Progress report of the working group on PAHO in the 21st Century

PAN AMERICAN HEALTH ORGANIZATION

WORLD HEALTH ORGANIZATION

134th

SESSION OF THE EXECUTIVE COMMITTEE

Washington, D.C., USA, 21-25 June 2004

Provisional Agenda Item 3.2

CE134/6, Add. I (Eng.)

22 June 2004

ORIGINAL: ENGLISH

PROGRESS REPORT OF THE WORKING GROUP

ON PAHO IN THE 21st

CENTURY

1.

The Working Group on PAHO in the 21st Century, created by Resolution

CD44.R14 of the 44th Directing Council, in September 2003, held the following

meetings:

-

26 and 27 February 2004, in Roseau, Dominica

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23 March 2004, in Washington, D.C.

2.

At the request of the Group, the Secretariat opened a virtual site to facilitate the

exchange of information on the various topics mentioned paragraph 4 below. The site is

accessible to all Member States that wish to participate by appointing a focal point.

3.

At the 38th Session of the Subcommittee on Planning and Programming, the

Chairman of the Working Group presented an oral report, which appears in Document

CD134/INF/1. He also informed the Subcommittee that the Consultative Group on the

Regional Program Budget Policy would prepare the preliminary analysis of the financial

and intangible resources (which shall be available at a later stage), while the United

States of America volunteered to undertake the analysis of the human resources

component, which is contained in Annex I.

CE134/6, Add. I (Eng.)

Page 2

5.

It should be noted that the Secretariat had prepared a first draft on the Challenges

in Public Health in the Americas for the Coming Years, which has been subsequently

modified and is presented as Annex III.

6.

Taking the opportunity of the World Health Assembly, in May 2004, the Working

Group held an information meeting, which was attended by 10 Member States, one

Observer State, and a representative of WHO.

7.

The Working Group presents this report for the consideration of the 134th Session

of the Executive Committee.

CE134/6, Add. I (Eng.)

Annex

I

PAHO’s Human Resources

(Prepared by the United States of America)

Introduction

The Working Group on PAHO in the 21

st

Century identified “Resources for Health” as a

significant issue for consideration. This topic was subsequently split into PAHO’s

resources and resources “in-country” available to member states and further subdivided

into financial and human resources. The Working Group tasked the PAHO Secretariat

with the development of the section on “in-country” human and financial resources. The

section on PAHO’s financial resources would be developed by the “Consultative Group

on Regional Budget Policy” under the direction of Dr. Karen Sealy, with input from

members of the 21

st

Century Working Group. The remaining section on PAHO’s human

resources was tasked to the United States for development. This piece may overlap with

issues identified under “Modalities for Technical Cooperation in Health.”

Training of PAHO Staff

The Working Group clearly delineated the need to increase capacity building in the

countries and subregions. While this may appear to speak only to the issue of human

resources in-country, PAHO personnel can play a critical role. Specifically, if effective

capacity building is to occur in-country, then the PAHO personnel assigned must have

significant training and expertise in sustainable capacity building. The PAHO Biennial

Program Budget (BPB) for 2004-2005 proposes 1.85 million dollars for staff

development. However, the description does not contain a category for specific staff

training on particular priority areas. The breakdown of the allocation of these funds

would be helpful for countries to review. Furthermore, it would be useful if priority areas

delineated for staff training within the BPB should fall directly in line with priorities

identified by Member Countries. Whereas it might be less efficient and financially

difficult for every country office to have an expert on capacity building, PAHO

headquarters could compile a small team of experts in this field that could be dispatched

on an as-needed basis to countries or subregions to help in capacity building efforts.

CE134/6, Add. I (Eng.)

Annex I

- 2 -

There are emerging issues within the region, which do not fall into PAHO’s historical

personnel composition, but which are emanating from the Director’s new vision. This

would include social communication experts, information management experts, and

program managers, among others. PAHO should develop a strategy to identify who can

fill these personnel gaps. Other PAHO technical experts may also need training in some

of these areas.

Hiring of PAHO Staff

Another suggestion would be to identify a list of core competencies that are necessary in

each of the PAHO country offices. Then, additional analysis would be required to

determine the other core-competencies and skill sets required of staff working in a

particular country. Central to this concept, however, is ensuring that PAHO headquarters

is geared to provide that set of workforce skills to personnel assigned to the field. This

would best address the Working Group’s concern that a “one-model fits all” approach to

country offices is not working effectively.

The Working Group also expressed concern about the process of hiring and retaining

consultants. The group noted there seems to be little oversight for determining whether

the consultants being hired are needed given the overall strategic areas of work identified

by member states. Furthermore, the group suggested that there seems to be lax policy for

determining the qualifications for consultants. One solution might be to develop a more

stringent policy for the hiring and evaluation of short-to-mid-term consultants. However,

direct country participation in this practice would probably be too burdensome both for

member countries and PAHO.

PAHO currently encourages women to apply for careers within the organization.

However, there is little activity to actively recruit and retain women in senior positions.

Rising through the ranks at PAHO frequently implies a move from country to country or

subregion to headquarters. For women, this generally implies a significant challenge due

to family obligations.

The aging of the PAHO workforce also will pose a significant issue for the organization

in the coming years. With retirement age of 62, there are a number of expert PAHO staff

persons who will be retiring soon. This will present a number of gaps in the organization

that PAHO will have to fill. It is not uncommon to see an individual retire from PAHO

one day and then be re-hired as a consultant the next. That position may then go unfilled

or revised.

Career Development

CE134/6, Add. I (Eng.)

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Annex I

CE134/6, Add. I (Eng.)

Annex II

WORKING PAPER: PAHO IN THE 21ST CENTURY

EVOLVING NATURE OF ASSOCIATIONS AND ALLIANCES IN

INTERNATIONAL DEVELOPMENT IN HEALTH PERTINENT

TO PAHO´S ROLE

(Prepared by Peru)

Alliances and associations are part of a long tradition in the political, social and economic

history of the countries, and through them important accomplishments in international

public health have been achieved. Foreseeable alliances influencing profoundly health

policies will continue expanding in this century. The challenge is to identify the risks and

opportunities, as well as the strengths and weaknesses of the Organization, to carry out

the changes that will permit greater relevance in this increasingly important and complex

interdisciplinary area.

Although in the specialized literature the alliances and the associations are different

entities, in the present document they will be considered interchangeable concepts. The

associations and alliances that respond to the interests of actors of diverse nature are

aimed at responding in a more organized comprehensive and effective way in areas of

interest to its associates. What is important is the subject and purpose, not the nature of

the participating organizations. Organizations with diverse interests and including

antagonistic positions can come together to forge strategic alliances. The evidence of

social, political, economic and technological challenges that are emerging in this century,

and whose nature is more complex and unpredictable, demands the joint action of new

actors in all professions and disciplines to address the aforementioned problems

satisfactorily.

One of the risks lies in that harmonizing the interests of the various actors can change the

direction of the objectives although it is usually considered acceptable if the primary

target is reached. Furthermore, it brings to the fore the issue of the analysis of ethical

aspects.

CE134/6, Add. I (Eng.)

Annex II

- 2 -

Associations between the public and private sectors are gaining more and more

importance particularly in the industrialized countries, and are expanding to various

areas. This subject is complex and requires that the consequences for public goods,

priorities, exclusion and justice be studied. In order to avoid that the steering role of

PAHO/WHO weakens due to new and powerful actors, as well as to changing scenarios,

it is fundamental to understand the rationality of the dynamic and of the interests that are

at stake, that is, to have the capacity to prepare a strategy that addresses this issue.

Among the main actors are other sectors, multilateral agencies, bilateral agencies,

financial institutions, private foundations and private companies, pharmaceutical

companies, civil society, religious groups, nongovernmental organizations, professional

associations, schools of medicine, other university centers, and the media.

