In accordance with the Constitution of the Pan American Health Organization, I have the honor of presenting the 2019 annual report on the work of the Pan American Sanitary Bureau, Regional Office for the Americas of the World Health Organization.
This report highlights the technical cooperation undertaken by the Bureau during the period July 2018 through June 2019, within the framework of the Strategic Plan of the Pan American Health Organization 2014-2019, defined by its Governing Bodies and amended by the 29th Pan American Sanitary Conference in 2017.
This report is complemented by the Financial Report of the Director and the Report of the External Auditor for the year 2018.
Carissa F. Etienne
Pan American Sanitary Bureau
It has been almost two years since my reelection to a second term as Director of the Pan American Sanitary Bureau (PASB or the Bureau), the Regional Office for the Americas of the World Health Organization (WHO). In my 2018 annual report, I identified the overarching theme of my second term as “Advancing health and well-being, leaving no one behind.” The theme aligns with the United Nations (UN) 2030 Agenda for Sustainable Development and its Sustainable Development Goals (SDGs), particularly the goal most directly addressing health, SDG 3 (“Ensure healthy lives and promote wellbeing for all at all ages”), and also with the Sustainable Health Agenda for the Americas 2018-2030: A Call to Action for Health and
Well-being in the Region (SHAA2030) (Document CSP29/6, Rev. 3). The SHAA2030 addresses SDG 3 and other selected SDGs, and incorporates their targets, adapting them as appropriate to the situation in the Region of the Americas.
The SHAA2030 was unanimously endorsed by the ministers and secretaries of health at the 29th Pan American Sanitary Conference in September 2017. It articulates Member States’ political vision and direction for health development and advancing to the SDGs in the Region of the Americas. The SHAA2030 is the product of an extensive consultative process and points the way forward for making the collective vision of “Health for All” in the Americas a new reality.
It is a tailored framework for addressing gaps in our Region’s achievement of both the Millennium Development Goals (MDGs) and the Health Agenda for the Americas 2008-2017, and articulates the actions needed for PAHO Member States to, by 2030, ensure the highest attainable standard of health for all in the Region, with universal access to health and universal health coverage, quality health services, and resilient health systems.
The 11 goals and 60 targets in the SHAA2030 recognize that although SDG 3 is the “health goal,” the SDGs are interlinked, and many of the goals affect health through their impact on the social, environmental, political, and other determinants of health. The SHAA2030 goals and targets align with PAHO’s long-standing focus on, and commitment to, reducing health inequities, and support the renewed focus on the right of everyone, everywhere, to the highest attainable standard of health, with particular emphasis on persons in conditions of vulnerability.
The SHAA2030 makes repeated reference to equitable access; comprehensive services; social participation; social and environmental determinants of health; and reduction of inequality and inequity in health. It is increasingly evident that multisectoral action and whole-of-government, whole-of-society, and Health in All Policies (HiAP) approaches are essential to address the Agenda. The repetition of these words reflects the commitment of PAHO’s Member States and the Bureau to vigorously address relevant issues—effective interventions for health priorities such as noncommunicable diseases (NCDs), responses to disasters due to natural hazards or other emergencies, and progress to universal health (UH) demand no less.
This annual report covers the period July 2018 through June 2019, and has as its theme “Advancing the Sustainable Health Agenda for the Americas 2018-2030.” It provides a summary of the Organization’s work during the period in pursuit of the SHAA2030 goals and targets, highlighting technical cooperation at subnational, national, subregional, and regional levels, and continued application of PAHO’s core functions related to leadership and partnerships; research, knowledge generation, and knowledge dissemination; norms and standards; ethical and evidence-based policy options; technical cooperation for change and sustainable institutional capacity; and health situation trends.
Regionally and globally, Member States have recommitted to the primary health care (PHC) strategy and integrated health service delivery networks (IHSDNs) as essential for advancing to UH and providing comprehensive services that address health promotion and disease prevention, diagnosis, treatment, rehabilitation, and palliation. In 2018, we celebrated the 40th anniversary of the ground-breaking Declaration of Alma-Ata that was made at the International Conference on Primary Health Care held in Kazakhstan (in the former Soviet Union) in 1978, and, in 2019, we published the Report of the High-Level Commission on Universal Health in the 21st Century: 40 Years of Alma-Ata. In April 2019, in conjunction with the launch of the Report of the High-Level Commission, we launched the PAHO Regional Compact on Primary Health Care for Universal Health: PHC 30-30-30, the Organization’s initial response to the recommendations of the High-Level Commission on Universal Health. This Compact establishes goals to, by 2030, reduce barriers that hinder access to health by at least 30 percent, and allocate at least 30 percent of the entire public health budget to the first level of care.
The Report and recommendations of the High-Level Commission on Universal Health align with the Declaration of Astana, the outcome document of the Global Conference on Primary Health Care: From Alma-Ata towards Universal Health Coverage and the Sustainable Development Goals, which was held in Astana, Kazakhstan, in October 2018. In the Declaration, the participating heads, ministers, and representatives of State and government reaffirmed their “commitment to the fundamental right of every human being to the enjoyment of the highest attainable standard of health, without distinction of any kind.” They remained “convinced that strengthening PHC is the most inclusive, effective, and efficient approach to enhance people’s physical and mental health, as well as social well-being, and that PHC is a cornerstone of a sustainable health system for universal health coverage and health-related SDGs.”
As the Bureau advances its technical cooperation, partnerships, and collaboration in pursuit of health, I once again express my sincere gratitude to those who contribute to the effectiveness of our work: PAHO Member States; Member States in other WHO regions; health and other ministries; staff at WHO Headquarters and in other WHO regional offices; other UN agencies; civil society; the health-supporting private sector; and all PASB personnel, in countries and in Washington, D.C.
As we collaborate to advance SHAA2030, we will face exciting, productive, and even challenging times. Recognizing health as both a necessary condition for and an outcome of sustainable development, we go forward with heightened awareness of the contribution that we will all have to make to achieve equitable outcomes for all.
The theme of the 2019 Annual Report of the Director of the Pan American Sanitary Bureau (PASB or the Bureau) is “Advancing the Sustainable Health Agenda for the Americas 2018-2030”. The Sustainable Health Agenda for the Americas 2018-2030 is the strategic policy instrument that provides direction and political vision for health development in the Region of the Americas for the stated period. The SHAA2030 represents an adaptation of the 2030 Agenda for Sustainable Development, primarily SDG 3, “Ensure healthy lives and promote wellbeing for all at all ages.” With its nine targets and four implementation mechanisms, SDG 3 aligns with the regional health development situation.
There are also several fora for PASB’s continued high-level advocacy in support of wellness, disease prevention and control, and health equity. These include the UN High-Level Meeting on UHC planned for September 2019; further alignment with global monitoring frameworks; and participation in joint initiatives to accelerate progress to the health-related SDGs, such as Towards a Global Action Plan for Healthy Lives and Well-Being for All: Uniting to Accelerate Progress towards the Health-Related SDGs, which is an effort by several international agencies to coordinate their actions at country level in support of SHAA2030, SDG 3, and other related SDGs. The Bureau will continue to support and guide Member States according to agreed frameworks and approved resolutions, and with flexibility to respond to changes in national, subregional, regional, and global situations and operating environments. In looking ahead, there are several opportunities to address the challenges identified and improve the chances of success, including the presentation of the proposed PAHO Strategic Plan 2020-2025 and proposed Program Budget of the Pan American Health Organization 2020-2021 (Official Document 358) to the 57th PAHO Directing Council in September 2019. The proposed Strategic Plan 2020-2025, developed under the theme of “Equity at the Heart of Health,” identifies specific actions to tackle health inequality, responding directly to SHAA2030 Goal 11 and, overall, to one of the core principles and values of the SHAA 2030 and the Organization. The proposed PAHO Strategic Plan 2020-2025 will be complemented by strategies and plans of action that address many specific issues, including quality of care in health services delivery; health promotion in the context of the SDGs; ethnicity and health; elimination of communicable diseases; elimination of industrially produced trans-fatty acids; equitable access to organ, tissue, and cell transplants; and strengthened IS4H.
The reporting period was not without its challenges. Among them were changes in national political administrations requiring PASB’s continued flexibility in adjusting and adapting to achieve agreed priority health objectives; economic crises and fiscal austerity in many countries that led to consideration and implementation of innovative resource mobilization strategies and partnerships by both Member States and the Bureau; and industry interference to weaken or restrict legislative and other frameworks for NCD risk factor control in several countries, which demanded evidence-based, high-level advocacy. Other challenges included the persistence of segmented and fragmented health systems, along with the need for greater emphasis on prevention, PHC, IHSDNs, a fit-for-purpose health work force, and adequate health financing. Also challenging was the less-than-optimal provision of timely, quality health information for evidence-based decision-making, planning, monitoring, and evaluation.
The Bureau undertook its customary periodic self-monitoring and analysis, and interventions for institutional strengthening continued, related to a) human resources management and continued implementation of the PAHO People Strategy; b) ethics, transparency, and accountability, boosted by the establishment of an Investigations Office and procedures that resulted in an unqualified audit by the Bureau’s new external auditor; c) resource mobilization, with 10 new partnerships established; d) planning and budgeting, with active Member State participation in the development of the proposed PAHO Strategic Plan 2020-2025; e) financial operations that resulted in a more efficient 2018 financial closure; f) enterprise risk management that provided key information for strengthening oversight and evaluation functions; g)procurement, which contributed to greater efficiency and cost-savings in Member States’ acquisition of medicines, vaccines, and health technologies; h) information technology services, including boosting cybersecurity measures; i) knowledge management, with the consolidation of three separate programs into a new Office of Knowledge Management, Publications, and Translations for greater efficiency and impact; j) communications for health (C4H), through continued implementation of the PASB Communications Strategic Plan 2018-2022; and k) general services, which resulted in improvements in security and logistical efficiency in operations in PAHO Headquarters and country offices.
Such partnerships were important factors for advances in reducing environmental health risks and improving water, sanitation, and hygiene (WASH). An evaluation of WASH in selected national health care facilities resulted in information that was the core source of regional data for the WHO-UNICEF Joint Monitoring Program’s WASH in Health Care Facilities: Global Baseline Report 2019. Published in April 2019, that document will provide a foundation for further integration of WASH into national health policies and plans. PASB’s collaboration with the PARLACEN resulted in a resolution by that parliamentary body recognizing that poor air quality is a public health issue and a significant environmental risk factor, and calling for the creation of laws and implementation of actions to improve air quality. PASB’s continued promotion of and support for its technical cooperation modality of cooperation among countries for health development (CCHD) leveraged the expertise of Member States themselves; enabled sharing of experiences and lessons learned; and supported transfer of technology for issues that included AMR, prevention of overweight and obesity, and management of mental health conditions.
PASB formed and maintained varied and effective partnerships to achieve goals over the review period. The Bureau worked with subnational, national, subregional, regional, and global entities, including subregional parliamentary bodies, municipal governments, universities, charities, and private sector entities, managing conflict of interest as appropriate through continued implementation of the Framework of Engagement with Non-State Actors (FENSA).
The Organization’s crosscutting themes of human rights, gender, ethnicity, and equity continued to underpin the Bureau’s technical cooperation. There were interventions to address the social determinants of health and improve the health of groups in conditions of vulnerability, including adolescents, indigenous people, Afro-descendants, and persons with different sexual and gender orientations, such as those identifying as lesbian, gay, bisexual, trans, and queer (LGBTQ). Efforts were made to enhance the provision of services tailored to their needs and to address such issues as sexual and reproductive health, including by using of the WHO Innov8 tool to analyze and improve adolescent health programs.
The work of PAHO-established commissions that analyzed regional issues related to PHC, UH, and reduction of inequities came to fruition. Examples include the Commission on Equity and Health Inequalities in the Americas and the High-Level Commission on Universal Health in the 21st Century: 40 Years of Alma Ata. Their recommendations related to strengthened services at the first level of care, social inclusion, and social participation, among other themes, and informed impacts and outcomes in the development of the proposed PAHO Strategic Plan 2020-2025. They also drove the launch of initiatives such as the PHC 30-30-30 Regional Compact, which aims to strengthen budgetary support for the PHC approach and improve access to health.
PAHO launched a Special Program on Antimicrobial Resistance (AMR) to encourage and support new action by Member States to lessen the impact of AMR in the Region. Support was provided to a regional network that is tracking antifungal resistance in Candida species, a common source of hospital-acquired bloodstream infections. PAHO also assisted efforts to strengthen prevention, diagnosis, and treatment of tuberculosis, with emphasis on countries that have the highest burdens of the disease. Other achievements in the prevention and control of communicable diseases included increased uptake of WHO’s “Treat All” policy recommendations on antiretroviral treatment (ART) initiation in people living with HIV, regardless of the CD4 count; certification of Argentina and Paraguay as malaria-free; significant reduction in suspected cases of cholera in the island of Hispaniola; and reports of only six cases of dog-associated human rabies in the entire Region. PASB also initiated interventions to enhance the prevention of illness and death due to incidents involving venomous animals, focusing on snakebites.
Advances were made in the prevention and control of several communicable diseases, and towards the elimination of others. The elimination of Rhodnius prolixus, the principal triatome vector of Chagas disease in Central America, was validated in Guatemala, Honduras, and Nicaragua during the reporting period. This means that the Central America subregion and Mexico are now free of the vector responsible for most of the endemicity of Chagas disease in that geographic area. Similarly, President Hayes Department in Paraguay was validated as having eliminated transmission of Trypanososma cruzi by the vector Triatoma infestans, making the entire country free of Chagas vectorial transmission. The successes represent significant achievements for these PAHO Key Countries, given the recognized challenges in eliminating vector-borne transmission of Chagas disease.
PASB’s technical cooperation contributed to legislative and regulatory efforts to decrease the harmful use of alcohol, which benefited both NCD reduction and road safety, as well as enhanced attention to mental health and neurological conditions. The Bureau’s support for mental health emphasized shifting the focus of action from the psychiatric hospital to the community and advancing the implementation of the WHO Mental Health Gap Action Program (mhGAP).
Emphasis was placed on continued implementation of the WHO Framework Convention on Tobacco Control (FCTC), through legislation, taxation, plain packaging of tobacco products, and antitobacco communication campaigns. Also emphasized was the reduction of childhood obesity, through measures to improve nutrition and physical activity in the school setting and to decrease the marketing of unhealthy commodities to children. The Caribbean subregion embraced initiatives to increase physical activity and promote healthy nutrition in all settings, with the Heads of State and Government of the Caribbean Community (CARICOM) endorsing “Caribbean Moves” in September 2018; the launch of “Barbados Moves” in Barbados in October 2018; and the introduction of “TT Moves” in Trinidad and Tobago in April 2019. There was heightened recognition of the need for innovative approaches to the prevention and control of the major NCDs—cardiovascular diseases, cancer, diabetes, and chronic respiratory diseases—and their main risk factors—tobacco use, unhealthy diet, physical inactivity, and harmful use of alcohol—as well as the need to strengthen the detection and management of mental health and neurological conditions. The Bureau led, coordinated, and contributed to Member States’ innovative measures to manage the crippling burden of NCDs, including greater use of legislative, fiscal, and regulatory measures to enable healthier choices. This was done in partnership with sectors other than health, civil society, and, where appropriate, the private sector. Countries developed national strategic and/or action plans for reduction of NCD risk factors and improved screening for and management of NCDs, based on commitments made at UN High-level Meetings on NCD Prevention and Control held in 2011, 2014, and 2018, and aligned with global, regional, and subregional frameworks for action.
Promoting inclusion and equity were important aspects of PASB’s technical cooperation in responses to disasters due to natural hazards or other emergencies in countries. The Bureau promoted the need for rights-based approaches and strengthened epidemiological surveillance, immunization programs, and clinical management of anticipated disease threats. Mass migration emerged as a significant challenge during the review period, as cross-border issues and the health of migrants came to the fore. PASB worked with national and local governments, other in-country partners, and other international agencies to identify and attend to the health needs of all affected populations in originating, transit, and destination countries. The Bureau also promoted the use of Disability Inclusion in Hospital Disaster Risk Management (INGRID-H), a results-oriented methodology to assess and improve the level of inclusiveness of a health facility with regards to persons with disabilities in the event of a disaster.
PASB promoted climate change adaptation to mitigate the effects of climate change on human health. These include increased heat-related mortality and morbidity, greater frequency of infectious disease epidemics, increased risk and severity of disasters due to natural hazards, population displacement from sea level rise and increased storm activity, and threats to food and nutrition security. The Bureau highlighted the need for a robust health sector response and for identifying health co-benefits in climate change mitigation measures implemented by other sectors. PASB’s efforts focused on the vulnerable small island developing States (SIDS) in the Caribbean and resulted in the development of the Caribbean Action Plan on Health and Climate Change 2019-2023, which represented a major breakthrough. The Action Plan aims to protect the populations of those countries from the adverse health effects of climate change by developing climate-resilient health systems, increasing awareness, mainstreaming funding opportunities to support countries, and promoting intersectoral mitigation actions in the health sector.
In technical cooperation related to outbreaks, emergencies, and disasters, PASB continued its work with countries to strengthen their implementation of the International Health Regulations (2005) (IHR). Interventions included training on infection prevention and control, outbreak investigation, and surveillance and containment of health care-associated infections; strengthening influenza pandemic preparedness and response capacities; and enhancing laboratory diagnostic capacity.
Systematic tracking of progress towards SHAA2030 and SDG 3 goals and targets will be of critical importance, and the impact and outcome indicators of the proposed Strategic Plan of the Pan American Health Organization 2020-2025 (Official Document 359) provide the primary means of doing so. The Bureau made renewed efforts to ensure adequate, timely, quality information for tracking progress, monitoring and evaluating health programs, and making evidence-based decisions, through the implementation of the information systems for health (IS4H) initiative. Important outputs of the initiative included the development of a road map for strengthening IS4H in the Caribbean subregion and the provision of grants to selected countries as a result of the PASB’s call for proposals to strengthen IS4H. PASB undertook complementary activities to improve evidence and knowledge in health, including the enhancement of platforms to facilitate knowledge exchange, such as the Health Information Platform for the Americas (PLISA). The Bureau continued to take advantage of advances in information and communication technology (ICT) to provide health information, publish scientific manuscripts, and improve health literacy, including through the Pan American Journal of Public Health (PAJPH).
There was progress toward the elimination of mother-to-child transmission of communicable diseases such as HIV and syphilis. The first report on the framework for the elimination of mother-to-child transmission (EMTCT) of HIV, syphilis, hepatitis B, and Chagas disease (EMTCT Plus) was published in April 2019. The report presents, for the first time, the baseline situation in the Region for congenital Chagas disease and hepatitis B among children.
There has been significant improvement in child health, with marked reduction of undernutrition and elimination of some vaccine-preventable diseases such as smallpox, poliomyelitis, rubella and congenital rubella syndrome, and measles. Nevertheless, recent outbreaks of measles in some countries and increases in childhood obesity threaten these gains in child health, and reducing neonatal mortality remains a challenge.
The Region of the Americas achieved the SDG 3.1 target of a maternal mortality ratio (MMR) less than 70 per 100,000 live births more than 10 years ago. However, some countries, and some population groups within countries, continue to have maternal mortality ratios that are higher than, respectively, the regional and national averages. This situation necessitates focus on issues of access to quality care and reduction of inequities to achieve the SHAA2030 target of an MMR less than 30 per 100,000 live births. In response, PASB has collaborated with Member States and partners to improve the management of obstetric emergencies and to strengthen maternal mortality surveillance, among other measures, in efforts to both measure accurately and reduce maternal deaths.
PASB’s technical cooperation to reduce maternal and child deaths was aligned with the PAHO Plan of Action for Women’s, Children’s, and Adolescents’ Health 2018-2030 (Document CD56/8, Rev. 1), which gives life to the Commitment to Action of Santiago. The Commitment to Action was endorsed at a high-level meeting (HLM) in Santiago, Chile, in July 2017, as part of the Every Woman Every Child – Latin America and the Caribbean (EWEC-LAC) movement, which aims to end preventable deaths of women, children, and adolescents, and ensure their
The PAHO Revolving Fund for Vaccine Procurement (PAHO Revolving Fund) and the Regional Revolving Fund for Strategic Public Health Supplies (PAHO Strategic Fund) continued to be strategic pillars of the Bureau’s technical cooperation, providing critical support to Member States for the timely procurement of quality vaccines and medicines. The Strategic Fund supplied medicines, diagnostic kits, equipment, and vector control supplies, with 60 percent of this activity being related to the diagnosis and treatment of HIV and AIDS, hepatitis C virus (HCV), and tuberculosis. These efforts enabled several countries to implement HIV treatment regimens based on the WHO July 2018 Interim Guidance for HIV Treatment and enhance the prevention and treatment of selected NCDs. The PAHO Revolving Fund supplied over 1.6 million doses of human papillomavirus (HPV) vaccine to countries to strengthen cervical cancer prevention programs, and the Strategic Fund scaled up acquisition of medicines and supplies for NCDs, including diabetes, cancer, and hypertension. At subregional level, the Strategic Fund supported negotiations led by the Southern Common Market (MERCOSUR) with manufacturers of HCV medicines, which resulted in reductions of up to 40 percent in the cost of one of the critical antiviral medicines.
Options for health financing were explored in light of the stagnation or reduction in budgetary allocations to health in some countries and decreases in official development aid to many, requiring tailored solutions to provide adequate resources for the health needs and ambitions of Member States. PASB advocacy and technical cooperation promoted and supported the implementation of evidence-based modalities, including national health insurance schemes and allocation to health of funds raised through taxation of unhealthy commodities that drive the NCDepidemic, such as tobacco, alcohol, sugar-sweetened beverages, and foods high in fats, sugar, and salt.
Work with IHSDNs focused on strengthening the first level of care and the integration of priority health programs, including those addressing NCDs, human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS), tuberculosis, and maternal and child health. The regional Plan of Action on Human Resources for Universal Access to Health and Universal Health Coverage 2018-2023 guided work at regional, subregional, national, and subnational levels to move towards outcomes that enhance teams at the first level of care and their work; promote and foster social responsibility of health training institutions in serving the needs of the communities in which they are located; and address issues related to quality, distribution, and performance of HRH.
PASB worked with Member States to strengthen not only their implementation of the PHCstrategy but also IHSDNs and the critical health systems components of human resources for health (HRH), health financing, and access to quality essential medicines, vaccines, and technologies.
An important aspect of the technical cooperation for UH, at both national and subregional levels, was strengthening stewardship and governance for health, including legal frameworks. Collaboration with the Central American Parliament (PARLACEN) led to an initiative to harmonize and strengthen legal frameworks for health in alignment with the 2014 Strategy on Health-related Law (Document CD53/13), and it included a model law and guidance for legislative revision in each Central American country and the Dominican Republic. There was also a review of a renewed conceptual framework of the essential public health functions (EPHFs), which constituted the final phase of consultations to revise the EPHF structure.
A core component of the Bureau’s technical cooperation over the review period was its continued work to advance to UH and reduce health inequities, addressing not only universal health coverage (UHC), but also universal access to comprehensive services for everyone, at the time of need, without risk of financial ruin. With increased awareness of this imperative, countries initiated or strengthened efforts to analyze their situation and implement tailored interventions, including strengthening their PHC strategy—a core component of UH—working to provide essential services for all and to progress to UH.
PASB intensified its interprogrammatic, coordinated efforts and work at regional, subregional, national, and subnational levels to realize the SHAA2030 vision (“a healthier and more equitable Region of the Americas, in harmony with the global vision and principles established in the 2030 Agenda for Sustainable Development”) and to address the moral and ethical foundation of the 2030 Agenda for Sustainable Development (“no one left behind”). Special attention was given to the Organization’s eight Key Countries—the Plurinational State of Bolivia (hereafter, Bolivia), Guatemala, Guyana, Haiti, Honduras, Nicaragua, Paraguay, and Suriname—in keeping with their particular challenges and the implementation of the PAHO Key Country Strategy; to groups and persons in conditions of vulnerability; and to countries experiencing political, migration, and other crises.
PASB made adjustments to, and strengthened, its technical cooperation over the period July 2018 to June 2019 in order to advance the SHAA2030, building on previous successes; maintaining health gains; addressing remaining and emerging challenges; and reducing health inequities. The Bureau noted, and took advantage of, the critical interlinkages not only among the SHAA2030 goals and targets, SDG 3, and the other 16 SDGs, but also among the SDGs themselves, and emphasized the importance of multisectoral partnerships in addressing health and its social, environmental, economic, and other determinants.
Member States have demonstrated solidarity and unfailing willingness to share resources, successes, experiences, and lessons learned, with the PASB’s facilitation, coordination, and support. There has been considerable progress in the Region related to the SHAA2030 goals, which address equitable access to comprehensive health services; stewardship and governance for health; human resources for health; health financing; essential medicines, vaccines, and technologies; information systems for health; evidence and knowledge in health; outbreaks, emergencies, and disasters; NCDs and mental health and neurological disorders; communicable diseases; and inequalities and inequities in health.
The Member States of the Pan American Health Organization (PAHO) and the Pan American Sanitary Bureau have always worked not only to improve the health of the peoples of the Americas but also to reduce inequities. Although significant progress has been made, much remains to be done. The Organization’s Governing Bodies have approved key strategies and plans of action, and adopted related resolutions, to address issues pertinent to the SHAA2030 and the 2030 Agenda for Sustainable Development, many of them having been put in place before the endorsement of the sustainable development frameworks.
 WHO. Climate change and human health - risks and responses. Summary. Geneva: WHO; 2003. Climate change and human health - risks and responses. Summary..
This report presents highlights of PASB’s technical cooperation with Member States and collaboration with key partners and stakeholders in addressing the SHAA2030 goals and targets over the period July 2018 to June 2019. It elaborates strategies, interventions, and achievements; notes challenges and lessons learned; summarizes the Bureau’s institutional strengthening; and looks forward to the continuation of PAHO’s key role in improving health outcomes for all people in the Region of the Americas and beyond, leaving no one behind.
The SHAA2030 was developed as the successor to the Health Agenda for the Americas 2008-2017 and in response to the UN General Assembly resolution A/RES/70/1, “Transforming our world: the 2030 Agenda for Sustainable Development,” the outcome document of the UN summit for the adoption of the post-2015 development agenda. The 2030 Agenda for Sustainable Development was adopted by the UN General Assembly in September 2015, with 17 SDGs and 169 targets addressing the three dimensions of sustainable development: economic, social, and environmental. The 2030 Agenda was characterized as a plan of action for people, planet, and prosperity that sought to strengthen universal peace; establish a collaborative partnership for its implementation that involved all countries, all stakeholders, and all people; and leave no one behind.
The SDGs came into effect on 1 January 2016 and built on the 2015 Millennium Development Goals (MDGs), which were established in 2000. Compared to the MDGs, the SDGs are broader in scope; go further to address the root causes of poverty; apply to all countries, not only to those categorized as “developing”; include a strong focus on the means of implementation; strengthen efforts to reduce inequities within and among countries; and enhance the progressive realization of human rights. Emphasis is placed on the integrated and interlinked nature of the goals, revitalization of the global partnership for sustainable development, and the needs of the poorest and most vulnerable members of society. The SDGs and SDG 3, the goal most directly related to health, with its nine targets and four implementation mechanisms, are summarized in Annex A.
In 2015, the PASB published the document titled Preparing the Region of the Americas to Achieve the Sustainable Development Goal on Health. It included fact sheets summarizing the status of the SDG 3 targets in the Region and pertinent PAHO/WHO mandates, programs, technical documents, as well as strategic partners related to the issues. This valuable resource also included an analysis of the alignment between the SDG 3 targets and the PAHO Strategic Plan 2014-2019. In 2017, the PAHO Regional Briefing on Implementation of the 2030 Agenda for Sustainable Development in the Region of the Americas summarized key organizational strategies and interventions for multisectoral action and partnerships in advancing to SDG 3. The document also emphasized interconnections among the SDGs, their impact on health, and the importance of an integrated approach in ensuring the realization of the 2030 Agenda for Sustainable Development. Examples of the influence of the other SDGs on SDG 3 are presented in Annex B of this report.
In order to enable the Region of the Americas to work with solidarity in advancing towards the achievement of SDG 3 and other SDGs that impact health, taking into account the Region’s specificities, PAHO’s Member States and the PASB developed a blueprint—the SHAA2030—to guide the Organization’s actions. The SHAA2030 goals are presented below.
Goal 1: Expand equitable access to comprehensive, integrated, quality, people-, family-, and community–centered health services, with an emphasis on health promotion and disease prevention.
Goal 2: Strengthen stewardship and governance of the national health authority, while promoting social participation.
Goal 3: Strengthen the management and development of human resources for health (HRH) with skills that facilitate a comprehensive approach to health.
Goal 4: Achieve adequate and sustainable health financing with equity and efficiency, and advance toward protection against financial risks for all persons and their families.
Goal 5: Ensure access to essential medicines and vaccines, and to other priority health technologies, according to available scientific evidence and the national context.
Goal 6: Strengthen information systems for health to support the development of evidence-based policies and decision-making.
Goal 7: Develop capacity for the generation, transfer, and use of evidence and knowledge in health, promoting research, innovation, and the use of technology.
Goal 8: Strengthen national and regional capacities to prepare for, prevent, detect, monitor, and respond to disease outbreaks, and emergencies and disasters that affect the health of the population.
Goal 9: Reduce morbidity, disabilities, and mortality from noncommunicable diseases, injuries, violence, and mental health disorders.
Goal 10: Reduce the burden of communicable diseases and eliminate neglected diseases.
Goal 11: Reduce inequality and inequity in health through intersectoral, multisectoral, regional, and subregional approaches to the social and environmental determinants of health.
In addition to the SDGs and PAHO Strategic Plan 2014-2019, many PAHO/WHO and other international frameworks and documents guide progress to the SHAA2030 goals and targets. Annex C of this report presents these goals and targets; their links to selected SDGs and SDG targets; and a selection of enabling and crosscutting PAHO and other international frameworks. Many of the PAHO frameworks demonstrate the Organization’s foresight in addressing several of the issues with an equity focus.
The SHAA2030 is made operational through implementation of PAHO Strategic Plans and their associated Program Budgets. The proposed PAHO Strategic Plan 2020-2025 and its three Program Budgets will be the principal instruments for the continued implementation of interventions to achieve the SHAA2030 goals and targets.
The PASB monitors and regularly reports on progress in fulfilling the resolutions adopted by the Pan American Sanitary Conference or the PAHO Directing Council, and in achieving the objectives of related strategies and plans of action, in collaboration with Member States and partners. Highlights of the Region’s overall progress and current status related to selected SHAA2030 goals and targets are presented below, supported by data where available.
In pursuit of equitable access to comprehensive health services, the Region of the Americas was the first WHO region to collectively endorse the goal of achieving universal health, through the 2014 Strategy for Universal Access to Health and Universal Health Coverage (Document CD53/5, Rev. 2). Most of PAHO’s Member States have adopted the Strategy to guide related health system reforms. Several countries initiated the development of national health policies, strategies, and/or plans, while others advanced the implementation of IHSDNs, established or strengthened health financing frameworks, and reduced critical deficits in HRH, all in pursuit of the UH objectives. Several countries provide examples of progress in improving access to comprehensive, quality, and integrated health services. Bolivia expanded and integrated the Mi Salud initiative. El Salvador consolidated its national initiative to strengthen health services networks. The Bahamas advanced in the development of national health insurance.
Although 25 countries increased public spending on health between 2011 and 2016, this has generally been at a slow pace: the regional average grew from 3.7 percent of gross domestic product (GDP) in 2011 to 4.2 percent in 2016, a 14 percent increase. In addition, despite their interventions to improve the situation regarding HRH, many countries have not yet reached the WHO-recommended level of 44.5 doctors, nurses, and midwives per 10,000 population considered essential to achieve the SDGs.
With regard to essential medicines, vaccines, and health technologies, most countries in the Region have an official Essential Medicines List (EML), and selection criteria have been established in the PAHO/WHO Health Technology Assessment (HTA) methodology for incorporating medicines and other health technologies into public sector coverage benefits. However, not all the EMLs are kept updated, and some lists still contain products with concerns about their safety, efficacy, or cost-effectiveness. Additionally, less than 50 percent of countries surveyed have established a mechanism that uses the HTA selection criteria. The Region has advanced substantially in strengthening national regulatory authorities (NRAs) to ensure that only quality medicines and health technologies are offered to the population, and eight PASB-designated regulatory authorities of regional reference now regulate products for roughly 82 percent of people in the Americas. Nevertheless, some 18 million people live in countries with no, or very rudimentary, regulatory oversight, and NRAs in most countries have institutional development plans that were formulated based on a standardized assessment of their capacities and gaps.
Maternal and child mortality are important markers of equitable access to comprehensive health services. Though the Region of the Americas achieved the SDG 3.1 target of a maternal mortality ratio less than 70 per 100,000 live births more than 10 years ago, the SHAA2030 target of less than 30 per 100,000 live births is yet to be achieved. Access to prenatal and delivery care has remained high in the Americas, with 89 percent of pregnant women having attended four or more antenatal care visits and 95 percent having had hospital delivery. The screening of pregnant women for HIV and syphilis also remained high, with an estimated 73 percent of all pregnant women with HIV infection and 87 percent of syphilis-positive pregnant women attending antenatal care.
One of the most important interventions to reduce maternal mortality is skilled attendance at birth. The Region has advanced substantially in access to and coverage by skilled birth attendance, reaching 95 percent at the regional level. However, some countries and certain population groups in the Region demonstrate access and coverage below the regional average, with maternal mortality ratios higher than the SHAA2030 target. The Bureau continues to work with the countries to identify the underlying causes of maternal deaths; strengthen health systems and improve access to skilled care; and remove the economic, cultural, and geographic barriers that contribute to health inequities.
Overall, the Region of the Americas has made progress in ensuring a strong policy environment in support of child survival and development, and is gradually applying a renewed child health agenda that speaks to development, learning, and health as indivisible outcomes. However, as with maternal health, there are inequities in and among countries, and child survival, especially in the neonatal period, remains a priority for action in the Region.
The SHAA2030 establishes a regional target of 9 or fewer neonatal deaths per 1,000 live births, and the PAHO Core Indicators 2018 reported a neonatal mortality rate for the entire Region of the Americas of 7.7 per 1,000 live births, with a rate of 9.4 neonatal deaths per 1,000 live births for Latin America and the Caribbean (LAC). The 2017 estimates published by the UN Inter-Agency Group for Child Mortality Estimates (UN IGME) presented a value of 7.9 neonatal deaths per 1,000 live births in the Region of the Americas and 9.6 deaths per 1,000 live births in LAC. According to these estimates, 15 countries (of a total of 34) had neonatal mortality rates higher than the SHAA2030 target, while the PAHO Basic Indicators 2018 showed that 22 countries and territories (of a total of 45) presented values higher than the SHAA2030 target. PASB continues its work to improve the management of neonatal and maternal emergency obstetric care and advance toward the regional target.
In 2016, 53 percent of deaths in children less than 5 years of age occurred during the neonatal period, and neonatal mortality is the most important component of infant and under-5 mortality. Between 1990 and 2017, under-5 mortality fell 68 percent overall, from 44 to 14 per 1,000 live births, based on UN IGME estimates. This decline reflects primarily decreases in diarrhea, pneumonia, undernutrition, and vaccine-preventable diseases as causes of mortality in the postneonatal period. In 2000, 8 percent of under-5 deaths were due to diarrheal diseases and 14 percent to lower respiratory infections; by 2016 these percentages were 4 percent and 10 percent, respectively. Sixteen countries in the Region have under-5 mortality rates above the average of 14 per 1,000 live births; the highest national rate is 71 per 1,000 live births.
While the regional prevalence of stunting decreased from 11 percent in 2000 to 7 percent in 2015, the lowest country value was 2 percent and the highest was 48 percent. Overweight in children less than 5 years of age was 7 percent for the Region as a whole, but in individual countries, values ranged from 4 percent to 12 percent.
In the Region of the Americas, both the prevalence of contraceptive use with modern methods and the unmet need for family planning are on track, with rates of 69 percent and 9 percent, respectively. However, there are important differences among countries and various population groups. For example, among adolescents, these rates are, respectively, 51 percent and 37 percent in Barbados; 64 percent and 20 percent in Costa Rica; 8 percent and 22 percent in Guatemala; and in 8 percent and 35 percent in Haiti. These divergent values illustrate inequities and the need for focus on and targeted interventions in specific priority populations such as adolescents.
