,

2.151, 2.157, 2.232, 7.16summary of activities, 8.64-8.83

Bermuda, 2.57, 2.60, 2.134Bibliographic Alert, 3.13Bilateral Financial Cooperation, 3.40-3.46BIREME (see Latin American Center on Health Sciences

Information)Blindness prevention, 2.190-2.193Blood, transfusion prdgram, 1.86-1.88Board of the Cartagena Agreement, 2.199Boletín de la Oficina Sanitaria Panamericana, 7.6, 7.7Bolivia, 1.3, 1.8, 1.9, 1.11, 1.12, 1.15, 1.20, 1.26,

1.41, 1.68, 1.75, 2.6, 2.38, 2.39, 2.49, 2.64,2.68, 2.69, 2.82, 2.92, 2.97, 2.101, 2.106, 2.139,2.142, 2.151, 2.155, 2.156, 2.162, 2.170, 2.182,2.185, 2.191, 2.199, 2.226, 3.4, 7.16

National Association of Water and Sanitation, 2.68National Institute of Occupational Health (INSO), 2.49

summary of activities, 8.84-8.104Bovine tuberculosis, 2.208, 2.215, 2.216Brazil, 1.3, 1.6, 1.7, 1.9, 1.11, 1.12, 1.15, 1.22, 1.26,

1.30, 1.31, 1.35, 1.39, 1.41, 1.44, 1.45, 1.46,1.62, 1.63, 1.64, 1.68, 1.71, 1.75, 1.77, 1.79,1.80, 1.86, 1.88, 2.3, 2.5, 2.7, 2.11, 2.32, 2.40,2.48, 2.59, 2.64, 2.72, 2.77, 2.78, 2.81, 2.87,2.88, 2.96, 2.100, 2.101, 2.105, 2.109, 2.112,2.117, 2.140, 2.141, 2.151, 2.153, 2.155, 2.156,2.157, 2.161, 2.162, 2.163, 2.165, 2.166, 2.169,2.170, 2.172, 2.174, 2.175, 2.178, 2.180, 2.188,2.191, 2.195, 2.197, 2.199, 2.200, 2.201, 2.208,2.214, 2.215-2.220, 2.222, 2.223, 2.226, 2.252,2.253, 2.255, 3.4, 3.5, 3.8, 3.13-3.14, 3.19,3.24, 3.27, 7.16

257

258 Annual Report

Lutz Institute, 1.64National Drug Center, 1.75National Housing Bank (BNH), 2.87, 2.88National Human Resource Center, 2.3National Institute for the Control of Health Quality (IN-

CQS), 1.87National School of Public Health, 1.31Research Council, 3.4summary of activities, 8.105-8,120

British West Indies (Anguilla, British Virgin Islands, andMontserrat)

summary of activities, 8.115-8.133Brucellosis, 2.208, 2.217, 2.220Bulletin of PAHO, 7.6Bulletin PASCCAP, 1.51

Cajanus, 2.27Canada, 1.12, 1.58, 1.82, 2.210, 2.249, 3.41

Canadian International Development Agency (CIDA),2.92, 2.245, 2.246

Center for Disease Control, 2.175International Development Research Center (IDRC),

1.81, 2.98, 2.170summary of activities, 8.134-8.138

Cancer, 2.184-2.189CARE, 2.21CAREC (see Caribbean Epidemiology Center)CAREC Surveillance Report, 2.122Caribbean Alcoholism Institute, 2.63Caribbean area countries (see individual countries)Caribbean Association of Nutritionists and Dietitians

(CANDI), 2.26Caribbean Community (CARICOM), 1.6, 1.28, 1.42,

2.30, 2.57, 2.65, 2.75, 2.85, 2.203, 3.25Caribbean Development Bank (CDB), 2.70, 2.75Caribbean Environmental Health Institute, 2.85Caribbean Epidemiology Center (CAREC), 2.117,

2.118, 2.119-2.125, 2.176research, 1.121technical cooperation, 2.125training, 2.122-2.124

Caribbean Food and Nutrition Institute (CFNI), 2.10,2.23-2.30

Carnegie Corporation, 2.24Cayetano Heredia University (Peru), 1.35Cayman Islands, 2.134Central American Bank for Economic Integration (BCIE),

1.72Central American Network of Documentation and Infor-

mation Centers, 1.54Central American University (Nicaragua), 2.17CEPANZO (see Pan American Zoonoses Center)CEPIS (see Pan American Center for Sanitary Engineer-

ing and Environmental Sciences)CFNI (see Caribbean Food and Nutrition Institute)Chagas' disease, 2.156Chemical Safety Programs, 2.84Chile, 1.7, 1.9, 1.10, 1.12, 1.41, 1.46, 1.62, 1.63,

1.64, 1.65, 1.68, 1.79, 1.80, 2.3, 2.5, 2.32, 2.34,2.36, 2.41, 2.48, 2.50, 2.52, 2.55, 2.58, 2.64,2.73, 2.98, 2.101, 2.109, 2.112, 2.163, 2.166,2.175, 2.179, 2.183, 2.186, 2.195, 2.201, 2.210,2.217, 2.226, 2.228, 3.14, 3.15, 3.27, 7.15

Institute of Nutrition and Food Technology (INTA),2.3, 2.5

Institute of Public Health, 1.62, 1.64summary of activities, 8.139-8.153

Cholera, 2.170Clark Hewlett Foundation, 3.47Codex Alimentarius Coordinating Committee, 2.197,