The principal function of PAHO in this regard, is to coordinate and promote a dialogue

among the various actors in order to defend public health goods. This task falls

somewhere between advocacy and direct participation, and requires an agreement with

actors of diverse institutional cultures, values and objectives, as well as recognition of

institutional weaknesses and strengths.

One of the strategies consists of forging alliances to obtain short-term results. The

starting point is to identify an area which the Organization recognizes not to have

sufficient institutional capacity. Another strategy is back multipurpose forums, such as

the Interinstitutional Coordinating Committees that have participation from the

governments, NGOs, civil society, that make it possible to address diverse subjects. The

alliances and the associations can also be constituted at the request of a former associate

or of a possible new associate to take advantage of the strong points of the Organization.

In order to sustain alliances and associations different types of resources are required, as

time, money and human resources. In any case, it is necessary to plan and to provide

means for sustaining the current alliances.

CE134/6, Add. I (Eng.)

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3

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Annex

II

W or k ing Gr ou p on PAH O in t h e 2 1 st Ce nt u r y 1 3 4 º Se ssion of t he Ex e cut ive Com m it t e e PAH O, W a sh in gt on, D .C., 2 1 - 2 5 Ju ne 2 0 0 4

Regional and Global Public Health Goods in the 21st Century and

their relation to Pan American Health Organization mandate

(Prepared by Argentina)

Summary

In relation to the agreements established during a meeting held on the occasion of

the World Health Assembly, Argentina has prepared a detailed document on

Regional Public Health Goods, which can be accessed on the website of the

Working Group on PAHO in the 21st Century. The aim of this document is to

encourage all countries of the Region to think about the subject, with the intention

to contribute through the collaboration of everyone to promote equity in health, to

combat disease, and to improve the quality of life as well as to extend the lives of

our peoples. Furthermore, various mechanisms are proposed in order that the

Pan American Health Organization can help the countries to understand and

respond to challenges and opportunities resulting from global and regional

policies, practices, and trends.

The process of globalization, accelerated during the last decades, is producing

positive and negative impacts on the health of the population. Globalization is

modifying the nature of the needs in health, as well as the type of interventions

that are required in order to fulfill them. In addition to local problems, communities

in general and health systems in particular must now increasingly confront

international transfer of health risks. We are faced with the need to guarantee

certain public goods regionally or globally and to introduce

far-reaching changes not only to the countries but also to the agencies that

cooperate with them.

In the framework of the opportunities and positive effects that globalization can

Annex II

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beyond national borders and are available for all population groups, regardless of

their social, economic, ethnic, cultural, or gender and across several generations.

The need for finding practical responses on how to manage the provision of

Regional Public Health Goods comes from the current debate on globalization’s

impact on health. The formulation and implementation of policies regarding the

provision and management of these goods implies a process where multiple

actors are involved (public, private, nongovernmental, national, and international).

Within the framework of this approach, we understand that international health or

global health can be defined as health problems, challenges, and actions that

transcend national borders, which can be influenced by the circumstances of

different countries and that are better served by cooperative processes. It implies

a reciprocal influence between health matters and international relations as well

as an approach from a broad perspective on which not only different disciplines

should intervene but also the analysis of national and international determinants of

health. Global health compels governments and other organizations to struggle to

CE134/6, Add. I (Eng.)

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Annex II

MODALITIES OF TECHNICAL COOPERATION RELATED TO HEALTH

(Prepared by Costa Rica)

SUMMARY

During the last decades, globalization has represented challenges for the various societies, mainly due to the

approximation of the countries and regions. The high levels of interdependence and interrelationship among

the countries and regions of the world, not only generates impact or political transformations,

economic-commercial, technological or environmental, but also social.

Within this context it is necessary to consolidate the efforts that are carried out in the national, regional,

hemispheric, and global areas in order to face or solve situations arisen as a result of these new trends, but

that have serious impact on the health sector, in order to continue to improve the human sustainable

development indexes. In this scenario, the Pan American Health Organization-PAHO, as the specialized

agency of public health that during its more than 100 years has been closely linked in the subject at the

hemispheric level, should continue to accompany and supporting the countries of the continent in its

surveillance and improvement of the health.

In order to improve the structure and the procedures of the organization, with the intention to adapting to the

changes and the challenges that as a result of those changes occur, it is necessary to carry out an analysis to

future of the technical cooperation performance with regard to health on the part of PAHO, seen from different

sides:

1.

INNOVATION AND NEW MODALITIES OF HEMISPHERIC COOPERATION:

In order to generate effective

and timely actions, PAHO has to be flexible in order to be always accompanying the national changes, as well

as international environment. It should:

-

strengthen its participation as an active partner in the process of technical cooperation with the

countries and to promote cooperation among them;

-

promote and apply the concept of collaboration or cooperation among all: all have something to give

or to offer, but also all need something;

-

seek support, or serve as support for our countries in the search for strategic alliances with other

entities or institutions of importance with regard to health, not necessarily governmental or

intra-regional;

Annex II

- 6 -

The heterogeneity of the countries makes it necessary to classify them in relation to its different variables,

competencies, and needs and to avoid utilizing a single variable. Similarly the traditional scheme of grouping

the countries, as the geographical one, does not represent or reflects uniformity in the realities or needs of the

countries. In light of this heterogeneity becomes necessary to classify the countries in relation to their different

variables, competencies, and needs, for example, in accordance with the progress in contrast to the

Millennium Development Goals, mainly the related to the health sector, to the Essential Public Health

Functions-EPHF, more vulnerable groups, etc.

At regional level, it could be recommended to include other elements or subjects of classification

in issues

that join together the countries and their technical capabilities

, so that the successful experiences and

the best capacities are united in “networks” for which PAHO can serve as great support and orientation.

2. STRATEGY OF COOPERATION WITH THE COUNTRIES:

It could help to define and to plan satisfactorily

the cooperation that PAHO gives and that the countries receive through the evaluation of the situation of the

countries in relation to health. This mechanism:

-

would help the countries to carry out an internal analysis of the challenges, weaknesses, needs,

trends, the critical events, new opportunities for the countries with regard to health, as well as the

strengths and the capacities in its responses or national contributions;

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would make it possible to know the situation of the countries and define a better assignment or

channeling of the resources (not only from PAHO);

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should be defined taking into account, and based on, the policies and plans defined per each

government with regard to health;

-

should be done through the active participation or promotion of partnerships among the various and

solid technical groups at the country level that are involved in the subject of health;

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is useful to define and to direct cooperation toward areas where there are more weaknesses and

needs;

-

could serve as a tool for defining or identifying the areas in which the countries are found more

strengthened or in which could maximize its own cooperation (“best practices”).

3. APPROACH OF THE GAPS AMONG THE CURRENT AND FUTURE DESIRED REALITIES:

In order to

serve the new challenges or realities it is very important and necessary to visualize where it is wished to arrive,

CE134/6, Add. I (Eng.)

- 7 -

Annex II

of the strategies with regard to public health or the subject of the comprehensive information systems). It is

important:

-

to involve gradually the Ministries of Economy, Environment, Planning, Education or Culture in the

processes of discussion and definition in subjects related to the health, in order to lead them to a

greater sensitization with this subject and

to

give a greater impetus and comprehensive nature to

the health sector

of the countries;

-

that

the countries define the role

of the Ministries of Health, the institutions of the Health Sector, as

well as other involved with the subject, for the monitoring and follow-up of policies and of performance

evaluation of the health systems;

-

provide the authorities who intervene directly or indirectly in the subject of health with the conceptual,

methodological, instrumental, and technological frameworks in order to carry out this monitoring of the

policies and undertaken actions or to undertake;

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development of human resources of the sector.