Data on the birth rate among adolescents aged 10-14 years are limited, as data collection and global estimates have focused on those aged 15-19 years, the group for the previous international adolescent fertility indicator. However, in support of the SDGs, international monitoring of adolescent pregnancy has been expanded to the age group of 10-19 years, which will improve data on pregnancies in girls younger than 15 years of age. According to estimates from the UN Population Fund (UNFPA), 2 percent of women of reproductive age in LAC had their first delivery before the age of 15 years. The estimated fertility rate in adolescents aged
15-19 years in LAC has decreased from 79 per 1,000 over the period 2000-2005 to 67 per 1,000 over the period 2010-2015. In the past three years, some countries in the Region, such as Colombia, Costa Rica, and Uruguay, have documented significant reductions in their adolescent birth rates, and the Bureau is supporting these countries to analyze the responses, identify contributory factors, and document lessons learned.
Preventing, mitigating, and responding to outbreaks, emergencies, and disasters remain priorities for the Region. Between 2013 and mid-2018, more than one in five disasters worldwide occurred in the Americas, resulting in 141 million victims and over 10,000 deaths. In recent decades, the Region’s countries have worked to mitigate the burden of disasters, epidemics, conflicts, and environmental and food-related emergencies by focusing on risk reduction and capacity-building for preparedness, response, and recovery. As a result of these efforts, most of the Region’s countries are now able to respond to less severe disasters and health emergencies without international assistance.
All PAHO Member States share the concept of a health disaster program as a requirement for appropriate emergency planning and response. The institutionalization of disaster programs continues, in keeping with the 1976 PAHO resolution CD24.R10, on emergency assistance to countries in the Americas. However, in 24 percent of the countries with formally established disaster programs, the programs do not have full-time staff or a dedicated budget.
Implementation of the IHR is a critical aspect of risk reduction, and countries’ strengthening of the IHR core capacities remains a priority. Annual reports submitted by PAHO Member States to the World Health Assemblies between 2011 and 2018 show steady improvements or plateauing of the average regional scores. The 2018 annual reports showed average regional scores close to or above 60 percent, and the scores were above global averages on all but one core capacity, “health service provision.” However, as in previous years, the scores remain heterogeneous across subregions, with North America showing the highest average scores and the Caribbean showing the lowest.
NCDs, including mental health disorders, remain major threats to the health of people in the Region. A majority of Member States developed and implemented—to a greater or lesser degree—national strategic plans or plans of action for NCD prevention and control. These frameworks, aligned with global, regional, and subregional guidance as appropriate to the national situation, have amplified efforts to reduce NCDs, their complications, and related premature mortality. The national frameworks commonly include several of the WHO Best Buys and Other Recommended Interventions for the Prevention and Control of NCDs, which present a list of proven, cost-effective options for reduction of the main NCD risk factors and management of the main NCDs.
Thirty (86 percent) of PAHO’s Member States are Parties to the Framework Convention on Tobacco Control. While implementation of the Convention’s provisions is uneven among the countries, there has been progress on several fronts, including the development of tobacco control legislation and tobacco taxation.
Overall, road traffic mortality remains unchanged, and mortality increased among the most vulnerable road users, namely pedestrians, motorcyclists, and cyclists. Road traffic deaths remain the second-leading cause of death among persons aged 15–29 years, highlighting the need to prioritize road safety on the adolescent health agenda.
There has been continued and accelerated implementation of the WHO mhGAP to scale up services for mental, neurological, and substance abuse disorders. The mhGAP package includes training for the management of depression at the first level of care, and several countries with significant rates of suicide have developed specific suicide prevention plans. These interventions are expected to improve community-oriented services and decrease the suicide mortality rate over time.
Intersectoral collaboration and partnerships at regional and national levels for the adoption of international standards in the treatment of substance use disorders have been strengthened. There is improved access to quality treatment for, substance use disorders through public health services networks, with the participation of ministries of health, national drug control commissions, and civil society organizations (CSOs). However, there has not been a decline in consumption of alcohol per capita in the Region, and PASB’s technical cooperation for implementation of the WHO SAFER alcohol control initiative continues, particularly with regard to restrictions on alcohol availability; drink-driving countermeasures; bans or comprehensive restrictions on alcohol advertising, sponsorship, and promotion; and alcohol taxation.
With regard to communicable disease prevention and control, the Region has been making steady progress. Mother-to-child transmission of HIV declined in the Region, as transmission rates fell from 37 percent in 2010 to 14 percent in 2018. On the other hand, reported cases of congenital syphilis increased by 22 percent for the period 2016-2017, for a total of 28,800 children in the Americas in 2017. Additionally, there are an estimated 9,000 new cases of congenital Chagas disease each year. Vaccination coverage for hepatitis B has stabilized at 87 percent of children under one year of age who received their third dose; however, policies for universal, timely hepatitis B vaccine birth dose are increasingly being adopted in the Region.
Countries are approaching the elimination of perinatal and early childhood transmission of hepatitis B, and have advanced in the elimination of malaria. Additionally, EMTCT of HIV, syphilis, hepatitis B, and Chagas disease in the Americas is progressing, through innovative, integrated, cost-efficient, and effective approaches. PASB recognizes the need to strengthen Member States’ access to effective ART for HIV and to enhance HIV drug resistance surveillance to detect and manage instances of resistance to first-line medicines, and the Bureau is taking appropriate action in collaboration with Member States and partners.
Elimination is also within reach for several neglected infectious diseases, including Chagas disease, leprosy, trachoma, lymphatic filariasis, and onchocerciasis (river blindness). Human rabies transmitted by dogs is also very close to elimination, and countries have achieved substantial reductions in the adverse impact of soil-transmitted helminthiasis, schistosomiasis, and fascioliasis in children and other populations at risk. However, the Region of the Americas has the social and environmental conditions for the continued transmission and dissemination of arboviral diseases such as chikungunya, dengue, and Zika. PASB is taking a collaborative and integrated approach to these threats by monitoring the progression and behavior of the viruses and by addressing related social and environmental determinants.
Reducing inequalities and inequities in health is an overarching focus of PAHO Member States and the Bureau. The PAHO Strategic Plan 2014-2019 was unique in its explicit focus on the reduction of health inequities at the impact level. This embrace of an equity lens in the planning and execution of all technical cooperation interventions provided the impetus for relevant managerial, planning, and budgetary adjustments. Progressivity—that is, ensuring that countries with greater needs received proportionate allocations—was reflected in the development of the 2012 PAHO Budget Policy that accompanied the PAHO Strategic Plan 2014-2019. An equity criterion was applied when assessing health needs and prioritizing health programs. In addition, the monitoring of social inequalities that impact health was institutionalized. Like the 2030 Agenda for Sustainable Development, SHAA2030 includes a goal that directly addresses the reduction of health inequalities and inequities. That SHAA2030 goal highlights the social determinants of health; the effects of hazardous chemicals and air, water, and soil pollution; water and sanitation; and migration.
Health promotion, defined as a process of enabling people to increase control over their health and its determinants, is critical for addressing the social determinants of health. This crosscutting strategy is made operational through mechanisms such as the collaborative Health in All Policies approach, which aims to improve health by incorporating health considerations into decision-making across sectors and policy areas, thus addressing the social, environmental, economic, and other determinants of health. All PAHO Member States have embraced health promotion as a crosscutting strategy, but the degree to which it is applied varies among countries. Many Member States address selected aspects, such as health education and health communication; others have developed health-promoting policies that take a settings approach—school, workplace, and community—to interventions; and yet others have national strategies on health promotion. PASB is working to validate indicators for the new Strategy and Plan of Action on Health Promotion within the Context of the Sustainable Development Goals 2019-2030 (Document CD57/10) and develop a baseline for the number of countries and territories implementing a national health promotion policy.
Given its enormous agricultural sector and both informal and formal mining industries, the Region of the Americas has significant public health concerns associated with hazardous chemicals. As part of their response, countries have been using the 2017 WHO Chemicals Road Map, a framework developed by WHO and UN Environment to enhance health sector engagement in the Strategic Approach to International Chemicals Management (SAICM). As an example, most Central American countries are participants in a multisector initiative to develop action plans that address chemical hazards. Countries throughout the Region have participated in global WHO networks on chemicals and health and on risk assessment. Those networks promote learning exchanges on the interface between science and policy, including in subregional networks that support operational clinical management coordination and policy discussions.
In 2016, WHO estimated that 234,000 premature deaths in the Americas were attributable to outdoor air pollution, and another 82,000 premature deaths to the use of solid fuels for household energy (household air pollution). In order to reduce the burden, countries have been strengthening their air quality legislation, setting air quality objectives aligned with WHO guidelines, improving air quality monitoring, building capacity to estimate the burden of disease attributable to air pollution, and developing early warning systems. They have also been working to eliminate household-contaminating fuels and technologies for cooking and to improve their capacity to evaluate the health impact of mitigation interventions.
Between 2015 and 2017, the Region reported slow progress towards improvements in water and sanitation based on SDG 6 targets, which address safe and affordable drinking water; water quality; water use efficiency; water resource management; water-related ecosystems; and adequate and equitable sanitation and hygiene. However, many Member States subsequently revised their national plans and policies to incorporate relevant targets and indicators, consider equity criteria, and include strategic objectives differentiated for groups in conditions of vulnerability, with the aim of implementing stronger measures to ensure more equitable and securely managed WASH systems and services.
Migration has long been a reality in the Region of the Americas, and PAHO Member States have been countries of origin, transit, destination, or return. Economic deprivation, food insecurity, environmental hazards, violence, political and/or religious persecution, and ethnic and gender-based discrimination can all give rise to massive migration flows. Many migrants may experience conditions of vulnerability that threaten their health and well-being during their journey; at border areas in transit countries; and in adapting to conditions and accessing the health system in destination countries. Member States have demonstrated regional solidarity in providing support for migrants and have undertaken arrangements for collaborative responses, but limited resources and reemerging diseases strain national health systems. The Bureau is working with countries in seeking mutually acceptable, equitable solutions that support the health of this vulnerable group.
Further progress in advancing the SHAA2030 will be marked by successes in reaching milestones that lead to the achievement of its goals and targets; by challenges that arise, based on national situations, external influences, and unexpected events; by devising strategies and innovations to overcome the challenges; and by PAHO’s unwavering attention to its organizational values of equity, excellence, solidarity, respect, and integrity, in pursuit of its mission: “To lead strategic collaborative efforts among Member States and other partners to promote equity in health, to combat disease, and to improve the quality of, and lengthen, the lives of the peoples of the Americas”.
 Bahamas, Belize, Bolivia, Brazil, Canada, Chile, Cuba, Dominican Republic, Ecuador, El Salvador, Guatemala, Guyana, Haiti, Jamaica, Nicaragua, Panama, Paraguay, Peru, Saint Kitts and Nevis, Saint Lucia, Saint Vincent and the Grenadines, Suriname, Trinidad and Tobago, United States of America, and Uruguay.
 Health workforce requirements for universal health coverage and the sustainable development goals, Human Resources for Health Observer Series No. 17, WHO 2016.
 The UN IGME comprises representatives from UNICEF, UN Population Division, World Bank, and WHO.
 UN IGME. Levels & trends in child mortality 2018. New York: UNICEF; 2018. Available at: UN-IGME-Child-Mortality-Report-2018.pdf.
 IHR core capacities and their implementation status in the Region can be consulted in Document CD57/INF/4, July 2019.
 Korenromp EL, Rowley J, Alonso M, Mello MB, Wijesooriya NS, Mahiané SG, et al. (2019) Global burden of maternal and congenital syphilis and associated adverse birth outcomes—Estimates for 2016 and progress since 2012. PLoS ONE 14(2): e0211720. journal.pone.0211720.
 PAHO. Health of migrants (Document CD55/11, Rev. 1). Washington, D.C.: PAHO; 2016.
SHAA2030 Goal 1:
Equitable access to comprehensive health services
Advancing UH—both access to and coverage of services that address health promotion and disease prevention, diagnosis, treatment, rehabilitation, and palliation—remains a critical priority for PAHO’s technical cooperation to reduce health inequities and make progress to health for all, leaving no one behind. The Strategy for Universal Access to Health and Universal Health Coverage, adopted by the 53rd Directing Council of PAHO in October 2014 (Resolution CD53.R14), states that “universal access to health and universal health coverage imply that all people and communities have access, without any kind of discrimination, to comprehensive, appropriate, and timely, quality health services determined at the national level according to needs, as well as access to safe, affordable, effective, quality medicines, while ensuring that the use of these services does not expose users to financial hardship, especially groups in conditions of vulnerability.” UH requires the formulation and implementation of multisectoral policies and actions to address the social determinants of health and promote a whole-of-society approach to enhancing health and well-being.
Currently, it is estimated that 30 percent of the population of the Americas lacks access to the health care it needs, with barriers that include financial, geographical, institutional, social, and cultural factors. On average, countries of the Region invest 4.2 percent of their gross GDP in health—less than the 6 percent minimum recommended by WHO—and allocate an average of 26 percent of their health budgets to the first level of care.
A linchpin of PASB’s technical cooperation during this period was the culmination of extensive work led by the Bureau to mark the 40th anniversary of the 1978 Declaration of
Alma-Ata. PASB undertook a formal consultation with Member States in support of the global process for the drafting of a new declaration on PHC, in the lead-up to the Global Conference on Primary Health Care. Held in October 2018 in Astana, that event was cohosted by the Government of Kazakhstan, WHO, and the United Nations Children’s Fund (UNICEF). The consultation with Member States generated extensive country engagement and deliberations, and the regional report of the consultation, submitted to WHO with input from 24 countries and territories (including from their civil society organizations), contributed significantly to the final Declaration of Astana. Thirteen PAHO Member States sent official delegations to the Global Conference, and national health authorities, other health leaders from the Region, and PASB personnel contributed to panels, presentations, and discussions.
A side event to commemorate the 40th anniversary of the Declaration of Alma-Ata was organized during the 56th PAHO Directing Council, which took place in September 2018. The event showcased public health milestones and PAHO responses over the 40-year period through print and audiovisual images. Concurrent with the Global Conference on PHC, two special issues of the Pan American Journal of Public Health (PAJPH), with a total of more than 30 original research articles, highlighted innovative paths taken by LAC countries to advance the PHC strategy, strengthen their health systems, and improve the health and well-being of their populations.
The High-Level Commission on “Universal Health in the 21st Century: 40 Years of Alma-Ata,” established by PAHO’s Director at the Regional Forum of the same name in December 2017, presented its report in April 2019 in Mexico City as part of the observance of World Health Day. The presentation of the Commission’s report was led by His Excellency Andres López Obrador, President of Mexico; Dr. Carissa Etienne, Director of PAHO; Ambassador Nestor Mendez, Assistant Secretary General of the Organization of American States (OAS) and Chair of the High-Level Commission; and Dr. Michelle Bachelet, UN High Commissioner for Human Rights. The event drew representatives from 29 countries and territories, including 20 ministers of health and other high-level government officials, as well as civil society representatives. The report highlights the importance of the PHC strategy and the need to eliminate barriers to access, and provides recommendations to achieve UH by 2030. These recommendations included developing people- and community-centered PHC-based models of care that take into account human diversity, interculturalism, and ethnicity; implementing intersectoral health interventions that promote substantive changes in the environmental, social, economic, housing, and basic infrastructure conditions of a population; creating social participation mechanisms that are genuine, deep, inclusive, and accessible; and developing a financing model that ensures sufficiency, quality, equity, efficiency, and sustainability.
Following the presentation of the report, PAHO’s Director launched the Regional Compact on Primary Health Care for Universal Health, PHC 30-30-30. The Compact calls for accelerated efforts to transform health systems towards equitable, comprehensive, and inclusive health care models based on the PHC strategy. Specifically, it proposes that countries reduce the barriers that hinder access to health by at least 30 percent, and allocate at least 30 percent of the entire public expenditure in health to the first level of care, by 2030.
PASB continued technical cooperation with Member States to transform the organization and management of health services through the development of people- and community-centered models of care that can expand access to quality services. During the reporting period, nine Member States—Bolivia, Costa Rica, Dominican Republic, Guatemala, Honduras, Jamaica, Panama, Paraguay, and Uruguay—made progress in the implementation of IHSDNs and other interventions to strengthen the first level of care and the integration of priority health programs, including those addressing NCDs, HIV, tuberculosis, and maternal and child health. PASB worked with Barbados to conduct an assessment of the health system’s capacity to address the needs of an aging population; it is expected that the results will be shared in the second half of 2019.
The Bureau supported the development of integrated health networks as part of the implementation of road maps for UH in Belize, Chile, Dominican Republic, Ecuador, Guatemala, Guyana, Jamaica, and Suriname, and worked with Dominica in the evaluation of the health system and the development of a new organizational model post-Hurricane Maria. PASB also provided integrated support across all health systems and services competencies—policy, regulation, financing, HRH, health services organization, health information systems, and medicines and health technologies—to the following Key Countries:
Bolivia, in the conceptual development of the Unified Health System, the organizational model, and the legislative framework.
Guatemala, in the adoption of a new model of care based on the PHC strategy.
Guyana, in the assessment of the current strategic plan and the improvement of health services for maternal health.
Haiti, in the assessment of the Program for Essential Medicines and Supplies (PROMESS).
Honduras, in support of the National Health Commission leading the transformation of health systems.
Paraguay, in the revision of the health network, quality of care, and human resources planning.
During the period under review, extensive country and regional consultations took place to develop the regional Strategy and Plan of Action to Improve Quality of Care in Health Service Delivery 2020-2025 (Document CD57/12). The Strategy and Plan of Action was approved by the 164th Session of the Executive Committee in June 2019, and will be presented to the PAHO 57th Directing Council in September 2019. Gaps in the quality of care affect individuals, families, and communities, with particular impact on populations in conditions of vulnerability. Regional data indicate that between 2013 and 2014, more than 1.2 million deaths could have been avoided if health systems had offered accessible, quality, and timely services. The new regional Strategy and Plan of Action represents a paradigm shift in the approach to quality of care in the provision of health services. It promotes interventions based on health systems and intersectoral perspectives, with a focus on strengthening the first level of care and its articulation with the other levels; empowering people, including health workers, to take action to improve the quality of care; orienting actions towards results; and improving the experiences and trust that people, families, and communities have in health services.
Interventions to improve maternal health and reduce maternal mortality are often conducted in programs that address both maternal and child health, as well as sexual and reproductive health, given the close relationships and synergies among the issues. This is well reflected in the global Every Woman Every Child (EWEC) movement, which was launched at the UN Millennium Development Goals Summit in 2010, and its regional arm, Every Woman Every Child – Latin America and the Caribbean.
EWEC was established to mobilize and strengthen multisectoral international and national action, involving governments, multilateral organizations, civil society, and the private sector, to address the major health challenges facing women, children, and adolescents around the world. The movement puts into action the Global Strategy for Women’s, Children’s and Adolescents’ Health 2016-2030, which presents a road map to end preventable deaths and ensure the well-being of women, children, and adolescents. The Global Strategy highlights three objectives: Survive—end preventable deaths; Thrive—ensure physical and mental health and well-being; and Transform—expand enabling environments.
PASB’s technical cooperation to reduce maternal mortality over the review period was in keeping with the PAHO Plan of Action for Women’s, Children’s, and Adolescents’ Health
2018-2030. The Plan of Action was developed within the framework of the Global Strategy for Women’s, Children’s, and Adolescents’ Health, with particular focus on addressing persons and groups in conditions of vulnerability, and reducing inequities. The technical cooperation benefited from the Director’s designation of a special advisor to provide enhanced focus on maternal mortality reduction in 10 priority countries: Bolivia, Dominican Republic, Guatemala, Guyana, Haiti, Honduras, Nicaragua, Paraguay, Peru, and Suriname. This focus was complemented and supported by the Bureau’s coordinated, interprogrammatic work at the regional level, for greater efficiency and effectiveness. The overarching technical cooperation strategy aimed to increase the quality of care in this population of at-risk women, modernize family planning strategies, and improve maternal health surveillance, particularly in underserved and more vulnerable groups.
The interprogrammatic Zero Maternal Deaths by Hemorrhage project continued to record successes in the participating countries, which included Argentina, Bolivia, Brazil, Colombia, Dominican Republic, Ecuador, Guatemala, Guyana, Peru, and Suriname. PASB promoted relevant training strategies and updated the curriculum with new evidence, supported by funding from the respective ministries of health, PAHO/WHO country offices, the Latin American Federation of Societies of Obstetrics and Gynecology (FLASOG), and the International Federation of Gynecology and Obstetrics (FIGO). One hospital in each of four countries—Bolivia, Dominican Republic, Guatemala, and Peru—implemented the project’s comprehensive package. Over a two-year period, all the participating hospitals showed a decrease in maternal mortality due to hemorrhage, with a total of 14 maternal deaths averted in the four hospitals.
A protocol was developed to analyze the relationship of maternal mortality due to hemorrhage and the availability and management of blood and its components. When the procedure was piloted in Honduras and Paraguay, the results showed that this cause of mortality was highest among mothers under 30; that availability of blood kits for such emergencies is low or nonexistent; that providers have little knowledge of blood components in obstetric emergencies; and that the relationship between maternal units and the transfusion service is weak to nonexistent. This points to the need for training in comprehensive blood supply, emergency blood management, and compliance with obstetric emergency management protocol. It is also necessary to reorganize blood service networks according to clinical needs and to improve the efficiency of those networks.
In related work, costs were assessed for the regionalization of blood services in Guatemala and within the Andean Region, the latter in collaboration with the Andean Health Organization (ORAS). Those exercises demonstrated that it is more costly and less efficient for hospitals to have their own blood banks than to centralize, in a dedicated institution, the tasks of obtaining voluntary donors, processing blood, and distributing certified blood to one or more hospitals.
Technical capacities to manage the main obstetric emergencies were strengthened through the training of trainers in Brazil, Bolivia, Chile, Colombia, Dominican Republic, Ecuador, Guyana, Honduras, Paraguay, and Suriname. Persons trained included participants from schools of medicine, nursing, and midwifery.
Updated family planning strategies, such as using immediate-post-obstetric long-acting reversible contraception, were promoted to the most vulnerable populations, including adolescents and indigenous, rural, and resource-poor women. These activities were undertaken in 11 countries.
PASB worked on the validation of a tool to promote culturally safe birth in four countries—Guatemala, Honduras, Paraguay, and Peru—under the Integrated Health Systems in Latin America and the Caribbean (IHSLAC) project, a collaborative effort between PASB and Global Affairs Canada (GAC). Working in collaboration with indigenous communities, this intervention was integrated with a series of “knowledge dialogues” to address key public health issues affecting women and youth. The project, which ends in 2019, is being implemented in 11 countries and aims to improve the health of children, young girls, and women living in conditions of vulnerability in LAC.
Workshops aimed at improving maternal mortality surveillance were held in 14 countries, based on the 2015 Guidelines for Maternal Death Surveillance and Response (MDSR): Region of the Americas. This initiative was funded by the United States Agency for International Development (USAID), with technical cooperation from WHO, UNFPA, the World Bank, UNICEF, and other partners. A virtual course to improve MDSR skills in all Member States is being developed and will be available through the PAHO Virtual Campus for Public Health (VCPH) in June 2020.
PASB organized a team of experts to conduct a perinatal audit exercise in hospitals in Grenada and Saint Kitts and Nevis. The main objective was to assess the burden of maternal and neonatal deaths, including stillbirths, and determine trends in the numbers and causes of death. This facilitated the identification of modifiable contributing factors and the development of strategies to prevent similar deaths, including the establishment of protocols and flow charts for the management of neonatal and maternal emergency obstetric care.
PASB’s technical cooperation to improve child health outcomes is aligned with the PAHO Plan of Action for Women’s, Children’s, and Adolescents’ Health 2018-2030. The Plan of Action gives life to the Commitment to Action of Santiago, which was endorsed at a high-level meeting (HLM) in Santiago, Chile, in July 2017, as part of the EWEC-LAC movement. The Commitment to Action calls for the implementation of the Global Strategy for Women’s, Children’s, and Adolescents’ Health, which highlights the urgency to reduce health inequities by taking decisive actions to transform the social, economic, and environmental conditions of families and communities. Based on human rights, the vision is to ensure that every woman, child, and adolescent in the Americas not only survives, but thrives, and is provided with opportunities to fulfill their human development potential.
The implementation of guidelines based on the best available evidence for monitoring, multidisciplinary care, and clinical follow-up of small and severely ill newborns (including those affected by congenital syndrome associated with Zika virus infection) is essential in order to achieve the best outcomes. In working to reduce preventable deaths of newborns and children under 5 years of age, PASB focused on improving the quality of care and developing tools and strategies to strengthen information systems related to neonatal and fetal mortality. The tools included those for assessment of essential conditions for neonatal intensive care units, while the strategies included training in neonatal and fetal mortality audits, and in preventing or addressing the main causes of newborn deaths.
Capacity-building workshops were held in 14 countries on auditing and analyzing neonatal and fetal deaths, strengthening information systems, and enhancing the quality of perinatal care. The workshops were informed by the identification of the main causes of neonatal death and disability—linked to prematurity, retinopathy of prematurity, birth defects, infections, and sepsis—and an assessment of the availability of relevant programmatic and regulatory tools. Technical resources, including advocacy and training materials and evidence-based clinical guidelines, were developed. In addition to the more general workshops, training of trainers took place in Colombia, Ecuador, and Guatemala. These activities were carried out in coordination with experts and partners, including WHO, UNICEF, and the March of Dimes. These efforts resulted in more than 350 nurses, neonatologists, pediatricians, ophthalmologists, and general practitioners receiving virtual and face-to-face training in the different topics; development of a guideline on retinopathy of prematurity in English and Spanish, and its dissemination through webinars and workshops at country level; and development of an evidence-based guideline on caring for extremely premature newborns with risk conditions. This last guideline was formulated with the contributions of 45 experts from 15 countries, and is in the final validation process.
Technical cooperation over the review period also included preparation of an advocacy document promoting surveillance for birth defects, given that these are the second-most prevalent cause of neonatal and infant mortality; training for the establishment of national surveillance systems for birth defects, including those linked to the Zika virus; mapping of the availability and characteristics of the surveillance systems; development and dissemination of tools for the coding and registration of birth defects using the Perinatal Information System (SIP); and preparation of a regional report presenting the current situation and the challenges to be addressed in the short and medium term. Two additional countries—El Salvador and Panama—established national birth defects surveillance systems and are producing data, while four countries—Barbados, Ecuador, Peru, and Saint Vincent and the Grenadines—are in the process of establishing the surveillance system. These activities were executed in coordination with partners such as the United States Centers for Disease Control and Prevention (U.S. CDC), the World Bank, and the International Clearinghouse for Birth Defects Surveillance and Research (ICBDSR) and through interagency coordination involving primarily WHO and USAID.
During the period under review, the Bureau undertook direct technical cooperation at national and/or institutional level related to the SIP, including convening two subregional meetings in Barbados and Trinidad and Tobago that included participants from 15 Caribbean countries and territories; visits to 12 countries; and provision of remote virtual support to the countries regarding information technology issues and SIP implementation.
A major achievement in the period under review was the finalization and implementation of SIP Plus, a web-based version of the SIP. SIP Plus increases accessibility to data entry from distant services at the first level of care and makes individual patient data available at all times, at all levels of care, through the internet or national governmental networks. The new SIP Plus version is being customized to country specificities, while maintaining a basic regional standard of data. In July 2018, the Ministry of Health of Trinidad and Tobago mandated that the SIP Plus Perinatal Record replace all current antenatal record forms, in both the public and private sectors, and in March 2019, SIP data were used to validate perinatal care in Uruguay.
PASB’s interprogrammatic work resulted in the development of a series of automatic reports that can be generated from SIP Plus data with “one click.” The Bureau provided training materials and courses at country level to make this user-friendly analysis accessible to all health care professionals. In some countries, SIP Plus was integrated into the undergraduate and postgraduate curricula of medical, midwifery, and nursing schools. SIP Plus can be embedded in national data networks and linked with multisectoral databanks, providing an opportunity to trace trends in cohorts of individuals, contribute to better understanding of gaps in population health, and improve the monitoring of health policies and services. This compatibility and the resulting increase in capacities for statistical analysis are supportive of SHAA2030 Goal 6 and Goal 7, which address, respectively, IS4H and evidence and knowledge in health.
The framework for the EMTCT of HIV, syphilis, hepatitis B, and Chagas disease (EMTCT Plus) was launched in 2017, aiming to have new generations free of the four diseases. The framework provides a road map with public health interventions targeting women before and during pregnancy, their partners, and new mothers and their babies.
The first EMTCT Plus report, the result of collaboration between PASB and UNICEF, was launched in April 2019. It describes the progress made in the Americas towards the EMTCT of HIV and syphilis between 2010 and 2017, and, for the first time, presents the baseline situation in the Region for congenital Chagas disease and hepatitis B among children. The report showed that access to prenatal and delivery care remained high in the Americas, with 89 percent of pregnant women having attended four or more antenatal care visits and 95 percent having had hospital delivery. Screening of pregnant women for HIV and syphilis also remained high, with an estimated 73 percent of all pregnant women with HIV infection and 87 percent of syphilis-positive pregnant women attending antenatal care.
PASB provided technical cooperation for the maintenance of EMTCT of HIV and syphilis in Anguilla, Antigua and Barbuda, Bermuda, Cayman Islands, Cuba, Montserrat, and Saint Kitts and Nevis, which were EMTCT-certified by WHO during 2015 and 2017, and require validation of the elimination status every two years. For that reason, and for upcoming EMTCT certification of additional countries, PASB maintains the structure of the Regional Validation Committee. The Bureau evaluated improvements in congenital syphilis elimination in the Region and published a related paper in the Pan American Journal of Public Health in April 2019.
Improving maternal and child health in Chocó, Colombia.
In 2017 to 2018, an initiative was implemented in post-conflict areas of the Colombian department of Chocó, to expand actions for the improvement of maternal and child health and the reduction of maternal and neonatal mortality. The project targeted more than 30,000 women of reproductive age, 8,000 female adolescents, and more than 3,000 newborns in Chocó, where 83 percent of the population is Afro-descendant and 12 percent is indigenous, with a potential beneficiary population reach of 65,738 children under 5 years of age and 150,570 women of childbearing age.
The initiative, supported by Global Affairs Canada, provided direct support to both national and local authorities, and included active community participation. It comprised two phases: 1) provision of support to professionals at health facilities, focusing on resuscitation and early care of newborns, and 2) work at community level, promoting actions for improving and/or maintaining maternal health and delivering healthy newborns, with the comprehensive participation of women, men, and adolescents.
All professional health workers—including obstetricians and gynecologists, pediatricians, general practitioners, and nurses—in Quibdó and other municipalities of Chocó were trained to manage obstetric and neonatal emergencies, and the regional referral hospital in Quibdó received materials and devices for local replication of the training. In addition, all traditional birth attendants, community health workers, and community leaders in Chocó were trained in methods of improving antenatal and intrapartum care, and received low-cost tools developed exclusively for the project to identify high-risk patients among women planning to have home deliveries.
Since the project began, no maternal death due to hemorrhage has been recorded. The use of new technologies and medical devices in complicated pregnancies increased from zero to 100 percent, and at the community level a plan to improve maternal and perinatal health was developed with the participation of women, men, traditional midwives, community health workers, and other community members. The increased knowledge of recommendations based on evidence has had a positive impact at the community level, and mechanisms were put in place for empowerment to ensure a woman’s right to accompaniment during delivery. Local authorities considered the project to be one of the most productive implemented in this underserved region.
The Crianҫa Feliz program in Brazil
Brazil’s Crianҫa Feliz (“Happy Children”) program, launched in 2017, is an ambitious multisector initiative targeting families living in poverty who are part of the Government cash transfer program known as “Bolsa Família.” Crianҫa Feliz provides regular home visits starting in a woman’s pregnancy and continuing throughout the first 3 years of a child’s life, aiming to increase parents’ capacity to provide a nurturing, caring, stimulating, and safe environment for children and connect families with health and other social services. The core element of Crianҫa Feliz is the WHO-UNICEF parenting intervention known as “Care for Child Development (CCD).” During 2018, PASB mobilized experts from throughout the Region to train a core group of Brazilian personnel to roll out the CCD model at the state level. The Bureau supported the design of materials to introduce the model’s key concepts to state-level actors, organized meetings for the exchange of experiences, and provided continuous support to the program’s managers and technical team.
As of mid-2019, Crianҫa Feliz had been implemented in 2,600 of the country’s 5,500 municipalities, and more than 400,000 families were receiving home visits, including 80,000 pregnant women. As a means of evaluation, the Federal University of Pelotas initiated collection of baseline data for a randomized controlled trial comparing states with and without the program. PASB will continue to support the Brazilian authorities responsible for the Crianҫa Feliz program and focus on increasing the engagement of the Ministry of Health. Documentation of this experience will provide important lessons for other countries in the Americas, and globally.
Interventions for sexual and reproductive health are commonly implemented through programs on maternal and adolescent health; prevention and control of HIV and sexually transmitted infections (STIs); prevention and control of NCDs, with emphasis on reproductive tract cancer prevention, screening, and treatment; and reduction of gender inequities. Much of PASB’s technical cooperation in improving sexual and reproductive health in the Region over the reporting period is described in sections related to these issues; the following paragraphs provide additional information.
The Global Strategy for Women’s, Children’s, and Adolescents’ Health 2016-2030 includes attention to sexual and reproductive health and rights, promoting healthy sexual lives and access to a range of reproductive options for all people, with women having access to family planning and other reproductive health services and commodities. It is estimated that about
2 percent of women in LAC initiate sexual activity before age 15 years, and LAC is the only area in the world where the estimated number of pregnancies among girls under 15 years of age is increasing. Adolescents continue to face legal, societal, policy, and health system–related barriers that deny them access to confidential and quality sexual and reproductive health services and commodities.
PASB promoted the availability and accessibility of health services that are adolescent-friendly, and in 2018, the Bureau supported Honduras’ use of the WHO Innov8 tool to review its National Plan to Reduce Adolescent Pregnancies. The support included a sensitization meeting on the Innov8 approach, ongoing virtual support to the national team, and a working session with national health authorities to finalize the evaluation and redesign of the national plan. The Bureau also undertook technical cooperation with the Dominican Republic—the country with the highest adolescent fertility rate in the Region—for equity-based analysis of the status of adolescent pregnancy and to develop a new adolescent pregnancy prevention plan.
In Colombia, the “Health for Peace” UN interagency project, implemented through a partnership among PAHO/WHO, UNFPA, the International Organization for Migration (IOM) and the Ministry of Health, with funding from the UN Post-Conflict Multi-Partner Trust Fund (MPTF), built the capacity of health professionals in health centers and health posts to improve and expand sexual and reproductive health services, with an emphasis on preventing gender-based violence and pregnancy in adolescent girls.
SHAA2030 Goal 2:
Stewardship and governance of health
Strengthening national health authorities’ stewardship and governance of public health systems is essential to address barriers to access, overcome fragmentation and segmentation in the health systems, and advance to UH. “Strengthening of public health regulation and enforcement capacity” was one of the 11 EPHFs defined in 2000 to measure health system performance as part of the Public Health in the Americas initiative. In August 2018, PASB convened representatives from 15 schools of public health in 11 countries to review a renewed EPHF conceptual framework for the Americas. This resulted in increased collaboration among PASB, ministries of health, and academic institutions to strengthen health systems that ensure and prioritize the delivery of integrated, comprehensive public health actions. The review was the final step in the consultation process for revision of the EPHF conceptual framework, and the revised framework is scheduled for publication in the second semester of 2019.
The strengthening of legal frameworks and the overall legal capacities of health systems is key to enhancing stewardship and governance. PASB supported El Salvador, which sponsored the 2015 regional Strategy on Health-related Law (Document CD54/14, Rev. 1), in developing a next-generation legislation framework for constructing an integrated health system. The legislation includes regulations to measure and improve quality in essential health care services, including access to safe, effective, quality, and affordable medicines and vaccines for all, with a community-based primary care approach and guaranteed social participation. The law also strengthens the stewardship role of the Ministry of Health, consolidates the work of diverse and fragmented institutions, and provides a path for participatory national health policy planning. It also provides a wide array of tools for the integration and interaction of different institutions in the national health system.