2.219Cold chain, 2.127-2.128, 2.136

(see also Expanded Program on Immunization)Collaborative Cancer Treatment Research Program

(CCTRP), 2.186, 2.187Colombia, 1.4, 1.6, 1.7, 1.8, 1.9, 1.11, 1.13, 1.15,

1.16, 1.17, 1.20, 1.26, 1.29, 1.30, 1.40, 1.41,1.44, 1.46, 1.63, 1.65, 1.68, 1.69, 1.73, 1.75,1.79, 1.81, 1.82, 1.86, 1.88, 2.3, 2.5, 2.6, 2.32,2.36, 2.38, 2.39, 2.48, 2.49, 2.52, 2.55, 2.57,2.63, 2.64, 2.66, 2.86, 2.98, 2.100, 2.101, 2.105,2.112, 2.117, 2.118, 2.136, 2.140, 2.141, 2.142,2.151, 2.153, 2.155, 2.156, 2.157, 2.162, 2.163,2.164, 2.168, 2.170, 2.173, 2.174, 2.180, 2.183,2.188, 2.195, 2.197, 2.199, 2.200, 2.201, 2.212,2.217, 2.219, 2.222, 2.223, 2.226, 2.227, 2.228,2.237, 2.244, 2.246, 2.249, 2.250, 2.252, 2.253,2.255, 3.4, 3.8, 3.14, 3.24, 7.16

Institute for Family Welfare, 2.3Social Security Institute, 1.17, 2.49summary of activities, 8.154-8.176

Community Health Training Program for Central Amer-ica and Panama (PASCCAP), 1.30, 1.32, 1.36,1.44, 1.48-1.54, 3.19, 3.25

Community participation, 1.26Conference Services (PAHO), 7.19Contadora Group, 2.232Continuing education, 1.33Control of Communicable Diseases in Man, 7.2Control of diseases, 2.116-2.155Cornell University (USA), 2.5Costa Rica, 1.2, 1.7, 1.8, 1.9, 1.10, 1.11, 1.12, 1.13,

1.15, 1.16, 1.17, 1.18, 1.23, 1.39, 1.44, 1.50,1.51, 1.52, 1.53, 1.68, 1.75, 1.84, 1.86, 1.88,2.9, 2.14, 2.34, 2.52, 2.57, 2.61, 2.64, 2.91,2.98, 2.108, 2.112, 2.142, 2.157, 2.162, 2.180,2.183, 2.187, 2.189, 2.191, 2.195, 2.197, 2.210,2.243, 3.8, 3.15, 7.16

Clodomiro Picado Institute, 1.84Nutrition and Health Teaching Institute, 2.14Social Security Agency, 1.52summary of activities, 8.177-8.202

Cretinism, 2.6Cuba, 1.3, 1.7, 1.9, 1.26, 1.32, 1.33, 1.38, 1.44, 1.45,

1.64, 1.68, 1.73, 1.86, 1.88, 2.32, 2.33, 2.34,2.38, 2.48, 2.50, 2.52, 2.57, 2.61, 2.66, 2.72,2.79, 2.85, 2.101, 2.105, 2.112, 2.114, 2.117,2.118, 2.139, 2.160, 2.163, 2.166, 2.178, 2.183,2.195, 2.197, 2.219, 2.250, 3.4, 3.5, 3.8, 3.15,3.24, 3.27

Health Sciences Institute, 2.38Workers' Medicine Institute, 2.50summary of activities, 8.203-8.222

Damien Foundation (Belgium), 2.169Dengue, 1.66, 2.155, 2.173

Index 259

Denmark, 3.42Dental caries (see Oral health)Dental education, 1.39-1.40

(see also Oral health)Dental health (see Oral health)Development and Use of Health Education Materials,

1.26Diabetes mellitus, 2.183Diagnostic and therapeutic technology, 1.62-1.88Diphtheria, 2.127Directing Council, PAHO (see under Pan American

Health Organization)Disabled, health of the, 2.54-2.56Disaster relief (see Emergency preparedness and disaster

relief)Diseases

cardiovascular, 2.181-2.182deficiency diseases, 2.6diarrheal diseases, 2.139-2.144intestinal parasitic, 2.160noncommunicable diseases, 2.177-2.193prevention and control, 2.116-2.155sexually transmitted, 2.176vector-borne diseases, 2.145-2.159viral, 2.172-2.175(see also Specific disease)

Diseases Subject to International Health Regulations,2.170

Dissemination of knowledge, 3.12-3.17Distribution and Sales (PAHO), 7.7Dominica, 1.3, 1.8, 1.13, 1.25, 1.74, 1.88, 2.10, 2.29,

2.30, 2.57, 2.64, 2.68, 2.79, 2.85, 2.119, 2.125,2.134, 2.169

summary of activities, 8.223-8.239Dominican Republic, 1.3, 1.8, 1.9, 1.12, 1.13, 1.15,

1.29, 1.39, 1.41, 1.68, 1.79, 1.88, 2.5, 2.17,2.48, 2.57, 2.58, 2.59, 2.64, 2.75, 2.79, 2.89,2.91, 2.105, 2.108, 2.112, 2.118, 2.139, 2.153,2.158, 2.160, 2.169, 7.16