4. THE CONTRACTING, ASSIGNMENT, AND ADAPTATION OF THE WORK FORCE IN PAHO

HEADQUARTERS AND THE COUNTRY OFFICES:

The personnel of PAHO Headquarters should be

distributed so that it responds better to the geographical and epidemiological diversity that PAHO represents at

regional level. The profile of the people assigned for the representations of the countries, as well as their

training and experience should go strictly consistent with the needs and challenges identified by the countries

according to the health problems identified and prioritized to their interior. In order to assign the personnel

specialized in the country offices it definitively is necessary to consider seriously the existing of local technical

capabilities that each country has, since these can vary substantially. It is fundamental that the Headquarters

personnel or the consultants who go to the countries, indistinctly of the duration of their staying, they have to

be very clear that they go to work together and in coordination with local human resources. In light of this, it is

of utmost importance to have a clearly identified and prepared counterpart. The way in which the personnel of

the country offices is assigned should be a more democratic and inclusive process. The identification of the

“competencies” of human resources as well as the constant assessment of such competencies can be a

mechanism that helps in the process of contracting, assignment and adaptation of the work force, so much in

Headquarters, as well as the representations. Nevertheless, more than the evaluation and supervision of the

contracted personnel, it is also of fundamental importance to establish efficient mechanisms of evaluation,

supervision and monitoring of the supported activities or carried out by human resources, both internal, and

external.

CE134/6, Add. I (Eng.)

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Annex II

“ GOVERNA NCE OF PA HO”

A PA PER

PREPA RED FOR

THE WORKING GROUP OF THE

EX ECUTIVE COMMITTEE

ON

PA HO IN THE 2 1

ST

CENTURY

BY THE

GOVERNMENT OF BA RBA DOS

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Annex II

This paper focuses on “The Governance of PAHO,” which is Barbados’ remit in the Working Group of the Executive Committee on PAHO in the 21st _{Century and will be centred on three main categories of PAHO’s} operations:

1. Structure and governing bodies 2. Function

3. Process with regards to relationship with stakeholders

I. GOVERNANCE OF PAHO

Organizational governance may be understood in two dimensions. The first refers to the means through which authority is exercised in the management of the organizational resources; where issues of participation, legitimacy, accountability and transparency are essential.

The second refers to the ability to discharge functions effectively, efficiently and equitably through the design, formulation and implementation of policies, which is an act of protection and enhancement of the Organization. In general, governance can be understood as the structure and processes of policy and decision making that involves both the internal and the external actors and stakeholders.

In relation to PAHO, with reference to the aforementioned dimensions, the first refers to the Constitution of PAHO (legal framework and regulations) as it relate to its capacity to promote and guide policy in the interest of the Member States. PAHO governance is exercised through its Governing Bodies: the Pan American Sanitary Conference which is composed of all thirty-five Member Governments, the Directing Council which is also composed of all the Member Governments, and the Executive Committee of the Directing Council, which is comprised of only nine of the Member Government.

The second dimension, although overlapping with the first is more directly related to the Pan American Sanitary Bureau or the Secretariat of PAHO. This dimension of PAHO’s governance refers to the protection and enhancement of the Organization on behalf of the Member States. This is expressed through the managerial process (planning, programming, budget approval and execution), while emphasizing accountability, performance and efficiency in processes and in staff development and appraisal. Being centred on the ability to discharge functions effectively, efficiently and equitably through the design, formulation and implementation of policies links PAHO’s organizational development to governance in this case.

The following specific issues were identified to be redressed under the Terms of Reference “Governance of PAHO” by the Working Group on PAHO in the 21st _century.

A. Structure and Governing Bodies

Specific Issue 1:

Improve communication within governing bodies and amongst Member States.

Specific Issue 2

Organizational and budgetary structure to fulfil the mission of the Governing Bodies and meet the needs of the countries

Specific Issue 3

Assessment of regional centres

CE134/6, Add. I (Eng.)

Annex II

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Specific Issue 1

Enhancing efficiency of PAHO by the use of country offices to build partnerships, capacity building and strengthening of institutions particularly for developing states.

Specific Issue 2

Bringing focus to the operational side of what PAHO does.

Specific Issue 3

Evaluation of the implementation of PAHO’s Mandate.

Specific Issue 4

Evaluation of Strategies and allocation of resources to carry out mandate.

C. Process with regards to relationship with stakeholders

Specific Issue 1

Relationship between PAHO and WHO

Specific Issue 2

Reaffirm commitment as member states to the Organization.

Specific Issue 3

What is the view of the other Stakeholders of PAHO?

Specific Issue 4

Decentralization of resources and staff from Headquarters to Country Offices

Methodology

The paper was prepared using a variety of methodologies:

1. Key informant interviews were conducted with:

• Former Ministers of Health and Permanent Secretaries from National Health Authorities.

• Current and former technical and administrative staff from PAHO’s Headquarters and the Office of Caribbean Program Coordination.

• Focus group discussion on the subject among the Minister of Health/ Chairman of the PAHO 21st _{Century Committee (Barbados), the Permanent Secretary, Deputy Permanent Secretary,} Chief Medical Officer, Chief Health Planner and Environmental Health Officer (former PAHO Associate Consultant, Strategic Alliance and Partnerships/Training Program in International Health)

2. Review of PAHO/WHO’s literature and Websites

3. Review of documents and reports of PAHO’s technical discussions/meetings with other members of the international community.

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Annex II

Timetable of Work

1. April 30th_{, 2004 dissemination of first draft paper via e-mail and posting of paper on PAHO website for} feedback, comments, and suggestions from Member Governments.

2. May 14th_{, 2004 review of comments, suggestions and feedback from Governments and other} stakeholders and the amendment of the document for the second draft presentation at meeting in Geneva in May.

3. June 21st_{, presenting of amended third draft document to Executive Committee Working Group. Review} of paper for final presentation

4. September 2004 Final presentation of Document.

Support from Secretariat

1. Dissemination of draft paper and posting of draft document on PAHO’s Website

2. Soliciting the support and input of all Member Government for the paper.

3. Providing literature and other relevant documentation for research purposes.

CHALLENGES OF PUBLIC HEALTH FOR THE 21ST CENTURY

PRELIMINARY ANALYSIS -- DRAFT FOR DISCUSSION

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INTRODUCTION... 3

THINKING IN FUTURE TENSE ... 3

THE ROLE OF FUTURES AND SCENARIOS... 4

KEY DRIVERS AND TRENDS ... 4

GLOBALIZATION... 5

ENVIRONMENTAL CHANGE AND QUALITY OF NATURAL RESOURCES... 6

SCIENCE AND TECHNOLOGY... 6

THE DETERMINANTS OF HEALTH:TRENDS AFFECTING HEALTH CONDITIONS... 7

De mographics and Social Tre nds ... 8

Political... 9 Economics ...1 0 He alth Se ctor, Syste ms, and Se rvice s ...1 2 TRENDS IN INTERNATIONAL HEALTH DEVELOPMENT COOPERATION...1 4

THE CONTEXT OF HEALTH...1 6

EPIDEMIOLOGICAL POLARIZATION...1 7 LIFE CYCLE...1 8 SPECIAL GROUPS...1 8 SPECIFIC HEALTH PROBLEMS...1 9

THE UNFINISHED AGENDA ...2 0

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Introducti on

The pre liminary analysis o f c halle nge s fo r public he alth was pre pare d at the re que st o f the me mbe rs o f the Wo rking Gro up o n PAHO (Pan Ame ric an He alth Organizatio n)1 _{in the 2 1 st}

Ce ntury that me t Fe bruary 2 6 -2 7 in Ro se au, Do minic a. The pre se nt do c ume nt inc lude s the re visio ns by the me mbe rs o f the Wo rking Gro up sugge ste d during the ir se c o nd me e ting in Washingto n D.C, Marc h 2 3 .

The c halle nge s fo r public he alth in the ne xt fe w ye ars c o uld be gro upe d in thre e majo r fe ats:

•

Co mple te the unfinishe d age nda, e mbo die d fo r many c o untrie s in the UN Mille nnium De ve lo pme nt Go als (MDG).