At subregional level, in 2019 PASB presented a follow-up initiative to an agreement signed by the PARLACEN in 2015 to harmonize and strengthen legal frameworks for health in alignment with the regional Strategy on Health-related Law. The follow-up initiative includes a model law and guidance for legislative revision in each Central American country and the Dominican Republic. Discussions were initiated with the Andean and Southern Common Market (MERCOSUR) parliaments regarding similar strategies.
The Bureau promoted the right to health and exchange of legislative best practices during the 4th Congress of the Health Committees of the Parliaments of the Americas. More than 35 legislators from 13 countries shared their experiences, with the aim of harmonizing national health-related legislation with PAHO policies and strategies on UH and international human rights instruments.
SHAA2030 Goal 3:
Human resources for health
Noting the need to expand the availability of qualified HRH for the transformation of health systems in the Americas, in September 2018 the 56th PAHO Directing Council approved the Plan of Action for Human Resources for Universal Access to Health and Universal Health Coverage 2018-2023 (Document CD56/10, Rev. 1). The Plan of Action provides a comprehensive analysis of the health work force in the Americas, based on the Strategy on Human Resources for Universal Access to Health and Universal Health Coverage (Document CSP29/10) that was approved by the 29th Pan American Sanitary Conference in September 2017; extensive input from Member States; and three subregional consultations. It specifically notes the need to ensure that gender, ethnicity, migration, and human rights issues are considered in health workforce policies and plans.
One of the major challenges facing the Region of the Americas is the deployment of multidisciplinary teams at the first level of care to address the needs of vulnerable populations in underserved areas. Ten countries—Belize, Dominica, El Salvador, Guatemala, Guyana, Haiti, Honduras, Nicaragua, Paraguay, and Suriname—participated in a PASB-coordinated workshop held in Washington, D.C., in October 2018, on National Health Workforce Accounts (NHWAs) that was intended to improve management skills, data generation, and workforce planning. Subsequently, PASB organized intersectoral workshops for capacity-building in workforce planning in four countries—Belize, Guatemala, Paraguay, and Suriname—and worked with Belize to develop that country’s Strategic Plan on Human Resources for Universal Health 2019-2024. The Bureau also collaborated with Member States to advance health workforce planning based on scenario modeling and competencies, and rolled out an initiative on managing workforce data and integrating the NHWAs for policy development and planning based on the needs of the whole health system.
The Strategy on Human Resources for Universal Access to Health and Universal Health Coverage notes that within the Region, though education in the health sciences has grown exponentially in the past few decades, there is insufficient regulation of related processes, with resulting concerns about the quality of training, the relevance of many academic programs, and professional practice. However, an increasing number of training institutions are redefining their social responsibilities and commitment to the communities they serve by developing professional profiles consistent with the health needs of the population and demonstrating their social accountability. In late 2018, the Bureau finalized a new Indicators for Social Accountability Tool (ISAT) that can be used to monitor the advancement of a social mission in professional education for health. In March 2019, PASB participated in the 21st Pan American Conference on Medical Education in Cartagena, Colombia, and collaborated in the development of the Cartagena Declaration on Medical Education and Social Accountability, linking the challenges of medical education to the PHC strategy.
With PASB’s support, Argentina organized a regional meeting of the Regional Network for Interprofessional Education in the Americas (REIP) in 2018, where representatives from 15 countries discussed implementation of the network’s guidelines and biennial work plan 2018-2019. The Regional Network was established with the support of the ministries of health of Argentina, Brazil, and Chile during a regional technical meeting on interprofessional education (IPE) held in Brasilia in December 2017, and has promoted several webinars and produced technical documents to help countries to develop their own IPE plans. As of mid-2019, 19 countries had plans to implement strategies for IPE and collaborative practice in health.
In order to address and improve the skills mix within health systems, PASB launched an Advanced Nurse Practice initiative as part of interprofessional education and collaborative practice in six countries: Brazil, Colombia, Chile, Mexico, Peru, and Uruguay. The Bureau also developed the document Strategic Directions for Nursing in the Region of the Americas, which was launched on International Nurses’ Day in May 2019.
The mobility of HRH continues in the Region, from rural to urban areas and from less well-resourced countries to better-resourced ones. PASB worked with 12 countries adversely affected by health workforce mobility to develop strategies to improve planning and forecasting related to HRH, and retention of the existing work force. As part of this process, and in order to achieve the goals established in the Plan of Action on Human Resources for Universal Access to Health and Universal Health Coverage 2018-2023, the Bureau supported the development of advanced intersectoral strategic health workforce plans in five countries: Belize, Costa Rica, Guatemala, Paraguay, and Suriname.
In the Caribbean subregion, the Bureau cooperated with the Caribbean Regional Nursing Body in the finalization of the Regional Strategic Plan for Nursing and Midwifery 2020-2024 and finalized a study on migration of the health work force in the Caribbean. Twenty-six countries and territories participated in the study, the preliminary findings of which were presented to the Caucus of CARICOM Ministers of Health in September 2018, prior to 56th Directing Council of PAHO. The results showed that almost 60 percent of the health professionals who are still residing in their home countries and who participated in the study stated that they would migrate if given the opportunity. The number of places available in nursing schools in the Caribbean subregion is estimated to be sufficient to meet the needs of the subregion, but shortages of nurses result from an attrition rate of 55 percent during training and the migration to other countries of 73 percent of those who graduate. These findings highlight challenges that Caribbean countries face with health workforce education and retention, especially regarding specialized nursing; health workforce planning; and regulation of migration. PASB worked with countries in the subregion to address these issues, supporting the development and implementation of integrated HRH plans, with notable progress made in Antigua and Barbuda, Dominica, Saint Kitts and Nevis, and Saint Vincent and the Grenadines.
In January 2019, PASB collaborated with the High Council of Central American Universities (CSUCA) and SE-COMISCA, the Executive Secretary of the Council of Ministers of Health of Central America and the Dominican Republic (COMISCA), to prepare a road map for the accreditation of careers in health in Central America and the Dominican Republic, with a focus on family and community health programs. SE-COMISCA and the General Secretariat of CSUCA also signed a memorandum of understanding that included the development and professional training of HRH in the Central American subregion, and identified strategic lines of action. The latter include adaptation to health sector programs of the qualifications framework for higher education; identification of the criteria and process for accreditation of professional and technical careers in health; harmonization of subregional health curricula; and mobility of health professionals in Central America and the Dominican Republic. By April 2019, this subregional initiative resulted in a mapping of family and community health training programs in eight countries—Belize, Costa Rica, Dominican Republic, El Salvador, Guatemala, Honduras, Nicaragua, and Panama—and defined a pool of competencies for the first level of care and family health physicians. A proposal for the phased implementation of a health career pathway was completed and validated by the countries.
Also in Central America, work began on a multicentric study of factors that influence career choices at the first level of care among social service physicians. The sample includes 2,545 interns and social service physicians from more than 25 schools of medicine in Costa Rica, El Salvador, Guatemala, Honduras, and Nicaragua.
In the South American subregion, PASB’s technical cooperation provided opportunities for South-South cooperation and exchange of experiences to facilitate implementation of the regional Plan of Action on Human Resources for Universal Access to Health and Universal Health Coverage 2018-2023. These opportunities included:
a) A meeting of human resources observatories in the subregion, held in Uruguay in August 2018.
b) A workshop on implementation of the Plan of Action for Human Resources for Universal Health for South American countries, held in Peru in November 2018.
c) The launch of a new Latin American Network of Schools of Public Health during the 5th International Medical Education Conference in Peru in May 2019. The network includes both undergraduate and graduate institutions, and will draw on the experiences of the Network of Schools of Public Health (RESP) of the Union of South American Nations (UNASUR). PASB facilitated efforts by the new network to review public health teaching methods in the Region and to support the implementation, monitoring, and evaluation of the Strategy for Universal Access to Health and Universal Health Coverage in the Americas.
d) A meeting on information systems, regulation of professional practice, and planning of medical residencies, held in Argentina in June 2019.
The Virtual Campus for Public Health continued its functions as a valued resource for learning. A total of 40 countries and territories participated in continuing education strategies and programs for health personnel through the VCPH or equivalent e-learning networks, and as of December 2018, the VCPH had reached 550,000 users.
SHAA 2030 Goal 4:
Within a macroeconomic context that is limiting the availability of financial resources for health systems and services in many countries, especially in small island developing States (SIDS), there has been renewed focus on examining financing strategies, fiscal space for health, and opportunities for efficiency gains within health systems and services. Only four countries—Canada, Cuba, United States of America, and Uruguay—have reached and maintained the goal of 6 percent of GDP dedicated to heath financing, the level generally considered necessary to achieve universal health.
Average out-of-pocket spending on health remains high in the Region, constituting nearly one-third of total expenditure on health. Most Member States do not have coverage schemes to provide all essential medicines without direct payment at the point of service, and out-of-pocket payments for medicines and health technologies range from 30 to 70 percent of overall out-of-pocket spending for health. This is the second-largest item—after human resources—in public health budgets, and constitutes a major barrier to access to needed health services for a significant portion of the population, with many families facing an ongoing risk of falling into poverty as result of catastrophic health expenses.
Several countries, including Anguilla, Antigua and Barbuda, Bahamas, Grenada, and Jamaica, began discussing health financing reforms, including the option of implementing national health insurance (NHI) programs. By mid-2019, Anguilla had completed draft NHI legislation; Antigua and Barbuda developed its System of Health Accounts, supported by collaboration between the Bureau and the Health Economics Unit (HEU) at the University of the West Indies (UWI) St. Augustine Campus in Trinidad and Tobago; Grenada had reviewed its package of benefits, as well as funding sources and the governance framework for the NHI; and Saint Kitts and Nevis had initiated an actuarial assessment of its NHI package of benefits.
PASB coordinated a Caribbean Subregional Dialogue on Health Financing, held in Barbados in August 2018, in support of CARICOM Member States’ commitment to advance to UH. The Subregional Dialogue brought together high-level government officials from CARICOM countries, representatives from the main Caribbean subregional institutions, and international experts to discuss challenges in financing health services in the Caribbean and identify opportunities for strengthening subregional collaboration on the issue. PASB’s technical cooperation on payment systems for IHSDNs continued, with the goal of reducing fragmentation by implementing financing mechanisms to promote IHSDNs based on the PHC strategy.
SHAA2030 Goal 5:
Essential medicines, vaccines, and technologies
Member States continued to make important advances in building the capacity of regulatory systems and in developing medicines and health technologies as core strategies to increase access to medicines and technologies that meet international standards in quality, safety, and efficacy.
By mid-2019, the Caribbean Regulatory System (CRS), an innovative subregional regulatory body for the Caribbean managed by the Caribbean Public Health Agency (CARPHA) and established with PASB’s technical cooperation, had registered or tentatively registered
37 products, and was on pace to add 60 recommended medicines during 2019, almost twice the total recommended medicines in 2017 and 2018. The approved medicines included a cure for hepatitis C contained in the WHO Essential Medicines List, and a number of medications for NCDs. By June 2019, the CRS had received nearly 200 reports of adverse events and substandard and falsified medicines through VigiCarib, its pharmacovigilance and post-market surveillance program. Like the CRS itself, VigiCarib was developed on the premise that a regional approach would facilitate pooling of resources, sharing of information, coordination of activities, and efficiencies of scale in CARICOM Member States, and contribute to overall health system strengthening.
The CRS is increasingly recognized as an effective model for SIDS with limited human resources. In February 2019, PASB and CARICOM presented the CRS initiative to ministers of health of the Pacific Islands at a meeting convened by the WHO Regional Office for the Western Pacific (WPRO) in Fiji. Based on the CRS experience, the Pacific Islands decided to move forward with their own regional regulatory approach, looking to CARICOM as a leader in this area.
In August 2018, as part of efforts to strengthen the drug regulatory agencies in Central America and the Dominican Republic, a pilot project was initiated for the joint review of drug dossiers. The project brought together technical personnel from each country’s drug regulatory agency, with the goal of improving the registration process for new pharmaceutical products in the Central American subregion and creating synergies to increase access to safe and effective medications. The pilot project was supported by PASB, USAID, and the World Bank.
PASB collaborated with WHO to produce the first Global Benchmarking Tool (GBT) to evaluate national drug regulatory capacity. GBT will allow countries around the world to identify strengths and gaps in their regulatory capacities and to prioritize critical areas for systematic and transparent institutional development. The GBT utilizes elements of PASB’s own regional tool, which has been applied to regulatory systems in the Americas over the past 10 years and which was improved through extensive consultations with drug regulatory authorities from around the world. In April 2019, a pilot application of the GBT was concluded in El Salvador, yielding results that will be used to validate the tool and methodology throughout the Region.
PASB organized the 9th Conference of the Pan American Network for Drug Regulatory Harmonization (PANDRH) in El Salvador in October 2018, with the theme of “Commemorating 20 years of PANDRH and 40 years of Alma-Ata: the contributions of regulatory harmonization to achieving Health for All.” Two hundred participants attended from various sectors and institutions, including WHO, PAHO, national regulatory authorities, the pharmaceutical industry, nongovernmental organizations (NGOs), and professional associations. PANDRH Member States adopted concept notes and recommendations on the current state of the regulation of advanced therapy medicinal products, regulatory reliance principles, and regulatory systems models for small states/markets with limited resources. The documents provide valuable guidance for countries in their efforts to strengthen pharmaceutical quality, safety, efficacy, and regulatory systems.
In a related effort, PASB organized a pricing network meeting for Member States that are part of the Health Technology Assessment Network of the Americas (RedETSA). Held in Buenos Aires in November 2018, the meeting focused on the role of health technology assessment in expanding effective and equitable access to medicines. PASB also developed a list of priority medical devices for the first level of care—the first such list—to guide countries in the rational selection and use of medical devices. The list comprises 257 medical devices identified through an evidence-based approach that was validated by Member States. The objectives are to increase the availability of these devices at the first level of care and ensure the responsiveness of the health centers within IHSDNs. The Bureau also proposed a new model for the assessment, selection, incorporation, prescription, dispensing, rational use, and monitoring of medicines and health technologies; the model is being piloted in Paraguay.
In order to contribute to improvements in quality and safety, PASB’s technical cooperation enabled assessments of radiotherapy services, which were completed in 17 countries in 2018. In Belize, PASB partnered with the International Atomic Energy Agency (IAEA) for an assessment of radiology quality control standards and radiation safety risk, with a view to enhancing radiology services and radiation protection in the country.
The PAHO Strategic Fund supported negotiations—led by MERCOSUR—with manufacturers of HCV medicines that resulted in reductions of up to 40 percent in the cost of one of the critical antiviral medicines. The Strategic Fund also collaborated with MERCOSUR Member States on a negotiating strategy for 2019 to procure HCV and oncological medicines.
Immunization remains a flagship program in the PHC strategy and is a driving force for UH. In 2018, regional vaccination coverage for the third dose of the diphtheria, tetanus, and pertussis (DPT) vaccine remained at 88 percent, and 22 countries and territories increased their vaccination coverages from the 2017 levels.
PASB’s technical cooperation during the review period sought to maintain quality immunization programs and included regional workshops on the rapid response to measles, rubella, or polio outbreaks; yellow fever; and timely and quality notification through the PAHO/WHO-UNICEF Joint Reporting Form. At subregional level, there was a training workshop for all managers of the Expanded Program on Immunization (EPI) in the Caribbean, and in-country activities took place in 22 countries and territories to build national capacity in areas such as cold chain and effective vaccine management; data quality assessment; vaccination in large cities;
EPI planning and operation; and electronic immunization registries.
Four countries added new vaccines to their national immunization schedules during the reporting period: Guatemala introduced the HPV vaccine and Haiti introduced the pneumococcal vaccine in 2018, while Saint Lucia and the Turks and Caicos Islands introduced the HPV vaccine in 2019. A total of 40 countries and territories in the Region are now using the HPV vaccine. Despite that progress with the HPV vaccine, in 2019, one of the two global suppliers announced its exit from the regional and global markets, leaving only one source of supply for the vaccine, at least until 2022. This market situation gives cause for concern regarding the supply and price of the vaccine. Vaccine hesitancy in relation to HPV vaccine also presents a challenge, with less than optimal uptake of the vaccine despite the increases noted. PASB will continue its close working relationships with countries to prevent HPV vaccine stockouts and to strengthen its evidence-based advocacy for increased uptake of the vaccine.
Evaluations were conducted of the British Virgin Islands immunization program, the National Immunization Technical Advisory Group in Chile (CAVEI), and the PAHO regional immunization program (RIP).
a) The evaluation in the British Virgin Islands made recommendations for improvements in immunization logistics and cold chain, training of health workers, implementation of an electronic immunization registry (EIR), and development of strategies for communication and social mobilization.
b) The evaluation in Chile recommended that CAVEI seek to increase its own visibility and public awareness of its work to boost vaccine acceptance and confidence by the community and health care practitioners.
c) The RIP evaluation, undertaken by an independent external committee, recommended that the RIP be more assertive in promoting vaccination and more responsive to the arguments of vaccine hesitancy groups; assess needs and improve training and incentives for its staff; perform evaluations of country immunization programs more frequently, particularly in Key Countries; and review its financial arrangements, especially the relative contributions of external donors and the Organization, and possibly seek new funds from both old and new partners.
PASB mounted an extensive response in the field to outbreaks of vaccine-preventable diseases in the Region. This included technical cooperation with the Bolivarian Republic of Venezuela (hereafter, Venezuela) to develop a broad-reaching vaccination campaign that immunized close to 9 million children aged 1 to 4 years. PASB mobilized technical experts to assist the response to outbreaks, including measles in Argentina, Brazil, Colombia, Ecuador, Peru, and Venezuela; diphtheria in Haiti and Venezuela; and yellow fever in Brazil. The Bureau also worked with health authorities in all countries in LAC to enhance preparedness for potential outbreaks. In addition to ministries of health, partners in this work included the Global Initiative for the Elimination of Measles and Rubella, the U.S. CDC, and UNICEF. PASB mobilized approximately US$ 9 million to support these activities.
PASB’s flagship Vaccination Week in the Americas (VWA) initiative celebrated its 17th anniversary in April 2019 under the theme of “Protect your community. Do your part.” During that celebration, 65 million people were vaccinated in 45 countries and territories. Given the resurgence of measles in the Region, VWA 2019 took on special urgency. For example, the U.S. CDC indicated that 981 individual cases of measles had occurred in 26 states over the period 1 January to 31 May 2019, the largest number of cases reported in the United States of America since 1992 and since measles was declared eliminated in 2000. Other highlights of VWA 2019 included:
a) Administration of 450,000 doses of measles vaccine through an array of activities that included “mop-up” campaigns and other vaccination activities reported from 23 countries and territories, including targeting high-risk groups.
b) Implementation of a mass immunization campaign against influenza in Brazil—the site of the regional VWA launch—that reached 59 million people. Additionally, some 3,500 health professionals administered both influenza and routine vaccines in indigenous communities, with the goal of ensuring that nearly 700,000 children and adults in these areas were up to date with recommended immunization schedules.
c) Implementation of influenza campaigns in 13 other countries, in anticipation of increased circulation of the influenza virus in subsequent months.
d) Administration of yellow fever vaccine in at-risk areas in at least four countries—Bolivia, Brazil, Colombia, and Ecuador.
e) Vaccination of adolescents against HPV in 16 countries and territories.
f) Special efforts to vaccinate populations in conditions of vulnerability, including pregnant and postpartum women, health workers, older adults, indigenous populations, individuals with chronic diseases, and prisoners and prison workers, in 17 countries and territories.
PASB negotiated and finalized an important agreement with the University of Texas Medical Branch for the administration of a patent that protects a breakthrough Zika vaccine. The Bureau also provided legal support to expand country participation in the PAHO Revolving Fund and the PAHO Strategic Fund, including ongoing negotiations with Mexico, certain provinces in Argentina, and several governmental entities in Colombia.
SHAA2030 Goal 6:
Information systems for health
In continued recognition of the ever-expanding need for and critical importance of timely, quality, updated health and health-related information, PASB maintained its technical cooperation to advance the IS4H framework. The framework was launched in 2016 to address the need for subnational data to monitor the health-related SDG targets and, more generally, to ensure that policy- and decisionmakers have the data they need to formulate health interventions that truly "leave no one behind."
During the reporting period, PASB collaborated with the CARICOM-supported IS4H Technical Working Group to produce a road map for improving the Caribbean subregion’s health information systems. The road map was subsequently endorsed by CARICOM and the Council of Ministers of the Organization of Eastern Caribbean States (OECS).
Following a call for IS4H proposals, PASB awarded grants to 36 grantees from 27 countries and territories to implement projects in 2019 aimed at making information systems more interoperable and interconnected. The Latin American and Caribbean Network for the Strengthening of Health Information Systems (RELACSIS) leveraged its alliances and partners throughout the Americas to ensure that IS4H-related technical information and webinars were disseminated free of charge to network members and other audiences. This action provided Member States with a medium for sharing successful practices and receiving information on PASB-recommended methodologies, tools, policies, and strategies related to IS4H.
Within the same framework, PASB worked with 15 countries and territories to apply the IS4H maturity assessment tool and formulate recommendations for improving their health information systems. PASB also collaborated with the Inter-American Development Bank (IDB) to use the IS4H maturity assessment tool to direct investments for information systems and digital health. Other partners in these efforts included USAID; GAC; the Italian Hospital of Buenos Aires, which is a WHO Collaborating Center; and academic partners, including the University of Illinois, the University of Utah, and Harvard University.
Vital registration data comprise important components of IS4H, but are often inaccurate and incomplete. During the period under review, the Bureau organized five regional trainings and three virtual courses for 500 coders working in vital registration in Latin American countries. The learning interventions included a November 2018 training for coders from 19 countries to conduct intentional searches for maternal deaths among all sources of death registration within countries—that is, an audit of death certificates—in order to identify maternal deaths that were not originally included in the total count. The training used the methodology for the Deliberate Search and Reclassification of Maternal Deaths (BIRMM) that was developed by Mexican Center for the Classification of Diseases (CEMECE), which is a WHO Collaborating Center for the Family of International Classifications.
Two regional workshops—in August 2018 with 16 countries and March 2019 with 12 countries—trained professionals from ministries of health and national statistics offices in a methodology used by the UN Maternal Mortality Estimation Inter-agency Group (UN MMEIG) to estimate maternal mortality and by the UN Inter-Agency Group for Child Mortality Estimates to measure stillbirths and child mortality. Following the training, PASB engaged national teams from targeted countries to identify strategies for strengthening the quality and coverage of data to better inform governments’ interventions and UN estimates.
Both the SHAA2030 and the 2030 Agenda for Sustainable Development call on Member States to monitor both national and subnational progress towards the respective goals and targets for improving the health and well-being of all populations. The global SDG mandate has presented significant challenges for PASB and the countries of the Americas, since the Bureau’s ongoing data collection through the Regional Core Health Data Initiative does not cover 10 of the 27 SDG 3 indicators, and many countries do not collect subnational data disaggregated by key sociodemographic stratifiers. Progress toward the SHAA2030 goals will be tracked primarily through the impact and outcome indicators of the proposed PAHO Strategic Plan 2020-2025, which were identified in consultation with the 21-member Strategic Plan Advisory
Group (SPAG) and which will be presented for approval by the 57th Directing Council in September 2019.
The Health Information Platform for the Americas (PLISA) is the Organization’s repository for data collected on 170 core health indicators (365 when disaggregated); mortality data shared by Member States; and health issues ranging from antimicrobial resistance to immunizations. PLISA underwent improvements during the reporting period, allowing countries to exchange epidemiological data, leverage their analysis capabilities for dengue and Zika, and follow up on key indicators, including the case fatality rate for dengue. Ongoing efforts are focused on expanding PLISA’s capacity to include epidemiological information on chikungunya, leishmaniasis, malaria, and other vector-borne diseases.
SHAA2030 Goal 7:
Evidence and knowledge in health
During the review period, PASB continued its technical cooperation to facilitate and enable evidence-based policy development, decision-making, and planning, spearheaded by the Latin America and Caribbean Center of Health Sciences (BIREME), a PAHO specialized center located in Brazil.
An additional 35,000 new documents were indexed into LILACS, PAHO’s bibliographic index of the Region’s scientific and technical health literature, and over 20,000 terms updated in English, French, Spanish, and Portuguese in DeCS, the Organization’s vocabulary for indexing scientific information. LILACS served as a cornerstone for two new virtual health libraries:
a) The Virtual Health Library (VHL) on Traditional, Complementary, and Integrative Medicine (VHL-TCIM) was launched in December 2018 in recognition of the importance of traditional medicine to inclusive intercultural approaches. The VHL-TCIM promotes the visibility, access, use, and development of scientific information and educational materials on intercultural and inclusive health system models. This is exemplified by PASB’s interprogrammatic development of an initiative to integrate indigenous traditional knowledge into disaster risk reduction, along with a corresponding regional network that includes indigenous peoples.
b) The CARPHA EvIDeNCe Portal was established to serve as a live repository for research, syntheses, and policy-relevant documents and health information to support evidence-informed decision-making in the Caribbean. The Bureau presented the Portal at the
49th Conference of the Association of Caribbean University, Research, and Institutional Libraries (ACURIL) in June 2019.
The International Database of GRADE Guidelines (BIGG), a database of new evidence, was launched in 2018. BIGG gathers public health and practice evidence-informed guidelines produced by WHO, PAHO, government institutions, and national and international scientific associations in several countries that meet PAHO/WHO-recommended standards. BIGG was integrated into the PAHO VHL, with more than 600 indexed guidelines and links to the full text, offering high-quality, evidence-informed recommendations for public health and its practice. Also in 2018, a new interoperability framework was developed that facilitates the continuous updating of the Global Index Medicus (GIM) with technical and scientific literature from across WHO regions; the GIM portal is expected to be revamped in late 2019.
The Repository of Legislation on Risk Factors in NCDs was launched in August 2018. The Repository provides access to the legal frameworks that countries have developed to combat chronic diseases. It has demonstrated benefits in systematizing the organization and monitoring of and access to NCD-related legislation in Member States. It aims to strengthen stewardship and governance in advancing to UH, and also provides a model for collating health legislation.
Within the framework of the regional program for research in tropical diseases/PAHO Small Grants Program, the Bureau strengthened countries’ capacity to conduct implementation research. In the reporting period, five implementation research projects were approved and funded for tuberculosis, malaria, and leishmaniasis. The Bureau also implemented the TDR Structured Operational Research and Training Initiative (SORT IT), which aims to improve the capacity of national public health workers in protocol design and writing, data analysis, scientific writing, and results dissemination. During the reporting period, training was conducted for public health workers in Ecuador, Paraguay, and Uruguay through integrated operational research and capacity-building related to disease-specific programs and health systems.
Starting in mid-2018, PASB, in collaboration with Mexico’s CEMECE, UNICEF, UN MMEIG, USAID, and Argentina’s Ministry of Health:
a) coordinated a series of virtual and in-person sessions with six Central American countries—Costa Rica, El Salvador, Guatemala, Honduras, Nicaragua, and Panama—to build health professionals’ capacity to analyze vital statistics data and address data quality challenges, with a special emphasis on mortality-related SDG indicators;
b) worked with four countries—Bolivia, Colombia, Dominican Republic, and Ecuador—to enhance health professionals’ knowledge of the methodology for estimating and analyzing infant, neonatal, and maternal mortality at national and subnational levels;
c) trained professionals from ministries of health and national statistics offices in 20 Member States to establish targets and analyze subnational data to determine social inequities related to SHAA2030 and SDG indicators.
SHAA2030 Goal 8:
Outbreaks, emergencies, and disasters
Advances continued in the institutionalization of disaster management programs. As of the end of 2018, 26 countries and territories had a formal health disaster management program;29 had a health emergency response plan; 23 had health emergency response teams in place; 27 had health emergency operations centers; and 30 had a national emergency coordination committee within the ministry of health. However, despite notable progress, gaps still remain. For example, of the 26 countries and territories with formally established disaster programs, only 20 have programs that are staffed full-time and have a dedicated budget.
Over the period under review, PASB continued—and enhanced, where needed—its technical cooperation with countries facing disasters due to natural hazards or other emergencies, including issues related to mass migration, climate change, and disease outbreaks. These responses covered immediate and ongoing situations, post-event and recovery phases, and climate change adaptation. The responses involved collaboration with national health and other authorities, and regional and international partners, to identify and fill gaps, and build national and subnational capacities to mitigate and respond to various scenarios.
PASB’s work to improve Member States’ resilience to emergencies and disasters was undertaken in collaboration with key partners, including the Spanish Agency for International Development Cooperation (AECID); U.S. CDC; USAID’s Office of U.S. Foreign Disaster Assistance (USAID/OFDA); U.S. Department of Health and Human Services Office of the Assistant Secretary for Preparedness and Response (HHS/ASPR); United Kingdom Department for International Development (DFID); European Union (EU) European Civil Protection and Humanitarian Aid Operations (ECHO); UN Central Emergency Response Fund (CERF); WHO Contingency Fund for Emergencies (CFE); and the Governments of Macau, New Zealand, and Switzerland.
Strengthening capacity for decision-making during emergencies in Chile, Dominican Republic, and Haiti
PASB, in coordination with the ministries of health and the national health services in Chile, Dominican Republic, and Haiti, and with support from partners, organized workshops on coordination and decision-making mechanisms for health emergency response operations.
These workshops, conducted within the framework of the IHR, aimed to strengthen the capacity of technical personnel to make decisions during health emergencies and to develop, update, and disseminate the standard operating procedures. This would enable a timely, coordinated, and comprehensive health response in which all components of the health sector are represented within a multi-risk response plan.
Representatives from the Member States noted the impact of climate change on the occurrence of disasters and stressed the relevance of the workshops in helping countries in the Americas to respond appropriately and reduce the impacts of emergencies and disasters. The importance of physical or virtual health emergency operating centers in bringing together political and technical aspects, and contributing to timely execution of emergency plans, was underscored.
Mass migration and growing public health needs in Venezuela and neighboring countries
Between 2015 and 2018, over 3 million Venezuelans migrated to other countries in the Region and beyond, due to the ongoing political and socioeconomic situation in the country. The crisis has severely impacted Venezuela’s health system capacity, resulting in shortages of health workers, medicines, and health commodities and supplies, as well as inadequate maintenance of critical health equipment and essential services such as water, electricity, medical gases, food provision, and waste disposal. These developments have put at risk or reversed health gains, and the interruption of epidemiologic surveillance systems and weakening of immunization programs have caused a reemergence of diseases that were previously eliminated, such as measles and diphtheria, or controlled, such as malaria. Neighboring countries—Brazil, Colombia, Ecuador, and Peru—continue to receive large numbers of Venezuelan migrants and serve as the first stop for those in transit to other locations in the Americas. This migratory flow constitutes a risk for the spread of communicable diseases across the Region of the Americas.
PASB has been scaling up its technical cooperation to strengthen health service networks in Venezuela and neighboring countries to deal with active disease outbreaks and growing health needs. During the review period, the Bureau collaborated with national authorities and external partners to develop the Master Plan for HIV, Tuberculosis and Malaria Control in Venezuela, and hosted a meeting of partners and stakeholders to present and discuss the Master Plan. The Master Plan attracted funds totaling
$5 million from the Global Fund to Fight AIDS, Tuberculosis and Malaria (the Global Fund) for the purchase of ART through the PAHO Strategic Fund.
The Bureau mobilized over $20 million from the international community to support the adaptive capacity of national and local health systems, and collaborated with national authorities and other health partners to support local health services and provide essential health care to the most vulnerable groups, among both migrants and the host population. In Colombia, Ecuador, and Peru, efforts focused on improving access to and capacity for delivery of essential health services, and on strengthening national and decentralized health surveillance, information management, and monitoring systems for outbreak detection and control.
In Venezuela, PASB increased short-term, high-impact interventions to strengthen institutional and community capacity for outbreak surveillance and control; for clinical management of cases related to high-impact, high-consequence pathogens; and for preparation for emerging health threats. In 2018, through funding from strategic partners and its own resources, PASB procured 82 tons of essential medicines and medical supplies for prioritized health facilities, main health programs, and strategic NGO partners. In the first three months of 2019, the Bureau procured an additional 80 tons of medicines and supplies, including products for the management of complicated malaria, measles, and diphtheria; reproductive health emergencies; and NCDs.
The Bureau provided technical cooperation and logistical support for the implementation of a national measles and diphtheria vaccination campaign that reached nearly 9 million children. PASB assisted with direct procurement of 9 million doses of measles-rubella vaccine and 1.5 million doses of tetanus-diphtheria (Td) vaccine, as well as syringes and safety boxes; recruitment of eight international experts and 30 national professionals; provision of transportation for field operations, including in the remote areas of the states of Amazonas and Delta Amacuro; and training of vaccinators and health professionals. PASB also established the Incident Management System (IMS) in May 2018, deploying over 60 professionals from PAHO Headquarters and country offices to collaborate in technical, administrative, and logistics management.
In partnership with MERCOSUR, the MERCOSUR Social Institute, the Amazon Cooperation Treaty Organization (ACTO), and ORAS, PASB supported the work of border health technical working groups that, among other issues, addressed the health challenges associated with mass migration in the South American Chaco, the Andean altiplano, and the Amazon Basin.
Technical cooperation has increased considerably in Venezuela and neighboring countries to address the critical needs linked to the prolonged and complex mass migratory phenomenon. However, important gaps remain in ensuring continued availability of and nondiscriminatory access to critical health services for the most vulnerable groups.
The Emergency Medical Team (EMT) initiative aims to enhance emergency preparedness and support the rapid and efficient deployment of national and international medical teams to provide coordinated, quality clinical care, in order to significantly reduce loss of life and prevent long-term disability from disasters due to natural hazards, outbreaks, and other emergencies. The EMT initiative focuses on capacity strengthening and response at local and national levels, supports national health authorities in their leadership role, and leverages countries’ national capacities to support each other.
The majority of the work by PASB with EMTs, to date, has been on the introduction of the EMT initiative to countries and territories in the Region; the development of operational tools and Medical Information and Coordination Cells (CICOMs), which are designed to facilitate handling of information and coordination of EMTs during emergencies and disasters; and the strengthening of the logistical and operational capacities of EMTs. The Bureau’s work with Member States has involved the identification, registry, mentoring, strengthening, and classification of local and national EMTs, and the adoption of the initiative’s global standards. The initiative also includes over 30 NGOs from LAC involved in humanitarian health assistance, and facilitates sharing and analysis of good practices, technical concepts, and operational issues in EMT development and response, for continuous improvement.
As of December 2018, 39 countries and territories have officially introduced the EMT initiative at national level and are actively being supported by PASB to build national and local capacity in the area of health emergency management and create their own national EMTs. More than 500 health emergency management personnel from the countries have been sensitized and trained in EMT coordination mechanisms, and five regional courses for EMT coordinators have been held in Panama (2015), Costa Rica (2016), Chile (2017), United States of America (2018), and Barbados (2019). These interventions contributed to the establishment of a regional roster of 112 trained EMT coordinators from 35 countries and territories, ready for deployment nationally, regionally, and globally to support the coordination of emergency medical assistance.
During the reporting period, 23 Member States officially designated national EMT focal points to represent their countries in the Regional EMT Group. Three national institutions or organizations have had their EMTs verified as international teams by WHO: U.S. Team Rubicon, the Ministry of Health of Ecuador, and the Costa Rican Social Security Fund. Additionally, 30 teams are currently enrolled in a mentoring process to achieve the WHO international classification. Also, five countries—Chile, Colombia, Costa Rica, Ecuador, and Peru—are actively implementing national procedures to request and deploy EMTs, and they are pursuing implementation of CICOMs, with PASB’s technical cooperation.
The Bureau worked with the Barbados Defense Force and the Regional Security System (RSS) in the Caribbean to complete training for and procurement of the field hospital that will be used by the Eastern Caribbean response teams. The hospital setup will be certified as EMT Level 1 by WHO in July 2019, and work was initiated to strengthen the hospital to reach EMT Level 2 status by 2020, with support from the Government of the United States and the Government of China.