National Drinking Water and Sewerage Institute (IN-APA), 2.89

summary of activities, 8.240-8.263DPT, vaccine, 1.83, 2.133, 2.134Drug abuse (see Drug dependency)Drug dependency, 2.62, 2.63Drugs, essential, 1.70-1.77, 4.11

policies for the production and marketing, 1.71

ECO (see Pan American Center for Human Ecologyand Health)

Economic Commission for Latin America and the Carib-bean (ECLAC), 2.72, 2.73, 2.241, 4.5

Ecuador, 1.3, 1.7, 1.8, 1.9, 1.15, 1.16, 1.20, 1.24,1.26, 1.30, 1.39, 1.41, 1.45, 1.68, 1.73, 1.75,1.79, 1.86, 1.88, 2.5, 2.6, 2.40, 2.55, 2.89,2.101, 2.105, 2.106, 2.151, 2.155, 2.156, 2.159,2.168, 2.195, 2.197, 2.199, 2.201, 2.210, 2.222,2.223, 2.226, 2.227, 2.228, 2.239, 2.244, 2.246,2.250, 2.253, 3.5

National Institute of Hygiene, 2.159summary of activities, 8.264-8.283

Educación médica y salud, 7.6, 7.7

Education and trainingcontinuing, 1.33dental, 1.39-1.40nursing, 1.37-1.38public health and health administration, 1.43-1.44veterinary public health, 1.41-1.42, 2.201

Educational Technology in Health Centers (CENTES),1.45

Educational Technology and Health Nucleus (NUTES),1.45, 3.19

Elderly, health of, 2.51-2.53El Salvador, 1.9, 1.10, 1.12, 1.14, 1.15, 1.17, 1.18,

1.23, 1.24, 1.30, 1.32, 1.33, 1.36, 1.38, 1.39,1.41, 1.48, 1.49, 1.50, 1.53, 1.66, 1.68, 2.17,2.18, 2.39, 2.52, 2.57, 2.64, 2.68, 2.70, 2.91,2.117, 2.136, 2.162, 2.182, 2.234, 2.246

Social Security Institute, 1.17summary of activities, 8.284-8.300

Emergency preparedness and disaster relief, 2.236-2.246

Environmental health, 2.67-2.115Environmental pollution, prevention and control, 2.84-

2.85Environmental quality, 2.67-2.115, 2.204EPI Newsletter, 2.136EPI Notes, 2.122EPI Revolving Fund, 1.80, 2.137Epidemiological Bulletin, 2.116, 7.6Epidemiological information and surveillance system

(ECO), 3.17Epidemiology, 2.116-2.118European Economic Community (EEC), 2.132, 2.245Excreta disposal, 2.67-2.75Expanded Program on Immunization (EPI), 1.61, 1.83,

2.126-2.138Revolving Fund, 1.80, 2.137targets for 1985, 2.133-2.134

Expanded Textbook and Instructional Materials Program(PALTEX), 1.46, 1.60-1.61, 2.143

External financial resources, mobilization of, 3.34-3.35

Family planning (see Maternal and child health/familyplanning)

FAO (see Food and Agriculture Organization of theUnited Nations)

Federal University of Rio de Janeiro (Brazil), 1.45Fellowships (PAHO), 1.55-1.59Five-Year Regional Plan of Action on Women, Health,

and Development, 2.247-2.254Fluoridation, 1.40, 2.9, 2.57, 2.75Food

consumption, 2.4availability, 2.3protection, 2.197-2.198, 2.209, 2.219

Food and Agriculture Organization of the United Nations(FAO), 2.21, 2.29, 2.115, 2.199, 2.225

Food and nutrition, 2.2-2.12(see also Caribbean Food and Nutrition Institute and In-

stitute of Nutrition of Central America and Pan-ama)

Food and nutrition surveillance, 2.5Foot-and-mouth disease, 2.199

260 Annual Report

Ford Foundation, 3.47Foundations (see under name of foundation)France, 3.44French Antilles and Guiana

summary of activities, 8.301-8.307Fundamentals of Ophthalmology for General Practition-

ers, 2.191

Generation of knowledge, 3.2-3.11German Leprosy Relief Association, 2.168Germany, Federal Republic of, 3.43

Agency for Technical Cooperation (GTZ), 2.5, 2.68,2.91, 2.96, 2.97, 2.98, 2.99, 7.17

Global Hepatitis Control Program (WHO), 2.172Global Technical Cooperation Program (IDB/PAHO/

WHO), 2.70Goiter, endemic, 2.6Grenada, 1.88, 2.40, 2.64, 2.85, 2.125, 2.134, 2.139,

2.169summary of activities, 8.308-8.319

Growth charts, 2.25Guatemala, 1.8, 1.9, 1.10, 1.11, 1.12, 1.13, 1.15,

1.17, 1.18, 1.23, 1.26, 1.30, 1.33, 1.35, 1.39,1.41, 1.48, 1.49, 1.52, 1.53, 1.66, 1.68, 1.77,2.7, 2.8, 2.14, 2.17, 2.18, 2.32, 2.50, 2.63, 2.64,2.68, 2.78, 2.79, 2.91, 2.98, 2.108, 2.112, 2.117,2.139, 2.160, 2.161, 2.191, 2.243, 7.15