•

Sustain ac hie ve me nts o f the last two de c ade s (vac c ine pre ve ntable dise ase s, life e xpe c tanc y, impro ve quality o f life o f ye ars gaine d): pro te c t vulne rable c o untrie s and po pulatio ns whe re disparitie s are gre ate r, fo ste r e me rge nc y pre pare dne ss to fac e natural disaste rs and o utbre aks.

•

Tac kle the ne w age nda with a po pulatio n base d appro ac h, impro ve d fo re sight and c o llabo rative strate gie s, fo c using o n de ve lo ping appro priate skills and c o mpe te nc ie s. Altho ugh a c halle nge is c o mmo nly unde rsto o d as a spe c ific hurdle o r diffic ulty, it c an also be c o me a summo ns to e ngage in spe c ial e ffo rts that will turn this de fy into o ppo rtunitie s and ac c o mplishme nts. In the partic ular c ase o f public he alth, the c halle nge s fo c us primarily o n the po pulatio n, e mphasize s dise ase pre ve ntio n and pre ve ntio n fo r the who le c o mmunity, public se rvic e e thic s, and a se t o f inte rve ntio ns aime d at e nviro nme nt, human be havio r and life style , and me dic al c are

The pre se nt do c ume nt se e ks to appro ac h the c halle nge s fo r public he alth in the Re gio n o f the Ame ric as with a future s’ pe rspe c tive in the c o nte xt o f ke y drive rs o f c hange and tre nds that shape he alth, he alth c are . The c o nte xt o f he alth in the re gio n is highlighte d taking into c o nside ratio n the main tre nds and c o nditio ns affe c ting po pulatio n gro ups. The last

se c tio ns o f the do c ume nt addre ss the “unfinishe d age nda”, mainly illustrate d by the Unite d Natio ns Mille nnium Go als and late r, the ne w age nda o f c halle nge s with brie f sugge stio ns fo r an e me rging age nda fo r ac tio n. The last se c tio n inc lude s a summary table listing the c halle nge s o f public he alth that e me rge fro m the analysis and whic h inc lude tho se me ntio ne d by the me mbe rs o f the Wo rking Gro up o f PAHO in the 2 1 st Ce ntury.

T

HINKING

I

N

F

UTURE

T

ENSE

Transfo rmatio ns in so me se c to rs and issue s are so de e p that it may no t be e ffe c tive o r e ve n po ssible to so lve so me c urre nt pro ble ms with the same type o f thinking use d whe n the se we re ge ne rate d. Unc e rtainty, c o mple xity and inte rde pe nde nc e c harac te rize c urre nt re gio nal and glo bal frame s o f re fe re nc e . This c o nte xt make s natio ns, go ve rnme nts and o rganizatio ns, public and private mo re pe rme able to the e ffe c ts o f e xte rnal fac to rs, and if

1 _{Resolution CD44R.14 of the 44th Directing Council of the Pan American Health Organization mandated the}

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ac c urate unde rstanding o f the c hanging nature o f issue s o r ide ntifying ne w re le vant issue s may be hampe re d, the re fo re affe c ting the c apac ity to re spo nd time ly and appro priate ly. The re fo re , suc c e ssful navigatio n o f the future to ave rt risks and harne ss o ppo rtunitie s unde r ne w rule s de pe nd o n the c apac ity to antic ipate , e mbrac e c hange and adapt, c alling fo r de ve lo ping gre ate r fo re sight c apac ity.

Thinking in the future te nse with a ke e n aware ne ss o f the past and the pre se nt is ge rmane to public he alth and me dic ine , whe n re c o gnizing the c o nside ring the nature o f the tre nds and the re le vanc e o f pro pe rly addre ssing the c halle nge s o f public he alth in the Re gio n. Gre ate r fo re sight allo ws harne ssing the be ne fits o f c hange and inno vatio n.A fo rward vie w c an pro duc e use ful insights to de ve lo p time ly re spo nse s to c halle nge s, sinc e it e nable s gre ate r aware ne ss, re duc e s unc e rtaintie s, c o ntribute s to the ide ntific atio n o f e arly warning signs and c re ate s o ppo rtunitie s fo r ac tio n.

The Role of Futures and Scenarios

The fie ld o f future s studie s is c lo se ly re late d to antic ipato ry disc ipline s, suc h as lo ng-te rm planning, po lic y analysis and strate gic manage me nt.2 _{As the unc e rtainty and c o mple xity}

has inc re ase d, go ve rnme nts, age nc ie s and vario us o rganizatio ns have inc re asingly use d antic ipato ry me tho ds and to o ls to e xplo re multiple alte rnative future s, re -e xamine go als and prio ritie s, suppo rt the re ne wal o f strate gie s and mo tivate ac tio n thro ugh partic ipatio n, thus drawing pe o ple to ge the r to wards c re ating share d future s and go als.

Mo st future s wo rk invo lve s the c re atio n o f so me kind o f sc e nario . Sc e nario s are image s o f po ssible , plausible , de sirable and unde sirable future s. Ho we ve r, the se image s o r sto rie s o f the future are no t pre dic tio ns; the y are use d as le arning to o ls to c hange me ntal mo de ls and inc re ase fo re sight. Cre ative and strate gic thinking thro ugh sc e nario s adds

o rganizatio nal fle xibility and suppo rt po lic y fo rmulatio n. The pro c e ss allo ws a c o lle c tive appro ac h to issue s fro m multidime nsio nal and transdisc iplinary pe rspe c tive s.

K

EY

D

RIVERS AND

T

RENDS

Ke y drive rs and tre nds are no t go o d o r bad in the mse lve s, ho we ve r the y may e xe rt diffe re nt e ffe c ts (po sitive (re pre se nt o ppo rtunitie s), ne gative (re pre se nt thre ats), o r inno c uo us (no e ffe c t) o n the issue o f inte re st. Own situatio n, be lie fs and po sitio ns de fine the inte rpre tatio n o f the ir e ffe c ts as we ll as the re spo nse s.

Majo r ke y drive rs o f c hange o r driving fo rc e s are de fine d as c o mpe lling fo rc e s that affe c t in fundame ntal ways all sphe re s o f human ac tivity, shaping human inte rac tio ns (pro duc tio n,

2 _{The roots of future studies and foresight are found in Europe and the United States, their conceptual and}

methodological evolution in the Region of the Americas is linked to the history of social and economic planning and management. Many countries have engaged in the visionary construction of futures in diverse sectors, and some are involved in processes of technology foresight linked to public policy formulation through initiatives supported by the Organization for Industrial Development (UNIDO). See Costa Filho, A. Planificación y construcción de futuro. Instituto Latinoamericano y del Caribe de Planificación Económica y Social (ILPES). Santiago de Chile: ILPES; 1988 and Yero, L. Los Estudios del Futuro en América Latina. En: Medina Vásquez, J. y Ortegón, E. Eds. Prospectiva: Construcción Social

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trade , wo rk c o nsumptio n, c o mmunic atio ns, prac tic e s, be lie fs, attitude s, so c ial and po litic al re latio ns, e thic al standards and c o gno sc itive mo dalitie s). Glo balizatio n, c hange s in the natural e nviro nme nt, and sc ie nc e and te c hno lo gy are ge ne rally c o nside re d driving fo rc e s o f c hange . Co nve rse ly, tre nds are c o ntinuo us patte rne d e ve nts that shape the future o f issue s o r o bje c ts o f inte re st, the y may be mo re lo c alize d, and the ir e ffe c ts may no t be as bro ad o r the transfo rmatio ns so de e p as tho se c ause d by ke y drive rs. Fo r the purpo se o f this pape r, tre nds have be e n gro upe d in te rms o f the de te rminants o f he alth, due to the nature o f the ir e ffe c ts o n he alth o utc o me s and he alth c are pro c e sse s.