The IHR provide the overarching framework for Member States to collaborate in addressing global health security. The legally binding regulations require States Parties to notify the WHO IHR focal point—hosted by the PASB for the Region of the Americas—of events, irrespective of origin or sources, that may have international public health implications. Such events may eventually be determined to constitute public health emergencies of international concern, based on defined criteria. Strengthening countries’ core capacities to implement the IHR remains an important priority for PASB’s technical cooperation, and work under the IHR umbrella during the reporting period was executed with support from U.S. CDC, GAC, and Brazil’s national voluntary contributions.
Epidemic intelligence (EI) is the cycle of organized and systematic collection, analysis, and interpretation of information from all sources in order to detect, verify, and investigate potential health risks. The activities captured throughout this cycle are core functions under the IHR. EI requires an efficient global early warning system and network that publishes risk assessments from all events that may have public health implications in the IHR National Focal Point Event Information Site within 48 hours of the completion of the assessment.
A critical aspect of the fulfillment of the IHR is the capacity of countries to communicate efficiently and accurately, both internally and externally, on events that may constitute a public health emergency of international concern, on a 24-hour basis. Between 1 July 2018 and 17 May 2019, 117 events that occurred in the Americas were registered in the internal WHO Event Management System: 10 required documentation with rapid risk assessment; information regarding 8 events was disseminated through the secure WHO Event Information Site for National IHR Focal Points; and information regarding 3 events was published on the public WHO Disease Outbreak News web page.
Consequent on its risk assessment and analysis functions, PASB issued a total of 28 Epidemiological Alerts and Updates between 1 July 2018 and 17 May 2019, mainly related to vaccine-preventable diseases. The Epidemiological Alerts and Updates included recommendations to address the events, and were the only publicly available authoritative source of updated information related to events in Venezuela.
The period covered by this report coincided with the introduction of a revised IHR reporting tool. The tool, which includes changes in the delineation of essential public health functions related to the IHR core capacities, facilitates the mandatory submission of States Parties’ Annual Reports to the World Health Assembly, pursuant to Article 54 of the IHR. Thirty-three (94 percent) of the 35 States Parties in the Americas submitted Annual Reports to the 72nd World Health Assembly in May 2019. Thirty-one of the States Parties submitting Annual Reports for 2018 had their data analyzed: 17 (55 percent) indicated that they had tested, reviewed, and updated at least one of the instruments constituting their national health emergency framework; 11 of 31 (35 percent) indicated that budgets were distributed in a timely manner and executed in a coordinated fashion; and 19 of 31  (61 percent) indicated that an emergency public financing mechanism was in place across relevant sectors, allowing structured reception and rapid distribution of funds for responding to public health emergencies.
The average scores for the Region of the Americas were close to or above 60 percent, and the scores related to 12 of the 13 IHR core capacities were above the global average, with the health service provision core capacity being the exception. The highest average regional score, 92 percent, continued to be for events associated with zoonotic hazards, while the core capacities on human resources and response to events associated with chemical hazards had the lowest scores: 65 percent and 63 percent, respectively. Nevertheless, the status of the core capacities among subregions in the Americas remained heterogeneous. The highest average subregional scores were consistently observed for North America, and the Caribbean subregion accounted for most of the core capacities with the lowest average scores, in the areas of legislation and financing; zoonotic events and the human-animal interface; surveillance; human resources; risk communication; points of entry; chemical events; and radiation emergencies.
The 2018 IHR Monitoring and Evaluation Framework (IHR MEF) includes one mandatory component, the State Party Annual Report, and three voluntary ones: After-Action Review of Public Health Events, Simulation Exercises, and Voluntary External Evaluations (VEE). During the reporting period, PASB worked with Grenada to host a VEE, based on the 2018 Joint External Evaluation (JEE) tool, and the Bureau is supporting Argentina, Dominican Republic, and Haiti in their preparations to host (or rehost, in the case of Haiti) VEEs during the second semester of 2019. Four States Parties included VEEs in their Biennial Work Plans 2018-2019, and four additional States Parties expressed their interest in hosting a VEE. PASB supported Simulation Exercises in Bolivia, Brazil, and Dominican Republic, and After-Action Reviews of Public Health Events in Brazil and Dominican Republic.
Strengthening infection prevention and control (IPC) is a core capacity under the IHR. During the reporting period, PASB provided training on IPC, outbreak investigation, and surveillance and containment of health care–associated infections (HAIs) in 30 countries and territories. The Bureau continued to advocate for national prioritization of the IPC-HAI agenda, use of the WHO framework for implementation of IPC core components, and nomination of
IPC national focal points. Technical cooperation with specific countries included:
a) Dominican Republic: An outbreak of nontuberculous mycobacteria provided a window of opportunity for PASB to raise awareness of the IPC agenda and to support development of a national guideline on IPC best practices.
b) Ecuador: A multiprofessional working group was established to revise the current IPC policies and implement a minimum set of indicators for HAI surveillance.
c) Guyana: A histoplasmosis outbreak in April 2019 among workers in manganese mines highlighted the need to revise the national IPC policy and begin training of health workers on preparedness (early identification of emerging and reemerging diseases with potential for outbreaks or epidemics) and response (prompt investigation of cases, with implementation of containment measures and communication of findings).
d) Suriname: After a national assessment of minimum standards for IPC in health facilities and a nosocomial outbreak in neonatal units, PASB supported the reinforcement of national capacities and policies for IPC and HAI surveillance.
e) Trinidad and Tobago: PASB supported the development of a national policy on IPC and HAI surveillance, including the roles and responsibilities of health workers, as well as the publication of the national manual on IPC.
Influenza pandemic preparedness and response capacities were strengthened in 23 countries through PASB’s technical cooperation. Outputs included assessment of national surveillance systems, enhanced utilization of data for evidenced-based policy-making, and assessment of the severity of seasonal influenza. Outcomes included not only an improvement in national capacities in influenza pandemic preparedness and response but also broadening of the regional network of professionals to support countries in the event of a pandemic. In addition, Argentina and Trinidad and Tobago received training in influenza laboratory quality management and biosafety; Bolivia and Dominican Republic strengthened their multisectoral rapid response teams; and Colombia, Dominican Republic, El Salvador, Haiti, Jamaica, Mexico, Paraguay, and Suriname had their capacity built for effective deployment of pandemic vaccines and supplies.
Cholera outbreak in Haiti
In 2018, 3,786 suspected cases of cholera were reported in Haiti, primarily in the departments of Artibonite and Centre, the lowest annual number since the start of the epidemic in 2010. In 2019, as of mid-April, 308 suspected cases were reported, with the last laboratory-confirmed case reported in early February 2019.
The steady reduction in reported cholera cases can be attributed to the concerted support provided by international partners. This includes the uninterrupted technical cooperation that PASB has undertaken with the Haitian Ministry of Public Health and Population (MSPP) and other national authorities, including the National Potable Water and Sanitation Agency (DINEPA), with support from CERF and the World Bank. The Bureau supported epidemiological surveillance, laboratory capacity, medical case management, and vaccination.
Since July 2018, the system of “labo-moto nurses”—a network of field nurses established in December 2017 to transport samples from acute diarrhea treatment centers (CDTAs)—has been functional in 6 of the 10 departments that reported nearly all suspected cases. Other initiatives included the provision of cholera sampling materials (Cary Blair) to CTDAs; training of CTDA health workers to collect samples from persons with cholera in compliance with biosecurity standards; and provision of laboratory test results to CTDAs. Between July 2018 and April 2019, the labo-moto nurses transported 1,556 cholera samples, supplied 2,041 Cary Blair to the CTDAs, and trained 1,299 CDTA health workers.
The initiatives contributed to a significant increase in nationwide reported cases from 2017, when less than 30 percent of suspected cholera cases were sampled. There was 80 percent sampling in 2018, and 97 percent in 2019 (as of mid-May); the increase in sampling and confirmation of suspected cases of cholera in this Key Country has led to a better understanding of cholera transmission and has informed decision-making to better orient the use of limited in-country resources.
Yellow fever outbreak in Brazil
The most significant yellow fever (YF) outbreak in Brazil in recent history began in 2016, and, as of June 2019, 2,236 confirmed human cases, including 759 deaths and 2,542 epizootics, had been reported, primarily along the east coast and in the Southeast Region. Of these, 82 confirmed human cases and 48 epizootics were reported between 1 January and 9 June 2019. As of mid-2019, PASB continued to work under an “alert mode,” and monitored the outbreak in collaboration with the national health authorities. The Bureau’s ongoing technical cooperation included epidemic intelligence, monitoring vaccination activities, mapping cases and epizootics, and periodic reporting on the evolution of the outbreak.
In December 2018, the Bureau convened a meeting with officials from the ministries of health of Argentina, Brazil, and Paraguay in the Brazilian city of Foz do Iguaҫu to discuss response strategies in the event of possible emergence of YF in the border areas. Participants agreed on a common response strategy adapted to the health structure of each country, based on comprehensive interventions, including vaccination, urban vector control, and epizootic surveillance. Relevant actions included vaccination in municipalities with low vaccination coverage; initiation of media campaigns; training of health professionals in YF surveillance and control; and strengthening of nonhuman primate surveillance for early detection.
PASB’s technical cooperation enhanced country-specific preparedness and response for YF in Argentina, Peru, and Suriname, focusing on strengthening countries’ laboratory networks, epizootic and epidemic surveillance, clinical management, and geographic risk assessments in line with the IHR. Predictive tools for YF forecasting, prevention planning, and early outbreak and response were also developed.
Adequate laboratory diagnosis and detection capacities are critical for countries to detect and report public health emergencies of international concern, as required under the IHR. During the reporting period, PASB contributed to training in:
PASB was also instrumental in providing laboratory supplies to countries to address the challenges that many face—including budgetary constraints, insufficient providers, and customs regulations—in obtaining critical laboratory reagents and materials.
The External Quality Assessment Program (EQAP) for laboratory performance was expanded to include endemic and emerging viruses and to ensure the accuracy of serological and molecular laboratory platforms for the diagnosis of arboviral diseases and influenza. Twenty-eight laboratories from 24 countries are currently participating in the EQAP.
In 2018, PASB conducted the first external quality assessment (EQA) for yellow fever molecular diagnosis for the Region of the Americas. The EQA panel was designed, coordinated, and distributed by the Bureau in collaboration with the Robert Koch Institute (RKI) in Germany. The EQA was planned to assess performance in national public health laboratories and at subnational level, and panels were sent to 31 laboratories in 21 countries. The overall results showed concordance with the expected results in 30 of 31 laboratories (97 percent), a validation of the benefit of the training activities and the implementation of reference methods and procedures across the Region.
During the review period, PASB collaborated with IAEA, the World Organization for Animal Health (OIE), and the WHO Collaborating Center for the Public Health Management of Chemical Exposures (WHO CC UNK-179) to support States Parties in strengthening intersectoral mechanisms to address this threat.
PASB’s technical cooperation contributed to the strengthening of national capacities in emergency preparedness and disaster risk reduction through training in mass casualty management and incident command management systems, and the development and finalization of multihazard disaster management plans. The Bureau developed, disseminated, and promoted guidelines and tools to strengthen countries’ capacity for health emergencies and disasters, including:
a) The Health Sector Multi-Hazard Response Framework, which was finalized in early 2019 and promoted at workshops in Dominican Republic and Guatemala
b) The Preparedness Index for Health Emergencies and Disasters, also finalized in early 2019, for countries to assess their capacity to respond to natural, man-made, and epidemic events
c) Information and new protocols for respiratory epidemiological studies to be conducted in volcanic crises
d) Preliminary guidelines titled Heat Wave and Measures to Take (available in Spanish only, as of June 2019), aimed at enhancing health sector capacities to prepare for and respond to this threat, in coordination with meteorological services. Between December 2018 and February 2019, seven countries in the Region—Argentina, Brazil, Chile, Mexico, Paraguay, Peru, and Uruguay—declared a heat wave alert almost concurrently, an occurrence not previously seen in the Region
e) The Incident Command System (ICS) for hospitals, which was introduced in all Central American countries. In seven countries—Costa Rica, Dominican Republic, El Salvador, Guatemala, Honduras, Nicaragua, and Panama— PASB trained 98 facilitators, who will replicate the methodology in their respective countries
EF4 tornado in Havana, Cuba
On 27 January 2019, a tornado categorized as EF4 (out of 5 levels on the Enhanced Fujita [EF] Scale) hit Havana directly. The unprecedented meteorological event affected approximately 532,000 inhabitants in 5 of the 15 municipalities of the Cuban capital, causing significant infrastructural damage, including to critical health facilities and public service systems. In total, 19 health institutions were damaged, including the Hijas de Galicia maternal hospital, which has the highest number of births in the capital city and the second highest nationally, and serves as a reference center for perinatal management. Following the tornado, the hospital had to be completely evacuated, affecting the continuity of essential health care for the most vulnerable groups, including children and pregnant women.
In response to this event, PASB activated its emergency response mechanism and provided direct support to the Cuban authorities to assess and attend to immediate humanitarian needs. The Bureau mobilized experts in damage assessment to accompany Ministry of Health officials in field visits and determine the most urgent actions to be taken, and provided support to monitor water quality in affected municipalities in order to avoid a complex epidemiological situation in the context of deteriorated environmental conditions.
PASB mobilized a total of $300,000 from CERF and the Government of Switzerland to support priority health sector responses, including rapid restoration of critical services in the damaged health facilities; strengthening of epidemiological surveillance; and control of water- and vector-borne diseases to prevent outbreaks. Repairs to damaged infrastructure and procurement of essential health supplies and equipment, including for vector control, epidemiological surveillance, and laboratory functioning, were identified as priorities for the restoration and strengthening of affected health services.
PASB, in collaboration with DFID, and with additional support from GAC, coordinated implementation of the third year of Phase II of the Smart Hospital initiative in the seven targeted countries: Belize, Dominica, Grenada, Guyana, Jamaica, Saint Lucia, and Saint Vincent and the Grenadines. The initiative aims to strengthen health facilities by combining improvements in safety and greening—the latter addressing, for example, renewable and sustainable energy and water use—to address gaps, boost resilience, and generate operational savings. During the review period, the achievements included:
a) Retrofitting of seven facilities in Dominica, Grenada, Saint Lucia, and Saint Vincent and the Grenadines, with identification of a further 13 facilities to be retrofitted by August 2019 (the peak of the annual hurricane season) and another 21 facilities for initiation of retrofitting over the next 6 months.
b) Assessment of 362 health facilities in 10 Caribbean countries—Antigua and Barbuda, Bahamas, Belize, Dominica, Grenada, Guyana, Jamaica, Saint Lucia, Saint Vincent and the Grenadines, and Suriname—and selection of 54 of the facilities for retrofitting. Ten percent of the selected facilities serve groups in conditions of vulnerability—specifically homes for youth, older persons, and persons with mental health conditions—and two facilities in two countries are strategically important health facilities responsible for storing health supplies for the entire country. In addition, evaluators were trained in the use of the Smart Hospitals Toolkit.
Within the context of the Safe Hospital initiative, PASB updated and published the Hospital Safety Index (HSI) guidelines in Spanish and English, and, in October 2018, trained 50 persons from 18 countries in the use of the updated guidelines.
Emergencies disproportionately affect populations in conditions of vulnerability, including persons with disabilities, who are usually excluded from disaster risk management policy-making and planning. This further increases their vulnerability and creates difficulties in responding to their needs after a disaster. In order to address this situation, PASB supported countries’ efforts for greater involvement of persons with disabilities and their families in health emergency risk management. In line with Article 11 of the UN Convention on the Rights of Persons with Disabilities—"Situations of risk and humanitarian emergencies"—the Bureau supported the implementation of corrective measures in prioritized hospitals, targeting structural and nonstructural elements linked to the inclusion of these persons, and preparing health personnel to respond to emergencies and disasters with an approach of "no one left behind.”
PASB developed practical tools to ensure that hospital response plans incorporate arrangements for persons with disabilities, and supported the piloting of the guidelines in three countries: Chile, Ecuador, and Mexico. The methodology used—Disability Inclusion in Hospital Disaster Risk Management (INGRID-H)—is a simple, practical, and results-oriented methodology to assess and improve the level of inclusiveness of a health facility with regards to persons with disabilities, in the event of a disaster. The piloting included assessment of health facilities, training of staff, and procurement of basic supplies to make the facilities more inclusive. The pilot studies contributed to the finalization and validation of the guidelines in September 2018, and their dissemination, in Spanish and English, in early December 2018. Peru reviewed the methodology in June 2019, and Chile and Mexico are implementing follow-up activities. There are plans to extend its application to other areas, including Emergency Medical Teams and community responses.
Developing countries of the Americas, and the most vulnerable populations in those countries, are disproportionately affected by climate change. Twenty-eight Member States identified health as a priority topic in their Nationally Determined Contributions (NDCs), which represent their efforts to reduce their countries’ emissions and adapt to the impacts of climate change. Those Member States also made commitments to build evidence on, prevent, prepare for, and quickly respond to climate-related threats. The Bureau provided technical cooperation in the preparation of health chapters within climate change National Adaptation Plans in Brazil, Chile, Colombia, Cuba, El Salvador, Guatemala, Honduras, and Saint Lucia. The Bureau is also in the process of developing country profiles on climate and health. These various diagnostic and planning tools strengthen health leadership engagement, provide evidence for advocacy, and facilitate resource mobilization efforts.
In partnership with CARICOM and its Member States and specialized agencies, the Bureau provided technical cooperation in the preparation, launch, and initiation of implementation of the Caribbean Action Plan on Health and Climate Change 2019-2023. The Action Plan urges Caribbean participation in the WHO Special Initiative on Climate Change and Health in Small Developing Island States, and its four strategic lines of action are aligned with the four key areas of the Special Initiative—empowerment, evidence, implementation, and resources. The Action Plan aims to protect Caribbean populations from the adverse health effects of climate change by developing climate-resilient health systems, increasing awareness, mainstreaming funding opportunities to support countries, and promoting intersectoral mitigation actions in the health sector. The EU has approved a grant to PASB for 7 million euros for a collaborative project called “Climate Resilient Health Systems in the Caribbean,” which is expected to begin during the second half of 2019. It is anticipated that this project will benefit CARIFORUM Member States.
PASB advocated for health at a meeting of Caribbean SIDS in August 2018 in San Pedro, Belize, to prepare for the September 2019 High-Level Mid-term Review of the SAMOA] SIDS Accelerated Modalities of Action] Pathway. The SAMOA Pathway document was produced at the Third International Conference on Small Island Developing States, which was held in 2014 in the island nation of Samoa. The 2018 Caribbean SIDS preparatory meeting resulted in the San Pedro Declaration. In that Declaration, the countries identified the need to enhance citizen and private sector engagement at the national level and to effectively mainstream the SAMOA Pathway (which covers the period 2015-2025) into national development plans. The Caribbean countries also reaffirmed that climate change was one of the greatest challenges of the time and acknowledged that its impacts, including sea level rise, continue to pose a significant threat to Caribbean SIDS and their efforts to implement the SAMOA Pathway.
The Bureau’s advocacy contributed to the participation of representatives from Caribbean SIDS in the Inter-regional Preparatory Meeting for the Mid-term Review held in Apia, Samoa’s capital city, in late 2018, which resulted in the Apia Outcome. The Apia Outcome reaffirms the SAMOA Pathway as an overarching framework for guiding SIDS in their global, regional, and national development efforts, and as an integral part of the 2030 Agenda for Sustainable Development.
In the South American subregion, the Bureau organized training for health and climate change officials to help them prepare the November 2018 Declaration of Ministers of Health of MERCOSUR and Associate States on Climate Change and Health.
SHAA2030 Goal 9:
Noncommunicable diseases, and mental health and neurological disorders
PASB’s technical cooperation for NCD prevention and control intensified during the review period. The Bureau contributed to Member States’ preparation for, and was represented at, the Third High-level Meeting of the UN General Assembly on the Prevention and Control of NCDs (HLM3-NCDs) held in September 2018. The HLM3-NCDs Political Declaration reaffirmed the political commitment of the heads and representatives of States and governments, to accelerate and scale up the implementation of commitments made in the 2011 Political Declaration and the 2014 Outcome Document of the previous HLMs of the UN General Assembly on NCD prevention and control. The 2018 Political Declaration acknowledged that some countries had made progress in addressing the commitments, but recognized the significant challenges that many others faced. The Declaration noted that the burden of NCDs continued to increase disproportionately in developing countries, where NCDs cause 85 percent of premature deaths, that is, those occurring in persons between 30 and 69 years of age.
The 2018 Political Declaration also affirmed that interventions should focus on the five main NCDs—cardiovascular diseases, diabetes, cancer, chronic respiratory diseases, and mental health and neurological conditions—and five main risk factors: tobacco use, unhealthy diet, harmful use of alcohol, physical inactivity, and air pollution. The countries committed to, among several other measures, the implementation of cost-effective, affordable, and evidence-based interventions and good practices, including the WHO “best buys” and other recommended interventions for the prevention and control of NCDs.
The Bureau continued promoting the Global HEARTS initiative in countries of the Americas as a comprehensive package of best practices for the prevention and management of cardiovascular diseases. HEARTS addresses Healthy lifestyles, Evidence-based protocols, Access to essential medicines and technologies, Risk-based management, Team-based care and task-sharing, and Systems for monitoring. Its four core components comprise a simplified, evidence-based hypertension treatment algorithm; the availability and affordability of a core set of high-quality antihypertensive medications; a registry of hypertensive patients for monitoring and performance evaluation; and task-sharing in a team-based approach at the first level of care.
During the review period, four new countries implemented HEARTS: Argentina, Ecuador, Panama, and Trinidad and Tobago, joining Barbados, Chile, Colombia, and Cuba as participants in the initiative. The four new countries added 22 health centers to the total number of health facilities implementing the initiative, for a total coverage of approximately 800,000 people in the eight participating countries.
Support for HEARTS implementation—which is ongoing—was provided through webinars, virtual courses, and dissemination of new tools such as the HEARTS technical modules and the Monitoring and Evaluation Framework for Hypertension Control Programs developed by PASB and the World Hypertension League (WHL). Approximately 460 health care professionals at the first level of care—including physicians, nurses, and nurse assistants—were trained in Argentina, Ecuador, Panama, and Trinidad and Tobago, and 8,030 persons in those countries were accredited as having successfully completed virtual courses on the management of hypertension at the first level of care and the secondary prevention of cardiovascular diseases. By mid-2019, these virtual courses had reached 82,354 health professionals at the first level of care in
29 countries and territories. A threat to the sustainability of the initiative is the high turnover of health workers. To address this issue, a network of individuals trained in HEARTS implementation at all levels of the ministries of health is being established, through training-of-trainers programs.
The Bureau’s technical cooperation to combat NCD risk factors and obesity, strengthen implementation of the PHC strategy and IHSDNs, and improve self-management benefit persons with diabetes as well as those with other NCDs.
a) In Honduras, the National Diabetes Institute was provided with equipment and supplies, and technicians trained, to improve capacity for the accurate and timely diagnosis of diabetes. This intervention was supported by a grant from the OPEC [Organization of the Petroleum Exporting Countries] Fund for International Development (OFID).
b) In Paraguay, there were improvements in the comprehensive care of persons living with NCDs in the network of health services, following the implementation of a demonstration model for the management and comprehensive care of chronic diseases, with an emphasis on diabetes. The model was implemented at the first level of care, in 124 family health units (USF) in three departments in the country. As of mid-2019, the program was being expanded to more USF facilities in the public health services network.
c) In Trinidad and Tobago, PASB contributed to the review and updating of the
Self-Management Manual and related educational tools for diabetes and hypertension, and facilitated training for NCD lay educators. These interventions aim to empower community members and persons living with NCDs to take greater responsibility for their own health and be better able to manage their chronic health conditions.
Following the WHO Director-General’s global call for cervical cancer elimination in May 2018, and building on PASB’s substantial previous work in this area, the Bureau rallied support for the new regional Plan of Action for Cervical Cancer Prevention and Control 2018-2030 (Document CD56/9). The Plan of Action, approved by the 56th PAHO Directing Council, commits Member States to implement high-impact interventions on a population-based scale along the continuum of health education and promotion, HPV vaccination, cervical cancer screening and diagnosis, and treatment for precancer and invasive cancer, with interventions tailored to the needs of priority populations in conditions of vulnerability.
Countries pledged to improve cervical cancer program organization and governance, including information systems and cancer registries; strengthen primary prevention through information, education, and HPV vaccination; improve cervical cancer screening and precancer treatment through innovative strategies; and increase access to services for invasive cancer diagnosis, treatment, and palliative care. These lines of action will put the Region of the Americas on the pathway to elimination of cervical cancer as a public health problem. In support of this goal, during the review period the PAHO Revolving Fund supplied over 1.6 million doses of
HPV vaccine to countries.
As part of its comprehensive strategy for cervical cancer prevention and control, Saint Kitts and Nevis included HPV vaccination in its national immunization program, and PASB contributed to the development of an action plan and training for Ministry of Health personnel and key stakeholders such as the media, faith-based organizations, parents, and adolescents. Although many countries are currently offering HPV vaccination as part of their immunization programs (see section “Maintaining and enhancing immunization” above), reaching the estimated 37 million girls in the targeted age group of 9-14 years remains a challenge, as coverage in most of the countries is less than the recommended 80 percent of this population.
Trinidad and Tobago is the only country in the Region of the Americas participating in the WHO cervical cancer costing study, which uses the WHO cervical cancer prevention and control costing tool (C4P). Trinidad and Tobago is also contributing to the regional campaign, “It is time to end cervical cancer”, that was launched in November 2018 in support of the regional Plan of Action for Cervical Cancer Prevention and Control 2018-2030. The campaign presents stories on cervical cancer prevention and control interventions in various countries in the Region, and relevant materials were disseminated to all countries for their use.
The Bureau’s technical cooperation resulted in updating of cancer control plans and treatment protocols, public outreach and education, and improvement in cancer information systems, in selected countries and in collaboration with key partners.
a) Belize: A needs assessment of the cancer control program was conducted, the National Plan for the Prevention and Control of Cancer updated, and an operational plan to support implementation over a three-year period developed.
b) Bolivia and Honduras: In order to enable improved detection and treatment of cervical precancerous conditions, colposcopy services were strengthened in 6 clinics in Bolivia and 10 clinics in Honduras, with the provision of colposcopes and other equipment and supplies, and retraining of colposcopists.
c) Colombia: The country’s National Cancer Institute (INC) collaborated with the International Agency for Research on Cancer (IARC) to generate information for the planning and monitoring of cancer programs in Latin America. This initiative also involved Argentina, El Salvador, Guatemala, Panama, Paraguay, and Peru.
d) Trinidad and Tobago: A multidisciplinary assessment of the cancer control program identified service delivery capacity and gaps in care, and provided the Ministry of Health with a road map to strengthen cancer services. PASB supported the development of an action plan to improve cancer control, as well as outreach and public awareness events aimed at improving cancer screening, early detection, and treatment.
e) South American subregion: As part of a horizontal cooperation initiative involving the UNASUR Network of National Cancer Institutes and Institutions (RINC) and IARC, a population-based cancer registry was established. This provides an important new technical tool for cancer monitoring and control in the subregion and the wider Region of the Americas.
While focusing on the five main NCDs, PASB continued its interprogrammatic work on chronic kidney disease of nontraditional causes (CKDnT) in Central America, and a progress report examining how Member States are advancing in addressing this priority health issue was prepared for the PAHO 57th Directing Council in September 2019. Countries that include Costa Rica, El Salvador, Guatemala, Honduras, Nicaragua, and Panama have developed integrated responses to increase the capacity of their health services for diagnosis and appropriate care and management. In addition, the countries are increasing their capacity to improve surveillance, by integrating epidemiological surveillance with environmental and occupational surveillance strategies.
PASB’s technical cooperation highlighted the significant gap between demand and availability of organs for transplant in the Region of the Americas. The regional Strategy and Action Plan on Donation and Equitable Access to Organ, Tissue, and Cell Transplants 2019-2030 was developed, based on voluntary donation and the observation of WHO Guiding Principles on Human Cell, Tissue and Organ Transplantation, for presentation to the 57th Directing Council in September 2019, aiming to create and expand active kidney transplant programs in every country of the Region, but particularly in Central America and the Caribbean.
PASB’s technical cooperation strengthened NCD surveillance systems in several Member States during the review period.
a) The Global School-based Student Health Survey (GSHS), which generates key information on risk behaviors of adolescents aged 13-17 years, was completed in five countries: Argentina, Bolivia, Panama (for the first time), Saint Lucia, and Saint Vincent and the Grenadines. The data will be used to generate country reports on adolescent alcohol and tobacco use, physical activity, obesity, mental health, and sexual behavior.
b) Seven countries made progress in implementing the Pan American STEPS survey on
NCDs and risk factors: Bahamas, Bolivia, and Ecuador completed the survey, with the latter two producing national estimates on NCDs and risk factors for the first time; Saint Kitts and Nevis and Saint Lucia adapted the protocol for their specific national situations and were expected to complete the survey in late 2019; and Antigua and Barbuda and Grenada initiated development of a plan to implement the STEPS survey in 2020.
c) Results of the NCD Country Capacity Survey (CCS) were released, and informed the publication of WHO NCD country profiles 2018, which includes data on NCD mortality, risk factor prevalence, capacity of national systems to prevent and control NCDs, and progress towards national targets related to the NCD Global Monitoring Framework, based on the nine global targets to be achieved by 2025. The results allowed NCD country program managers to compare their national NCD status with that of other countries in the Region.
PASB, in keeping with regional frameworks such as the Strategy for the Prevention and Control of NCDs 2012-2025 (Document CSP28/9, Rev. 1), the Plan of Action for NCD Prevention and Control 2013-2019 (Document CD52/7, Rev. 1), the Plan of Action for the Prevention of Obesity in Children and Adolescents 2014-2019 (Document CD53/9, Rev. 1), and the WHO Best Buys and Other Recommended Interventions for the Prevention and Control of NCDs, strengthened its technical cooperation to reduce NCD risk factors during the review period. Emphasis was placed on advocacy for fiscal policies to reduce the consumption of unhealthy products, such as increases in taxes on tobacco and alcohol products; the imposition of taxes on sugary drinks that raise the price by at least 20 percent, as recommended by WHO; enhancing nutrition literacy and ensuring front-of-package labeling (FoPL) of products to facilitate informed choices; restrictions on the provision and marketing of unhealthy foods and beverages to children; and interventions in school, community, and workplace settings to promote and enable healthy nutrition and increased physical activity. Advocacy also highlighted a possible co-benefit of increased taxation of unhealthy products, namely a boost in health financing, with some or all of the revenue raised going to NCD prevention and control and other priority programs.
An unhealthy diet featuring foods and nonalcoholic beverages high in fats, sugar, or salt—based on criteria such as those in the 2016 PAHO Nutrient Profile Model—and physical inactivity contribute significantly to obesity, overweight, diabetes, hypertension, and heart disease. The regional consumption of salt is 10 grams per person per day, twice the level recommended by WHO. Increases in obesity and overweight in the Region are evident, particularly in childhood, with 7 percent of children aged less than 5 years being overweight, a proportion that exceeds the global average of 6 percent. These patterns are a cause for concern, as they herald increases in the already crippling burden of NCDs in the Region.
The Bureau’s technical cooperation contributed to the development, implementation, updating, and/or assessment of national frameworks—including legislation, policies, plans, and guidelines—for the reduction of NCD risk factors and prevention and control of obesity and overweight, especially in children and adolescents, in 13 countries and territories:
a) Antigua and Barbuda developed a breast-feeding policy, established a breast-feeding committee, undertook training of trainers, and strengthened school nutrition policies and standards. These interventions supported preparation for Baby Friendly Hospital Certification, related to SHAA2030 Goal 1, but also relevant to SHAA2030 target 9.7, including through the recognized linkages between exclusive breast-feeding and prevention of childhood obesity.
b) The Bahamas included healthier food options in price-controlled “bread baskets” and expanded school health programs.
c) Belize developed a National School Feeding Program Menu Handbook in partnership with the ministries of health and of education, and UNICEF.
d) Brazil conducted an evaluation of the economic impact of obesity and obesity prevention strategies.
e) Brazil, Costa Rica, Paraguay, and Peru conducted formative research—in collaboration with the Costa Rican Institute for Research and Teaching in Nutrition and Health (INCIENSA)—to develop a social media strategy for reduction of discretionary salt consumption, which will be a reference for the rest of the Region.
f) Dominica, Grenada, and Saint Lucia strengthened school nutrition policies and standards.
g) Guatemala developed the National Strategy for the Prevention of Overweight and Obesity in Childhood and Adolescence.
h) Puerto Rico developed and implemented its Action Plan for the Prevention of Obesity.
i)Uruguay enacted new legislation on FoPL that will enter into force in 2020.
Law 30021 for healthy nutrition of children and adolescents in Peru
Peru approved a manual on advertising warnings related to Law 30021, which deals with the promotion of healthy nutrition for boys, girls, and adolescents. The manual regulates the use of black octagons with text stating "high in" sodium, sugar, or saturated fats and "contains trans fats" given on the front label of processed food products. The manual also regulates the advertising of such products in different media, and its approval and publication finalizes the regulations to enable the full entry into force of Law 30021.
Documentation of the process and experience for the development, approval, and implementation of Law 30021 in Peru provides a valuable model and tool for countries wishing to introduce nutritional labeling as part of their interventions to reduce modifiable NCD risk factors.
In complementary action, Peru increased the selective tax on sugary drinks, tobacco, alcohol, and fossil fuels. The new tax revenue will contribute to NCD prevention and control, reduction of violence and road traffic injuries, and protection of the environment.
The Bureau worked at regional and subregional levels to contribute to the promotion of healthy nutrition.
Brazil is leading a regional network for action for cardiovascular disease reduction through the reduction of salt intake.
In the Caribbean, the CCHD initiative “Advancing public health policies to address overweight and obesity in Chile and the Caribbean Community” between the Government of Chile and CARICOM, which was launched in 2017, continued. The initiative aligns well with CARICOM efforts in this area, including the July 2018 endorsement by CARICOM Heads of State and Government of FoPL as a priority.
In Central America and the Dominican Republic, the Bureau coordinated with the Institute of Nutrition of Central America and Panama (INCAP) to implement the toolkit of the Network for Global Monitoring and Support for Implementation of the International Code of Marketing of Breast-milk Substitutes as well as subsequent relevant World Health Assembly Resolutions (NetCode). PASB also collaborated with INCAP and COMISCA to develop a Central American subregional strategy for the reduction of salt consumption.
Front-of-package labeling in the Caribbean
The CARICOM Regional Organization for Standards and Quality (CROSQ) is currently leading the revision of the CARICOM Regional Standard: Specification for Labelling of Pre-packaged Foods (CRS 5:2010), to integrate front-of-package labeling provisions. The proposed “high in” approach to FoPL is a key policy to allow consumers quick and easy identification of prepackaged foods that are high in nutrients associated with the growing epidemic of NCDs and obesity in the Caribbean.
CROSQ’s regional process involves collaboration with various stakeholders, including civil society, private sector, academia, ministries of health, and other government sectors, such as finance, trade, and agriculture. A series of stakeholder consultations were held by national bureaus of standards across the Caribbean, and committees were established to develop national positions on the draft standard. A third round of stakeholder consultations is expected to take place during the second semester of 2019, before a final draft is produced and presented to the CARICOM Council for Trade and Economic Development (COTED).
This initiative has stirred public debate on the right to know the nutritional content of food products, with CSOs, such as the Healthy Caribbean Coalition, leading public education campaigns on this and other issues related to obesity and NCD prevention and control. The initiative has also triggered private sector engagement, and some industry entities have voiced concerns, proposing voluntary approaches and alternative FoPL systems that would not be as effective in achieving the intended public health objective.
Through this initiative, the Caribbean is closer to implementing the “high in” FoPL system, which will not only facilitate healthier choices by consumers but also serve as an enabling policy for other effective approaches, such as taxation, school-based nutrition policies, and the restriction of marketing to children, by clearly identifying processed and ultra-processed products that should be targeted by these measures. In order to achieve better policy alignment, COTED has called for a joint meeting of ministers of trade and of health to discuss and harmonize positions, and childhood obesity and alcohol reduction have been identified as priority policy areas.
During the review period, the Bureau’s technical cooperation addressed adequate physical activity as an important component of obesity and overweight prevention and part of integrated NCD risk factor reduction efforts at national and subregional levels.