Social Security Institutesummary of activities, 8.320-8.342

Guyana, 1.3, 1.8, 1.24, 1.26, 1.35, 1.41, 2.52, 2.61,2.86, 2.125, 2.203, 7.16

summary of activities, 8.343-8.362

Haiti, 1.3, 1.12, 1.24, 1.26, 1.45, 1.88, 2.7, 2.10,2.68, 2.151, 2.249, 7.16

summary of activities, 8.363-8.379Health of the disabled, 2.54-2.56Health education, 1.26Health of the elderly, 2.51-2.53Health Information and Documentation Center, 3.16Health personnel

educational technology, 1.45-1.46food and nutrition programs, 2.17-2.19training, 1.34-1.44, 2.36utilization, policies, 1.32

Health projects, formulation and administration, 1.23-1.24

Health servicesdiagnostic and therapeutic technology

essential drugs, 1.70-1.77laboratory services, 1.62-1.67radiation health, 1.68-1.69vaccine and biologicals production, 1.78-1.79

human resources developmentbibliographic information systems, 1.47Community Health Training Program for Central

America and Panama (PASCCAP), 1.48-1.54Educational technology and teaching materials,

1.45-1.46Expanded Textbook and Instructional Materials Pro-

gram, 1.60-1.61fellowship administration, 1.55-1.59

management, 1.28-1.33relevant problems, 4.1-4.14system development

health education and community participation, 1.26information, national systems, 1.18-1.22intrasectoral coordination, 1.15-1.17organization and development of the health service

network, 1.9-1.14planning and administration, 1.4-1.8project formulation and administration, 1.23- 1.24research, 1.25situation and trends, 1.1-1.3

Health statistics, 2.255Helen Keller International Incorporated, 2.56, 2.191,

2.192Hematology, quality control, 1.64Hemorrhagic fever with renal syndrome, 2.174Hipólito Unanue Agreement, 1.19, 1.75, 1.86, 2.150,

2.205Honduras, 1.3, 1.5, 1.9, 1.10, 1.11, 1.12, 1.14, 1.15,

1.16, 1.18, 1.23, 1.24, 1.26, 1.30, 1.33, 1.35,1.36, 1.39, 1.45, 1.48, 1.49, 1.50, 1.52, 1.79,2.7, 2.17, 2.20, 2.22, 2.39, 2.40, 2.52, 2.61,2.64, 2.68, 2.70, 2.91, 2.92, 2.108, 2.112, 2.114,2.117, 2.153, 2.156, 2.243, 2.250, 2.253, 3.4

summary of activities, 8.380-8.405Hospitals, 1.14

disaster preparedness, 2.240Housing, urban and rural, 2.83Human resources development

educational technology and teaching materials, 1.45-1.46

management, 1.28-1.33training, 1.34-1.44

Human settlements, 2.83Hydatidosis, 2.208, 2.211Hypertension as a Community Health Problem, 2.182

Ibero-American Social Security Organization (Spain),1.17

IBRD (see World Bank)IDB (see Inter-American Development Bank)Immunology, 1.67INCAP (see Institute of Nutrition of Central America and

Panama)INCAP Reports, 2.16Increasing the Operational Capacity of the Health Ser-

vices for the Attainment of the Goal of Health for Allby the Year 2000 (Technical Discussions, XXXMeeting of PAHO's Directing Council), 4.8

Index Medicus of Latin America, 3.13Infant mortality, 2.34Influenza, 2.175Information

environmental health, 2.101-2.103, 2.111national information systems, 1.18-1.22

PAHO, 7.13nutrition, 2.16

Institute of Nutrition of Central America and Panama (IN-CAP), 2.4, 2.5, 2.8, 2.9, 2.10, 2.13-2.22, 7.15

Institutional capacity, mobilization of, 3.18-3.21Inter-American Association of Sanitary and Environmen-

tal Engineering (AIDIS), 2.73, 2.93

Index 261

Inter-American Committee on Social Security (CISS),2.48

Inter-American Development Bank (IDB), 1.8, 1.24,1.41, 2.37, 2.69, 2.89, 2.91, 2.201, 2.202, 2.215,2.233, 2.234, 3.36-3.38, 7.17

Inter-American Institute of the Child, 2.56Inter-American Institute for Cooperation on Agriculture

(IICA), 2.199Inter-American Meeting on Animal Health at the Ministe-

rial Level (RIMSA III), 2.195International Agency for Research on Cancer, 2.109International Association on Water Pollution Research

and Control (IAWPRC), 2.73International Atomic Energy Agency (IAEA), 1.68International Bank for Reconstruction and Development

(see World Bank)International Center for Research on Women, 2.24International Center for Social Gerontology (France),

2.53International Classification of Diseases, 1.21, 1.22InternationalúDevelopment Agency (see under Canada)International Development Research Center (IDRC),

1.81International Drinking Water Supply and Sanitation Dec-

ade (IDWSSD), 2.67, 2.68, 2.86, 2.92International Eye Foundation, 2.192International Federation of Associations Against Leprosy

(ILEP), 2.168International Health Regulations, 2.170-2.171International Office of Epizootics (IOE), 2.199International Program for Chemical Safety (IPCS), 2.84International Regional Organization for Health in Agricul-

ture and Livestock (OIRSA), 2.199International Rehabilitation, 2.56International resources, mobilization of, 3.28-3.33International Union Against Cancer, 2.189International Union Against Tuberculosis, 2.164Intrasectoral coordination, 1.15-1.17lodine deficiency, 2.6Iron deficiency, 2.8

Jamaica, 1.6, 1.11, 1.26, 1.86, 1.88, 2.11, 2.24,2.29, 2.30, 2.52, 2.57, 2.70, 2.123, 2.125, 2.166,2.182, 2.214, 2.250, 2.253