Globalization

Glo balizatio n has be e n de fine d and de sc ribe d in a many ways, and it is diffic ult to disagre e that it is a c ritic al, c o mple x and unc e rtain drive r o f e c o no mic , po litic al, e nviro nme ntal so c ial, c ultural, te c hno lo gic al and c o gnitive transfo rmatio ns, with lo ng-te rm implic atio ns. Glo balizatio n has drive n the inc re ase d flo w and e xc hange o f go o ds and se rvic e s be twe e n natio ns, o f c apital thro ugh c o mpanie s o r individuals, o f labo r, and o f info rmatio n.3

Altho ugh asymme tric and inc o mple te , the transfo rmatio ns have c o ntribute d to inte nsify the inte gratio n o f natio nal and subre gio nal e c o no mie s thro ugh trade , financ e and

pro duc tio n in a glo bal marke t plac e me diate d by inte rac tive c o mmunic atio n and ne two rks o f pro duc e rs, supplie rs and c usto me rs. The ac c e le ratio n o f inte rc o nne c tivity has c re ate d “c o mmo n virtual spac e s” thro ugh the e xpo ne ntial e xpansio n o f inte rne t, while e -c o mme rc e is rapidly be c o ming a ne w way o f trading, sho pping and banking. At the same time , it has also inte nsifie d the inte rnatio nal transfe r o f he alth risks thro ugh humans, animals and fo o dstuffs, and also inc re ase d c o nc e rns fo r natio nal se c urity.

As gre ate r pe rme ability o f natio nal bo rde rs de c re ase s the distinc tio n be twe e n natio nal, re gio nal and glo bal he alth, but re pre se nt an o ppo rtunity fo r syne rgism in c o o pe ratio n thro ugh partne rships.4

Possible implications of globalization for public health

•

Transnatio nalizatio n and mo dific atio n o f patte rns o f distributio n o f dise ase s, he alth risks, wo rk, life style s, be havio rs, be lie fs, attitude s and symbo ls...

•

Highe r inte re st in addre ssing the gaps be twe e n individuals and gro ups with ac c e ss to the be ne fits o f de ve lo pme nt and tho se who have no t.

•

Inc re ase d atte ntio n to issue s re late d to trade and re gulatio n o f me dic al de vic e s, pharmac e utic als, and inte lle c tual pro pe rty rights.

•

Gre ate r aware ne ss o f o ppo rtunitie s o pe ne d by the inc re ase d flo w o f info rmatio n and kno wle dge to c re ate syne rgisms in c o o pe ratio n thro ugh partne rships.

•

Gre ate r c o nc e rns fo r he alth go ve rnanc e and e quity issue s as natio nal de c isio n making

3 _{Romanov, Roy J., Q.C. Building on Values: The Future of Health Care in Canada. Final Report. November 2002.}

Commissioner. Commission on the Future of Health Care in Canada, pp. 233. http://www.hc-sc.gc.ca/english/care/romanow/hcc0086.html

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Environmental Change and Quality of Natural Resources

Po pulatio n shifts, te c hno lo gic al c hange , e nviro nme ntally disruptive te c hno lo gie s and so c io e c o no mic transfo rmatio ns c o ntribute to shape the e nviro nme nt and the quality and quantity o f natural re so urc e s.Altho ugh many o f the e ffe c ts are diffic ult to quantify o r pre dic t ac c urate ly, pro gre ssive e nviro nme ntal de gradatio n, lo ss o f bio dive rsity and the c o ntaminatio n o f vital re so urc e s adve rse ly affe c t he alth and we ll be ing and c an ge ne rate lo ng te rm so c ial and e c o no mic c o sts and pe rhaps irre parable damage to the e c o syste m. The inc ide nc e and pre vale nc e o f c o mmunic able dise ase s (e .g. de ngue , malaria),

o c c upatio nal injurie s and c hro nic dise ase s asso c iate d with c he mic al and physic al age nts re fle c t the he alth e ffe c ts o f po o r e nviro nme ntal quality. Furthe rmo re , c hange s in c limatic patte rns c o ntribute to the air po llutio n and ae ro alle rge n le ve ls, to the appe aranc e and distributio n o f fo o d, wate r and ve c to r bo rne dise ase s, risk o f malnutritio n, dro ughts and famine , wate r sho rtage s, and inc re ase the fre que nc y o r se ve rity o f natural disaste rs. The latte r c ause physic al and human de vastatio n, po pulatio n displac e me nts, injury, de ath, and so c ial and e c o no mic lo sse s, so me time s se tting natio nal de ve lo pme nt bac k se ve ral ye ars.5

Possible implications of e nvironme ntal change for public he alth

•

Impro ve d kno wle dge abo ut the e ffe c ts o f po llutio n o f e sse ntial re sourc e s o n diarrhe al, re spirato ry and ve c to r bo rne dise ase s and o f e nviro nme ntal and o c c upatio nal

e xpo sure s to bio lo gic al and c he mic al po llutant to re spirato ry dise ase s, c anc e rs, birth de fe c ts and ne uro lo gic al c o nditio ns.

•

Disrupte d e c o syste ms and lo ss o f bio dive rsity e ffe c ts o n human and animal he alth, agric ultural pro duc tio n, e c o no mic pro duc tivity and sustainability o f fo o d so urc e s.

•

Diminishing fre sh wate r so urc e s se rio usly je o pardize human he alth, and may also be c re ate po litic al and arme d c o nflic ts that thre ate n pe ac e and de mo c rac y.

•

Gre ate r de mand fo r be tte r re gulatio n and c omplianc e , and fo r e nviro nme ntally frie ndly te c hno lo gie s.

Science and Technology

Sc ie nc e and te c hno lo gy, inc luding tho se advanc e s applie d to c o mmunic atio n and info rmatio n te c hno lo gy dramatic ally c hange o ur live s, and inc re asingly c halle nging the sc ie ntific basis o f me dic al and public he alth prac tic e . The se transfo rmatio ns have c o ntribute d to the e xpansio n o f e c o no mie s o f spe e d re plac ing e c o no mie s o f sc ale , the c usto mizatio n o f pro duc ts and se rvic e s, the maximizatio n o f re al time pro c e sse s, and the rapid o bso le sc e nc e o f pro duc t life c yc le s...

5 _{WHO. Climate change and human health-risks and responses. Summary. World Health Organization: Geneva. 2003.}

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Inno vatio ns in bio te c hno lo gy, nano te c hno lo gy6 _{and pharmac o ge ne tic s}7 _{will re vo lutio nize}

pre ve ntio n, diagno sis and tre atme nt. He alth-o rie nte d tele c o mmunic atio ns, me dic al imaging, sate llite te c hno lo gy and o the r info rmatio n syste ms will radic ally transfo rm he althc are thro ugh te le radio lo gy, te le me dic ine and te le he alth.8

The unbridle d de ve lo pme nt o f sc ie ntific and te c hno lo gic al inno vatio ns ge ne rate s c o nc e rn and ac tio ns abo ut e thic s, se c urity and c o nfide ntiality to the fo re fro nt o f the glo bal age nda. So me o f the to pic s addre sse d re late to e thic al issue s o f so c ial de plo yme nt o f ge ne tic individual info rmatio n, ac c e ssibility to the be ne fits o f inno vatio ns, bio e thic al re pe rc ussio ns o f c lo ning, transplantatio n and the use o f ge ne tic s in he alth c are . Eme rging issue s be ing addre sse d inc lude c ybe rthre ats, disruptio n o f e sse ntial func tio ns by physic al damage c ause d by te rro rism and natural c atastro phe s, invasio n o f syste ms, blac kmail, industrial e spio nage and data the ft.9

Possible implications of scie nce and te c hnology for public he alth

•

He ighte ne d aware ne ss abo ut the e thic al dime nsio ns o f he alth and he alth c are , suc h as he alth e quity, ac c e ss to c are , financ ing and re gulatio n, transplantatio n, c o nfide ntiality o f me dic al info rmatio n, as we ll as issue s re late d to life and de ath.