Belize: A memorandum of agreement was developed between the Mayors Association of Belize and the Ministry of Health for the promotion of wellness parks in all six districts of the country.
Brazil: Physical activity was included as a component of a national intersectoral converging agenda for action involving government, academia, civil society, and UN agencies. The other components of the agenda are air pollution and sustainable mobility.
Caribbean subregion: Since the launch of “Jamaica Moves” by the Ministry of Health in that country in 2017, with the aim of facilitating increased physical activity among the population, the effort expanded to the subregional level when CARICOM Heads of State and Government endorsed the “Caribbean Moves” initiative in September 2018.Supported by the PASB, the scheme spread to other countries in the subregion, such as Barbados, where “Barbados Moves” was launched in October 2018 as part of a National Wellness Initiative, and Trinidad and Tobago, where “TT Moves” was launched in April 2019.
Ecuador: A project funded by the Korean International Agency for Cooperation (KOICA) created inter- and multisectoral networks, which include academia and civil society, to strengthen primary care and health literacy, promote healthy nutrition and physical activity in schools, and prevent Zika virus infection. As a result of the project, which ended in February 2019, street food vendors began selling healthier options; schools implemented extracurricular hours for physical activities, resulting in increased physical activity among students; school district water supplies were disinfected in order to provide safe drinking water for school children; and health services were strengthened to improve NCD prevention and control.
Overall, the Region of the Americas is on track to reach the 2025 target of a 30 percent reduction in the age-standardized prevalence of tobacco smoking among both males and females 15 years and older. According to the WHO global report on trends in prevalence of tobacco smoking 2000-2025, the regional target for this indicator for 2025 is 14.2 percent; however, the projected prevalence for the Region for 2025 is lower, at 13 percent.
During the reporting period, the Bureau provided technical cooperation to support countries’ implementation of the WHO Framework Convention on Tobacco Control, based on the Strategy and Plan of Action to Strengthen Tobacco Control in the Region of the Americas 2018-2022 (Document CSP29/11).
Antigua and Barbuda approved comprehensive tobacco control legislation that made it one of 20 countries in the Region that have mandated smoke-free environments; one of 21 countries that require health warnings; and one of the 7 countries—Antigua and Barbuda, Brazil, Colombia, Guyana, Panama, Suriname, and Uruguay—that have banned tobacco advertising, promotion, and sponsorship—all measures that are aligned with the FCTC.
Barbados, Grenada, Saint Kitts and Nevis, Trinidad and Tobago, and Venezuela reviewed their tobacco legislation.
Brazil achieved the highest level of implementation of the MPOWER package, having implemented the six measures at the best practice level. MPOWER is intended to assist country-level implementation of effective FCTC interventions to reduce the demand for tobacco, and Brazil is the second country in the world (after Turkey) to achieve this landmark level. In recognition of this achievement, WHO and the Government of Brazil will launch the WHO Report of the Global Tobacco Epidemic 2019 in Brazil in July 2019.
Brazil and Colombia joined Argentina and Chile in imposing taxes on tobacco products that represent more than 75 percent of the final retail price.
Canada and Uruguay adopted plain packaging of tobacco products.
Guyana developed an antitobacco communication campaign for radio and television, billboards, posters, flyers, and print and social media. The campaign followed the country’s enactment in 2017 of tobacco control legislation that is among the most comprehensive in the Region.
Saint Lucia finalized a bill to amend its Public Health Act, with the aim of establishing smoke-free public spaces; as of mid-2019, the bill was under consideration for Cabinet approval. An 8-month antitobacco campaign was initiated in April 2018 using print and social media, television, and radio.
In August 2018, PASB hosted a regional conference in Washington, D.C., in preparation for two events to be held in October 2018: the Eighth Conference of the Parties to the FCTC (COP8) and the First Meeting of the Parties to the Protocol to Eliminate Illicit Trade in Tobacco Products (MOP1). The August regional conference allowed the exchange of experiences among FCTC Parties from the Americas and provided an opportunity to develop a more cohesive regional platform in preparation for COP8 and MOP1. PASB continues to facilitate coordination between the Parties to both treaties.
In 2018, the Bureau collaborated with the Ministry of Health and the Solidarity Fund for Health (FOSALUD) in El Salvador, the FCTC Secretariat, the UN Development Program (UNDP), and RTI International to prepare an investment case for tobacco control in that country. The development of investment cases has proven to be a powerful tool to support the design of tax policy on tobacco and to engage sectors beyond health in the implementation of the FCTC.
PASB’s collaborators and partners in this work include the Campaign for Tobacco-Free Kids, the International Union Against Tuberculosis and Lung Diseases, the Framework Convention Alliance, the American Cancer Society, Johns Hopkins University, the University of Illinois at Chicago, the InterAmerican Heart Foundation, and Vital Strategies.
PASB’s technical cooperation to reduce the risk factor of air pollution during the reporting period is described below under SHAA2030 Goal 11.
In support of the WHO Global Road Safety Report 2018, regional data collection and analysis on the key legislative and public health interventions and their impact was conducted in 30 countries in the Americas. The analysis for the Region of the Americas, also detailed in the fourth regional report on road safety published in 2018, Road Safety in the Americas, revealed that deaths from traffic injuries increased slightly, from 153,714 in 2013 to 154,997 in 2016, although mortality rates remained relatively stable, at 15.6 per 100,000 population in 2016, compared to 15.9 per 100,000 population in 2013.
The most vulnerable road users—pedestrians, motorcyclists, and cyclists—had the highest rates of road traffic deaths and injuries, and deaths of motorcycle users in particular increased. Overall, road traffic deaths remain the second-leading cause of death for young adults aged 15–29 years in the Region of the Americas, highlighting the need to prioritize road safety on the adolescent health agenda. The regional report shows that some aspects of road safety management, legislation, and postcrash care have improved in several countries. The report also provides an important tool to monitor progress and stimulate Member States to improve road safety, through the identification of key gaps and opportunities.
Reducing alcohol consumption and road injuries in Guatemala
In Guatemala, PASB took a leadership role in collaborative and cross-sectoral government efforts to strengthen the implementation and enforcement of the legal framework for reducing deaths related to alcohol and road traffic injuries. The OFID-funded initiative strengthened the capacity of managers in the Transit Department, National Civil Police (PNC), Municipal Police Officers (PMT), and health professionals in the emergency rooms of one of the largest national hospitals to conduct brief interventions.
In conjunction with the Ministry of the Interior, the Bureau organized a public forum for debate on the legal aspects of driving while intoxicated, the first time that authorities and officials from the National Institute of Forensic Sciences, the Association of Judges and Magistrates, the Institute of Criminal Public Defense, the Office of the General Prosecutor for Human Rights, the Dean of the Law School, the national municipal police, and national civilian transportation discussed this important issue. As a result of the forum, all participating entities signed an agreement to establish a technical working group, prepare a protocol, and revise the existing law on driving while intoxicated. This constitutes a major step for Guatemala in addressing alcohol- and traffic-related road safety issues through a collaborative approach.
PASB collaborated with the Executive Secretary of the Commission Against Addictions and Illicit Drug Trafficking (SECCATID) and the Ministry of the Interior at central, municipal, and community levels to strengthen the prevention and control of harmful alcohol consumption and the consumption of psychoactive substances. A specific aim of this initiative, which was supported by the Government of Sweden as part of a joint program for comprehensive rural development, was to protect indigenous populations from serious health issues due to harmful use of alcohol.
During the review period, the Bureau’s technical cooperation in addressing mental health and neurological conditions continued, within the framework of the WHO Mental Health Gap Action Program (mhGAP). The premise of the program is that, with appropriate and adequate care, psychosocial assistance, and medication, millions of persons could be treated for depression, schizophrenia, and epilepsy; prevented from suicide; and enabled to lead normal lives, even where resources are scarce. The mhGAP initiative aims to scale up services for mental, neurological, and substance use disorders in countries. It provides tools for use in nonspecialized health settings, including the mhGAP Operations Manual (updated in 2018), mhGAP Intervention Guide, and mhGAP training manuals. By mid-2019, 25 countries and territories in the Region had implemented mhGAP.
Strengthening the Mental Health Gap Action Program in countries
Anguilla, Saint Kitts and Nevis, and Saint Vincent and the Grenadines: These countries initiated implementation of the mhGAP, integrating mental health into the PHC strategy and focusing on the modules on depression and suicide, to reduce stigmatization and facilitate early diagnosis and management. Training of trainers to oversee continued mhGAP training of health care providers was a principal focus of the Bureau’s technical cooperation: 20 persons were trained in Anguilla, 35 in Saint Kitts and Nevis, and 30 in Saint Vincent and the Grenadines.
Argentina: A plan was developed for the phased, effective implementation of the mhGAP initiative, resulting in improved skills and capacity of central, provincial, and local health teams to undertake interventions at the first level of care. A total of 250 professionals were trained, and the phase of accountability for the local implementation of mhGAP was initiated, with the design of monitoring indicators that will allow adjustments to the implementation of the strategy.
The Bahamas: In 2018, a suicide prevention campaign and training of 25 health care professionals from the Family Islands took place, aiming to increase access to community-based mental health services. In interventions involving multisectoral groups—with representatives from the ministries of health, education, and national security, as well as other partners—a mental health literacy module was integrated into the Health and Family Life Education curriculum in eight secondary schools, and a violence prevention pilot project was initiated in one primary and one secondary school in New Providence, the most populous island of the Bahamas. These school-based projects aim to identify, link to care, and reduce stigmatization of children with mental health conditions, or those who are perpetrators or victims of youth violence.
Belize: Interventions included capacity-building for physicians and nurses in the mhGAP guidelines; training of trainers in mental health literacy for 65 personnel of the ministries of health and of education; and development of the National Strategic Plan for the Prevention and Control of Suicide. A key partner in improving mental health literacy was Dalhousie University (Canada), a PAHO/WHO Collaborating Center.
Colombia: By the end of 2018, 1,800 health professionals at the first level of care and in basic hospitals had been trained in mhGAP, covering almost the entire country. This is the only example in the Region of training with such a wide reach; it was carried out through the VCPH, using the expertise of four universities in the Region. The personnel trained through this initiative, will empower attention to mental health conditions at the first level of care in Colombia. This work can serve as an example for low- and middle-income countries, where as many as 75% of the people who have mental disorders do not have access to the treatment they need.
Dominican Republic: Important advances were made in reforming the model of mental health care to focus on the person, family, and community through deinstitutionalization, with replacement of the psychiatric hospital by a psychosocial center; creation of mental health units in provincial, municipal, and regional hospitals; investment in community health centers and reinforcement of the first level of care; and creation of other psychosocial rehabilitation services such as day care centers and residential facilities for persons with chronic mental disorders. A National Mental Health Plan 2019-2022 was developed in alignment with the PAHO Plan of Action on Mental Health 2015-2020.
Ecuador: The National Mental Health Plan was revised to strengthen the community-based approach.
Guyana: Important progress was made in integrating mental health into the first level of care, with the development of a road map for the introduction of community-based mental health services, establishment of a mental health unit to lead the implementation of both a mental health strategy and a suicide action plan, and the training of 233 health care providers in mhGAP.
Paraguay: Interventions for mental health reform included creation of a technical working group for the reform of mental health care and gradual transformation of the traditional psychiatric hospital–centered model to a holistic, community-centric approach. This is an important intervention, given that in 2003 and 2008 the country was sanctioned by the International Court of Human Rights for violating the rights of persons with mental health conditions, in relation to their health care.
Peru: The National Plan for Strengthening Community Mental Health Services 2018-2021 was approved, signaling the country’s institutionalization of mental health reform and a model based on human rights. The community mental health model includes extension of the budget for mental health and financing of the implementation of the Plan; establishment of 106 community mental health centers in 24 regions; strengthening of services at the first level of care, with 170 facilitators of the mhGAP program trained in Lima and the provinces; formulation of a package of political and regulatory tools, including sectoral policy for mental health, and standards for community mental health centers and protected homes; and development of a proposal for a CCHD project involving Chile, Paraguay, and Peru to exchange good practices in community mental health and promote mutual strengthening of relevant services in the countries.
Trinidad and Tobago: The Mental Health Policy and Plan was reviewed, and stakeholder consultations were initiated in 2019 to obtain final approval. The final version was agreed upon, and drafting of the implementation plan began. The country also developed a suicide prevention strategy, with its official launch planned for World Mental Health Day 2019, in keeping with the theme of this year’s observation, “Mental health promotion and suicide prevention.” Training on mhGAP in all Regional Health Authorities and an assessment of the impact of the training on mental health services and care were initiated by the Mental Health Unit, with PASB support.
Turks and Caicos Islands: A review and update of the country’s mental health legislation were initiated, with the aim of reducing stigmatization, fostering greater multisectoral collaboration, and ensuring linkages to community-based, in-country care—as appropriate—for persons with mental health conditions. PASB provided access to online mental health training resources for health care personnel.
Cognizant of the psychosocial impact of disasters and humanitarian emergencies on the general population, responders, and health care workers, PASB’s technical cooperation also focused on improving mental health and psychosocial support (MHPSS) for disaster-affected populations. Relevant interventions were implemented in nine countries: Antigua and Barbuda, Brazil, Colombia, Ecuador, Grenada, Nicaragua, Saint Lucia, Trinidad and Tobago, and Venezuela.
Enhancing psychosocial support in disasters and humanitarian emergencies
In Antigua and Barbuda, a mental health and psychosocial support (MHPSS) needs assessment was undertaken, an action plan developed, and 30 shelter managers trained in psychological first aid (PFA).
In Brazil, a proposal was developed for strengthening local capacity in MHPSS to manage persons affected by disasters and humanitarian emergencies.
The British Virgin Islands implemented a project aimed at building resilience at the individual and community levels in response to the devastation of Hurricanes Irma and Maria in 2017. This initiative utilized a multipronged approach that includes helping individuals to address the lingering psychological impact of the disasters; enhancing the capacity of health care workers, first responders, and other community workers to take care of their own mental health needs, while responding to the needs of others; and building resilience for future adverse events. The project also supported participating communities in the development of community-level resiliency plans, and included a national communication campaign to enhance awareness and educate the population on maintaining mental health in disaster situations.
In Colombia, interventions made through the Health for Peace initiative addressed advocacy and the development of institutional and community capacities in areas marked by armed conflict, recognizing issues related to mental health and psychoactive substance abuse, and paving the way for continued implementation of relevant strategies in 2019.
At the Colombia-Venezuela border, psychosocial support and mental health care was provided to both the migrant population and health professionals experiencing burnout.
In Ecuador, strengthening of the skills of health teams to respond to the situation of cross-border migration was included in the revised National Mental Health Plan.
In Grenada, Saint Lucia, and Trinidad and Tobago, training was conducted to strengthen national capacity for mental health support during disasters and for PFA.
In Nicaragua, a program was developed, involving the Ministry of Health and the Ministry of Families, for mental health care during and after the sociopolitical crisis that the country experienced in 2018. The program trained 120 facilitators in the standardized management for PFA and built the capacity of mental health teams of the Local Systems of Comprehensive Health Care (SILAIS) and Family and Community Health Teams (ESFAC), providing them with skills for the timely detection, prevention, and care of mental health conditions in affected individuals and families.
Teams from four Caribbean countries and territories—Belize, Bermuda, Cayman Islands, and Jamaica—were trained for the implementation of an evidence-based mental health literacy model intervention in schools. In addition, the first-ever country-level investment case for mental health in Jamaica was completed. The investment case demonstrated that for every 1.00 Jamaican dollar devoted to scaling up treatment for depression, anxiety, and psychosis, the expected return on investment is 5.50 Jamaican dollars.
PASB continued its work to strengthen intersectoral cooperation at the regional and country levels to improve access to and quality of treatment for substance use disorders. The main challenge remains how to effectively engage national health authorities in the effort to strengthen the public health dimension of policies to reduce substance use and its complications. Even though the focus of such policies is shifting from a repressive and punitive perspective to a more comprehensive approach that includes a public health component, strategies and resources remain skewed toward repressive and judicial interventions.
The Bureau participated in the validation of the International Standards for the Treatment of Drug Use Disorders prepared by WHO and the UN Office on Drugs and Crime (UNODC), as well as the standard criteria for accreditation of drug demand reduction programs prepared by the Cooperation Program on Drugs Policies (COPOLAD). As a result, the Bureau was particularly well positioned to support 18 countries as they implemented these standards during the reporting period.
The Bureau also worked to strengthen collaboration with global, regional, and subregional partners, including UNODC, the OAS Inter-American Drug Abuse Control Commission (CICAD), and CARICOM, in the development and updating of drug policies using a public health approach. PASB also undertook technical cooperation with national agencies responsible for drug policies in 14 countries, and this work helped to position PAHO as a key actor in the reorientation of current drug policies toward a more comprehensive, balanced, and integrated approach. During 2018 and 2019, PASB renewed its memorandum of understanding with CICAD, establishing specific projects to improve access to and the quality of treatment for substance use disorders through public health services networks. Project beneficiaries include ministries of health, national drug control commissions, and CSOs in Argentina, Bahamas, Jamaica, Panama, and Peru. PASB worked with the Bahamas to complete and adopt standards of care for drug treatment facilities run by both public sector agencies and NGOs.
In its technical cooperation to reduce the harmful use of alcohol, PASB worked with Guyana, Jamaica, and Suriname to develop national alcohol strategies and plans of action. In the Dominican Republic, health care providers were trained in the assessment and diagnosis of fetal alcohol spectrum disorders (FASDs), which led to the creation of the first diagnostic center for FASDs in the country in early 2019. The Bureau developed and launched a self-learning virtual course on alcohol and pregnancy in English, Spanish, and Portuguese, and by late June 2019, 4,500 students had taken the course.
PASB coordinated an ongoing regional study on alcohol, drugs, and road injuries in emergency rooms, with piloting of effective interventions for reduction of alcohol use in Dominican Republic, Jamaica, and Peru. In addition, the Bureau prepared and published a regional report on the level of implementation of policies for the reduction of the harmful use of alcohol in Member States, measuring their progress in executing the 2010 WHO Global Strategy to Reduce the Harmful Use of Alcohol. The Global Strategy was endorsed by PAHO Member States and made operational for the Region of the Americas through the 2011 PAHO Plan of Action to Reduce the Harmful Use of Alcohol (Document CD51/8, Rev. 1). The 2018 regional report suggested that there is ample room for PAHO Member States to develop more comprehensive and stringent alcohol policies, and the Bureau urged countries to use the report and its scoring scheme to monitor and compare their progress in this area of work.
In Turks and Caicos Islands, the WHO alcohol survey instrument was used to document, identify, and reduce gaps in its policies to decrease alcohol consumption, while in the Central American subregion, the Bureau used an interprogrammatic approach to work with the PARLACEN and SE-COMISCA to develop and obtain approval for a declaration targeting comprehensive alcohol regulation, the first in the subregion.
Subregional approach to alcohol reduction policies in Central America
PASB played a key role in the development of a proposal for the Central American Parliament aimed at strengthening and harmonizing alcohol legislation in Central America and the Dominican Republic, in line with WHO’s SAFER alcohol control initiative. SAFER promotes Strengthening restrictions on alcohol availability; Advancing and enforcing drink-driving countermeasures; Facilitating access to screening, brief interventions, and treatment; Enforcing bans or comprehensive restrictions on alcohol advertising, sponsorship, and promotion; and Raising prices on alcohol through excise taxes and pricing policies.
The proposal was approved in March 2019 during a workshop attended by 120 members of PARLACEN and was formally ratified by the plenary of PARLACEN in April 2019; it applies to all Member States of the Central American Integration System (SICA).
The PARLACEN resolution declared that harmful use of alcohol is a serious public health problem and recognized that there is no safe level of alcohol consumption. The resolution also called on all Central American countries and the Dominican Republic to update and strengthen legislation aimed at limiting the availability of alcohol; preventing drink-driving; banning alcohol marketing, promotion, and sponsorship; reducing alcohol demand through price control policies and taxation; preventing influence by the alcohol industry on public health policies; and guaranteeing access to trustworthy information about the use of alcohol.
The resolution also established, for the first time, an obligation of SE-COMISCA to compile and report to PARLACEN detailed information on countries’ fulfillment of the resolution. This work illustrates a promising area of public health action promoted by PASB and known as “community legislation”.
SHAA2030 Goal 10:
PASB continued its technical cooperation toward ending the epidemics of HIV and AIDS, STIs, and tuberculosis; eliminating malaria, neglected infectious diseases, and mother-to-child transmission of selected communicable diseases (as described under SHAA2030 Goal 1); combating hepatitis, waterborne diseases, and other communicable diseases; fighting antimicrobial resistance; and mitigating food safety risks.
The Organization continued to advance universal access to effective HIV treatment through technical cooperation to increase uptake of WHO’s recommendations on ART initiation in people living with HIV, regardless of the CD4 count (the “Treat All” policy). As of mid-2019, 29 (83 percent) of PAHO’s 35 Member States had adopted those recommendations, while the remaining 6 were in the process of updating their policies.
The Bureau collaborated with regional partners and WHO reference laboratories to support the expansion of HIV drug resistance surveillance and HIV treatment optimization in response to the emerging threat of resistance to commonly used first-line medicines. As of mid-2019,
16 countries had completed drug resistance surveys; 5 others—El Salvador, Haiti, Paraguay, Peru, and Uruguay were conducting such surveys; and 8 others—Argentina, Bolivia, Brazil, Cuba, Guatemala, Haiti, Jamaica, and Venezuela—had begun transitioning to regimens based on dolutegravir (DTG), which WHO recommended as first-line treatment in its July 2018 Interim Guidance for HIV Treatment. Ten countries—Argentina, Bolivia, Chile, Costa Rica, Guatemala, Guyana, Honduras, Paraguay, Peru, and Venezuela—procured DTG through the PAHO Strategic Fund.
According to global estimates reported in the August 2019 issue of the Bulletin of the World Health Organization, the prevalence and incidence of four curable STIs—chlamydia, gonorrhea, trichomoniasis, and syphilis—remained high, with an average of over 1 million new infections each day in 2016. These estimates are similar to those published in 2012, both globally and by region, and underscore the continuing public health challenge posed by these four STIs.
In line with the regional Plan of Action for the Prevention and Control of HIV and Sexually Transmitted Infections 2016-2021 (Document CD55/14), PASB has prioritized actions to address infections with syphilis and gonorrhea, and prevent infection with HPV. These actions include work to roll out rapid diagnostic testing; standardize and simplify diagnostic algorithms for syphilis among pregnant women and key populations in El Salvador, Guatemala, Honduras, and Nicaragua; and pilot interventions in Barbados, Jamaica, Suriname, Trinidad and Tobago, and the six independent Member Countries of the OECS (Antigua and Barbuda, Dominica, Grenada, Saint Kitts and Nevis, Saint Lucia, and Saint Vincent and the Grenadines). The work in the Caribbean was done in partnership with the multi-country Global Fund grant for the OECS and CARPHA. In the past year, the Bureau has published the Epidemiological Alert for the extended-spectrum cephalosporin resistance in Neisseria gonorrhoeae and has provided technical cooperation to improve national antimicrobial resistance surveillance to guide treatment.
Despite advances in its prevention and control, tuberculosis remains a significant public health issue. PASB contributed to Member States’ preparation for, and was represented at, the first High-level Meeting on Ending Tuberculosis of the UN General Assembly held in September 2018. The Political Declaration from this HLM calls for greater efforts and investments towards the ending the tuberculosis pandemic by 2030 and sets specific measurable milestones to be achieved by 2022. During the period under review, PASB’s technical cooperation with countries was guided by the regional Plan of Action for the Prevention and Control of Tuberculosis 2015-2019 (Document CD54/11, Rev. 1), the WHO 2018 End TB Strategy, and the September 2018 HLM Political Declaration. The Bureau gave priority to countries with high-burden tuberculosis, and actions included strengthening prevention, diagnostic, and treatment interventions, as well as managerial capacity. The interventions emphasized groups in conditions of vulnerability, interprogrammatic and intersectoral approaches, and active civil society participation. Innovative initiatives, such as Tuberculosis Control in Large Cities and the tuberculosis elimination initiative, were promoted.
The Bureau undertook technical cooperation with all 18 of the Region’s Global-Fund-eligible countries as part of the Fund’s application process. By mid-2019, all the countries had succeeded in accessing new funding for HIV, tuberculosis, and malaria, with a total allocation of $351.3 million for the Region. As of April 2019, there were 42 active grants in 18 countries and six multicountry proposals. PASB also supported activities related to sustainability and transition (“transition readiness assessment”) in 8 countries “graduating” out of the Global Fund during the reporting period—Belize, Costa Rica, Cuba, Dominican Republic, El Salvador, Panama, Paraguay, and Suriname.
PASB collaborated with the Global Fund in other areas, including the joint agreement to strengthen pharmaceutical supply chains and reduce the risk of essential medicine shortages and stockouts in eight countries—Bolivia, Cuba, Ecuador, El Salvador, Guatemala, Honduras, Nicaragua, and Paraguay; the Elimination of Malaria in Mesoamerica and the Island of Hispaniola (EMMIE) initiative; and the regional project to strengthen tuberculosis laboratory networks in
As part of the implementation of the regional Plan of Action for Malaria Elimination 2016-2020 (Document CD55/13), PASB successfully supported Argentina and Paraguay in completing their malaria elimination certification processes in July 2018 and May 2019, respectively. Other countries that are very close to eliminating malaria, particularly Belize, Costa Rica, El Salvador, and Suriname, received PASB’s ongoing support to consolidate the interruption of transmission. The Bureau supported all endemic countries with the adaptation of plans and strategies towards malaria elimination, and provided technical and financial resources for initiatives in countries with high-burden areas where there is renewed political interest, such as Colombia, through the Pact for the Elimination of Malaria and in Peru, through the Municipalities for Zero Malaria initiative.
The Bureau promoted actions with greater impact at the local level through the development of a technical framework to address the malaria foci and consolidation of collaborative efforts against malaria in some of the highest-burden municipalities in Brazil, Colombia, Guatemala, Guyana, Haiti, Honduras, Nicaragua, Peru, and Venezuela.
In 2018, the PASB became part of the new Regional Malaria Elimination Initiative (RMEI), assuming the role of lead entity for technical cooperation. RMEI targets Central American countries, Colombia, and the Dominican Republic, in partnership with the IDB, and leverages new technical approaches, capacity development, mobilization of resources, and a renewal of political interest. Other partners include COMISCA and the Bill and Melinda Gates Foundation.
These diseases are often seen as markers of inequities, given that they are more common among populations living in poor socioeconomic conditions, with a low income, limited education, little or no access to basic services such as potable water and adequate sanitation, and barriers to accessing health services.
In its technical cooperation to address the elimination of lymphatic filariasis (LF) during the review period, PASB mobilized $1.5 million per year for two years—$1 million from USAID and $500,000 from the Ending Neglected Diseases (END) Fund—and supported the LF elimination program in Guyana.
The elimination of Rhodnius prolixus, the domestic vector of Chagas disease, as a public health problem was validated in Guatemala, Honduras, and Nicaragua during the reporting period. This means that the Central America subregion and Mexico are now free of the vector responsible for most of the endemicity of Chagas disease in that geographic area. Similarly, Paraguay was certified as having eliminated vector transmission by Triatoma infestans of Trypanososma cruzi, the parasite that causes Chagas disease, in the Presidente Hayes department and therefore in all its territory. The successes represent significant achievements for these Key Countries, given the recognized challenges in eliminating vector-borne transmission of Chagas disease.
The Region is on the verge of eliminating human rabies transmitted by dogs. There has been a marked reduction in human cases of dog-mediated rabies, and during the period under review only two countries—Dominican Republic and Haiti—reported cases of this infection, a total of six. Both countries are implementing prevention programs, and in Haiti there was a significant increase in access to rabies postexposure prophylaxis by persons in conditions of vulnerability. PASB facilitated the donation to Haiti of 15,000 doses of human rabies vaccines from Brazil, and 3,000 doses from Paraguay. Eight countries reported canine rabies—Argentina, Bolivia, Brazil, Colombia, Dominican Republic, Guatemala, Haiti, and Venezuela—and 27 countries and territories procured rabies immunological products (human/animal vaccines and immunoglobulin) through the PAHO Revolving Fund. Mexico finalized external validation for elimination of dog-mediated human rabies, as noted in the 2018 Third Report of the WHO Expert Consultation on Rabies.
PASB’s technical cooperation contributed to the implementation of pre-exposure prophylactic programs for sylvatic rabies in the Amazonian regions of Brazil, Colombia, and Peru, and to herbivore rabies prevention in Guyana, reducing the impact of the disease on indigenous and other populations in conditions of vulnerability.
Assessment of the epidemiological situation regarding brucellosis was initiated in Brazil, Ecuador, Panama, and Paraguay, focusing on improving national control programs and collaboration between the animal health and public health sectors. PASB continued its support for the South American Initiative for the Control and Surveillance of Cystic Echinococcosis/Hydatidosis, and provided technical cooperation for the documentation of interruption of transmission of schistosomiasis in Antigua and Barbuda and Saint Lucia.
Incidents with venomous animals have high morbidity rates and are a cause of mortality worldwide. In May 2018, the 71st World Health Assembly adopted resolution WHA71.5 “Addressing the burden of snakebite envenoming,” aiming to reduce related deaths, dysfunctions, and suffering. In the Region of the Americas, LAC countries are particularly affected by incidents involving venomous snakes—mainly in rural areas—and other venomous animals such as scorpions, spiders, caterpillars, and bees. During the reporting period, PASB, through the Pan American Foot-and-Mouth Disease Center (PANAFTOSA), a PAHO specialized center located in Brazil, convened the first meeting of official laboratories producing antivenom in Latin America, and initiated coordination of a technical guide as reference material for the diagnosis and treatment of incidents involving venomous animals in the Region.
In addition to the efforts described under SHAA2030 Goal 1 regarding the elimination of mother-to-child transmission of hepatitis B through EMTCT Plus, PASB focused on supporting the scale-up of quality hepatitis B and C testing and treatment in the Region. With the publication of the 2018 WHO hepatitis C care and treatment guidelines recommending pangenotypic direct-acting antivirals, the Bureau supported alignment of national guidance in Argentina, Brazil, Colombia, Ecuador, and Peru, and initiated a Caribbean-wide process for the development of hepatitis C guidelines, a first in hepatitis treatment. The alignment of national hepatitis B testing and treatment guidelines with the 2015 WHO hepatitis B guidelines was supported in the Caribbean, Ecuador, and Peru.
For the first time, the Bureau convened a Caribbean subregional meeting on the prevention and control of hepatitis. Also for the first time, an integrated meeting of heads of hepatitis, HIV, and tuberculosis programs in Latin American countries was held, in Guatemala in November 2018. National planning for hepatitis control was initiated or supported in several countries, including Ecuador, Guatemala, and Peru; Honduras became the first Central American country to draft a national hepatitis strategy; and Colombia published the first integrated national strategy for HIV, STIs, tuberculosis, and hepatitis in the Region.
PASB made substantial efforts in supporting countries to better understand current and future epidemiological and health system costs associated with hepatitis B and C epidemics, including: the development of an investment case for hepatitis and implementation of mathematical modeling and a consensus-building process to project disease burden and the economic impact of action to address the epidemics in Brazil and Chile; and hepatitis program reviews in Bolivia, El Salvador, and Peru; the review in El Salvador was conducted in partnership with the U.S. CDC.
As described in previous sections on outbreaks, emergencies, and disasters, and below in sections on water, sanitation, and hygiene, the prevention and control of vector-borne diseases such as dengue, chikungunya, and Zika virus and waterborne diseases such as cholera continue to pose challenges for several countries in the Region of the Americas. Major reductions in cholera in the island of Hispaniola—from 3,895 suspected cases reported in 2018 to 452 in the first half of 2019—signal advances toward elimination. However, as noted in the regional Strategy for Arboviral Disease Prevention and Control (Document CD55/16) approved by the 55th Directing Council in 2016, enhanced efforts are needed to control several mosquito-borne diseases.
PASB’s technical cooperation continued to focus on further reduction of cholera in the island of Hispaniola; addressed capacity-building for effective vector control programs through training in mosquito identification, vector surveillance, and insecticide resistance in Dominica, Saint Kitts and Nevis, and Saint Vincent and the Grenadines; and assessed the Rodent Control Program in Barbados, with recommendations to strengthen the program as a means of preventing outbreaks of leptospirosis and Hantavirus.
Antimicrobial resistance (AMR) is both a growing threat to health gains and a serious challenge for the attainment of SHAA2030 Goal 10 and several other SHAA2030 goals and targets, including those related to maternal, newborn, and under-5 mortality, and some related to NCDs. With funding support from Canada, Germany, and the U.S. CDC, PASB launched a new special program on AMR in 2018 to enhance Member States’ actions—based on their context, needs, and priorities—to lessen the impact of AMR.
Progress in this area is reflected in countries’ development and implementation of AMR national action plans (NAPs) under the “One Health” approach. By the end of 2018, 16 countries in the Americas had NAPs in place, and 13 others were developing such plans. PASB provided direct technical cooperation to 8 countries—Cuba, Dominican Republic, El Salvador, Guatemala, Guyana, Haiti, Paraguay, and Suriname—to develop NAPs during the reporting period.
In November 2018, the European Commission endorsed the proposed “Working together to fight AMR” initiative. The initiative, coordinated by PASB and implemented in collaboration with the UN Food and Agriculture Organization (FAO) and the World Organization for Animal Health (OIE), has the overall objectives of tackling AMR by engaging with major global players and strategic countries and of advancing the WHO Global Action Plan on AMR (2015) by sharing experiences, advocating best practices, and stimulating actions in seven South American countries: Argentina, Brazil, Chile, Colombia, Paraguay, Peru, and Uruguay.
PASB assisted countries in implementing multidisciplinary, evidence-based operational interventions for antimicrobial stewardship programs:
A Hospital Antimicrobial Use Point Prevalence Survey was conducted in Barbados, Guyana, and Saint Lucia, and a standardized tool was developed in a secure web-based application to capture data for the survey on antibiotic use.
Practical guidelines were published for decisionmakers in support of health workers and for the implementation of cost-effective AMR stewardship interventions.
Seven countries—Costa Rica, Cuba, Guyana, Mexico, Nicaragua, Paraguay, and Peru—were supported to implement antimicrobial stewardship programs.
A one-week training in AMR detection, surveillance, and analysis was held for microbiologists and health information officers from the Caribbean subregion.
The Bureau facilitated the development of a two-year CCHD initiative between Argentina and CARICOM aimed at strengthening national and regional AMR detection and surveillance in the 14 independent CARICOM Member States. The initiative aims to build technical capacity to conduct high-quality testing for the detection of AMR, collate and analyze AMR laboratory data, and use the laboratory results to monitor trends and improve prescribing practices, as well as to foster AMR policies, prevention, and interventions. The initiative contributes to the implementation of the WHO Global Antimicrobial Surveillance System (GLASS), which was launched in 2015 to support the implementation of the Global Action Plan on Antimicrobial Resistance. It also supports Caribbean countries in achieving compliance with the IHR, and as of mid-2019, PASB was seeking to mobilize resources to allow the Dutch and United Kingdom territories in the Caribbean to participate in the initiative.
The Bureau participated in the 2019 meeting of the United States of America Presidential Advisory Council Combating Antibiotic-Resistant Bacteria (PACCARB) and in several PACCARB meetings and discussions regarding surveillance, antimicrobial stewardship, and infection prevention and control. The Bureau also played a prominent role in ensuring that AMR was included in the Declaration from the G20 Leaders’ Summit held in Argentina in late 2018.
The PASB took part in negotiations with the Government of Denmark, the World Bank, and the Consultative Group for International Agricultural Research (CGIAR) to reach an agreement for the establishment of the International Centre for Antimicrobial Resistance Solutions (ICARS) in Denmark. ICARS will strengthen the global fight against AMR, serving as an independent global knowledge center and resource for national and international bodies, and promoting tailored and economically feasible solutions that take into account all aspects of the One Health approach, with particular focus on low- and middle-income countries.
