Third Evaluation of the Implementation of the Strategies for Health for All by the year 2000
Region of the Americas

	Introduction
	Trends in socioeconomic development
	Demographic Trends
	Health and environment
	Health Resources
	Health Services
	Proposed Strategies

Introduction

In 1977, the Member States of the World Health Organization (WHO) unanimously adopted the Global Strategy for Health for All by the Year 2000 (Resolution WHA30.43) and, subsequently, the Plan of Action for its implementation. The World Health Assembly also proposed that the respective reports be analyzed every two years by the regional committees, the Executive Board, and the World Health Assembly and that, every six years, an evaluation be performed to determine the effectiveness and impact of the national, regional, and global strategy. The process was initiated in 1983 with a first monitoring report.

To facilitate monitoring of the progress and implementation of the national strategies for health for all and the preparation of the national reports, in 1982 WHO designed a common framework, which has subsequently been modified to reflect the comments and suggestions of the Member States and Regional Offices. This is the third version (CFE3).

The purpose of the third evaluation—the last before the year 2000—was to permit the Member States to evaluate progress in meeting the goal of health for all and applying the primary health care strategy, with a view to identifying the areas that require priority action and the elements that hinder or facilitate this progress. The present report was based on the results of 33 national reports received at Headquarters up to 25 July 1997 and other complementary sources. The reporting countries represented more than 90% of the population of the Region of the Americas. All the national reports were sent to WHO and are also available at PAHO Headquarters.

The consolidated report is organized according to the eight sections presented in the Common Framework, and the results obtained at the national and regional level will be analyzed by the WHO Executive Board and the World Health Assembly in 1998. The delegations to the XL Directing Council of PAHO are invited to analyze and approve the present report during the discussion of the topic to contribute to the analysis that will be conducted at the global level in 1998.

The preparation of the regional summary presented a number of challenges. Although most of the reports reached PAHO Headquarters by the established deadline, a number were considerably delayed and some never arrived. While the 33 countries from which reports were received represent over 90% of the population of the Region, the fact that the content of the reports varied considerably in its breadth and depth made it difficult to draw valid regional conclusions about the status of achieving health for all by the year 2000 based on these reports alone.

Given the above, it was recognized that this regional summary could not be the sum of the information provided in the country reports. Accordingly, this report reflects the best information available—in some instances, that available in the specific programs in the Regional Office. The individual country reports are available for review at both PAHO and WHO Headquarters to answer specific questions.

The main conclusions drawn from the 37 country reports received at PAHO Headquarters and complemented with other information sources, are the following:

Trends in socioconomic development.

• By mid-decade, nearly all the countries of the Region had moved toward democratic and participatory models of government. However, serious problems of governance persist. This shift has led to the need to redefine the relationship between government and civil society through the speedy adoption of political and organizational reforms known as State reform. Despite the countries’ efforts to improve the contribution of national health policy, there still are serious constraints to achieving better results.
• The principal trends that have affected this period have been the ongoing process of economic globalization and the strengthening of subregional trading block, in the Region of the Americas.
• The socioeconomic trends showed that there are currently more poor people in the Latin American and Caribbean subregion than in the early 1980s, with the greatest concentration in urban areas. In absolute terms, the number of people below the poverty line in Latin America grew from 197 million in 1990 to 209 million in 1994, with 65% of this population concentrated in urban areas, although the proportion of poor in the total rural population remained greater than in the cities.

 

Demographic Trends

• Demographic trends in the Region have not changed. The decline in fertility and the aging and urbanization of the population have persisted and even intensified, as have the inequities and inequalities of the socioeconomic and demographic situation in the countries. By mid-decade in the 1990s, the population of the Americas reached 774 million (from 331 million in 1950), nearly 13% of the current world population, with estimates indicating that it will reach 1,062 million by the year 2025. In terms of population, Latin America’s relative weight in the Hemisphere has increased over time: in 1950 it accounted for 48.7% of the population; in 1995, 61.3%; and, according to current projections, by 2025 it will have 65.1% of the Region’s population. The population of North America, in contrast, has fallen from 50.1% in 1950 to 37.7% in 1995, with estimates putting it at 33.9% by 2025.
• Since the second evaluation of the strategy for HFA/2000 (1991), using the classification developed by CELADE to indicate the stages of demographic transition, the countries have been grouped as follows:
• Group I, incipient transition (high birth rate; high mortality; moderate natural growth, on the order of 2.5%): Bolivia and Haiti are still in this category.
• Group II, moderate transition (high birth rate; moderate mortality; high natural growth of around 3.0%): Peru has moved out of this category; El Salvador, Guatemala, Honduras, Nicaragua, and Paraguay remain.
• Group III, full transition (moderate birth rate; moderate or low mortality; moderate natural growth of around 2.0%): Chile moved out of this category; Peru moved in; Brazil, Colombia, Costa Rica, Dominican Republic, Ecuador, Guyana, Mexico, Panama, Suriname, Trinidad and Tobago, and Venezuela remain.
• Group IV, advanced transition (moderate or low birth and mortality rates; low natural growth on the order of 1.0%): Chile moved into this group; Argentina, Bahamas, Barbados, Canada, Cuba, Guadeloupe, Jamaica, Martinique, Puerto Rico, United States, and Uruguay remain.