•

Appre c iatio n fo r the o ppo rtunitie s to apply sc ie nc e and te c hno lo gy inno vatio ns to impro ve he alth and me dic ine , inc luding the se arc h fo r e quity-o rie nte d te c hno lo gie s to fo re c ast and manage he alth, e pide mio lo gic al surve illanc e in “re al time ,” te le he alth in rural are as, and o the rs.

•

Applic atio ns to so c ial de ve lo pme nt: ne two rks to stre ngthe n go ve rnanc e and

ac c o untability, c hanne ls and site s fo r re trie val and sharing, c re atio n o f kno wle dge as a share d re ne wable re so urc e ac ro ss bo rde rs.

The Determinants of Health: Trends Affecting Health Conditions

Change s in he alth status (e ithe r tho se that e xpre ss re duc tio n o r impro ve me nt o f adve rse o utc o me s, inc re asing he alth gains and impro ve me nt o f func tio n) are the pro duc t o f c o mple x inte rac tio ns o f struc tural de te rminants (ge ne tic e ndo wme nt, the so c ial and physic al e nviro nme nt) as we ll as o f pro c e ss de te rminants (individual re spo nse thro ugh

6 _{Nanotechnology involves “research and technology development at the atomic, molecular or macromolecular levels, in}

the length scale of approximately 1-100 nanometer range, creating and using structures, devices and systems that have novel properties and functions because of their small and/or intermediate size, and the ability to control or manipulate on the atomic scale.” National Nanotechnology Initiative. What is Nanotechnology.

http://www.nano.gov/html/facts/whatIsNano.html

7 _{Pharmacogenetics is the study of how genes affect the way people respond to medicines, including antidepressants,}

chemotherapy, drugs for asthma and heart disease, and many others, where outcomes will improve tailoring medicines to people’s genetic make-ups and thus improve safety and effectiveness. http://www.nigms.nih.gov/pharmacogenetics/

8 _{Daar, A.S. et al. Top ten biotechnologies for improving health in developing countries. Nat Genet. 2002 Oct;}

32(2):229-32. Oct 2002. htp://www.utoronto.ca/jcb/pdf/toptenng.pdf.Pang, T. The impact of genomics on global health. Am J Public

Health.2002; 92: 1077-1079.http://www.ajph.org/cgi/content/full/92/7/1077

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de te rminants may be be yo nd the sc o pe o f ac tio n the he alth se c to r, ac tual o ppo rtunitie s e xist to c o ntribute to the mo dific atio n o f he alth o utc o me s thro ugh e ffe c ting pro c e ss de te rminants.

De m o g r a p h i c s a n d So c i a l Tr e n d s

By mid 2 0 0 3 , the po pulatio n o f the Latin Ame ric an and Caribbe an Re gio n had re ac he d 5 4 0 millio n. The pro je c tio ns indic ate that this numbe r will inc re ase to 6 9 0 millio n pe o ple by 2 0 2 5 and 7 8 9 by 2 0 5 0 , with an e stimate d po pulatio n c hange o f 4 6 % be twe e n 2 0 0 3 and 2 0 5 0 .1 0

Abo ut 7 7 .4 % o f the re gio n’s po pulatio n live s in urban are as, a figure lo we r o nly to that o f No rth Ame ric a.1 1 _{Rapid urbanizatio n (inte rnal and also due to e xte rnal migratio n) c an}

furthe r strain urban spac e s, and be partic ularly injurio us fo r po o r and lo w inc o me dwe lle rs. As se rvic e s are stre tc he d to ac c o mmo date ne w po pulatio ns, se rvic e s and ho using are furthe r re duc e d in quantity and quality. Po ve rty, e nviro nme ntal de gradatio n and limite d ac c e ss to basic sanitatio n and to quality re c re atio n are as, o fte n c o uple d with limite d skills adve rse ly affe c t individuals’ so c ial and psyc ho lo gic al we ll be ing. Unle ss c o mmunitie s are re silie nt and so c ially c o he sive , the risks o f injury and de ath are e xac e rbate d.

Migratio n c o ntinue s to be an impo rtant tre nd, and 2 0 millio n pe rso ns have e migrate d fro m the c o untrie s o f the Re gio n, thre e quarte rs to the Unite d State s, with wo me n

o utnumbe ring me n in intrare gio nal and e xtrarre gio nal migrato ry flo ws. Co nside ring the impo rtanc e o f the se tre nds, re c e nt initiative s are fo c using atte ntio n o n the he alth dime nsio ns o f migratio n thro ugh a human rights frame wo rk, with a vie w to inc re ase unde rstanding abo ut the plight o f diffe re nt type s o f migrants, the de te rminants o f the ir mo ve me nt and ho w go ve rnme nts and the inte rnatio nal c o mmunity c an be st addre ss the inhe re nt issue s.1 2

With re spe c t to e duc atio n, the se c to r has be e n re lative ly pro te c te d fro m the de le te rio us e ffe c ts o f e c o no mic do wnturns sinc e the late e ightie s. Go ve rnme nts have lo ng re c o gnize d the value o f e duc atio n to sustain and ac hie ve go als in o the r se c to rs, and have

imple me nte d appro priate me asure s to impro ve its quality. Primary e duc atio n is virtually unive rsal in the Re gio n ho we ve r; gaps are more no tic e able in se c o ndary e duc atio n and fo r lo w inc o me individuals whe re the atte ndanc e rate do e s no t re ac h 3 5 % as natio nal ave rage in any c o untry in Latin Ame ric a.

One impo rtant re gio nal pro ble m is sc ho o l dro p o ut; abo ut 4 0 % o f c hildre n do no t c o mple te primary e duc atio n and in 7 2 % to 9 6 % o f po o r familie s have he ads o f ho use ho lds with nine ye ars o f sc ho o ling o r le ss. The se fac ts have implic atio ns fo r he alth and the re duc tio n o f po ve rty, sinc e ge tting o ut o f po ve rty o r avo iding be c o ming po o r re quire s be twe e n 1 1 and

10 _{Population Reference Bureau. www.prb.org}

11 _{United Nations.World Urbanization Prospects. 2002. (2001 Revision)}

12 _{WHO. International Migration, Health and Human Rights. World Health Organization Geneva. 2002.}

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1 2 ye ars o f fo rmal e duc atio n in o rde r to o btain wo rk that wo uld e nsure suffic ie nt inc o me .1 3

The situatio n o f wo me n is highly re le vant to the subje c t o f disc ussio n. De spite

impro ve me nts in the ir so c ial status, highe r e duc atio nal attainme nt and auto no my, the une qual distributio n o f po we r be twe e n the se xe s c o ntinue to limit wo me n’s full

partic ipatio n in de c isio n making at ho me , in the c o mmunity and in so c ie ty. Fo r many wo me n, the burde n o f wo rk and family re spo nsibilitie s c o ntribute s to pe rpe tuate vario us fo rms o f disc riminatio n and vio le nc e , whic h in turn he ighte ns vulne rability and hinde rs the full e xe rc ise o f the ir rights.

Othe r so c ial tre nds o f re le vanc e to public he alth are the gro wth o f so c ial mo ve me nts and o rganizatio ns linke d to e quity, he alth and human rights, many in the he art o f inte rnatio nal advo c ac y. This tre nd has be e n suppo rte d by o the r tre nds in so c ial de ve lo pme nt thinking and ac tio n, and to the re c o gnitio n o f the value o f e nhanc ing e ndo ge no us variable s fo r so c ial de ve lo pme nt.