In related work, PASB partnered with the U.S. CDC and Canada to support a meeting of the Regional Network for Antifungal Resistance Surveillance of Invasive Mycotic Diseases. The Network will coordinate regional surveillance and strengthen national capacities in the implementation of the Global AMR Surveillance System. Argentina, Brazil, Chile, Colombia, Costa Rica, Cuba, Guatemala, Mexico, Panama, Peru, Venezuela, and the United States of America are part of the regional organization, which is developing a surveillance protocol for antifungal resistance in Candida species, a common source of hospital-acquired bloodstream infections. A pilot project using the protocol in Latin America is planned for 2020.
Food safety and food inspection, based on risk analysis, are vital components of a modern food control system. PASB worked at the Caribbean subregional level to strengthen risk-based regulation by national food safety authorities in the subregion, and a key output during the review period was the development of a generic manual on risk-based inspection. The manual targets national food safety authorities responsible for ensuring food safety in the interests of public health, consumer protection, and international trade. The manual is consistent with Codex Alimentarius guidelines and standards, particularly principles and approaches for national food control systems and food hygiene, as well as the other codes of practice, such as for fish, dairy, meat, and street foods. The manual was validated by senior food inspectors who were trained on risk-based food inspection at a subregional workshop, and serves as both a training tool for use by national food safety authorities and a template for the creation of national manuals for Caribbean food inspectorates.
The Inter-American Network of Food Analysis Laboratories (INFAL) encompasses 250 member laboratories from 31 countries. In 2018, approximately 5,000 technical laboratory personnel from 19 countries were trained through INFAL webinars. The Network also coordinated one interlaboratory comparison in microbiology with 41 participants from 23 countries.
PASB also undertook technical cooperation at the national level.
Food safety systems were assessed in Costa Rica, El Salvador, and Suriname, and the implementation of recommendations for their strengthening was initiated.
Honduras received funding in the amount of $150,000 from the FAO/WHO Codex Trust Fund to strengthen its national Codex Committee, with activities lasting until 2021; the Bureau provided technical cooperation for the implementation of the project.
In Peru, PASB undertook technical cooperation with the General Directorate of Environmental Health and Food Safety of the Ministry of Health (DIGESA), in collaboration with the National Agrarian Health Services of the Ministry of Agriculture and Risk (SENASA) and the National Fisheries Health Agency of the Ministry of Production (SANIPES), to develop food safety risk communication guidelines.
In Trinidad and Tobago, a national food safety policy was developed and approved by the national Cabinet.
SHAA2030 Goal 11:
Inequalities and inequities in health
Strengthening mechanisms to measure and track inequities and progress towards Sustainable Development Goals and targets is a priority for the PASB. The Bureau convened a regional meeting in March 2019 titled “The Sustainable Development Goals in Health in the Americas: Challenges for the Monitoring of Equity and Proposals for Progress.” The event initiated the establishment an Organization-wide, equity-focused, framework to monitor regional and country-level progress towards the SHAA2030 and SDG 3 targets. Potential methodologies for measuring inequalities related to the 27 SDG 3 indicators were examined, and the meeting produced a map linking each indicator with routine data collection mechanisms to determine baseline and target data. Participants in the meeting included personnel from across PASB’s technical departments and several PAHO/WHO country offices, as well as experts from WHO in Geneva, the WHO Regional Office for Europe, the Federal University of Pelotas in Brazil, the Institute for Health Metrics and Evaluation (IHME), and the Johns Hopkins University Bloomberg School of Public Health.
PASB’s work in health promotion addresses the social determinants of health and is a critical component of technical cooperation with Member States to advance the SHAA2030. During the review period, the new framework for relevant technical cooperation, the regional Strategy and Plan of Action on Health Promotion within the Context of the Sustainable Development Goals 2019-2030 (Document CD57/10), was developed through an extensive consultative process. The process included a regional meeting in Brazil, which drew 70 participants from 31 countries and territories, and 35 national consultations involving ministries of health and representatives from other sectors, including academia and civil society. The finalized document was approved by the 164th Session of the Executive Committee for presentation to the 57th Directing Council in September 2019.
The degree to which health promotion is used as a crosscutting approach varies among countries, and there is need for all Member States to include health promotion in their national health policies and plans as an approach that includes not only health education activities but also intersectoral work, community participation, and other aspects of the PHC strategy. Seventeen countries have health promotion policies; 9 include health promotion in their national health plans: Argentina, Chile, Colombia, Costa Rica, Cuba, Ecuador, Jamaica, Mexico, and Peru; and 7 have a national strategy on health promotion: Chile, Costa Rica, El Salvador, Guatemala, Mexico, Panama, and Peru.
In order to strengthen the implementation of the SHAA2030 at the local level and advance health-promoting policies, PASB worked with the Latin American Federation of Cities, Municipalities and Associations of Local Governments (FLACMA) to reinvigorate the healthy cities and municipalities movement in the Region. The Bureau contributed to the creation of a special Health Commission within FLACMA to focus on health promotion, HiAP, and the implementation of the SHAA 2030 and the 2030 Agenda for Sustainable Development at the local level.
PAHO has celebrated Wellness Week in the Americas annually in September since 2011, modeled after the annual Caribbean Wellness Day established by CARICOM heads of State and government through their seminal 2007 Port-of-Spain Declaration on NCD prevention and control, and celebrated each September. The Wellness Week initiative seeks to mobilize a range of actors with the potential to positively impact their communities, including health promoters, staff from ministries of health, mayors, community leaders, and civil society in general. The slogan of Wellness Week 2018 was "Building healthy communities for everyone," highlighting the importance of health promotion in everyone's decision-making, in all settings, to improve the lives of all. The 2018 campaign highlighted stories of persons from eight countries—Barbados, Belize, Bolivia, Colombia, Cuba, Ecuador, El Salvador, and Jamaica—undertaking health promotion interventions in their communities.
In mid-2018, PASB began a review of current approaches for addressing health equity in its technical cooperation. The review examined the coherence and effectiveness of health equity mandates and technical cooperation undertaken in fulfillment of the PAHO Strategic Plan 2014-2019, and analyzed barriers to the implementation of health equity initiatives within the Organization. The assessment concluded that much work in health equity had been concentrated on the measurement of inequalities and on approaches within the UH and social determinants frameworks, and proposed strategies for a broader range of health equity approaches.
In September 2018, the Commission on Equity and Health Inequalities in the Americas, which was established by the Director of PAHO in 2016 under the chairmanship of Sir Michael Marmot, submitted to the 56th Directing Council an executive summary of its findings on the social causes and contexts of ill health in the Region and proposals for effective action to address them. In April 2019, PASB received the Commission’s final report, which contains 12 recommendations framed around three principal factors influencing health equity: structural drivers (political, social, cultural and economic structures; structural racism; and climate change), conditions of daily life (early life and education, working life, income and social protection, violence, environment and housing, and health systems), and governance systems and the observance of human rights. The report also recognizes the intersection and compounding effects of the various forms of disadvantage, and, in response, PASB established an interprogrammatic group to analyze optimal alignment of the Bureau’s work with the Commission’s recommendations. A related information document was developed, and it will be presented to PAHO’s 57th Directing Council in September 2019, coinciding with the regional launch of the Commission’s final report.
In January 2019, PASB secured funding from a significant new partner, the Robert Wood Johnson Foundation, to support a priority focus on equity in health. The resources target knowledge gaps on the scope and effectiveness of national and subnational policies to reduce health inequities; enhancement of knowledge exchange with health equity networks that include civil society, academia, and program implementers; and development of guidance, tools, and training on pro-health equity policy-making and planning for Member States.
During the review period, the Bureau conducted and published a systematic review of HIV, STIs, and viral hepatitis among indigenous and Afro-descendant people in Latin America. The study identified gaps in existing data on the burden of these diseases and highlighted the need to improve national surveillance by systematically collecting and analyzing ethnicity variables, and implementing integrated biobehavioral studies using robust methodologies and culturally sensitive strategies; to develop a Region-wide response policy that considers the needs of indigenous peoples and Afro-descendants; and to implement an intercultural approach to health and service delivery to eliminate health access barriers and improve health outcomes for these populations.
PASB conducted extensive national and subnational consultations with indigenous peoples, Afro-descendants, Roma people, ministries of health, and other relevant entities using a variety of modalities—including face-to-face and virtual meetings—to inform the development of the PAHO Strategy and Plan of Action on Ethnicity and Health 2019-2025 (Document CD57/13). The aim was to ensure that all perspectives were incorporated into this new framework, which will be presented to the 57th Directing Council in September 2019. The framework builds on the 2006 Health of Indigenous Peoples of the Americas initiative (Document CD47/13); aligns with the OAS-PAHO Plan of Action for the Americas for Implementation of the International Decade for People of African Descent 2016-2025; implements the guidance in the PAHO Policy on Ethnicity and Health, adopted by the 29th Pan American Sanitary Conference in 2017 (Document CSP29/7, Rev. 1); and takes into consideration the 2018 PAHO Health Plan for Indigenous Youth in Latin America and the Caribbean and the 2018 PAHO Health Plan for Afro-descendant Youth in Latin America and the Caribbean. Once approved, the new Strategy and Plan of Action will provide significant guidance for advancing health equity in the Region of the Americas.
PASB collaborated with the National Center for Intercultural Health in the Ministry of Health of Peru to promote the inclusion in health registries of the self-identification of indigenous, Afro-Peruvian, and other peoples. Such identification allows analysis of disaggregated data, identification of inequities, and development of specific actions to address the needs of people in conditions of greatest vulnerability and exclusion. Also in Peru, the Bureau supported the piloting of a WHO qualitative tool for use in conducting situation analyses of demand-side barriers to effective access to health faced by people working in the informal economy. The pilot focuses on the situation of Venezuelan migrants, and the results will inform initiatives to advance UH in Peru.
A pro-equity methodology called the Cross Cutting Themes (CCTs) Criteria Tool was developed in 2017 under the IHSLAC project. PASB has refined and piloted a more integrated version of the instrument, creating an online platform with user-friendly guidance and examples to facilitate use of the methodology. The new version was applied in PAHO/WHO country offices for reporting on the IHSLAC project at the end of 2018. PASB plans to use the new methodology and platform more widely to create, monitor, and keep updated a database of the approaches that both the Bureau and Member States use to address the CCTs.
Gender inequality is well recognized as a significant underlying driver of health inequity among men, women, and those with diverse gender identities. This inequality is mediated through socially and culturally determined male-female differences in exposures, behaviors, and access to health care, and through biases in health service provision and health research, among other factors.
During the reporting period, PASB undertook a study to review regional and country efforts towards gender mainstreaming in health (GMH). The study included an analysis of gender mainstreaming definitions and institutional requirements in regional policy documents and mandates; a systematic review of documented results of gender mainstreaming in national health policies and programs, focusing on gender and health priorities in SDG 3 and SDG 5; a review of PAHO documents, scientific publications, and information available on the web; and conducting semi-structured interviews with experts. These components were complemented by the development of three case studies—in Guatemala, Guyana, and Peru—focusing on stakeholders’ experiences and lessons learned from the mainstreaming of gender in the respective health sectors. The studies were completed with the countries’ participation, and for each country PASB organized virtual presentations of the findings and recommendations and facilitated collaboration among partners to stimulate further work.
The comprehensive FASB study and the case studies in the three countries have led to a series of recommendations on GMH: setting minimum requirements for institutional as well as programmatic interventions; documenting effective and successful strategies and their results; expanding the scope and definitions, with measurable operational plans and a focus on results; and strengthening capacities for gender-based analysis and monitoring and evaluation. The recommendations were presented at an expert group meeting during the Women Deliver 2019 Conference held in Vancouver, Canada, in June 2019.
PASB’s technical cooperation contributed to the strengthening of capacities for gender analysis in Grenada, Saint Lucia, and Saint Vincent and the Grenadines, with the intent to extend similar interventions to other eastern Caribbean countries. The initiative involved the development of gender profiles on specific health topics—such as HIV and STIs—in collaboration with each ministry of health and its partners, to provide baseline information for monitoring advances and developing new initiatives.
In efforts to strengthen the capacity of Caribbean health systems to respond to violence against women, a training-of-trainers exercise was implemented in that subregion on evidence-based health system responses to survivors of intimate partner and sexual violence. The main objectives of this work were to strengthen health care providers’ capacity to identify, and provide care for, survivors of violence, and to strengthen the collaboration between government and CSOs that provide care to women survivors. The intervention was undertaken in collaboration with the Public Health Agency of Canada (PHAC) and the Johns Hopkins University School of Nursing (JHSON-CC), which is a PAHO Collaborating Center for HRH. Other partners included UNFPA, UNICEF, UN Women, the World Bank, and CARICOM.
In late 2018, the Bureau signed a memorandum of understanding with the World Professional Association for Transgender Health (WPATH), a nonprofit, interdisciplinary, professional and educational organization devoted to transgender health, to develop a five-module virtual course on LGBT health. The course will be hosted by the PAHO VCPH and is expected to be launched by the end of 2019.
In 2018, the Director of PAHO developed a report on LGBT health and barriers in accessing health services (Document CD56/INF/11, Corr.) with input from PASB’s LGBT interprogrammatic working group. The presentation of the report to the 56th Directing Council in September 2018 fulfilled a mandate established in 2013 through PAHO resolution CD52.R6 “Addressing the causes of disparities in health service access and utilization for LGBT persons.” The findings and recommendations of the Director’s report aim to guide countries’ efforts to eliminate barriers that LGBT persons experience in accessing health services, particularly by promoting social and financial protection in a nondiscriminatory manner, and protecting their right to health.
Adolescents face many barriers to receiving the full range of quality, age-appropriate preventive, promotional, and curative services that they need. Where services exist, they may be fragmented and not aligned with the health care needs of young people. Multisectoral approaches and interventions targeting families, schools, and communities, and efforts to identify and target the most vulnerable groups of young people with evidence-based interventions, remain limited in number and scope.
PASB’s technical cooperation in adolescent health contributes to advancing a number of SHAA2030 targets, in particular those related to NCDs and mental health disorders, communicable diseases, road traffic incidents, violence, substance abuse, maternal mortality, and sexual and reproductive health. In 2018, PASB finalized a regional report on the status of adolescent health in the Americas, based on 19 regional indicators and information on the implementation of the PAHO Adolescent and Youth Regional Strategy and Plan of Action 2010-2018. The report reveals that significant progress has been made at regional and country levels in the development and implementation of actions for adolescent and youth health, including the establishment of adolescent health programs in most countries; the availability and use of strategic information; expansion of health services for adolescents; capacity-building of stakeholders in a range of adolescent health topics; and introduction of school- and family-based interventions. However, the report also notes that not all groups have benefited equally from this progress, and adolescent mortality has remained stagnant, with homicides, suicides, and traffic fatalities as leading causes of death in this age group.
The regional report’s recommendations include provision of adequate funding for multisectoral adolescent and youth health programs that address the social determinants of health; establishment of an adolescent-responsive health system; implementation of school-, family-, and community-based interventions to protect and promote children’s and adolescents’ health; utilization of evidence-based approaches that target groups in conditions of vulnerability; monitoring and evaluation to inform strategic planning and timely adaptation of programs and services; and engagement of young people as agents of change.
WHO’s Global Accelerated Action for the Health of Adolescents (AA-HA!), launched in 2017, provides guidance for developing comprehensive, evidence-based, multisectoral adolescent health plans and strategies that are aligned with the SDGs and the Global Strategy for Women’s, Children’s and Adolescents’ Health. During the period under review, PASB trained teams from eight countries—Brazil, Dominican Republic, Ecuador, El Salvador, Haiti, Honduras, Panama, and Peru—to apply the AA-HA! guidance, and supported four countries— Belize, Honduras, Guyana, and Suriname—to develop a new generation of adolescent health plans.
In addition to supporting the use of WHO’s Innov8 tool to review interventions for the reduction of adolescent pregnancies, PASB supported the use of the tool to analyze adolescent health programs. Innov8’s eight-step analytic process for health programs aims to operationalize the SDGs’ commitment to “leave no one behind,” and its application results in recommendations for concrete actions to address health inequities, support gender and ethnic equality, address critical social determinants of health, and progressively realize UH and the right to health.
The Bureau supported the translation and implementation of the WHO 2019 publication “Handbook for conducting an adolescent health services barriers assessment (AHSBA) with a focus on disadvantaged adolescents.” The AHSBA is a methodology for identifying subpopulations without effective health service coverage and the most important barriers that they face. Mexico has requested the implementation of the ASHBA during the next year.
PASB’s technical cooperation over the reporting period contributed to the reduction of insults and threats to the health of the environment, and to enhancing water, sanitation, and hygiene in countries and selected subregions.
In collaboration with ministries of health, environment, and energy, the Bureau conducted a situational assessment of national readiness to reduce the residential use of solid fuels and kerosene using the Household Energy Assessment Rapid Tool (HEART) in Honduras, Mexico, Panama, Paraguay, and Peru. The HEART toolkit is a novel method to stimulate conversation between sectors following the Health in All Policies guidelines. Using the toolkit with the countries allowed PASB to engage the respective health sectors in relevant discussions and produce a report for each country that provides a diagnosis of the situation and a road map to improve access to clean energy for all.
As part of the global BreatheLife campaign—a joint initiative of WHO, UN Environment, and the Climate and Clean Air Coalition—PASB helped build capacities to address ambient air pollution in several Member States. This technical cooperation included a workshop in Colombia on air monitoring systems, emissions inventories, and transport, as well as support for the development of road maps for action in Argentina, Honduras, and Paraguay.
The Bureau supported the training of environmental health officers and other stakeholders in British Virgin Islands, Montserrat, and Saint Kitts and Nevis in monitoring indoor air quality. In addition, country capacity was enhanced in the area of onsite wastewater management, and specific country guidelines were developed and adopted.
In the Central American subregion, PASB proposed and negotiated an initiative on air quality and health with the PARLACEN, which endorsed it by resolution in May 2019. The resolution recognizes poor air quality as a public health issue and as a significant environmental risk factor for NCDs that should be prioritized and adequately addressed. The resolution requires SE-COMISCA and the Central American Commission for Environment and Development (CCAD) to establish or strengthen technical norms for air quality to protect people’s health; urges SICA Member States to review their legal frameworks in this area; and calls for the creation, with PASB technical cooperation, of an observatory on air quality in the Central American subregion. PASB proposed a model law for use in creating or strengthening legislation related to air quality, which was also approved by the PARLACEN.
With funding from UN Environment and the Global Environmental Facility (GEF), the Bureau undertook technical cooperation on the elimination of lead in paint, organizing the first regional workshop on the subject in June 2019. PASB also began work on other GEF projects for the implementation of the Minamata convention on mercury, in Argentina (thermometer replacement), the Caribbean (skin lightening products), and Uruguay (dental amalgam phasedown).
PASB applied the WASH Protocol in Health Care Facilities to evaluate health care facilities in six countries—Bolivia, Guatemala, Honduras, Panama, Paraguay, and Peru—on measures related to water, sanitation, hygiene, drainage, health care waste, and vector control. This information, which will form the basis for the integration of WASH into national health policies and plans, was the core source of regional data for the WHO-UNICEF Joint Monitoring Program’s WASH in Health Care Facilities: Global Baseline Report 2019, which was published in April 2019. Partners and supporters in this work included WHO, UNICEF, the IHSLAC project, and the Government of Peru.
In Brazil, the Bureau coordinated and implemented TrackFin, a methodology for tracking financing for WASH at the subnational level. In addition, the Bureau applied the Global Analysis and Assessment of Sanitation and Drinking Water (GLAAS) methodology in 25 countries and territories. Both instruments revealed substantial gaps in countries’ understanding and tracking of financing to the WASH sector, which makes it difficult to generate evidence-based planning and budgeting decisions. PASB will continue to promote the TrackFin methodology and support a regional study on the affordability of WASH services within a human rights framework. Partners and supporters in this work include the Association of Regulators of Water and Sanitation of the Americas (ADERASA), AECID, FIOCRUZ Brazil, the Government of Peru, and WHO.
In 2018, Member States faced important challenges regarding health and migration, described above under SHAA2030 Goal 8, “Outbreaks, emergencies, and disasters.” Additionally, noting State-led actions on international migration, PASB convened a high-level meeting in Washington, D.C., in November 2018, where ministers of health and other representatives from 32 countries and territories across the Region of the Americas identified a series of actions aimed at improving the health response to the mass migration that is occurring in the Region. Based on that input and in further consultation with Member States, PASB published the Guidance Document on Migration and Health, which outlines people-centered actions, a multi-hazard approach, and shared responsibility among national and subnational institutions and authorities, and the public and private sectors.
The results of PAHO’s technical cooperation are manifest in its Member States, and PASB continued to tailor its country-level interventions according to national priorities and needs, identified through development of a Country Cooperation Strategy (CCS) for each country. Each CCS is fully aligned with SHAA2030, SDG 3, and related SDGs, as appropriate to the national situation. Each CCS also guides the Organization’s work with and in the country, as well as reflects the midterm vision for technical cooperation with the respective Member State. During the reporting period, CCSs were completed in 10 countries—Antigua and Barbuda, Barbados, Bolivia, Brazil, Chile, Dominica, Grenada, Saint Kitts and Nevis, Saint Lucia, and Saint Vincent and the Grenadines—and evaluated in 4: Costa Rica, Dominican Republic, Mexico and Panama.
Guided by the principle of “leaving no one behind” and attendant to the needs of the eight designated Key Countries, which face critical structural, economic, and social challenges, PASB advanced implementation of the PAHO Key Country Strategy. Close monitoring and adjustment of technical cooperation with these countries during the review period, including a formal review of the technical cooperation with Haiti, resulted in timely and effective interventions in the countries, which maximized PASB’s added value and impact.
PASB has a long history of championing and contributing to the promotion of South-South and triangular cooperation, initially through its technical cooperation among countries (TCC) initiative, and now through the CCHD program, the successor to TCC. CCHD not only leverages the expertise within the Organization, but also—as importantly—identifies and mobilizes the know-how within countries themselves to formulate tailored solutions to health issues. During the reporting period, the experiences of cooperation among PAHO Member States were documented in publications by the UN Office of South-South Cooperation (UNOSSC), the Ministry of Foreign Affairs of Argentina, and WHO.
For the second consecutive year, PASB and the Ibero-American General Secretariat (SEGIB) joined forces to contribute to the visibility and understanding of South-South and triangular cooperation in the health sector in the Region of the Americas, by developing and publishing a collaborative report. This 2018 edition, which was launched during the Second High-level UN Conference on South-South Cooperation (BAPA+40) held in Buenos Aires, Argentina, in March 2019, presents country profiles for each of the Member States that reported to SEGIB. The report also analyzes the contribution of South-South and triangular cooperation to the SDGs beyond SDG 3, demonstrating the multisectoral approach of the projects.
Over the review period, five projects were approved through the CCHD initiative, facilitating exchanges among 25 countries and territories, of which 6 are Key Countries. The five projects were:
towards universal health for the population of the South American Chaco, involving Argentina, Bolivia, Brazil, and Paraguay;
advancing public health policies to address overweight and obesity in Chile and the CARICOM, involving CARICOM and Chile;
improvement of maternal and child health at the northern border of the Dominican Republic and Haiti, involving the Dominican Republic and Haiti;
strengthening national and regional antimicrobial resistance detection and surveillance in CARICOM Member States, involving Argentina and CARICOM;
generating critical information for planning and monitoring cancer control programs in Latin America, involving Argentina, Colombia, El Salvador, Guatemala, Panama, Paraguay, and Peru.
PASB allocated $1.9 million to this cooperation modality and mobilized $1.2 million in in-kind contributions from the participating Member States. All the projects contributed directly to selected SHAA2030 and SDG 3 targets, as well as to SDGs 2 and 17. In addition, PASB worked to strengthen the offices of international relations of the ministries of health and launched a community of practice for representatives of those offices in November 2018. The objectives of this community of practice are to facilitate improvements in national governance for global health and international cooperation for health, and promote health diplomacy and cooperation among countries.
PASB’s country focus was also enhanced through close collaboration with Member States in critical planning, budgeting, and assessment exercises, including the joint end-of-biennium evaluation process; development of the proposed PAHO Strategic Plan 2020-2025, along with indicators for the Plan and the SHAA2030, through the SPAG; development of the new regional Budget Policy; and preparation of the proposed Program Budget 2020-2021. More details are provided in Part 3 of this report under “Planning and budgeting.”
 Argentina, Brazil, Canada, Chile, Cuba, Ecuador, El Salvador, Guatemala, Nicaragua, Paraguay, Peru, Suriname, and United States of America.
 PAHO. “Universal health in the 21st century: 40 years after Alma-Ata.” Report of the High-Level Commission. Washington, D.C.: PAHO; 2019.
 Argentina, Bahamas, Bolivia, Brazil, Chile, Colombia, Costa Rica, Cuba, Curaҫao, Dominican Republic, Ecuador, El Salvador, Grenada, Guatemala, Guyana, Haiti, Honduras, Nicaragua, Panama, Paraguay, Peru, Saint Kitts and Nevis, Saint Lucia, Saint Martin, Suriname, Trinidad and Tobago, Uruguay, United States of America, and Venezuela.
 Hurricane Maria impacted Dominica in 2017.
 WHO. Programming strategies for postpartum family planning. Geneva: WHO; 2013.
 Bolivia, Colombia, Dominican Republic, Guatemala, Guyana, Haiti, Honduras, Paraguay, Peru, Suriname, and Venezuela.
 Global Affairs Canada is formally known as the Department of Foreign Affairs, Trade and Development (DFATD) Canada.
 Bolivia, Colombia, Ecuador, Guatemala, Guyana, Haiti, Honduras, Nicaragua, Paraguay, Peru, and Suriname.
 Bolivia, Brazil, Colombia, Dominican Republic, Guatemala, Guyana, Haiti, Honduras, Nicaragua, Paraguay, Peru, Saint Lucia, Saint Vincent and the Grenadines, and Suriname.
 Colombia, Dominican Republic, Ecuador, Grenada, Guatemala, Guyana, Haiti, Honduras, Nicaragua, Paraguay, Peru, Saint Lucia, Saint Vincent and the Grenadines, and Trinidad and Tobago.
 Argentina, Barbados, Brazil, Chile, Colombia, Costa Rica, Cuba, Ecuador, El Salvador, Guatemala, Mexico, Nicaragua, Paraguay, Uruguay, and Venezuela.
 The SIP was developed in 1983 by the Latin American Center for Perinatology, Women, and Reproductive Health (CLAP/WR), a PAHO specialized center located in Uruguay. The SIP is used in 26 countries and territories in LAC—Anguilla, Antigua and Barbuda, Argentina, Belize, Bermuda, Bolivia, Brazil, Colombia, Dominica, Dominican Republic, Ecuador, El Salvador, Grenada, Guatemala, Guyana, Honduras, Mexico, Nicaragua, Panama, Paraguay, Saint Lucia, Saint Kitts and Nevis, Saint Vincent and the Grenadines, Suriname, Trinidad and Tobago, and Uruguay—adapted to their needs and prioritized indicators.
 Anguilla, Antigua and Barbuda, Bahamas, Barbados, Belize, Dominica, Grenada, Guyana, Haiti, Jamaica, Montserrat, Suriname, Saint Lucia, Saint Vincent and the Grenadines, and Trinidad and Tobago.
 Bolivia, Brazil, Colombia, Dominica, Dominican Republic, Guyana, Honduras, Paraguay, Saint Lucia, Saint Vincent and the Grenadines, Suriname, and Trinidad and Tobago.
 PAHO. New Generations Free of HIV, Syphilis, Hepatitis B, and Chagas Disease: EMTCT Plus in the Americas, 2018. Washington, D.C.: PAHO; 2019.
 Silviera MF, Gomez Ponce de Leon R, Becerra F, Serruya SJ. Evolution towards the elimination of congenital syphilis in Latin America and the Caribbean: a multicountry analysis. Rev. Panam Salud Publica. 2019;43:e31. https://doi.org/10.26633/RPSP.2019.31.
 Argentina, Brazil, Chile, Colombia, Costa Rica, Cuba, Dominican Republic, Mexico, Nicaragua, Peru, and United States of America.
 Argentina, Bolivia, Cuba, Chile, Dominican Republic, El Salvador, Guatemala, Guyana, Honduras, Panama, Peru, Paraguay, and Uruguay.
 Argentina, Brazil, Chile, Colombia, Costa Rica, Cuba, Dominican Republic, Guatemala, Guyana, Honduras, Nicaragua, Paraguay, Peru, Suriname, and Uruguay.
 Argentina, Bolivia, Brazil, Chile, Colombia, Costa Rica, Cuba, Dominican Republic, El Salvador, Guatemala, Guyana, Honduras, Nicaragua, Panama, Paraguay, Peru, Suriname, Uruguay, and Venezuela.
 Belize, Bolivia, Brazil, Dominica, El Salvador, Guatemala, Guyana, Haiti, Honduras, Nicaragua, Paraguay, and Suriname.
 Anguilla, Antigua and Barbuda, Aruba, Bahamas, Barbados, Belize, Bermuda, Bonaire, British Virgin Islands, Cayman Islands, Curaҫao, Dominica, French Guiana, Grenada, Guyana, Haiti, Jamaica, Montserrat, Saint Lucia, Saint Kitts and Nevis, Sint Maarten, Saint Vincent and Grenadines, Suriname, Trinidad and Tobago, Turks and Caicos Islands, and U.S. Virgin Islands.
 Anguilla, Antigua and Barbuda, Argentina, Aruba, Bahamas, Barbados, Belize, Bermuda, Bolivia, Bonaire, Brazil, British Virgin Islands, Cayman Islands, Costa Rica, Chile, Colombia, Cuba, Curaҫao, Dominican Republic, Ecuador, El Salvador, Grenada, Guatemala, Guyana, Haiti, Honduras, Jamaica, Mexico, Montserrat, Panama, Paraguay, Peru, Puerto Rico, Saint Kitts and Nevis, Saint Lucia, Saint Vincent and the Grenadines, Suriname, Trinidad and Tobago, Turks and Caicos Islands, and Uruguay.
 Bolivia, Chile, Colombia, Costa Rica, Cuba, Dominican Republic, Ecuador, El Salvador, Guatemala, Honduras, Mexico, Nicaragua, Panama, Paraguay, Peru, Uruguay, and Venezuela.
 Anguilla, Barbados, Belize, Bermuda, British Virgin Islands, Chile, Curaçao, Dominica, Dominican Republic, Ecuador, Grenada, Guatemala, Haiti, Honduras, Jamaica, Mexico, Nicaragua, Panama, Peru, Saint Lucia, Suriname, and Trinidad and Tobago.
 Argentina, Bolivia, Brazil, British Virgin Islands, Chile, Colombia, Cuba, Dominican Republic, Ecuador, Grenada, Guatemala, Guyana, Haiti, Honduras, Jamaica, Mexico, Nicaragua, Panama, Paraguay, Peru, Uruguay, and Venezuela.
 Anguilla, Antigua and Barbuda, Argentina, Aruba, Bahamas, Barbados, Belize, Bermuda, Bonaire, Bolivia, Brazil, Canada, Cayman Islands, Chile, Colombia, Costa Rica, Dominican Republic, Ecuador, Grenada, Guadeloupe, Guatemala, Guyana, Honduras, Jamaica, Mexico, Montserrat, Panama, Paraguay, Peru, Puerto Rico, Saba, Saint Lucia, Saint Vincent and the Grenadines, Sint Eustatius, Sint Maarten, Suriname, Trinidad and Tobago, Turks and Caicos Islands, United States of America, and Uruguay.
 Unless otherwise indicated, all monetary figures in this report are expressed in United States dollars.
 U.S. CDC. Measles cases in 2019. Available at https://www.cdc.gov/measles/cases-outbreaks.html. Accessed 7 June 2019.
 Anguilla, Barbados, Belize, Brazil, British Virgin Islands, Colombia, Dominica, Dominican Republic, Grenada, Guatemala, Honduras, Jamaica, Mexico, Montserrat, Nicaragua, Panama, Paraguay, Saint Kitts and Nevis, Saint Lucia, Saint Martin, Saint Vincent and the Grenadines, Suriname, and Trinidad and Tobago.
 Barbados, Belize, Colombia, Dominica, Grenada, Honduras, Jamaica, Panama, Paraguay, Saint Lucia, Suriname, Trinidad and Tobago, and Uruguay.
 Anguilla, Barbados, Belize, Colombia, Grenada, Guatemala, Honduras, Jamaica, Mexico, Montserrat, Panama, Paraguay, Saint Lucia, Sint Maarten, Trinidad and Tobago, and Turks and Caicos Islands.
 Bahamas, Belize, Bermuda, British Virgin Islands, Colombia, Costa Rica, Dominican Republic, Ecuador, Guatemala, Guyana, Honduras, Jamaica, Nicaragua, Panama, Peru, Suriname, and Uruguay.
 The call for applications closed in November 2018.
 Argentina, Antigua and Barbuda, Bermuda, Bolivia, Brazil, British Virgin Islands, Chile, Colombia, Costa Rica, Cuba, Curaҫao, Dominican Republic, Ecuador, Guatemala, Guyana, Honduras, Jamaica, Mexico, Nicaragua, Panama, Paraguay, Peru, Suriname, Saint Vincent and Grenadines, Trinidad and Tobago, Uruguay, and Venezuela.
 Anguilla, Bahamas, Barbados, Bermuda, British Virgin Islands, Dominica, Ecuador, Guyana, Honduras, Jamaica, Saint Lucia, Saint Vincent and the Grenadines, Suriname, Trinidad and Tobago, and Turks and Caicos Islands.
 Argentina, Bolivia, Chile, Colombia, Costa Rica, Cuba, Ecuador, Dominican Republic, El Salvador, Guatemala, Haiti, Honduras, Mexico, Nicaragua, Panama, Peru, Paraguay, Uruguay, and Venezuela.
 Brazil, Bolivia, Colombia, Dominican Republic, Ecuador, El Salvador, Guatemala, Guyana, Honduras, Haiti, Jamaica, Nicaragua, Panama, Paraguay, Peru, and Suriname.
 Bahamas, Bolivia, Dominican Republic, Ecuador, Guatemala, Haiti, Jamaica, Honduras, Mexico, Nicaragua, Paraguay, and Trinidad and Tobago.
 The UN MMEIG comprises representatives from UNFPA, UNICEF, UN Population Division, WHO, and World Bank.
 SPAG had representation from all PAHO subregions: the Caribbean (Antigua and Barbuda, Bahamas, Dominica, Guyana, Saint Lucia, and Trinidad and Tobago), Central America (Costa Rica, El Salvador, Guatemala, Honduras, Nicaragua, and Panama), North America (Canada, Mexico, and the United States of America), and South America (Argentina, Bolivia, Brazil, Ecuador, Paraguay, and Venezuela). Panama was appointed Chair, and the Bahamas, Vice Chair.
 GRADE = Grading of Recommendations Assessment, Development and Evaluation.
 The HRP/TDR/PAHO Small Grants Program is joint initiative among TDR, the Special Program for Research and Training in Tropical Diseases that is cosponsored by UNICEF, the UN Development Program (UNDP), the World Bank, and WHO; HRP, the UNDP/UNFPA/UNICEF/WHO/World Bank Special Program of Research, Development and Research Training in Human Reproduction (HRP); and PAHO.
 Bahamas, Brazil, Bolivia, Colombia, Costa Rica, Dominican Republic, Ecuador, El Salvador, Guatemala, Guyana, Honduras, Haiti, Jamaica, Mexico, Nicaragua, Panama, Paraguay, Peru, Suriname, and Trinidad and Tobago.
 Anguilla, Antigua and Barbuda, Argentina, Bolivia, Brazil, Canada, Cayman Islands, Chile, Colombia, Cuba, Dominican Republic, Ecuador, El Salvador, Grenada, Guatemala, Jamaica, Martinique, Mexico, Nicaragua, Paraguay, Puerto Rico, Saint Vincent and the Grenadines, Suriname, Trinidad and Tobago, Turks and Caicos Islands, and United States of America.
 Anguilla, Antigua and Barbuda, Bahamas, Barbados, Belize, Bolivia, Brazil, Canada, Cayman Islands, Colombia, Costa Rica (in progress), Cuba, Dominica, Ecuador, El Salvador, Grenada, Guatemala, Guyana, Jamaica, Martinique, Mexico, Nicaragua, Panama, Puerto Rico, Saint Vincent and the Grenadines, Suriname, Trinidad and Tobago, Turks and Caicos Islands, and United States of America.