Health and environment.

• Despite the progress in expanding coverage, there are serious problems related to water quality and water supply, as well as solid waste disposal. The 1995 coverage for the total population with access to water supply through house connections and other acceptable means. In the field of sanitation, by 1995 the total coverage of wastewater and excreta disposal facilities had increased to 69%. The urban services remained constant at 80%; however, rural services were extended to approximately 40% of the population. One of the most critical sanitary problems in Latin America remains the lack of sewage treatment. The 1995 survey indicated that the percent of sewage collected that receives treatment is just above 10%. As a result of the cholera epidemic, countries have increased investment in water supply and sanitation.
• There is interest in moving toward sustainable development, a concern shared by the population, governments, and nongovernmental organizations.

 

Health resources.

• The financial constraints in the social sectors over the past decade have increasingly revealed the serious limitations of institutions in terms of resource management, a situation that has worsened due to the rising costs in the services. In 1994 the countries of Latin America and the Caribbean spent around US$ 118 billion on health, or about $250 per capita. National health expenditure (NHE) in the Region in 1994 represented 7.5% of the gross domestic product (GDP).
• In contrast to the 1970s, infrastructure development policy in the past 15 years has stagnated and is currently one of the components with the greatest need for state policy support. Infrastructure development is one component that requires strengthening within the health sector reform processes. Another is improving the mechanisms to ensure the supply of essential drugs and other supplies.
• Since the second evaluation there have been significant changes in the formulation and implementation of national and health sector policy. Decentralization, social participation, and inter- and intrasectoral coordination are part of the strategies that have been promoted and that in some places have yielded positive results.
• The lack of an adequate information system affects the timeliness and reliability of the data, with reports indicating that some i nformation systems on health services have not been updated in over 20 years. This problem hinders the definition of a health policy grounded in the identification of the sector’s priority problems and needs.

 

Health services.

• A good number of countries have taken significant steps toward the creation or strengthening of health promotion and health education units in their ministries of health.
• The countries have accorded high priority to the care of children under five and women. Action has been geared toward improving coverage. However, the population’s need for access persists due owing to a variety of constraints. There is a growing trend toward the delivery of integrated health services to priority population groups.
• Immunization rates in the Region are high. The last case of poliomyelitis occurred in 1991. Other important gains have been made toward the elimination of measles and neonatal tetanus.
• The need for financing and other resources has been considered a constraint to expanding and maintaining health programs. In many countries decentralization to the local level and greater community involvement could contribute to the sustainability of the activities.
• Great progress has been made toward achieving a steady increase in life expectancy at birth, linked to the decrease in infant mortality and communicable diseases. At the same time, however, there has been an increase in chronic diseases and disabilities. The importance of diseases such as tuberculosis, dengue, and malaria has persisted or even grown in the Region. Although some indicators have improved, large gaps still persist between countries and between and within communities or social groups, a fact that should be considered when establishing policies to approach or achieve the objectives of the goal.
• The vision of HFA represents a desired future state that we will approach by renewing commitment to the goal and by implementing suitable strategies and concrete actions. This vision may be summarized as a shared understanding of health in which the energies of the Hemisphere respond ethically to the challenges that arise for the achievement of sustainable human development with dignity and equity in the future of the Americas. This vision is based on a value system guided by equity, solidarity, and sustainability.

Proposed Strategies

The strategic and programmatic orientations of PAHO for the period 1995-1998 refer to: health promotion and protection, disease prevention and control, environmental protection and development, health in human development, and health systems and services development. These represent a point of departure for processes aimed at reshaping or identifying new strategies of action geared toward renewing the goal of HFA in the Americas.

With the new millennium approaching, the Member States should renew their commitment to the goal of HFA and its health strategies within the context of the social, economic, political, environmental, and technological trends that are affecting the health of the populations, the environment, and the health services, giving priority to the adoption of policies to resolve their health problems in a sustainable manner and steadily improve the quality of life of their peoples.

Source: Division of Health and Human Development, Health Situation Analysis Program, HDP/hda,PAHO.

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