A c e ntral to pic to the pre vio us me ntio n is the he ighte ne d re le vanc e o f so c ial c apital fo r de ve lo pme nt. Nume ro us e ffo rts have c e nte re d o n building the so c ial c apital o f e xc lude d gro ups and o n c o mmunity me c hanisms fo r co o pe rative o rganizatio n. The se are built o n the pre mise that as standards o f so c ial re c ipro c ity are ado pte d and ne two rks o f inte rac tio n, suppo rt, and partic ipatio n e stablishe d, po sitive so c ial indic ato rs (sc ho o l pe rfo rmanc e , ge ne ral he alth c o nditio ns, so c ial, e c o no mic and ge nde r e quity, ge nde r and rac ial to le ranc e ; and so c ial fre e do ms) inc re ase and ne gative o ne s are re duc e d.

Po l i t i c a l

De mo c rac y has galvanize d in the re gio n, and c itize ns assign gre ate r value to de mo c rac y and to the re spe c t o f human rights. Po litic al partic ipatio n has inc re ase d in natio nal and lo c al go ve rnanc e instanc e s, and the so c ial dime nsio ns o f de ve lo pme nt have be e n re c o gnize d at the highe st le ve ls o f go ve rnme nt and glo bal instanc e s.

Altho ugh pe o ple in ge ne ral value de mo c ratic institutio ns, the satisfac tio n with the way in whic h institutio ns e xe rc ise the ir autho rity and po we r, and o n the pe rfo rmanc e o f the go ve rnme nts has e ro de d. So c ial unre st, so c io e c o no mic instability, inse c urity c an thre ate n de mo c rac y and e ffe c tive go ve rnanc e . Inc o nsiste nc ie s o r at le ast the pe rc e ptio n o f

be twe e n e le c to ral pro mise s and ac tual pe rfo rmanc e are c o ntributing fac to rs. The latte r may be affe c te d by the po te ntial diminishe d c apac ity o f public institutio ns to fo rmulate and e nfo rc e so c ial and he alth po lic ie s, partic ularly distributive o r re gulato ry po lic ie s that aim at impro ving e quity and pro te c t the public . No ne the le ss, the go ve rnme nts o f the Re gio n are c o mmitte d to e ffo rts le ading to impro ve d pe rfo rmanc e , gre ate r transpare nc y and so c ial re spo nsibility.

The se arc h fo r se lf-de te rminatio n, the re e mpo we rme nt o f the po pulatio n and c o mmunitie s, and e ffe c tive c itize n partic ipatio n are still pe nding issue s. In many c ase s, the transfe r o f

13 _{Hopenhayn, Martin. Educación, Comunicación y Cultura en la Sociedad de Información: Una perspectiva}

Latinoamericana. Revista de la CEPAL, No. 81, diciembre 2003, pp. 175-194.

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no t suc c e e de d in ade quate ly de ve lo ping lo c al institutio nal c apac itie s. Similarly, the pro c e sse s that fo ste r auto no my in public administratio n have no t always yie lde d gre ate r e ffic ie nc y and be tte r quality se rvic e s, and c itize n c o ntro l is still marginal o r no ne xiste nt. The c urre nt c o nte xt has re de fine d a ne w e ra o f public po lic y whe re he alth is inc re asingly inte rse c ts with do me stic and fo re ign po lic y, natio nal and glo bal se c urity, so ve re ignty, go ve rnanc e , multilate ral and bilate ral strate gie s and natio nal and inte rnatio nal inte re sts.1 4

Human se c urity has advanc e d to the fo re fro nt o f the glo bal age nda, and it is c o nc e ive d as a “c o mple me nt to state se c urity, furthe rs human de ve lo pme nt and e nhanc e s human rights.” This inte grate d appro ac h c e nte rs o n se ve ral issue s fo r ac tio n aime d at pro te c ting pe o ple ’s vital fre e do ms and fo ste ring e mpo we rme nt.1 5

Ec o n o m i c s

The pe rsiste nc e and the se ve rity o f po ve rty and inc o me ine quality are pe rvasive o bstac le s to fac to rs that e xac e rbate vulne rability to risks and so c ial e xc lusio n, thus hampe ring he althy e c o no mic gro wth and pro spe ro us c ivil so c ie tie s. Ove rall, Latin Ame ric an and Caribbe an c o untrie s are c harac te rize d by a slo w and unstable gro wth, adve rse struc tural patte rns, une qual distributio n o f inc o me , de te rio ratio n o f e mplo yme nt and diffe re ntial o ppo rtunitie s fo r trade . The Re gio n has the highe st GNI pe r c apita o f all re gio ns, ye t, it e xhibits the gre ate st disparitie s and po ve rty le ve ls are fo ur time s that o f o the r re gio ns with similar GDP.1 6

With re spe c t to the re duc tio n o f po ve rty and indige nc e rate s, the se have stagnant sinc e 1 9 9 7 . Be twe e n 1 9 9 9 and 2 0 0 2 , the po ve rty rate ro se fro m 4 3 .8 % to 4 4 .0 % while e xtre me po ve rty re ac he d 1 9 .4 % o f the re gio n’s po pulatio n. Curre ntly, abo ut 2 2 5 millio n are

c o nside re d po o r, and abo ut 1 0 0 millio n pe o ple are e stimate d as indige nt.

14 _{Lee, Kelly. Health, Foreign Policy and Security: A Review of the Literature. Discussion paper prepared for The Nuffield Trust.}

Programme of Work on Global Health and Foreign Policy. The Nuffield Trust, January 2002. http://www.nuffieldtrust.org.uk/policy_themes/docs/hfps.pdf

15 _{See United Nations. Human Security Now. United Nations Commission on Human Security. United Nations; New York, 2003.} http://www.humansecurity-chs.org/finalreport/pdf

16 _{According to a recent publication, inequality in the Region is so appalling that even for countries with the best income}

distribution (Uruguay and Costa Rica), the Gini Coefficient is worse than for the most unequal Eastern European country.. De Ferranti, David et al. Desigualdad en América Latina y el Caribe: ¿Ruptura con la Historia? Estudios del Banco Mundial sobre América Latina ye l Caribe. Banco Mundial, octubre 2003.

http://wbln0018.worldbank.org/LAC/LAC.nsf/ECADocByUnid/4112F1114F594B4B85256DB3005DB262?Opendocument Numbe r (in millio ns ) and Pe rc e ntage o f Po o r and Indige nt1 7

2 0 0 0 2 0 0 1 2 0 0 2 2 0 0 3

Numbe r % Numbe r % Numbe r % Numbe r %

Po o r, no n indige nt

2 0 7 4 1 .1 2 1 2 4 2 .5 2 2 0 4 3 .4 2 2 5 4 3 .9

cpm/ shd/ hp

2 0 0 4 -0 4 -0 2

1 1

The c o nc e ntratio n o f inc o me pre se nts re gio nal variatio ns, but fo r the mo st part and sinc e 1 9 9 7 , it has re maine d unc hange d o r e ve n wo rse ne d in mo st c o untrie s, a fac t that

se rio usly hampe rs the ac hie ve me nt o f the go al o f re duc ing po ve rty.1 8 _{Mo re o ve r, data}

sho ws that life e xpe c tanc y is gre ate r in c o untrie s with high-inc o me le ve ls, and at similar inc o me le ve ls, life e xpe c tanc y is gre ate r in the c o untrie s with narro w inc o me gaps. The ave rage pro po rtio n o f inc o me fo r the po o re st 4 0 pe rc e nt o f ho use ho lds is abo ut 1 3 , 6 %i (e xtre me s are Bo livia with 9 , 5 % and Uruguay with 2 1 , 5 %). The ric he st gro ups c apture san ave rage o f 3 6 , 1 % o f the inc o me in Latin Ame ric a (e xtre me value s are 2 7 , 3 % in Uruguay and 4 6 , 8 % in Brazil).1 9

Extre me po ve rty, hunge r and malnutritio n are distinc t phe no me na with syne rgic and insidio us c o nse que nc e s fo r physic al and me ntal we ll be ing. This is spe c ially so fo r c hildre n unde r 5 suffe ring fro m c hro nic malnutritio n, be c ause o f its high pre vale nc e and

irre ve rsible e ffe c ts o n sc ho o l pe rfo rmanc e , psyc ho lo gic al and physic al de ve lo pme nt, se rio usly hampe ring the ir so c ial and e c o no mic c o ntributio n to so c ie ty. Appro ximate ly 5 4 millio n pe o ple in the Re gio n suffe r fro m so me de gre e o f unde rno urishme nt and abo ut 2 0 % was unde rno urishe d in so me c o untrie s (Bo livia, Do minic an Re public , Guate mala, Haiti, Ho nduras, Nic aragua), whe re as in o the rs the figure was be lo w 5 % (Arge ntina, Chile and Uruguay). While e ffo rts are unde r way, impro ve me nts are slo w. In re c e nt ye ars, gre ate r aware ne ss is pro mpting de c isive ac tio ns to c urb o be sity in adults and mo st re c e ntly in c hildre n, whic h is a risk fac to r fo r se ve ral c hro nic c o nditio ns.