 Anguilla, Bahamas, Barbados, Bermuda, Bolivia, Canada, Cayman Islands, Chile, Colombia, Costa Rica (in progress), Cuba, Dominican Republic, Ecuador, El Salvador, Guyana, Jamaica, Martinique, Mexico, Nicaragua, Puerto Rico, Saint Kitts and Nevis, Turks and Caicos Islands, and United States of America.
 Anguilla, Bahamas, Barbados, Belize, Bolivia, Brazil, Canada, Cayman Islands, Chile, Colombia, Costa Rica, Cuba, Dominica, Ecuador, El Salvador, Guatemala, Guyana, Jamaica, Martinique, Mexico, Nicaragua, Panama, Puerto Rico, Saint Lucia, Saint Vincent and the Grenadines, Turks and Caicos Islands, and United States of America.
 Anguilla, Antigua and Barbuda, Bahamas, Barbados, Belize, Bermuda, Bolivia, Brazil, Canada, Cayman Islands, Chile, Colombia, Costa Rica, Cuba, Dominica, Ecuador, El Salvador, Grenada, Guyana, Jamaica, Martinique, Mexico, Nicaragua, Panama, Puerto Rico, Saint Vincent and the Grenadines, St. Kitts and Nevis, Trinidad and Tobago, Turks and Caicos Islands, and United States of America.
 Antigua and Barbuda, Bolivia, Canada, Cayman Islands, Chile, Colombia, Cuba, Dominican Republic, Ecuador, Guatemala, Jamaica, Martinique, Mexico, Nicaragua, Paraguay, Puerto Rico, Saint Vincent and the Grenadines, Suriname, Turks and Caicos Islands, and United States of America.
 Anguilla, Antigua and Barbuda, Argentina, Bahamas, Barbados, Belize, Bermuda, Bolivia, Brazil, British Virgin Islands, Cayman Islands, Chile, Colombia, Costa Rica, Cuba, Dominica, Dominican Republic, Ecuador, El Salvador, Grenada, Guatemala, Guyana, Haiti, Honduras, Jamaica, Mexico, Montserrat, Nicaragua, Panama, Paraguay, Peru, Saint Kitts and Nevis, Saint Lucia, Saint Vincent and the Grenadines, Suriname, Trinidad and Tobago, Turks and Caicos Islands, Uruguay, and Venezuela.
 Antigua and Barbuda, Argentina, Bahamas, Barbados, Bermuda, Bolivia, Brazil, Canada, Cayman Islands, Chile, Colombia, Costa Rica, Cuba, Dominican Republic, Ecuador, Guatemala, Guyana, Haiti, Honduras, Nicaragua, Jamaica, Mexico, Panama, Paraguay, Peru, Puerto Rico, Saint Kitts and Nevis, Saint Lucia, Saint Vincent and the Grenadines, Suriname, Trinidad and Tobago, Turks and Caicos Islands, United States of America, Uruguay, and Venezuela.
 Argentina, Bolivia, Brazil, Canada, Chile, Colombia, Costa Rica, Cuba, Dominican Republic, Ecuador, El Salvador, Grenada, Guatemala, Guyana, Haiti, Jamaica, Mexico, Nicaragua, Panama, Peru, Saint Vincent and the Grenadines, Uruguay, and Venezuela.
 IHR (2005) State Party Self-assessment Annual Reporting Tool. Geneva: WHO; 2018. Available at https://bit.ly/2YdSLM3.
 Antigua and Barbuda, Argentina, Bahamas, Belize, Brazil, Canada, Chile, Colombia, Costa Rica, Cuba, Dominica, Dominican Republic, Ecuador, El Salvador, Guatemala, Haiti, Honduras, Jamaica, Mexico, Nicaragua, Panama, Paraguay, Peru, Saint Kitts and Nevis, Saint Lucia, Saint Vincent and the Grenadines, Suriname, Trinidad and Tobago, United States of America, Uruguay, and Venezuela.
 Brazil, Canada, Costa Rica, Cuba, Ecuador, El Salvador, Mexico, Nicaragua, Suriname, United States of America, and Uruguay.
 Argentina, Bahamas, Brazil, Canada, Chile, Colombia, Costa Rica, Cuba, Dominica, Ecuador, El Salvador, Jamaica, Mexico, Nicaragua, Saint Vincent and the Grenadines, Suriname, Trinidad and Tobago, United States of America, and Uruguay.
 IHR core capacities and their implementation status in the Region can be consulted in Document CD57/INF/4, July 2019.
 Anguilla, Antigua and Barbuda, Bahamas, Barbados, Bermuda, Bolivia, British Virgin Islands, Cayman Islands, Colombia, Costa Rica, Dominica, Dominican Republic, Ecuador, El Salvador, Grenada, Guatemala, Guyana, Haiti, Honduras, Jamaica, Montserrat, Nicaragua, Panama, Saint Kitts and Nevis, Saint Lucia, Saint Vincent and the Grenadines, Suriname, Trinidad and Tobago, Turks and Caicos Islands, and Venezuela.
 Barbados, Bolivia, Brazil, Canada, Chile, Colombia, Costa Rica, Dominica, Dominican Republic, Ecuador, El Salvador, Haiti, Honduras, Jamaica, Mexico, Panama, Paraguay, Peru, Puerto Rico, Saint Vincent and the Grenadines, Suriname, Uruguay, and United States of America.
 Argentina, Barbados, Belize, Bolivia, Chile, Colombia, Costa Rica, Cuba, Dominica, Dominican Republic, Ecuador, El Salvador, Guatemala, Guyana, Haiti, Honduras, Jamaica, Mexico, Nicaragua, Panama, Paraguay, Peru, Saint Lucia, Suriname, Uruguay, and Venezuela.
 Argentina, Bolivia, Brazil, Colombia, Cuba, Chile, Ecuador, El Salvador, French Guiana, Guatemala, Haiti, Honduras, Jamaica, Mexico, Nicaragua, Panama, Paraguay, Peru, Puerto Rico, Suriname, Trinidad and Tobago, Uruguay, United States of America, and Venezuela.
 Argentina, Bahamas, Barbados, Belize, Bolivia, Brazil, Colombia, Costa Rica, Cuba, Dominican Republic, Ecuador, Guyana, Jamaica, Mexico, Nicaragua, Panama, Paraguay, Peru, Suriname, Uruguay, and Venezuela.
 Argentina, Brazil, Colombia, Costa Rica, Cuba, Chile, Dominican Republic, Ecuador, El Salvador, Guatemala, Honduras, Mexico, Nicaragua, Panama, Paraguay, Peru, United States of America, and Venezuela.
 Antigua and Barbuda, Argentina, Bahamas, Barbados, Belize, Brazil, Chile, Colombia, Costa Rica, Cuba, Dominica, Dominican Republic, Ecuador, El Salvador, Guatemala, Honduras, Haiti, Jamaica, Mexico, Nicaragua, Paraguay, Peru, Saint Kitts and Nevis, Saint Lucia, Saint Vincent and the Grenadines, Suriname, Uruguay, and Venezuela.
 Information on the Declaration and a copy of the Declaration itself (in Spanish) are at https://bit.ly/2L81k3d.
 Antigua and Barbuda, Argentina, Barbados, Bolivia, Brazil, Chile, Colombia, Costa Rica, Cuba, Dominica, Dominican Republic, Ecuador, El Salvador, Guadeloupe, Guatemala, Haiti, Honduras, Jamaica, Mexico, Nicaragua, Panama, Paraguay, Peru, Puerto Rico, Saint Kitts and Nevis, Trinidad and Tobago, United States of America, Venezuela, and Uruguay.
 A grant from OFID supported interventions in Bolivia and Honduras.
 PAHO. Epidemic of chronic kidney disease in agricultural communities in Central America: case definitions, methodological basis, and approaches for public health surveillance. Washington, D.C.: PAHO; 2017. Available at http://iris.paho.org/xmlui/handle/123456789/34132.
 WHO. Noncommunicable diseases country profiles 2018. Geneva: WHO; 2018.
 WHO. Taxes on sugary drinks: why do it? Geneva: WHO; 2017. Available at https://bit.ly/2KbHxQq.
 Global Health Observatory Data Repository. Global and regional trends by WHO regions 1990-2030. Overweight 1990-2018. Available at https://bit.ly/2Y48hoJ.
 Antigua and Barbuda, Bahamas, Belize, Brazil, Dominica, Grenada, Guatemala, Paraguay, Peru, Puerto Rico, Saint Lucia, Trinidad and Tobago, and Uruguay.
 WHO. WHO global report on trends in prevalence of tobacco smoking 2000-2025, second edition. Geneva: WHO; 2018. Available at https://bit.ly/2ThRdhj.
 Antigua and Barbuda, Argentina, Barbados, Brazil, Canada, Chile, Colombia, Costa Rica, Ecuador, El Salvador, Guatemala, Guyana, Honduras, Jamaica, Panama, Peru, Suriname, Trinidad and Tobago, Uruguay, and Venezuela.
 Antigua and Barbuda, Argentina, Barbados, Bolivia, Brazil, Canada, Chile, Costa Rica, Ecuador, El Salvador, Guyana, Honduras, Jamaica, Mexico, Panama, Peru, Saint Lucia, Suriname, Trinidad and Tobago, Uruguay, and Venezuela.
 RTI International. Studying investment in tobacco control in low- and middle-income countries: investment cases for the FCTC. Available at: https://www.rti.org/impact/studying-investment-tobacco-control-lmics and https://bit.ly/2xdFjre.
 WHO. Global status report on road safety 2018. Geneva: WHO; 2018. Available at
 Antigua and Barbuda, Argentina, Barbados, Belize, Bolivia, Brazil, Canada, Chile, Colombia, Costa Rica, Cuba, Dominica, Dominican Republic, Ecuador, El Salvador, Grenada, Guatemala, Guyana, Honduras, Jamaica, Mexico, Panama, Paraguay, Peru, Saint Lucia, Suriname, Trinidad and Tobago, United States of America, Uruguay, and Venezuela.
 Argentina, Bahamas, Belize, British Virgin Islands, Chile, Colombia, Costa Rica, Cuba, Dominica, Dominican Republic, Ecuador, El Salvador, Grenada, Guatemala, Guyana, Honduras, Jamaica, Mexico, Nicaragua, Panama, Peru, Sint Maarten, Suriname, Trinidad and Tobago, and Venezuela.
 COPOLAD a collaboration between the European Union (EU) and the Community of Latin American and Caribbean States (CELAC).
 Argentina, Bahamas, Chile, Colombia, Costa Rica, Ecuador, El Salvador, Guatemala, Honduras, Jamaica, Mexico, Panama, Paraguay, Peru, Saint Lucia, Trinidad and Tobago, Uruguay, and Venezuela.
 Argentina, Bahamas, Chile, Costa Rica, Dominican Republic, Ecuador, Guatemala, Jamaica, Panama, Paraguay, Peru, Suriname, Uruguay, and Venezuela.
 PAHO. Alcohol Policy Scoring: Assessing the level of implementation of the WHO global strategy to reduce the harmful use of alcohol in the Region of the Americas. Washington, D.C.; PAHO; 2018. Available at https://bit.ly/31atfnT.
 Antigua and Barbuda, Argentina, Brazil, Colombia, Cuba, Dominica, Grenada, Guatemala, Honduras, Jamaica, Mexico, Nicaragua, Saint Kitts and Nevis, Saint Lucia, Saint Vincent and the Grenadines, and Suriname.
 UN General Assembly document A\73\L.4.
 Belize, Bolivia, Colombia, Costa Rica, Cuba, Dominican Republic, Ecuador, El Salvador, Guatemala, Guyana, Haiti, Honduras, Jamaica, Nicaragua, Panama, Paraguay, Peru, and Suriname.
Argentina, Belize, Bolivia, Chile, Colombia, Costa Rica, Cuba, Dominican Republic, Ecuador, El Salvador, Guatemala, Guyana, Honduras, Mexico, Nicaragua, Panama, Paraguay, Peru, Uruguay, and Venezuela.
Argentina, Aruba, Barbados, Belize, Bermuda, Bolivia, Brazil, Cayman Islands, Chile, Colombia, Costa Rica, Cuba, Dominican Republic, Ecuador, El Salvador, Grenada, Guatemala, Guyana, Honduras, Nicaragua, Panama, Paraguay, Peru, Suriname, Trinidad and Tobago, Uruguay, and Venezuela.
Argentina, Belize, Brazil, Canada, Chile, Colombia, Costa Rica, Grenada, Guyana, Haiti, Mexico, Peru, Saint Kitts and Nevis, Suriname, Trinidad and Tobago, and United States of America.
Antigua and Barbuda, Bahamas, Cuba, Dominica, Dominican Republic, Ecuador, Guatemala, Honduras, Nicaragua, Paraguay, Saint Lucia, Saint Vincent and the Grenadines, and Venezuela.
PAHO; Florida International University. Recommendations for Implementing Antimicrobial Stewardship Programs in Latin America and the Caribbean: Manual for Public Health Decision-Makers. Washington, D.C.: PAHO; FIU; 2018.
Antigua and Barbuda, Bahamas, Barbados, Belize, Dominica, Grenada, Guyana, Haiti, Jamaica, Saint Kitts and Nevis, Saint Lucia, Saint Vincent and the Grenadines, Suriname, and Trinidad and Tobago.
Argentina, Aruba, Barbados, Belize, Bolivia, Brazil, Canada, Chile, Colombia, Costa Rica, Cuba, Dominica, Dominican Republic, Ecuador, El Salvador, Guatemala, Guyana, Honduras, Jamaica, Mexico, Nicaragua, Panama, Paraguay, Peru, Saint Kitts and Nevis, Saint Lucia, Saint Vincent and the Grenadines, Suriname, United States of America, Uruguay, and Venezuela.
Argentina, Bolivia, Brazil, Chile Colombia, Costa Rica, Cuba, Dominican Republic, Ecuador, El Salvador, Guatemala, Honduras, Mexico, Nicaragua, Panama, Paraguay, Peru, Uruguay, and Venezuela.
Argentina, Barbados, Bolivia, Brazil, Chile, Colombia, Costa Rica, Cuba, Dominican Republic, Ecuador, Guatemala, Guyana, Honduras, Jamaica, Mexico, Nicaragua, Panama, Paraguay, Peru, Suriname, Trinidad and Tobago, Uruguay, and Venezuela.
Anguilla, Antigua and Barbuda, Aruba, Bahamas, Brazil, British Virgin Islands, Canada, Cayman Islands, Chile, Costa Rica, Cuba, Dominica, Dominican Republic, El Salvador, Guatemala, Grenada, Guyana, Honduras, Jamaica, Mexico, Montserrat, Nicaragua, Paraguay, Peru, Puerto Rico, Saint Kitts and Nevis, Saint Lucia, Saint Vincent and the Grenadines, Suriname, Trinidad and Tobago, and Venezuela.
 The national consultations were held in Anguilla, Antigua and Barbuda, Argentina, Aruba, Barbados, Bermuda, Bolivia, Brazil, British Virgin Islands, Canada, Cayman Islands, Chile, Colombia, Cuba, Dominica, Dominican Republic, El Salvador, Grenada, Guatemala, Guyana, Haiti, Honduras, Jamaica, Mexico, Nicaragua, Panama, Paraguay, Peru, Puerto Rico, Saint Kitts and Nevis, Saint Lucia, Saint Vincent and the Grenadines, Suriname, Venezuela, and Uruguay.
 Argentina, Barbados, Brazil, Canada, Chile, Colombia, Costa Rica, Cuba, Dominican Republic, Ecuador, El Salvador, Guatemala, Guyana, Honduras, Jamaica, Panama, and Peru.
 Russell NK, Nazar K, del Pino S, Alonso Gonzalez M, Díaz Bermúdez XP, Ravasi G. HIV, syphilis, and viral hepatitis among Latin American indigenous peoples and Afro-descendants: a systematic review. Rev Panam Salud Publica. 2019;43:e17. Available at https://doi.org/10.26633/RPSP.2019.17.
 Four crosscutting themes—gender, equity, human rights, and ethnicity—were identified in the PAHO Strategic Plan 2014-2019 as programmatic approaches to be applied across all program areas to improve health outcomes and reduce inequities in health.
PAHO. The Health of Adolescents and Youth in the Americas. Implementation of the Regional Strategy and Plan of Action on Adolescent and Youth Health 2010-2018. Washington, D.C.: PAHO; 2018 (updated February 2019). Available at http://iris.paho.org/xmlui/handle/123456789/49545.
Anguilla, Antigua and Barbuda, Argentina, Barbados, Belize, Brazil, British Virgin Islands, Bolivia, Chile, Colombia, Costa Rica, Cuba, Dominican Republic, Ecuador, El Salvador, Guyana, Haiti, Honduras, Jamaica, Mexico, Panama, Paraguay, Peru, Trinidad and Tobago, and Venezuela.
Antigua and Barbuda, Argentina, Aruba, Bahamas, Barbados, Belize, Brazil, Canada, Chile, Colombia, Costa Rica, Curaҫao, Dominican Republic, Ecuador, El Salvador, Grenada, Guatemala, Guyana, Haiti, Honduras, Mexico, Nicaragua, Panama, Paraguay, Peru, Saint Vincent and the Grenadines, Sint Maarten, Suriname, Trinidad and Tobago, United States of America, Uruguay, and Venezuela.
PAHO. Regional ministerial meeting on mass migration on health, 29 November 2018: Meeting proceedings. Washington, D.C.: PAHO; 2018. Available at https://bit.ly/2OEMm4o.
UNOSSC. Good practices in South-South and triangular cooperation for sustainable development – Volume 2. New York: UNOSCC; 2018. Available at https://bit.ly/2QReSQP.
WHO. Promoting health through South-South and triangular cooperation: selected WHO country case studies. Geneva: WHO; 2019 (WHO/CCU/19.05).
PAHO; SEGIB. South-South and triangular cooperation in health in Ibero-America 2018. Washington, D.C.: PAHO, SEGIB; 2018. Available at http://iris.paho.org/xmlui/handle/123456789/50514.
Antigua and Barbuda, Argentina, Bahamas, Barbados, Belize, Bolivia, Brazil, Chile, Colombia, Dominica, Dominican Republic, El Salvador, Guatemala, Guyana, Haiti, Jamaica, Montserrat, Panama, Paraguay, Peru, Saint Kitts and Nevis, Saint Lucia, Saint Vincent and the Grenadines, Suriname, and Trinidad and Tobago.
During the period under review, the Bureau’s internal administration and management systems were monitored and strengthened where needed in order to improve PAHO’s efficiency and impact. Adjustments were made to the organizational structure to better reflect the priorities for technical cooperation with Member States on their journey towards achievement of the SHAA2030 and the SDGs. Those changes included the establishment of the new Department of Evidence and Intelligence for Action in Health (EIH). EIH, which subsumed the former Health Analysis Unit, was created in order to improve the utilization of new technologies for data acquisition and analysis and to enhance PASB’s capacity for forecasting and provision of early intelligence, evidence, and strategic information to inform technical cooperation. Two new units, Health Promotion and Social Determinants (PS) and Climate Change and Environmental Determinants of Health (CE), were also created, along with the two special programs of Antimicrobial Resistance (AR) and of the PAHO Strategic Fund (SF). The adjustments facilitated the continuation of PASB’s close alignment with ongoing WHO reform and strategic planning, while recognizing and respecting PAHO’s status as an independent international organization which, along with its Director, is directly accountable to the Member States of the Americas.
Human resources management
PASB continued to implement its People Strategy through actions to strengthen alignment and agility, foster talent at every level, and provide inspiring leadership for change.
The Bureau developed and adopted new guidelines for reprofiling PASB positions to meet evolving programmatic needs and ensure that the Organization is fit for purpose. The reprofiling process entails reviews of workforce composition to determine the most efficient distribution of positions and skills required to undertake the Organization’s technical cooperation. In 2018, the Organization completed reprofiling processes in its country offices in Ecuador and Haiti.
Workforce statistics for the reporting period reflected progress toward gender parity, particularly at the P.4 and higher post levels. Overall, PASB has reached gender parity in the professional and higher categories: 51 percent women and 49 percent men. The Bureau’s data for 2018 indicate that:
At Headquarters, women accounted for 54 percent of professional staff, while in PAHO/WHO country offices and the Pan American Centers, the percentage of women in this category was 48 percent. Both figures are unchanged from 2017.
Appointments to fixed-term positions comprised 79 professionals and national professional officers: 35 (44 percent) were men and 44 (56 percent) were women. This number includes conversions from temporary to fixed-term appointments.
The appointment of women increased substantially in 2018, with 44 women being appointed to professional positions, compared with 25 in 2017.
Of the 24 PAHO/WHO Representatives in the countries, 13 (54 percent) are men and 11 (46 percent) are women.
These achievements demonstrate PASB’s commitment to extend leadership and managerial opportunities to both women and men, and to encourage a diverse pool of candidates for such positions.
PASB strengthened its existing learning programs, while also creating new staff learning opportunities, in order to foster organizational talent and support career development. A multiyear agreement with the United Nations System Staff College (UNSSC) was signed, and a new management and leadership training initiative was launched for senior and mid-level managers. The first cohort of 29 participants completed the certificate program, which includes a 360-degree assessment and coaching based on the UN System Leadership Framework. A second cohort with 32 participants began training in late May 2019.
The PAHO/WHO Representatives (PWRs) play a critical role in ensuring that PASB’s technical cooperation is relevant, appropriate, impactful, and of the highest standard. The Bureau mounted a special training initiative for internal staff interested in becoming a PWR, in order to improve their chances of successfully competing in WHO’s Global Assessment Process for Heads of Country Offices.
The Bureau also renewed its orientation program for new hires and personnel rotating across duty stations, as well as its language learning program. By adopting virtual instructor-led training (VILT), PASB was able to offer group classes in all four official languages: English, French, Portuguese, and Spanish.
In 2019, PASB conducted an internal survey on staff engagement, which was completed by 74 percent of personnel—the highest response rate on record for internal surveys. The results revealed that personnel felt strongly connected to the Organization’s mission, but also suggested room for improvement in the organizational climate, particularly through enhanced internal communication and management practices.
Ethics, transparency, and accountability
As detailed in document CE164/8 presented to the 164th Session of the PAHO Executive Committee in June 2019, the Bureau continued efforts to ensure ethical conduct in its operations and activities within the framework of the PAHO Integrity and Conflict Management System (ICMS); help employees resolve conflicts and address related workplace concerns; and nurture a positive climate of inclusion, accountability, and transparency throughout the Organization.
During the reporting period, personnel at Headquarters and in country offices participated in face-to-face training on ethical behavior, conflicts of interest, fraud prevention and detection, use of social media, personal and sexual harassment, and whistleblower protection. Eighteen sessions of an interactive seminar titled “How to Have Difficult Conversations: Bringing the Best Out of You and Others” were held, resulting in 611 persons being trained. The seminar included self-assessment exercises, group assignments, and role-play activities focused on helping PASB personnel acquire skills for resolving conflicts in the workplace in a positive and effective way. Training on civility in the workplace was provided to more than 60 senior directors, managers, and PAHO/WHO Representatives, highlighting the impact of incivility in the workplace, which includes lower productivity and morale and greater absenteeism and staff turnover.
PASB made available, through the PAHO iLearn platform, an online training curriculum that included a self-learning UN course named “Prevention of Harassment, Sexual Harassment, and Abuse of Authority in the Workplace” and a UN video titled “To Serve with Pride: Zero Tolerance for Sexual Exploitation and Abuse.” The curriculum is mandatory for all PASB personnel, regardless of position or type of contract. In addition, the Ethics Office collaborated with the Office of the Ombudsman to develop a dedicated training session on sexual harassment in the workplace. This new training program aims to provide a better understanding of what constitutes sexual harassment, how to avoid behavior that might give rise to an allegation of sexual harassment, ways to manage it, and the resources available in the Bureau to prevent and address it. The training was launched in December 2018, and by mid-2019, 161 employees had participated.
A new Investigations Office—established in early 2018—conducted several investigations into allegations of wrongdoing and reported its findings to the PASB administration as a basis for corrective measures. The new office is functionally independent and reports to the PAHO Executive Committee, while collaborating with other PASB administrative units to ensure consistency, coordination, and optimization of resources, as reported to the 164th Session of the Executive Committee in June 2019 (Document CE164/9).
PASB continued to ensure compliance with the Framework of Engagement with Non-State Actors (FENSA) (Document CD55/8, Rev. 1), adopted in 2016 by the 55th PAHO Directing Council through resolution CD55.R3. More than 120 due diligence and risk assessment exercises were conducted by the Office of Legal Counsel on proposed engagements with non-State actors. The Bureau actively coordinated with the WHO Secretariat for consistent implementation of FENSA and adapted processes and procedures as needed to take into account PAHO’s unique legal status.
Ten internal audits were undertaken during the reporting period: 4 at country offices (Brazil, Haiti, Trinidad and Tobago, and Venezuela), 2 at Headquarters (addressing information technology security and travel expenditure), and 4 related to specific projects (3 covering Mais Médicos and 1 addressing the Smart Hospitals project). For the first time in recent years, none of the findings of individual internal audit assignments in this period were rated as “unsatisfactory,” signaling continuing improvement in internal controls, attributable to the PAHO Management Information System (PMIS) and increased awareness of the importance of internal controls among PASB management and personnel.
The Audit Committee of PAHO continued to provide its advisory services in two sessions during this period. Specifically, the Committee provided guidance on the development of PASB policies for fraud prevention and evaluation assignments and advice on matters ranging from information technology (IT) security to enterprise risk management and the operations of the recently established investigations function.
In the area of evaluation, PASB launched a new platform in the second quarter of 2019 that assembles evaluation reports from different parts of the Organization and makes them available to all PASB personnel. The platform allows greater information sharing and facilitates more systematic follow-up of findings, recommendations, and lessons learned from evaluations, thus providing an important feedback loop for planning and designing new PASB initiatives.
The End-of-Biennium (EoB) 2016-2017 Report was completed in 2018 and was presented to Member States at the 56th Directing Council held in that year. It documented advances toward achieving the health impact goals, outcomes, and outputs contained in the PAHO Strategic Plan 2014-2019 and the Program Budget 2016-2017. This evaluation, the second joint assessment between Member States and PASB, was conducted based on lessons learned from the EoB 2014-2015 report and reflects the Organization’s commitment to accountability and transparency.
PASB continued to implement the Resource Mobilization Strategy 2016-2019 to fill the financial gap for effective technical cooperation with Member States. Actions taken included the relaunching of the Resource Mobilization Network to build capacity, strengthen planning, and generate more effective resource mobilization across the Organization.
The Bureau worked to strengthen and expand its relations with existing partner organizations—at regional, subregional, national, and subnational levels—while also seeking to forge new partnerships. In terms of financial partnerships, between mid-2018 and mid-2019, the Bureau mobilized $55.9 million in PAHO voluntary contributions (including national voluntary contributions and emergency funds) from existing partners and 10 new partners. The latter comprise the Government of the British Virgin Islands, the University of the West Indies (UWI), the END Fund, the Swiss Agency for Development and Cooperation (SDC), the Robert Wood Johnson Foundation, the Bernard Van Leer Foundation, the United Arab Emirates, Argentina’s Secretariat for Comprehensive Drug Policies (SEDRONAR), and two secretariats of health in Brazil, of the state of Espírito Santo and of the municipality of Florianópolis.
In working to enable the multisectoral approach needed to achieve the SHAA2030,
SDG 3, other SDGs, and particularly in support of SDG 17, the Roadmap for Working with the Private Sector was developed to promote coordinated private sector engagement, in alignment with FENSA. That guide provides multiple lines of action to build impactful partnerships, and a solid foundation for achieving and sustaining the objectives of the PAHO Strategic Plan 2014-2019 and the proposed PAHO Strategic Plan 2020-2025.
PASB conducted a survey of technical departments and country offices to capture and compile information on the work being done with CSOs, including the type of engagement that the Bureau has with them; enablers for closer collaboration with CSOs; and the optimal fora for successful engagement.
Planning and budgeting
Member States continued to play a critical role in providing guidance to PASB on its strategic planning, monitoring, and assessment processes. Consistent with the mandate from PAHO Member States for joint accountability and responsibility (Document CD52.R8), PASB finalized the joint end-of-biennium assessment of the PAHO Program and Budget 2016-2017 during this period, with the participation of the majority of Member States. The joint assessment requires the commitment of all countries and territories, is an integral part of PAHO’s results-based management framework, and reflects the Organization’s commitment to continuously improving accountability and transparency.
Much of the development of the proposed Strategic Plan 2020-2025 (SP20-25), under the theme of “Equity at the Heart of Health,” took place during the reporting period, with active participation and input from PAHO Member States, as well as from staff at all levels of the Bureau. The SP20-25 reflects a joint commitment between Member States and the PASB for the next six years, sets out strategic directions based on Member States’ collective priorities, and specifies public health results to be achieved during the stated period. The proposed SP20-25 is a principal instrument for implementation of the SHAA2030—the 11 goals of which form the impact-level objectives of the Plan—and aligns closely with the WHO 13th General Program of Work (GPW) 2019-2023.
The development of the new Strategic Plan, which will be submitted to the 57th PAHO Directing Council in September 2019 for approval, was supported by the Strategic Plan Advisory Group (SPAG), which is comprised of representatives of 21 Member States and was established by the 162nd Session of the Executive Committee in June 2018. The SPAG worked closely with the PASB to provide strategic and technical input for the SP20-25 in an iterative and rigorous process, and the end result represents the best collective thinking on where and how the Bureau and the Member States should concentrate their efforts over the next six years.
The SPAG endorsed the use of the PAHO-adapted Hanlon method to identify the programmatic priorities for the SP20-25. This method has been recognized by Member States as a systematic, objective, and robust approach to identify public health priorities in the Region. National prioritization consultations were launched in December 2018, and each consultation included individual assessments by senior public health officials with a broad understanding of the national public health context. Forty-seven countries and territories identified their programmatic priorities using the PAHO-adapted Hanlon method, and the consolidated regional results will inform the implementation of the SP20-25 and its Program Budgets; guide the allocation of resources; and steer resource mobilization efforts.
In response to Member States’ concerns and recommendations from an external evaluation, PASB developed a new Budget Policy (Document CD57/5) for implementation with the SP20-25. The main objective of the Budget Policy is to provide an evidence-based, empirical foundation for assigning budget ceilings across PAHO Member States, while allowing sufficient flexibility to respond to evolving political, health, and technical developments. During the formulation of the SP20-25, PASB worked with the SPAG to develop a new health needs index and the Budget Policy. The SPAG supported the 2019 Sustainable Health Index Expanded Plus (SHIe+), which will be used for the same purposes as the previous needs index: to identify key countries for technical cooperation and to calculate the needs-based component of the 2019 Budget Policy. The new Budget Policy was approved by the 164th Session of the Executive Committee in June 2019, and will be submitted to the 57th Directing Council in September 2019 for approval.
Concurrent with the development of the SP20-25, the Bureau developed the proposed Program Budget 2020-2021 (PB20-21). This Program Budget defines the health outcomes and outputs to be achieved collectively by the Bureau and the Member States during the 2020-2021 period, and establishes a budget to achieve these results. The PB20-21 is aligned with and responds to relevant health mandates, including the SHAA2030, the proposed SP20-25, the WHO 13th General Program of Work, and the WHO Program Budget 2020-2021. The proposed PB20-21 was developed with coordinated inputs from all levels of the Bureau, and it is a key instrument for corporate accountability to Member States. It will be submitted to the 57th Directing Council in September 2019 for approval.
PASB managed total revenue of $1.393 billion during 2018, the financial year that closed during the period of this report. This included $266.8 million for the PAHO Program Budget, $678.3 million for procurement of vaccines and public health supplies on behalf of Member States, and $439.4 million in national voluntary contributions from Member States, of which $427.5 million was from Brazil. The latter amount was $93 million less than during the prior reporting period, mainly due to a decline in the value of the Brazilian real against the United States dollar. Total assessed contributions due from Member States increased from $62 million in July 2018 to $141 million in June 2019. During this period, real-time financial reporting for managers was significantly enhanced through the deployment of dashboards for monitoring of both the Program Budget and procurement on behalf of Member States.
The United Kingdom National Audit Office (NAO), which was appointed as PAHO’s new external auditor by the 29th Pan American Sanitary Conference in September 2017, delivered an unmodified audit opinion for 2018, reflecting the Bureau’s compliance with the International Public Sector Accounting Standards (IPSAS). The audit found no weaknesses or errors considered material to the accuracy, completeness, or validity of PAHO’s financial statements. The NAO provided broad recommendations regarding the management of the Working Capital Fund and other cash resources in support of the Program and Budget, the PAHO Resource Mobilization Strategy, budgetary monitoring and oversight, and the overarching assurance provided by compliance, risk management, and oversight activities.
PASB continued to reorganize services and responsibilities to increase efficiency. As a result, positions in the Financial Resources Management Department were reduced by a further 15 percent over the period 1 July 2018 to 30 June 2019, freeing additional resources for underwriting technical cooperation.
During the reporting period, a new interest-bearing demand deposit account was established for the Organization’s Headquarters, resulting in an additional $1 million in interest revenue for 2018, as well as improved liquidity. With due diligence on investment policy and implementation, the Miscellaneous Revenue goal for the first year of the biennium was achieved.
A revised quarterly and monthly cost center financial compliance process was established, resulting in a more efficient 2018 financial closure, and the approval of expenses to be charged to WHO purchase orders was decentralized to the cost centers to facilitate timely implementation of small commitments (under $10,000) received from WHO. In another innovation, a new category of focal point was established in cost centers to facilitate the establishment and timely monitoring of Letters of Agreement for technical cooperation. Training was provided to 20 of these focal points across 14 country offices and Headquarters departments.
PASB developed several new automated reports to expedite financial reporting to donors and to monitor the implementation levels of funds received. PASB also employed new data analysis tools to improve accounting reporting and monitoring and to enable more specific and efficient analysis of the Organization’s spending trends.
Enterprise risk management
During the period under review, PASB continued to strengthen its enterprise risk management (ERM) system as one of the critical pillars of effective, results-based management. At strategic level, risks and related mitigation actions were included in the framework of the proposed SP20-25 and the PB20-21, for discussion at the 57th Directing Council in September 2019. In 2018, for the first time, the ERM risk register and the listings of the main institutional risks were used as a significant source of information to guide work related to PASB’s oversight and evaluation functions, reflecting the increasing maturity of the Organization’s ERM process.
During the review period, the PAHO Revolving Fund for Vaccine Procurement (the Revolving Fund) and the PAHO Regional Revolving Fund for Strategic Public Health Supplies (the Strategic Fund) provided Member States with timely access to affordable vaccines, injection devices, essential medicines, and related supplies.
The renewal of PASB’s partnership with the Global Fund in 2018 provided countries participating in the PAHO Strategic Fund with access to antiretrovirals at more competitive prices and with improved supply. The arrangement enhanced PAHO’s position as a strategic player among UN agencies and other international organizations.
Information technology services
PASB continued to implement an IT strategy focused on improving the reliability, security, quality, and agility of IT services to support its technical cooperation and enabling programs. This entailed the introduction of new cybersecurity controls aligned to industry best practices, particularly since the risk of a cyberattack has been identified as one of the major risks facing the Bureau’s IT systems. Related measures included the introduction of an Information Security Awareness Program, continuous information security risk assessment of new applications, and implementation of a new Security Operations Center to improve cybersecurity incident monitoring and response.
Further enhancement and optimization of the PMIS took place, with the development of new dashboards and reports to support informed decision-making, and implementation of a new framework to support and monitor technical cooperation activities. Enhancements to improve procurement processes included a new electronic signature, a new web portal that allows interaction with suppliers, and a new electronic contract review committee within the PMIS. Additionally, the PMIS was configured to enable head-count planning.
The Bureau continued to add secure and cost-effective cloud-based services to improve mobility and sustainability. The new services allow staff to access their work tools and repositories from any location, on any device. PASB also advanced in developing and enhancing digital workflow tools to improve collaboration, institutional memory, and business efficiencies in the workplace. A new mobile app was launched to better support Governing Bodies’ meetings, with more user-friendly processes for registration of and collaboration among participants.
During 2018, PASB created a new Office of Knowledge Management, Publications, and Translations, merging three formerly separate programs. The new office is charged with positioning PAHO as the authoritative source of multilingual scientific and technical health information and publications for the Americas, and providing technical cooperation to build capacity in knowledge management, publishing, and multilingualism in Member States.