National Transfusion Center, 1.88summary of activities, 8.406-8.423

Japan, 3.42Japanese Shipbuilding Industry Foundation (JSIF),

2.169Javeriana University (Colombia), 1.75, 2.38Joaquím Nabuco Foundation (Brazil), 2.3, 2.5

Kellogg Foundation, W. K., 2.5, 2.41, 2.53, 3.9, 3.47Laboratory services, 1.62-1.67

Latin American Cancer Research Information Project(LACRIP), 3.15

Latin American Center on Health Sciences Information(BIREME), 1.47, 3.13-3.14

Latin American Health Information Network, 1.47, 3.14

Latin American Institute of Economic and Social Planning(ILPES), 1.5, 1.44, 3.24

Latin American Network of Collaborating Institutions inUrban Sanitation, 2.81

Latin American Perinatology Center (CLAP), 1.26,2.33, 2.42-2.47

Legal matters (PAHO), 7.15-7.18Leishmaniasis, 2.157Leprosy, 2.167-2.169Leprosy Relief Work of Emmais (Switzerland), 2.169Leptospirosis, 2.218

Malaria, 2.146-2.154research, 2.153-2.154

Management (see Planning and administration, healthservices)

Managerial strategy, PAHO, 6.1-6.6Maternal and child health and family planning, 2.31-

2.41Maternal and Child Health and Primary Care-Facts and

Trends, 2.34Measles, 2.127Medical education, 1.35-1.36Medical records, 1.13MEDLINE, 3.13Meetings

Appropriate Technology in Prenatal Care, Interregio-nal Conference on, 1.26, 2.35

Cervical Cancer, Regional Meeting on Control of,2.179

Consultative Group on Legislation in Public and Pri-vate Administration, 1.7

Coordination of Health Personnel Programs, Interre-gional Meeting on, 1.29

Endemic Goiter and Cretinism, V Meeting of thePAHO/WHO Technical Group on the Control of,2.6

Epidemiology, Regional Meeting on Uses and Pros-pects of, 2.116

Food and Nutrition Surveillance, PAHO/WHO Con-sultative Group on, 2.5

Foreign Ministers of the River Plate Basin, XI and XIIMeetings of, 2.198

Inter-American Meeting on Animal Health at the Minis-terial Level (RIMSA III), 2.195

Laboratory Programs, Regional Seminar on, 1.62Ministers of Health of the Caribbean (1984), 1.12,

2.119Ministers of Health and Directors of Social Security In-

stitutions of Central America and Panama, 1.15Occupational health activities in the health service net-

work (seminar-workshop), 2.48Prevention of Blindness, International Workshop on,

2.193Prevention of Occupational Hazards, VII Inter-Ameri-

can Congress on the, 2.48Primary Health Care Strategies and Infant Mortality

(regional workshop), 2.34Psychology of Health, International Seminar on the,

2.61Regional Symposium on Water Supply and Sanitation

in Low-lncome Neighborhoods of Urban Areas,2.73

262 Annual Report

Technological Development in Health, InternationalMeeting, 3.8

Technology in Prenatal Care, First International Meet-ing on, 3.9

Urban Sanitation Services of Latin American Metropol-itan Areas, 2.81, 2.100

Veterinary Public Health Experts, 1 Meeting of, 2.205Mental health, 2.61-2.64Mexico, 1.2, 1.6, 1.7, 1.9, 1.13, 1.15, 1.22, 1.24, 1.26,

1.30, 1.35, 1.39, 1.41, 1.43, 1.46, 1.62, 1.63,1.64, 1.65, 1.66, 1.68, 1.69, 1.71, 1.79, 1.80,1.83, 2.11, 2.32, 2.33, 2.34, 2.48, 2.55, 2.57,2.59, 2.70, 2.72, 2.75, 2.79, 2.83, 2.99, 2.100,2.101, 2.105, 2.110, 2.112, 2.113, 2.136, 2.139,2.140, 2.141, 2.142, 2.153, 2.157, 2.166, 2.169,2.173, 2.179, 2.180, 2.183, 2.185, 2.187, 2.188,2.195, 2.197, 2.214, 2.219, 2.241, 2.242, 2.246,2.249, 2.252, 3.4, 3.8, 3.15, 3.19, 3.27, 7.16

General Management for Biological Products and Re-agents, 1.64

Mexican Psychiatry Institute, 2.63National Institute of Virology, 1.83, 3.27National Reference Laboratory, 1.83, 3.27summary of activities, 8.424-8.441

Montserrat, 2.134, 2.169McConnell, Edna, Foundation, 3.47

National University (Paraguay), 2.38National University of San Marcos (Peru), 1.45Netherlands, 2.245, 3.45Netherlands Antilles, 1.69

summary of activities, 8.442-8.456Network for Information on Zoonoses and Foot-and-

Mouth Disease, 3.17Network of National Centers for the Classification of Dis-

ease, 3.19Network of National Community Health Training Nuclei

for Central America and Panama, 3.19Network of Perinatology Centers, 3.19Network of Programs of Continuing Education and Su-

pervision, 3.19Nicaragua, 1.3, 1.5, 1.9, 1.10, 1.11, 1.12, 1.14, 1.23,

1.24, 1.35, 1.38, 1.39, 1.41, 1.44, 1.49, 1.51,1.68, 1.73, 1.86, 1.88, 2.9, 2.10, 2.17, 2.22,2.32, 2.40, 2.78, 2.79, 2.89, 2.91, 2.101, 2.106,2.117, 2.118, 2.153, 2.164, 2.176, 3.4, 3.14, 3.27