The c urre nt and future situatio n o f the gro wing numbe r o f o lde r adults is o f e qual c o nc e rn. Co nside ring that o nly two o ut o f five o lde r adults re c e ive so c ial se c urity be ne fits in the urban are as, many c o ntinue wo rking o r re turn to wo rk, ge ne rally in lo we r paying jo bs and/ o r in the info rmal se c to r.This po pulatio n gro up also te nds to inc lude a majo rity o f wo me n, have fe we r ye ars o f sc ho o l and ge nde r disparitie s unfavo rable to wo me n, whic h plac e s the m at gre ate r risk.

Une mplo yme nt and sub e mplo yme nt are c o ntributing fac to rs to po ve rty, partic ularly whe n vo latility and unc e rtainty c harac te rize e c o no mic ac tivity Emplo yme nt c o nditio ns have de te rio rate d and une mplo yme nt inc re ase d o ve rall fro m 6 % to 9 % in the Re gio n. Mo re o ve r, the info rmal se c to r has e xpande d and se ve n o ut o f te n jo bs c re ate d in urban are as

o c c urre d in the info rmal se c to r. The quality o f wo rk o fte n pre e mpts so c ial se c urity and he alth be ne fits pro te c tio n, thus inc re asing vulne rability and e xpo sure to risks.Impo rtant gaps e xist be twe e n unskille d and skille d wo rke rs, and be twe e n fo rmal and info rmal wo rke rs, the latte r lac king so c ial and he alth be ne fits as we ll as o ppo rtunitie s to advanc e .

17 _{Alicia Bárcena, Secretaria Ejecutiva Adjunta de la CEPAL. Presentación, Objetivos del Desarrollo. Reunión de la}

Mesa Directiva Ampliada del Comité Especial de Población y Desarrollo del Periodo de Sesiones de la CEPAL. _Marzo

10, 2004, Santiago, Chile

18 _{Improvements reached over 0.05 of the Gini Index. CEPAL Panorama Social de America Latina, 2002-2003. CEPAL,}

Santiago, Chile. LC/G.2218. Noviembre 2003.

http://www.eclac.cl/cgi-bin/getProd.asp?xml=/publicaciones/xml/0/12980/P12980.xml&xsl=/dds/tpl/p9f.xs

19 _{The Latin American countries with the highest concentration of income as reflected on the Gini coefficient are as of}

cpm/ shd/ hp

2 0 0 4 -0 4 -0 2

1 2

dynamic s o f he alth, po ve rty and ge nde r e quity. In spite o f impro ve me nts in e duc atio n and so c ial po sitio n, wo me n are still mo re like ly to be une mplo ye d and o ve rre pre se nte d in the info rmal se c to r, c o nc e ntrate o n lo we r paying jo bs and be subje c t to wage disc riminatio n. In the c ase o f wo me n who are he ads o f ho use ho lds, the y and the ir c hildre n are o fte n drawn to mo re disadvantage d po sitio ns.

So c ial e xpe nditure s have re distributive e ffe c ts that be ne fit the lo we st inc o me gro ups, and altho ugh the patte rns are une ve n, mo st c o untrie s have made e ffo rts to inc re ase the pe rc e ntage o f GDP allo c ate d to so c ial se c to rs. This is a po sitive tre nd in the Re gio n whe n c o nside ring that ave rage so c ial e xpe nditure s inc re ase d fro m 1 0 .4 % to 1 3 .1 % o f the GDP and ve ry fe w c o untrie s re duc e d the ir so c ial spe nding. Ye t, the inc re ase s had little e ffe c t o n the re duc tio n o f disparitie s2 0_{. Co untrie s like Arge ntina and Uruguay fo r e xample pro te c te d}

so c ial spe nding e ve n unde r the strain o f impo rtant re duc tio ns o f GDP be twe e n 1 9 9 9 and 2 0 0 0 . Ho we ve r, this situatio n was diffic ult to sustain by 2 0 0 2 whe n the GDP c o nstraints inc re ase d with an 1 1 % re duc tio n and so c ial spe nding was re duc e d.

Me asuring po ve rty and disparitie s in the Caribbean is mo re diffic ult due to the lac k o f ho use ho ld surve ys and the c o mparability o f data. Ho we ve r, so me studie s sho w that the inc ide nc e o f po ve rty is highe st in Haiti (8 0 % o f indige nc e ). Do minic a, Guyana, Saint Vinc e nt and the Gre nadine s and Suriname sho w lo we r rate s than Haiti but highe r than tho se o f the re st o f the c o untrie s. Ho we ve r, Bahamas has ve ry lo w rate s o f po ve rty and the se c o mpare favo rable with o the r c o untrie s with high rate s o f e c o no mic de ve lo pme nt. Amo ng Caribbe an c o untrie s rural po ve rty te nds to be highe r in rural are as, diffe ring fro m the situatio n in Latin Ame ric a. Une mplo yme nt rate s are c o nside re d high, and ac c o rding to ECLAC “the re are impo rtant links be twe e n po ve rty and de linque nc y, drug traffic king, intrafamily vio le nc e and c hild abuse .”Enviro nme ntal he alth issue s are o f high impo rtanc e in the subre gio n due to the o cc urre nc e o f natural disaste rs, vo lc anic e ruptio ns, and hurric ane s affe c t se rio usly the poo re st po pulatio n o f the subre gio n.2 1

He a l t h Se c t o r , Sy s t e m s , a n d Se r v i c e s

Altho ugh he alth se c to r re fo rms pro mo te d during the nine tie s we re wide spre ad and aime d at po sitive financ ial, struc tural and institutio nal c hange s, so me re le vant aspe c ts o f public he alth we re ne gle c te d. One c onse que nc e o f this situatio n, c o uple d with the e ffe c ts o f vario us tre nds, affe c te d the c apac ity o f go ve rnme nts to fully e xe rc ise the ir ste e ring ro le and fully pe rfo rm e sse ntial public he alth func tio ns. A re le vant tre nd that re de fine d a ne w playing fie ld with ne w o r re po sitio n stake ho lde rs is e mbo die d in so me o f the implic atio ns o f the state and mo de rnizatio n pro c e sse s.Altho ugh the se have be e n asymme tric , the y have e nc o urage d the invo lve me nt o f a varie ty o f stake ho lde rs, particularly tho se in the private se c to r. The ir invo lve me nt has ge nerate d ne w dynamic s and transfo rmatio ns.

20 _{Regional public social spending rose until 2001 (from US$ 501 to US$ 552 dollars per capita). Panama, Uruguay,}

Argentina, Brazil, Costa Rica and Bolivia assigned a large proportion of GDP to social sectors in the mid-1990s, and the levels rose to between 18% and 26% of GDP by 2000-2001. CEPAL Panorama Social de America Latina, 2002-2003. Op. cit, pp.178.