In the context of multilingualism, in April 2019, PASB officially launched the Spanish version of the latest International Classification of Diseases (ICD-11). That Spanish version was developed in cooperation with other institutions, mainly Collaborating Centers. Also, in addition to providing all technical and governance documents in PAHO’s four official languages, the Bureau translated 80 WHO publications (70 into Spanish, 9 into Portuguese, and 1 into French) during the reporting period.
The Bureau continued its publication of the 98-year-old Pan American Journal of Public Health, a scientific, peer-reviewed, open-access journal. During the reporting period, 180 original scientific manuscripts were published, and there were special issues on primary health care, NCDs, mental health, financing and fiscal space for UH, and men’s health. That content helped fill knowledge gaps and inform policy-making, often reflecting technical cooperation activities at the regional, subregional, and national levels.
In its role as an authoritative source of scientific and technical information, PASB published 32 new scientific and technical publications, and 31 other original documents. These 63 publications and more than 50,000 other documents are available at PASB’s Institutional Repository for Information Sharing (IRIS), the full-text, online library of the Organization. Additionally, technical cooperation was undertaken with ministries of health and public institutes in Brazil, Dominican Republic, El Salvador, and Puerto Rico to build their own repositories, based on PASB’s best practices. This intervention will contribute to preservation and sharing of institutional memory on public health in the Americas.
Over the period under review, PASB’s information products were disseminated at several key events, including the Canadian Public Health Association Conference and Canadian Conference on Global Health, both held in Canada; the American Public Health Association Conference, held in the United States of America; the Guadalajara International Book Fair, held in Mexico; and the 72nd World Health Assembly, held in Geneva.
During 2018-2019, nine new PAHO/WHO Collaborating Centers were designated in the Americas, bringing the number of active centers in the Region to 190. These centers continued to make an important contribution to PASB’s technical cooperation by generating knowledge and evidence related to the Organization’s programmatic areas and Member States’ health priorities. Countries with Collaborating Centers include Argentina, Bolivia, Brazil, Canada, Chile, Colombia, Costa Rica, Cuba, Grenada, Honduras, Jamaica, Mexico, Peru, the United States of America, and Uruguay.
Communication for health
The Bureau promoted strategic and effective health communication based on the framework set out in the PASB Communications Strategic Plan 2018-2022, which calls for targeted and evidence-based messaging and the use of emotive content and storytelling to engage and persuade audiences more effectively. During the reporting period, PASB undertook interventions to build capacity in crisis communications for national health professionals in the Dominican Republic, and in storytelling and photography for ministry of health staff and other health experts from 27 countries during the 6th Regional Meeting on Polio held in December 2018 in Guatemala.
In early 2019, the Bureau completed a “brand evolution” exercise that resulted in the adoption of a new PAHO visual identity and new guidelines for communication products and channels, to strengthen both institutional and health communications.
During the period under review, PASB invested in improved security and infrastructure at Headquarters, where a new security company was contracted, and in country offices, including Barbados, Brazil, Honduras, Peru, Trinidad and Tobago, Uruguay, and Venezuela. Additionally, 16 vehicles were replaced in country offices, including in Belize, Colombia, Costa Rica, Ecuador, Guatemala, Guyana, Mexico, Nicaragua, Panama, Peru, and Trinidad and Tobago. A new travel agency was selected for Headquarters and for six country offices that use the agency’s services—The Bahamas, Barbados, Belize, Haiti, Jamaica, and Trinidad and Tobago—resulting in a reduction in service fees.
ICMS members include the Ethics Office, Office of the Ombudsman, Office of the Legal Counsel, Human Resources Management, Information Security Officer, Internal Oversight and Evaluation Services, Investigations Office, Board of Appeal, and PAHO/WHO Staff Association.
Entities with which PASB has had no agreements during the last five years.
The Programmatic Priorities Stratification Framework (PPSF), approved by Member States in the PAHO Strategic Plan 2014-2019, has served as a key instrument to guide the allocation of all resources available to PASB and to target resource mobilization efforts for implementation of the Plan. The PAHO-adapted Hanlon method was approved by the 55th Directing Council in 2016 through resolution CD55.R2 as the instrument to implement the PPSF and identify the programmatic priorities of the Strategic Plan.
Anguilla, Antigua and Barbuda, Argentina, Aruba, Bahamas, Barbados, Belize, Bermuda, Bolivia, Bonaire, British Virgin Islands, Canada, Cayman Islands, Chile, Colombia, Costa Rica, Cuba, Curaҫao, Dominica, Dominican Republic, Ecuador, El Salvador, Grenada, Guatemala, Guyana, Haiti, Honduras, Jamaica, Mexico, Montserrat, Nicaragua, Panama, Paraguay, Peru, Puerto Rico, Saba, Saint Kitts and Nevis, Saint Lucia, Saint Vincent and the Grenadines, Sint Eustatius, Sint Maarten, Suriname, Trinidad and Tobago, Turks and Caicos, United States of America, Uruguay, and Venezuela.
Anguilla, Antigua and Barbuda, Argentina, Aruba, Bahamas, Barbados, Belize, Bermuda, Bolivia, Brazil, British Virgin Islands, Cayman Islands, Chile, Colombia, Costa Rica, Cuba, Curaҫao, Dominica, Dominican Republic, Ecuador, El Salvador, Grenada, Guatemala, Guyana, Haiti, Honduras, Jamaica, Montserrat, Nicaragua, Panama, Paraguay, Peru, Saint Kitts and Nevis, Saint Lucia, Saint Vincent and the Grenadines, Sint Maarten, Suriname, Trinidad and Tobago, Turks and Caicos Islands, Uruguay, and Venezuela.
Anguilla, Antigua and Barbuda, Aruba, Bahamas, Barbados, Belize, Bermuda, Bolivia, British Virgin Islands, Cayman Islands, Colombia, Costa Rica, Cuba, Dominica, Dominican Republic, Ecuador, El Salvador, Grenada, Guatemala, Honduras, Jamaica, Montserrat, Nicaragua, Panama, Paraguay, Peru, Saint Kitts and Nevis, Saint Lucia, Suriname, Trinidad and Tobago, Turks and Caicos Islands, Uruguay, and Venezuela.
Argentina, Bahamas, Belize, Bermuda, Bolivia, Brazil, Chile, Colombia, Costa Rica, Cuba, Dominican Republic, Ecuador, El Salvador, Guatemala, Guyana, Honduras, Nicaragua, Panama, Paraguay, Peru, Trinidad and Tobago, Turks and Caicos Islands, Uruguay, and Venezuela.
Argentina, Barbados, Belize, Bolivia, Brazil, Canada, Chile, Colombia, Costa Rica, Cuba, Dominican Republic,
El Salvador, Guatemala, Guyana, Haiti, Honduras, Jamaica, Mexico, Nicaragua, Panama, Paraguay, Peru, Suriname, Trinidad and Tobago, United States of America, Uruguay, and Venezuela.
The Organization’s work towards advancing SHAA2030 over the reporting period has not been without its challenges. There are many factors that threaten to delay progress and derail achievements, such as the changing political landscape in many Member States; the dissolution of some integration mechanisms as well as apparent fissures in the Region’s much-lauded solidarity; massive population migration and resulting pressures on border areas and on originating, transit, and destination countries, with important implications for health; increasing costs of medicines, including several essential for effective management of NCDs; and more frequent disasters due to natural hazards and climate change.
However, over the years, the Bureau has learned how to adapt in order to address the challenges that invariably occur, and to take advantage of lessons learned to tailor its technical cooperation and enable advances toward Member States’ agreed health goals. In its operations during the reporting period, PASB had several lessons demonstrated and reinforced, which will be useful to all levels of the Organization as work continues.
Changes in political administration occurred, and may yet occur, as a result of elections held or planned at national, provincial, and municipal levels in several countries, including Argentina, Belize, Brazil, Guatemala, and Guyana. The focus on and preparations for the elections often cause delays in technical cooperation activities. New governments may have different health priorities and policies, and changes in national counterparts often require sensitization of new personnel at political and technical levels to evidence-based priorities and ongoing programs and interventions. Implementation of national health policy can evolve with changes in national health authorities. For example, in Brazil, the Mais Médicos Program is transitioning to place greater focus on the recruitment of Brazilian doctors at the municipal level, in many cases replacing doctors from Cuba who were working in underserved and remote areas of Brazil. In some countries, there may be high turnover at policy-making and technical levels within national health authorities, negatively impacting the Bureau’s technical cooperation.
Inadequate mechanisms for the participatory development of equity-enhancing policies and programs, involving key stakeholders and partners from government, civil society, and the private sector—taking possible conflict of interest into account—and including end users of the interventions and groups in conditions of vulnerability. The Region of the Americas remains one of the most socially inequitable regions in the world, as reflected in its profound and persistent inequities in health. There are limitations in the common understanding of programmatic, inclusive, and integrated means of working towards health equity, including insufficient knowledge, tools, and experience to enhance community participation and engagement. There is also inadequate awareness and sensitivity regarding cultural dialogues and cultural differences, including limited understanding of the cultural constructs of women’s empowerment at community level. This is compounded by unequal knowledge and practice regarding gender equality, newer gender constructs (such as gender identities), data analysis to identify gender issues, and evaluation of the impact of gender mainstreaming.
Inadequate policy coherence within the health sector and across various sectors, which leads to fragmented, sporadic, and conflicting strategies, rather than synergies and convergence in addressing national priorities and global and regional agreements. This issue is often aggravated by the many stakeholders providing support in specific technical areas, with limited intersectoral and interagency collaboration and coordination, and insufficient implementation of joint technical cooperation interventions. An associated factor is inadequate integration into health systems and services of health promotion that focuses on health education, health literacy, and disease prevention, as well as the social and other determinants of health.
Divided political scenarios in some subregions, with different political integration groupings in the same subregion, each with its own agenda, and increasing requests for technical cooperation from parliamentary bodies and multisectoral entities in the subregions.
Gaps between political commitments and technical interventions regarding priorities, vision, and medium- and long-term planning to address some health priorities. In many countries, health and health-related interventions are driven by the resources mobilized, rather than by evidence-based priorities. As an example, while political commitment to NCD prevention and control has been repeatedly expressed in global, regional, and subregional fora, this has not translated, in most countries, to the desired levels of political leadership, investment, integration into health systems strengthening, and effective cross-government coordination. The high turnover of NCD-related staff in ministries of health in many countries has impeded progress, and so have the challenges of changing health systems from the acute care model for infectious diseases and maternal and child health conditions towards chronic care.
Economic crises and fiscal austerity measures in many countries, coupled with declining levels of official development assistance and foreign direct investment in the Region, have resulted in loss of national staff and technical cooperation counterparts and reductions in resources available for health and health-related programs, despite persisting gaps in health services and systems and evident health inequities. Health sector reform in some countries omits important efforts to reduce segmentation and fragmentation; increase the health budget; eliminate out-of-pocket payments; and address the sufficiency, quality, and distribution of HRH. Although more countries in the Region are reaching middle-income status according to international poverty level indices, most are making only slow progress in increasing the allocation of national resources to health. At the current rate, targeted countries will not meet the benchmark of allocating at least six percent of GDP to public expenditure in health by the end of 2019.
Limited resource mobilization from development partners for high- and middle-income countries, despite persisting health inequities in these Member States, with high levels of competition for resources from other technical cooperation agencies and NGOs.
Delayed recovery of countries after devastating disasters due to natural hazards. As an example, the impact of Hurricane Maria, a Category 5 hurricane that affected the British Virgin Islands, Dominica, Puerto Rico, and Sint Maarten in 2017, is still being felt in those countries and territories.
Undesired effects of undocumented, mass migration on the health systems of originating, transit, and destination countries with limited resources. This exodus poses a challenge to the rights and well-being of all involved parties, including migrant families, and may aggravate the already challenging movement of skilled health personnel from less-resourced to better-resourced countries.
Limited success in extending quality health services to remote areas where there are scattered, indigenous, and/or border populations in conditions of vulnerability.
Lack of standardized health and health-related information to monitor progress toward achievement of SHAA2030 goals and targets, and delays in meeting deadlines for reporting, often exacerbated by simultaneous, repetitive, and complex survey requests.
Industry interference in legislative, regulatory, and fiscal measures to reduce NCD risk factors, and, where laws have been drafted, delays in their enactment and enforcement. There is also limited PASB capacity to provide technical cooperation in the area of health-related legislation.
PASB also faces challenges in some enabling areas:
PASB must remain politically neutral and impartial, working with all legitimate governments, political parties, and key stakeholders in health, documenting experiences and good practices, and advocating for the development and implementation of evidence-based policies and programs that transcend partisan politics.
With new national political administrations, positioning PAHO and health priorities in the early days of the administration can facilitate advocacy and effective relationships for health. At any stage of the administration, the process to develop or evaluate a PAHO/WHO CCS facilitates understanding of PAHO’s role and its technical cooperation by national counterparts, health and other sectors, and other development agencies.
In interacting with political integration entities at the political, policy-making, and technical levels, PASB should advocate for and support intersectoral meetings, to facilitate policy coherence and address the social, environmental, economic, and other determinants of health. The Bureau needs to maintain high-level, evidence-based advocacy for health priorities and proven interventions, and work to keep them on the political agenda, particularly in relation to issues such as mental health, intersectoral approaches to NCD risk factor reduction, and continuation of strategies for the prevention and control of low-prevalence communicable diseases. There should be advocacy for an explicit focus on equity, not only in indicators, but also in public policies and intersectoral action. Fulfilling the promise of “leaving no one behind” requires building institutional capacities and informing policymakers of pro-equity, cost-effective programs and interventions at the local level, in addition to establishing health inequality monitoring systems. Furthermore, in high-level advocacy with policymakers (especially newly elected ones), it is useful to refer to global, regional, and subregional frameworks for health when negotiating and agreeing on technical cooperation interventions. The development of investment cases related to interventions for priority issues is an important addition to the evidence base for informing advocacy and intersectoral action.
Promotion of public health and the right to health should be strengthened, as should the application of human rights principles in support of issues such as the health of migrants. It is also critical to strengthen mechanisms for collaborating with nontraditional stakeholders—such as parliamentary commissions, ministries of foreign affairs and development, and national human rights committees—whose engagement is fundamental for the progressive realization of the right to health.
Interprogrammatic collaboration and joint interventions facilitate efficient and effective use of financial resources and technical capacities, and WHO Collaborating Centers, professional associations, and expert consultants are important in extending and complementing PASB’s technical cooperation capabilities.
Collaboration with and strengthening of CSOs—NGOs, academia, faith-based organizations, trade unions, and others—are critical success factors for PASB’s technical cooperation. The Bureau should undertake technical cooperation and leverage partnerships with these entities, including grassroots organizations working at the subnational level, to empower them to advocate and influence political leadership. PASB’s partners should also include users of the health system and the general public, and the Bureau should ensure, to the extent possible, a balanced representation of stakeholders in activities for policy development. Strategic partnerships with academic institutions in developing and strengthening the capacity of HRH are fundamental.
Stakeholders’ expectations must be managed and an understanding promoted of their roles and responsibilities in achieving synergy, alignment, and harmonization in strategic approaches for equitable health outcomes.
Subregional approaches are advantageous in producing public goods that can be adopted or adapted by countries; in sharing lessons; in enhancing cooperation among countries; and in pooling and mobilizing resources. Technical cooperation counterparts at this level should be the subregional political integration entities, in the framework of their respective mandates and agreements, rather than individual member countries of the entities. Where there are several integration entities in a subregion, PASB should identify, and develop mechanisms to address, their common health goals, thus fostering complementarity and convergence of the agendas to the extent possible, for greater technical cooperation impact.
A focus on IS4H is essential, with adequate investment of resources, integration of information subsystems, and interoperability. IS4H should provide timely, accurate information that drives evidence-based advocacy and decision-making, enables monitoring and evaluation of progress toward SHAA2030 goals and targets, and counters special interest interference and lobbying that is antagonistic to health.
Resources to facilitate and enable institutionalization and sustainability of initiatives and interventions must be provided. In addition to adequate resources, strategic partnerships, continuity of leadership, and capacity strengthening are important factors for sustainability.
It is important to assess the impact of legislation, regulations, and fiscal measures on health, with the last-mentioned including taxes on sugary drinks, tobacco, alcohol, and fossil fuels. Such assessments can be presented to decisionmakers, and they can added to the evidence base. Communication strategies to sensitize, inform, and favorably influence the public on health-promoting measures are essential components of the implementation of these measures. Advances in information and communication technology should be utilized, including with the use of virtual meetings and social media. Further, networking with other regional institutions involved in information production and dissemination facilitates the development of information products and services adapted to the realities of Latin America and the Caribbean.
In PASB’s enabling areas, lessons learned include the need for:
Throughout the many changes in PAHO’s operating environment since the Organization was first established in 1902, its work has focused on the ultimate goal of improving the health and well-being of all peoples in the Region of the Americas. With the SHAA2030 as the lodestar, and guided by PAHO’s Member States and the PAHO Strategic Plan 2014-2019, the PASB continued to strengthen its normative function, and to prioritize and adjust its technical cooperation interventions to achieve national, subregional, regional, and global health goals aligned with its vision and mission.
Universal health, with the PHC approach as a core component, is critical for improving equitable health outcomes related to all the SHAA2030 goals and targets. PASB will continue to promote and advocate for implementation of the PHC 30-30-30 Compact and implement the regional Strategy for Universal Health. These frameworks are complemented by the new regional Strategy and Plan of Action to Improve Quality of Care in Health Service Delivery 2020-2025 (Document CD57/12), which will be presented to the 57th Directing Council in September 2019.
Technical cooperation towards universal health will be tailored to the national situation as appropriate, but always emphasizing the first level of care; access to comprehensive, quality services, and essential vaccines and medicines; social inclusion and participation; and focus on people in conditions of vulnerability, in the framework of progressive realization of the right to health. The United Nations High Level Meeting on Universal Health Coverage, scheduled for September 2019, provides an opportunity for PASB to engage with heads of State and government, ministers of health, and other key stakeholders, including civil society, in the consultation process leading to the Political Declaration on Universal Health Coverage. The Bureau will continue its advocacy for the inclusion of a wider perspective of universal health coverage—one that is more aligned with the Region’s commitment to universal health, encompassing both access and coverage.
In further pursuit of health equity and to strengthen measures that tilt the social and other determinants of health in favor of, rather than against, equitable health outcomes, PASB’s promotion of and contributions to multisectoral, whole-of-government, and whole-of-society actions are essential. PASB has prepared a Strategy and Plan of Action on Health Promotion in the Context of the Sustainable Development Goals 2019-2030 (Document CD57/10), which seeks to renew health promotion by shifting its focus beyond individual behavior to enabling technical and political actions that support a wide range of social and environmental interventions to “make the healthier choice the easier choice.”
The Strategy and Plan of Action on Health Promotion is complemented by the development of a new Strategy and Plan of Action on Ethnicity and Health 2019-2025, which makes operational the regional Policy on Ethnicity and Health, adopted by the 29th Pan American Sanitary Conference in 2017 (Document CSP29/7, Rev. 1). This Policy addresses action to ensure an intercultural approach for access to health and the social determinants of health, from a standpoint of equality and mutual respect, valuing the cultural practices of the Region’s ethnic groups, their lifestyles, social organization, value systems, traditions, and world views. Both the Strategy and Plan of Action on Health Promotion 2019-2030 and the Strategy and Plan of Action on Ethnicity and Health 2019-2025 will be presented to the 57th Directing Council in September 2019.
The occurrence of some communicable diseases in the Region has been reduced to the point where their elimination is a realistic target. PASB has developed the PAHO Disease Elimination Initiative: A Policy for an Integrated Sustainable Approach to Communicable Diseases in the Americas (Document CD57/7), which was approved by the 164th Session of the Executive Committee in June 2019 and which will be presented to the 57th Directing Council in September 2019. The diseases targeted include, but are not limited to, malaria; tuberculosis; cholera; plague; human rabies; and several neglected infectious diseases, such as Chagas disease, leprosy, trachoma, lymphatic filariasis, and onchocerciasis (river blindness). The Disease Elimination Initiative also addresses the reintroduction of vaccine-preventable diseases such as measles and rubella, and, in addition to these communicable diseases, targets elimination of cervical cancer as a public health problem, based on its close links with HPV infection and the availability of cost-effective prevention interventions. The Initiative is also targeting certain environmental determinants related to communicable diseases, including the elimination of open defecation and of polluting biomass cooking fuels, both of which pose significant public health challenges in certain geographic areas.
NCDs remain high among the priorities for PASB’s technical cooperation with Member States. Their burden and impact on health, productivity, and the economy strain national health budgets and health facilities, and negatively impact sustainable development. While advocating for and contributing to quality care at all levels of the health system, especially at the first level of care, PASB will continue to focus on risk factor reduction. There will be enhanced advocacy in political fora, and implementation of school-, work-, and community-based interventions, in partnership with health and other sectors, civil society, and the private sector, guided by FENSA. PASB will continue its work on all the main NCD risk factors, including introduction of a regional Plan of Action to Eliminate Industrially Produced Trans-fatty Acids 2020-2025 (Document CD57/8), given the significant contribution of these substances to unhealthy diets. The Plan of Action will be presented to the 57th Directing Council in September 2019.
Many PAHO Member States, including SIDS, face severe difficulties in providing services such as invasive and noninvasive cardiac interventions and renal dialysis, complemented, where necessary, by “high-tech, high-cost” procedures such as organ transplants. Such procedures are often made necessary by NCD complications and have the potential to prolong and improve the quality of life. PASB has developed a Strategy and Plan of Action on Donation and Equitable Access to Organ, Tissue, and Cell Transplants 2019-2030, for consideration by the 57th Directing Council in September 2019. The objective of the Strategy and Plan of Action is to promote the expansion of equitable and quality access to organ, tissue, and cell transplants in PAHO Member States through voluntary donation, observing the WHO Guiding Principles on Human Cell, Tissue and Organ Transplantation. Additionally, the Bureau will continue to explore and support South-South cooperation and shared services initiatives to meet this need.
Situation analyses—including identification of inequities—and monitoring and evaluation of initiatives, strategies, and plans of action are essential for informed decision-making, programmatic adjustments, and identification of successes, gaps, challenges, and lessons learned. Information systems for health that produce data disaggregated by income, sex, age, race, ethnic origin, migration status, disability, geographical location, and other relevant characteristics of their national and subnational context are a critical component of the health system, and continued technical cooperation in IS4H is a priority for PASB. A regional Plan of Action for Strengthening Information Systems for Health 2019-2023 (Document CD57/9), with a goal of strengthening the use of interconnected and interoperable information systems in Member States, through enhanced information and communications technology (ICT) and management of data for the benefit of public health, has been developed and will be presented to the 57th Directing Council in September 2019.
Efficient and effective IS4H in countries will enable accurate tracking of progress towards the SHAA2030 and SDG 3 targets and contribute to the WHO Impact Framework, which will measure progress to the ambitious triple billion target of the WHO 13th General Program of Work.
Notwithstanding its imperative to promote and implement the frameworks approved by PAHO Governing Bodies in advancing the SHAA2030 and the 2030 Agenda for Sustainable Development, the Bureau is also fully committed to the strategic approaches outlined in Phase 1 of a joint initiative named Towards a Global Action Plan for Healthy Lives and Well-Being for All: Uniting to Accelerate Progress towards the Health-Related SDGs. As at June 2019, the initiative involved WHO and 10 other leading global organizations active in health, and this Global Action Plan is expected to contribute significantly to the attainment of the SDGs by 2030. Its strategic approaches—align joint efforts with country priorities and needs; accelerate progress by leveraging new ways of working together and unlocking innovative approaches; and account for contributions to progress in a more transparent and engaging way—are synchronous with PAHO’s technical cooperation mechanisms.
The Bureau, in its capacity as the Regional Office for the Americas of WHO and the specialized agency for health of the Inter-American System, guided by the PAHO Strategic Plan 2020-2025, looks forward to strengthening multisectoral partnerships for enhanced, strategic, and effective technical cooperation with PAHO Member States through its regional, subregional, and national entities, in order to advance the Sustainable Health Agenda for the Americas 2018-2030 and the 2030 Agenda for Sustainable Development.
1 billion more people benefiting from universal health coverage, 1 billion more people better protected from health emergencies, and 1 billion more people enjoying better health and well-being.
Gavi, the Vaccine Alliance; Global Financing Facility; Global Fund; UNAIDS; UNDP; UNFPA; UNICEF; UNITAID; UN Women; and World Bank.
AECID Spanish Agency for International Development Cooperation
AIDS acquired immunodeficiency syndrome
AMR antimicrobial resistance
ART antiretroviral treatment
CARICOM Caribbean Community
CARPHA Caribbean Public Health Agency
CCHD cooperation among countries for health development
CCS Country Cooperation Strategy
CERF Central Emergency Response Fund (United Nations)
CICAD Inter-American Drug Abuse Control Commission
CICOM Medical Information and Coordination Cell
COMISCA Council of Ministers of Health of Central America and the Dominican Republic
CRS Caribbean Regulatory System
CSO civil society organization
DFID Department for International Development (United Kingdom)
EMTs Emergency Medical Teams
EMTCT elimination of mother-to-child transmission
EPHF essential public health function
EU European Union
EWEC Every Woman Every Child
EWEC-LAC Every Woman Every Child - Latin America and the Caribbean
FAO Food and Agriculture Organization of the United Nations
FCTC Framework Convention on Tobacco Control
FENSA Framework of Engagement with Non-State Actors
FoPL front-of-package labeling
GAC Global Affairs Canada
GDP gross domestic product
HCV hepatitis C virus
HHS/ASPR U.S. Department of Health and Human Services Office of the Assistant Secretary for Preparedness and Response
HIV human immunodeficiency virus
HLM high-level meeting
HLM3-NCDs Third High-level Meeting on Noncommunicable Diseases Prevention and Control
HPV human papillomavirus
HRH human resources for universal health
IAEA International Atomic Energy Agency
ICT information and communications technology
IDB Inter-American Development Bank
IHR International Health Regulations (2005)
IHSDNs integrated health services delivery networks
IHSLAC Integrated Health Systems in Latin America and the Caribbean
IS4H information systems for health
LAC Latin America and the Caribbean
LGBTQ lesbian, gay, bisexual, trans, and queer
MERCOSUR Southern Common Market
mhGAP Mental Health Gap Action Program
MHPSS mental health and psychosocial support
NCDs noncommunicable diseases
NGO nongovernmental organization
NSAs non-State actors
OAS Organization of American States
OFID OPEC [Organization of the Petroleum Exporting Countries] Fund for International Development
ORAS Andean Health Organization
PAHO Pan American Health Organization
PARLACEN Central American Parliament
PASB Pan American Sanitary Bureau
PASC Pan American Sanitary Conference
PB20-21 Program Budget 2020-2021
PFA psychological first aid
PHAC Public Health Agency of Canada
PHC primary health care
PMIS PAHO Management Information System
SDG Sustainable Development Goal
SE-COMISCA Executive Secretary of the Council of Ministers of Health of Central America and the Dominican Republic
SHAA2030 Sustainable Health Agenda for the Americas 2018-2030
SICA Central American Integration System
SIDS small island developing States
SP20-25 Strategic Plan 2020-2025
SPAG Strategic Plan Advisory Group
STIs sexually transmitted infections
UH universal health
UHC universal health coverage
UNAIDS Joint United Nations Program on HIV/AIDS
UNDP United Nations Development Program
UNICEF United Nations Children’s Fund
UNFPA United Nations Population Fund
UNGA United Nations General Assembly
UNODC United Nations Office on Drugs and Crime
UN Women United Nations Entity for Gender Equality and the Empowerment of Women
USAID United States Agency for International Development
USAID/OFDA USAID’s Office of U.S. Foreign Disaster Assistance
U.S. CDC United States Centers for Disease Control and Prevention
VCPH Virtual Campus for Public Health
VWA Vaccination Week in the Americas
WASH water, sanitation, and hygiene
WHO World Health Organization
The Pan American Sanitary Bureau is grateful for the support of its Member States through their quota contributions and for the generous voluntary contributions and collaboration of governments, agencies, and institutions including, but not limited to:
Action on Smoking and Health
Amazon Cooperation Treaty Organization
American Cancer Society
American Heart Association
American Public Health Association
American Speech-Language-Hearing Association
Andean Health Organization
Association of Regulators of Water and Sanitation in the Americas
Bernard van Leer Foundation
Bill and Melinda Gates Foundation
Binational Development Plan for the Peru-Ecuador Border Region, Peru Chapter
Brazilian Health Regulatory Agency
Campaign for Tobacco-Free Kids
Caribbean Development Bank
Caribbean Public Health Agency
Caribbean Regional Nursing Body
CARICOM Regional Organization for Standards and Quality
CBM (Christian Blind Mission) International
CDC (Centers for Disease Control and Prevention) Foundation
Central American Parliament
City of Buenos Aires
Climate and Clean Air Coalition
Commission against Addiction and Illicit Drug Trafficking (Guatemala)
Community of Latin American and Caribbean States
Cooperation Program between Latin America, the Caribbean and the European Union on Drugs Policies
Costa Rican Social Security Fund
Council for International Organizations of Medical Sciences
Council of Ministers of Health of Central America and the Dominican Republic
Department of Foreign Affairs, Trade and Development (Canada)
Directorate for Development Cooperation and Humanitarian Affairs (Luxembourg)
District Health Fund, Bogotá District Health Secretariat
DNDi (Drugs for Neglected Diseases initiative) Latin America
END (Ending Neglected Diseases) Fund
European Civil Protection and Humanitarian Aid Operations
Federal University of Pelotas
Food and Agriculture Organization of the United Nations
Framework Convention Alliance
Framework Convention on Tobacco Control Secretariat
Gavi, the Vaccine Alliance
George Alleyne Chronic Disease Research Center, Caribbean Institute for Health Research
Global Environment Facility
Global Fund to Fight AIDS, Tuberculosis and Malaria
Global Men’s Health Foundation
Government of Argentina
Government of Brazil
Government of Canada
Government of Chile
Government of China
Government of Cuba
Government of Germany
Government of Haiti
Government of Luxembourg
Government of Macau
Government of New Zealand
Government of Nicaragua
Government of Norway
Government of Spain
Government of Sweden
Government of Switzerland
Government of the Republic of Korea
Government of the United States of America
Government of the Virgin Islands (British)
Government of Trinidad and Tobago
Healthy Caribbean Coalition
Hemispheric Program for the Eradication of Foot-and-Mouth Disease
Higher Council of Central American Universities
Ibero-American General Secretariat
Institute for Health Metrics and Evaluation
InterAmerican Heart Foundation
Inter-American Development Bank
Inter-American Drug Abuse Control Commission
Inter-American Network of Food Analysis Laboratories
International Agency for Research on Cancer
International Agency for the Prevention of Blindness
International Atomic Energy Agency
International Bank for Reconstruction and Development
International Clearinghouse for Birth Defects Surveillance and Research
International Federation of Gynecology and Obstetrics
International Organization for Migration
International Union against Tuberculosis and Lung Disease
Italian Hospital of Buenos Aires
Johns Hopkins University
Johns Hopkins University Bloomberg School of Public Health
Johns Hopkins University School of Nursing
Joint United Nations Program on HIV/AIDS
Korea International Cooperation Agency
Latin American and Caribbean Network for the Strengthening of Health Information Systems
Latin American Association of Pharmaceutical Industries
Latin American Confederation of Clinical Biochemistry
Latin American Federation of the Pharmaceutical Industry
Latin American Society of Nephrology and Hypertension
March of Dimes Foundation
MERCOSUR Social Institute
Ministry of Agriculture and Livestock of Ecuador
Ministry of Agriculture, Livestock, and Food Supply of Brazil
Ministry of Foreign Affairs and International Cooperation of Italy
Ministry of Foreign Affairs and Trade of New Zealand
Ministry of Foreign Affairs of Chile
Ministry of Health, Labor and Welfare of Japan
Ministry of Health of Argentina
Ministry of Health of Bolivia
Ministry of Health of Brazil
Ministry of Health of Chile
Ministry of Health of Costa Rica
Ministry of Health of El Salvador
Ministry of Health of Panama
Ministry of Health of Peru
Ministry of Health of the Province of Jujui (Argentina)
Ministry of Health of the Province of Santa Fe (Argentina)
Ministry of Health of the Province of Santiago del Estero (Argentina)
Ministry of Health of Trinidad and Tobago
Ministry of Interior of Guatemala
Ministry of Public Health and Social Assistance of Guatemala
Ministry of Public Health of Ecuador
Ministry of Public Health of Guyana
Ministry of Public Health of the Dominican Republic
Mundo Sano Foundation
National Alliance for Hispanic Health
National Cancer Institute (Colombia)
National Drug Board (Uruguay)
National Health Foundation (Brazil)
National Health Regulation, Control and Surveillance Agency (Ecuador)
National Institute for the Coordination of Ablation and Implantation (Argentina)
National Institute of Social Services for Retirees and Pensioners (Argentina)
National Livestock Council (Brazil)
National Regulatory Agency for Private Health Insurance and Plans (Brazil)
National Service for Animal Health and Quality (Paraguay)
Network of National Cancer Institutes and Institutions
Network of Schools of Public Health of UNASUR
Norwegian Agency for Development Cooperation
Office of United States Foreign Disaster Assistance
OPEC Fund for International Development
Organization of American States
Organization of Eastern Caribbean States
Oswaldo Cruz Foundation
Pan Caribbean Partnership against HIV/AIDS
Permanent Mission of Brazil to the OAS
Provincial Municipality of Palpa (Peru)
Public Health Agency of Canada
Robert Koch Institute
Robert Wood Johnson Foundation
Rosarino Center for Perinatal Studies
Sabin Vaccine Institute
Secretariat for Comprehensive Drug Policies (Argentina)
Secretariat of Health of Honduras
Secretariat of Health of Mexico
Secretariat of Health of the City of São Paulo (Brazil)
Secretariat of Health of the Municipality of Florianópolis (Brazil)
Secretariat of Health of the State of Bahia (Brazil)
Secretariat of Health of the State of Espírito Santo (Brazil)
Secretariat of Health of the State of Maranhão (Brazil)
Secretariat of Health of the State of Pará (Brazil)
Secretariat of Health of the State of Pernambuco (Brazil)
Secretariat of Health of the State of Rio Grande do Sul (Brazil)
Secretariat of Health of the State of São Paulo (Brazil)
Secretariat of Health of the State of Tocantins (Brazil)
Solidarity Fund for Health (El Salvador)
South American Council on Health
Southern Common Market
Spanish Agency for International Development Cooperation
Special Program for Research and Training in Tropical Diseases
Swiss Agency for Development and Cooperation
Task Force for Global Health
Therapeutic Goods Administration, Department of Health of Australia
Union of South American Nations
United Arab Emirates
United Kingdom Department for International Development
United Nations Central Emergency Response Fund
United Nations Children's Fund
United Nations Development Program
United Nations Entity for Gender Equality and the Empowerment of Women
United Nations Environment Program
United Nations Foundation
United Nations Fund for International Partnerships
United Nations Inter-Agency Group for Child Mortality Estimates
United Nations Maternal Mortality Estimation Inter-Agency Group
United Nations Office on Drugs and Crime
United Nations Partnership to Promote the Rights of Persons with Disabilities
United Nations Population Fund
United Nations Post-Conflict Multi-Partner Trust Fund for Colombia
United Nations Secretariat for the International Strategy for Disaster Reduction
United Nations Trust Fund for Human Security
United States Agency for International Development
United States Centers for Disease Control and Prevention
United States Department of Health and Human Services
United States Food and Drug Administration
United States Pharmacopeia
University of Illinois at Chicago
University of Utah
University of the West Indies
Wellcome Genome Campus
WHO Collaborating Center for the Family of International Classifications
WHO Collaborating Center for the Public Health Management of Chemical Exposures
WHO Regional Office for Africa
WHO Regional Office for Europe
WHO Regional Office for South-East Asia
WHO Regional Office for the Eastern Mediterranean
WHO Regional Office for the Western Pacific
World Association for Sexual Health
World Health Organization Contingency Fund for Emergencies
World Hypertension League
World Organization for Animal Health
World Professional Association for Transgender Health
World Resources Institute Ross Center for Sustainable Cities