Center for Research and Health Studies (CIES), 1.51National Water and Sewerage Institute (INAA), 2.89summary of activities, 8.457-8.474

Nonhuman primates, 2.200Norway, 3.42Nursing

education, 1.37-1.38services, 1.11-1.12, 2.253

Nutrition, 2.2-2.12training, 2.28

Nutrition Alert, 3.13Nutritional anemias, 2.8NYAM News, 2.27

Occupational health (see Workers' health)Oklahoma State University (USA), 1.84

Onchocerciasis, 2.159Operational Network of Food and Nutrition Institutions,

2.12, 3.19Oral health, 2.57-2.60

(see also Dental health)Oral rehydration, 2.139-2.140Oswaldo Cruz Foundation (Brazil), 1.64, 1.81Overseas Development Administration (United King-

dom), 2.99

PAHO in Action, 7.14PAHO's Executive Committee (see under Pan American

Health Organization)PAHO Governing Bodies, 5.1-5.9

(see also Pan American Health Organization)PAHO/WHO-UNICEF Nutrition Support Program, 2.6,

2.10, 2.26, 2.29, 2.30Pan American Center for Human Ecology and Health

(ECO), 2.85, 2.107-2.115information, dissemination of, 2.111research, 2.108-2.109technical cooperation, 2.112-2.115technology development, 2.110training, 2.112

Pan American Center for Sanitary Engineering and Envi-ronmental Sciences (CEPIS),2.80, 2.85, 2.87, 2.95-2.106, 2.209

information, dissemination of, 2.101-2.103research, 2.96-2.98technical cooperation, 2.105-2.106technology development, 2.99-2.100training, 2.104

Pan American Foot-and-Mouth Disease Center(PANAFTOSA), 2.194, 2.221-2.228

information, dissemination of, 2.224research, 2.222technical cooperation, 2.226- 2.228technology, 2.223training, 2.225

Pan American Health and Education Foundation(PAHEF), 3.48

Pan American Health Organization (PAHO)administrative support

conference services, 7.20general services, 7.19personnel, 7.21-7.27procurement, 7.28

Advisory Committee on Health Research, 1.25, 1.30,3.6

Advisory Committee on Prevention of Blindness,2.193

Directing CouncilXXVIII Meeting, 1.15, 2.197XXIX Meeting, 2.250, 5.3XXX Meeting, 1.15, 2.37, 2.54, 2.116, 2.126,

2.232, 2.254, 3.23, 4.7, 5.4, 5.7Executive Committee

92nd Meeting, 2.37, 5.4, 5.5fellowships, administration of, 1.55-1.59information systems, 7.13-7.14managerial strategy, 6.1-6.6technical support

Index 263

distribution and sales, 7.7information systems, 7.13legal matters, 7.15-7.18public information, 7.14publications, 7.2-7.5translations, 7.9-7.12visual aids, 7.8

Pan American Network for Information and Documenta-tion in Sanitary Engineering and Environmental Sci-ences (REPIDISCA), 2.101, 3.17

Pan American Zoonoses Center (CEPANZO), 2.166,2.194, 2.195, 2.196, 2.206-2.220

information, dissemination of, 2.212research, 2.207-2.209technical cooperation, 2.215-2.220technology development, 2.210-2.211training, 2.213-2.214

Pan Caribbean Disaster Preparedness and PreventionProject, 2.245

Panama, 1.2, 1.5, 1.9, 1.11, 1.12, 1.15, 1.16, 1.17,1.23, 1.26, 1.30, 1.32, 1.33, 1.38, 1.39, 1.45,1.49, 1.68, 1.76, 2.14, 2.17, 2.20, 2.56, 2.57,2.61, 2.64, 2.79, 2.86, 2.87, 2.91, 2.112, 2.114,2.117, 2.156, 2.157, 2.161, 2.162, 2.176, 2.180,2.183, 2.195, 2.197, 2.222

National Water and Sewerage Institute (IDAAN), 2.87summary of activities, 8.475-8.492

Paraguay, 1.3, 1.9, 1.12, 1.14, 1.15, 1.18, 1.24, 1.26,1.38, 1.41, 1.68, 2.38, 2.68, 2.77, 2.78, 2.90,2.92, 2.101, 2.106, 2.156, 2.157, 2.215, 2.220,2.222, 2.227, 7.16

National Environmental Health Service (SENASA),2.90

summary of activities, 8.493-8.510Perinatal Health, 2.45Personnel (PAHO), 7.21-7.27Peru, 1.3, 1.9, 1.12, 1.13, 1.14, 1.15, 1.16, 1.20,

1.26, 1.30, 1.32, 1.35, 1.38, 1.39, 1.41, 1.43,1.45, 1.68, 1.73, 1.75, 1.82, 1.86, 2.3, 2.5, 2.6,2.9, 2.10, 2.32, 2.39, 2.40, 2.55, 2.57, 2.61,2.68, 2.78, 2.82, 2.90, 2.92, 2.96, 2.97, 2.98,2.99, 2.100, 2.101, 2.105, 2.114, 2.139, 2.151,2.155, 2.157, 2.162, 2.164, 2.170, 2.187, 2.191,2.200, 2.209, 2.215, 2.219, 2.222, 2.223, 2.225,2.226, 2.227, 2.228, 2.244, 2.246, 2.253, 3.4,3.5, 3.15, 3.19, 7.16

Educational Technology in Health Centers, 1.45Institute of Tropical Medicine, 2.157Luciano Barrere Center, 2.191Research Council, 3.4summary of activities, 8.511-8.528

Pesticides, 2.204Plague, 2.170Plan for Priority Health Needs in Central America and

Panama, 1.10, 1.23, 1.28, 1.43, 1.54, 2.10, 2.71,2.149, 2.161, 2.230-2.235, 3.25

Planning and administration of health services, 1.4-1.8Policies for the Production and Marketing of Essential

Drugs (Technical DiscussionsXXIX Meeting of PAHO Directing Council), 1.71

Polio, 2.127Primary Eye Care Manual, 2.191Primary health care

food and nutrition in, 2.10-2.11rural and urban areas, 1.11

veterinary medicine, 2.205Primate Reproduction and Preservation Station, 2.200Procurement, services (PAHO), 7.28Project for the Regional Monitoring of Integrated Chronic

Disease Programs (MORE), 2.178, 2.180Public health education, 1.43-1.44Public information (PAHO), 7.14Public Welfare Foundation, 3.47Publications (PAHO), 7.2-7.8

Committe on PAHO Publications Policy, 7.2distribution and sales, 7.7official documents, 7.4publications

other, 7.5periodicals, 7.6scientific, 7.3

Revolving Sales Fund, 7.7Puerto Rico, 2.106

Rabies, 2.195Radiation health, 1.68-1.69Red Cross, 2.243Regional Education Program for Animal Health and Vet-

erinary Public Health Assistants (REPAHA), 1.42,2.203

Regional Network on Advanced Training in Health Ser-vices Administration, 3.19

Regional Network of Educational Technology in HealthCenters, 3.19

Regional Network of Schools of Public Health and Post-graduate Programs in Preventive and Social Medi-cine, 3.19

Regional Program of Training in Animal Health (PRO-ASA), 1.41, 2.201, 2.225

Regional Seminar on Epizootiology and Animal HealthEconomics, 2.225

Rehabilitation, 2.55-2.56REPINDEX (computerized index under CEPIS), 2.102Research

acute respiratory infections, 2.162environmental health, 2.96-2.98, 2.108-2.109health, 3.3-3.7health services, 1.25malaria, 2.153- 2.154nutrition, 2.14, 2.24veterinary, 2.207-2.209, 2.222

Rheumatic fever, 2.182RIMSA (see Inter-American Meeting on Animal Health at

the Ministerial Level)Risk factors, 2.32, 2.44, 2.178Rockefeller Foundation, 3.47Royal Commonwealth Society for the Blind, 2.192

Salt fluoridation, 2.9, 2.57St. Christopher and Nevis, 1.25, 2.38, 2.85, 2.125,

2.134, 2.169summary of activities, 8.529-8.539

Saint Lucia, 1.8, 1.25, 1.74, 2.75, 2.85, 2.106, 2.125,2.134


264 Annual Report

St. Vincent and the Grenadines, 1.8, 1.74, 2.10, 2.29,2.30, 2.85, 2.125, 2.134, 2.169

summary of activities, 8.552-8.563San Carlos University (Guatemala), 1.53, 2.17Schistosomiasis, 2.158Smoking, 2.180Solid waste management, 2.76-2.82Spain, 7.2Special Program for Research and Training in Tropical

Diseases (UNDP/World Bank/WHO), 2.158,2.159

Subregional Project for Human Resource Development,2.92

Sugar, fortification of, 2.8Suriname, 1.8, 1.12, 1.24, 2.23, 2.27, 2.49, 2.123,

2.125, 2.139, 2.142, 2.158, 2.176summary of activities, 8.564-8.585

Surveillance Report, 2.122Switzerland, 2.169

Technical Cooperation Among Developing Countries(TCDC), 1.22, 2.72, 2.125, 2.243, 3.22-3.27

Technical DiscussionsPAHO's Directing Council

XXIX Meeting, 1.71XXX Meeting, 4.8

Technologydevelopment, 3.8-3.11education, 1.45-1.46

Tetanus, 2.127Texas University (USA), 2.50Tinker Foundation, 3.47Traditional midwives, 2.39Traffic accidents, 2.65-2.66Training (see Education and training)Translations (PAHO), 7.9-7.12Trasher Research Fund, 3.47Trinidad and Tobago, 1.6, 1.13, 1.39, 1.42, 1.63, 1.68,

1.88, 2.68, 2.117, 2.123, 2.125, 2.175, 2.182,2.203

summary of activities, 8.586-8.602Tuberculosis, 2.163-2.166Turks and Caicos Islands, 2.24, 2.134, 2.169

UNDP (see United Nations Development Program)UNESCO (see United Nations Educational, Scientific and

Cultural Organization)UNICEF (see United Nations Children's Fund)United Nations Center for Social Development and Hu-

manitarian Affairs (Austria), 2.53United Nations Children's Fund (UNICEF), 1.11, 2.10,

2.21, 2.22, 2.30, 2.33, 2.56, 2.132, 2.137, 2.233,2.243, 3.31, 7.17

United Nations Development Program (UNDP), 1.42,1.62, 1.77, 2.68, 2.85, 2.158, 2.203, 2.224, 3.29,7.17

United Nations Disaster Relief Office (UNDRO), 2.241,2.245

United Nations Educational, Scientific and Cultural Orga-nization (UNESCO), 2.85

United Nations Environmental Program (UNEP), 2.83,2.85, 2.110, 2.115

United Nations Fund for Drug Abuse Control (UN-FDAC), 3.32

United Nations Fund for Population Activities (UNFPA),2.38, 2.40, 2.132, 2.233, 3.30

United Nations High Commissioner for Refugees, 2.243United Nations University, 2.12Urban Sanitation, IX Latin American Course on, 2.82United States of America, 1.40, 1.58, 1.63, 1.65, 1.68,

1.79, 1.81, 1.82, 2.12, 2.33, 2.93, 2.140, 2.174,3.46

Agency for International Development (USAID), 2.5,2.20, 2.21, 2.37, 2.73, 2.99, 2.110, 2.123,2.132, 2.176, 2.200, 2.204, 2.234

Centers for Disease Control (CDC), 1.63, 2.5, 2.124,2.176, 2.209

Environmental Protection Agency, 2.100Food and Drug Administration, 1.81, 1.83, 2.123National Cancer Institute, 1.185, 2.189National Eye Institute, 2.192National Institute on Alcoholism and Alcohol Abuse,

2.63National Institute on Drug Abuse, 2.63National Institutes of Health, 2.200summary of activities, 8.603-8.620

University of Alabama (USA), 2.63University of Antioquia (Colombia), 1.4University of Chile, 2.3University of Costa Rica, 1.50, 1.51, 1.53, 2.17University of El Salvador, 1.36University of Honduras, 1.49, 1.50University of Illinois (USA), 1.40University of Miami (USA), 2.63, 2.204University of Panama, 1.40, 1.76, 2.17University of Pernambuco (Brazil), 2.10University of Sao Paulo (Brazil), 2.110University of Surrey (United Kingdom), 2.96, 2.99University of Valle (Colombia), 1.30, 2.5, 2.136, 2.237University of the West Indies (Jamaica), 2.24, 2.28,

2.29, 2.38Uruguay, 1.4, 1.6, 1.7, 1.9, 1.12, 1.13, 1.15, 1.26,

1.38, 1.41, 1.46, 1.68, 1.86, 1.88, 2.32, 2.36,2.38, 2.55, 2.64, 2.75, 2.77, 2.79, 2.105, 2.112,2.139, 2.156, 2.162, 2.179, 2.182, 2.183, 2.222,2.223, 3.5, 3.8, 3.14


Vaccines and biologicalsproduction, 1.78-1.88, 2.127-2.129(see also Expanded Program on Immunization)

Vectors, control of, 2.145-2.159Venezuela, 1.9, 1.13, 1.15, 1.20, 1.22, 1.24, 1.39,

1.41, 1.46, 1.63, 1.65, 1'.68, 1.75, 1.79, 1.86,2.6, 2.57, 2.75, 2.105, 2.118, 2.139, 2.140,2.153, 2.156, 2.159, 2.162, 2.163, 2.169, 2.178,2.183, 2.187, 2.193, 2.195, 2.199, 2.210, 2.227,2.228, 3.15, 3.19

summary of activities, 8.634-8.653Vesicular Disease Diagnostic Laboratory, 2.222Vesicular stomatitis, 2.222, 2.224Veterinary public health, 2.194-2.228

education, 1.41-1.42, 2.201-2.203Viral hepatitis, 2.172Virgin Islands (UK), 2.28, 2.123, 2.134

Index 265

Virgin Islands (USA), 2.61Visual aids (PAHO), 7.8Vitamin A deficiency, 2.7

Wastewater disposal, 2.67-2.75Water supply, 2.67-2.75Whooping cough, 2.127Women, health, and development, 2.247-2.254

Five-year Regional Plan of Action, 2.247-2.254Women, Health and Development in the Americas,

2.252Workers' health, 2.48-2.50World Bank, 1.9, 2.37, 2.66, 2.69, 2.78, 2.87, 2.89,

2.97, 2.158, 3.39World Environmental Monitoring System (SIMUVIMA),

2.100World Food Program (WFP), 2.3, 2.21, 3.33World Health Day, 7.14World Health Organization (WHO), 1.9, 1.11, 1.13,

1.14, 1.15, 1.17, 1.23, 1.25, 1.30, 1.37, 1.39,1.46, 1.55, 1.68, 1.69, 1.70, 1.71, 1.72, 1.73,

1.80, 1.82, 1.85, 2.21, 2.25, 2.32, 2.48, 2.52,2.54, 2.55, 2.64, 2.70, 2.71, 2.77, 2.79, 2.81,2.86, 2.88, 2.138, 2.149, 2.158, 2.161, 2.162,2.168, 2.172, 2.175, 2.178, 2.180, 2.187, 2.188,2.199, 2.224, 2.233, 2.237, 2.242, 2.245, 3.1,3.3, 3.5, 3.6, 3.7, 3.11, 3.12, 3.16, 3.18, 3.24,3.38, 3.39, 4.7, 6.4

American Region Program and Budget for the Bien-nium 1986-1987, 5.9

Collaborating Centers, 1.62,1.65,1.68,1.74,1.76,2.49,2.63, 2.191, 2.192

World Health Assembly (1984), 2.7, 2.164, 2.232World Metereological Organization (WMO), 2.83, 2.245

X Rays (see Radiation Health)

Yellow fever, 2.155, 2.170

Zoonoses, 2.195-2.205

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