Annual Report of t he Direct or – 2001
Promoting
Health in the
Americas
P an A m er ican Healt h Or ganiz at ion
P an A m er ican Sanit ar y Bureau,
Regional Office of the
World Health Organization
Also published in Spanish w ith the title:
Promoción de la salud en las Américas. Inf orme Anual del Direct or – 2001
ISBN 92 75 37302 7 PAHO Library Cataloguing-in-Publication Data
Pan American Health Organization
Promoting Health in the Americas. Annual Report of the Director–2001.— Washington, D.C.: PAHO, © 2001
xix, 124 p.—(Official Document 302) ISBN 92 75 17302 8
I. Title II. Series III. Author
1. HEALTH PROM OTION 2. HUM AN DEVELOPM ENT 3. HEALTH SERVICES
4. TECHNICAL COOPERATION
5. COM M UNICABLE DISEASE CONTROL 6. SUSTAINABLE DEVELOPM ENT NLM WA590
The Pan American Health Organization w elcomes requests for permission to reproduce or trans-late its publications, in part or in full. Applications and inquiries should be addressed to the Publications Program, Pan American Health Organization, Washington, D.C., U.S.A., w hich w ill be glad to provide the latest information on any changes made to the text, reprints and translations already available.
© Pan American Health Organization, 2001
Publications of the Pan American Health Organization enjoy copyright protection in accordance w ith the provisions of Protocol 2 of the Universal Copyright Convention. All rights are re-served.
The designations employed and the presentation of the material in this publication do not imply the expression of any opinion w hatsoever on the part of the Secretariat of the Pan American Health Organization concerning the status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries.
The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by the Pan American Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters.
Photos: Page 26, Carlos Gaggero, PAHO; page 40, Julio Vizcarra, PAHO; all other photos, Armando Waak, PAHO.
Mission
of the
Pan American
Sanitary Bureau
The Pan American Sanitary Bureau is the Secretariat of the Pan
American Health Organization (PAHO), an international agency
specializing in health. Its mission is to cooperate technically with
the Member Countries and to stimulate cooperation among them
in order that, while maintaining a healthy environment and
chart-ing a course to sustainable human development, the peoples of the
To the
Member
Countries
In accordance with the Constitution of the Pan American Health
Organization, I have the honor to submit the 2000–2001 annual report
on technical cooperation activities of the Pan American Sanitary Bureau,
Regional Office of the World Health Organization. Within the context of
the strategic and programmatic orientations for the 1999–2002
qua-drennium, defined by the Governing Bodies of the Pan American Health
Organization, the report analyzes the salient activities of the
Organiza-tion’s technical cooperation program during this period.
The report is complemented by the
Interim Financial Report of theDirec-tor for the Year 2000
.
Contents
The Director’s Message
. . . ix
Chapter
1
:
. . . 1
Health Promotion and Protection
Chapter
2
:
. . . 23
Health in Human Development
Chapter
3
:
. . . 39
Environmental Protection and Development
Chapter
4
:
. . . 59
Health Systems and Services Development
Chapter
5
:
. . . 85
Disease Prevention and Control
Chapter
6
:
. . . 109
Supporting the Delivery of Technical Cooperation:
1
PA SB direct ed m uch of it s t echnical cooper at ion
t ow ard
creat ing a new cult ure of healt h promot ion and prot ect ion t hat
view s healt h as a social value.
The Bureau pursued t his goal by promot ing a broad concept of healt h as t he basis f or human development and f or an accept able qualit y of lif e, and by encouraging M em-ber St at es t o pursue t he f ive act ion areas or st rat egies of healt h promot ion: est ablishing healt hy public policies, creat ing support ive environment s f or healt h, empow -ering communit ies, developing personal skills, and reorient ing healt h services.
A grow ing number of count ries in t he Region have recognized t he import ance of healt h promot ion as a pow erf ul public healt h st rat egy and have incorporat ed many of t hese act ion areas in t heir nat ional healt h plans and programs. These advances have been achieved t hrough act ive collaborat ion among nat ional government s, non-government al organizat ions (NGOs), nat ional and int ernat ional inst it ut ions, and com-munit ies. Alt hough progress has been made t ow ard many of t he goals of “ healt h f or all,” challenges remain.
The Fif t h Global Conf erence f or Healt h Promot ion—” Healt h Promot ion: Bridging t he Equit y Gap” —held in June 2000 in M exico Cit y, built on t he advances of t he f our previous int ernat ional healt h promot ion conf erences (Ot t aw a, 1986; Adelaide, 1988; Sundsvall, 1991; Jakart a, 1997). This conf erence brought t oget her 100 count ries t o re-view t he lessons learned since t he f irst conf erence w as held in Ot t aw a and t o renew t he commit ment t o promot e t he healt h of t he w orld’s people, t o increase int ersec-t oral collaboraersec-t ion, and ersec-t o improve ersec-t he inf rasersec-t rucersec-t ure f or healersec-t h promoersec-t ion. M inisersec-t e-rial delegat ions f rom almost all of t he count ries of t he Region of t he Americas part ic-ipat ed and all signed t he “ M inist erial St at ement f or t he Promot ion of Healt h: From Ideas t o Act ion,” also know n as t he M exico Declarat ion. In signing t he Declarat ion, PAHO M ember St at es have commit t ed t hemselves t o st rengt hening healt h promot ion planning by making healt h promot ion a f undament al priorit y in local, regional, na-t ional, and inna-t ernana-t ional policies and programs; na-t aking a leadership role na-t o ensure t hat all government sect ors and act ors in civil societ y part icipat e in t he implemen-t aimplemen-t ion of healimplemen-t h promoimplemen-t ion acimplemen-t iviimplemen-t ies implemen-t haimplemen-t simplemen-t rengimplemen-t hen and expand parimplemen-t nerships f or healt h; using every means available t o support t he preparat ion of nat ionw ide healt h promot ion plans of act ion t ailored t o each count ry’s circumst ances; est ablishing or st rengt hening nat ional and int ernat ional net w orks t o promot e healt h; advocat ing t hat UN agencies be account able f or t he impact on healt h of t heir development agenda; and inf orming t he Direct or General of t he World Healt h Organizat ion of t he progress made in t he perf ormance of t he above act ions so she can report on t his t o t he 107t h session of WHO’s Execut ive Board.
A st rat egic planning process involving PASB, t he Caribbean Food and Nut rit ion In-st it ut e (CFNI), t he Lat in American Cent er f or Perinat ology and Human Development , and t he Inst it ut e of Nut rit ion of Cent ral America and Panama (INCAP) w as init iat ed t o int egrat e t he t echnical areas w it hin a concept ual and met hodological f ramew ork f or healt h promot ion. Underst anding of t he basic det erminant s of healt h inequit ies has improved signif icant ly, yet social and economic inequit ies in t he Region cont inue t o
erode healt h condit ions f or many populat ion groups. For t his reason, healt h promo-t ion muspromo-t conpromo-t inue promo-t o f ocus on bridging equipromo-t y gaps among and w ipromo-t hin counpromo-t ries.
Building Healthy Public Policy
Public policies in all sect ors inf luence t he det erminant s of healt h and are import ant vehicles f or reducing social and economic inequit ies, f or example, by ensuring equi-t able access equi-t o goods and services, among equi-t hem healequi-t h care. The Regional Healequi-t hy Public Policy Init iat ive relies on a mult isect oral approach f or ensuring t he sust ainabil-it y of services; increasing prot ect ion and reducing risks; increasing care t o indigenous groups; enhancing coverage and impact at t he local level; and improving qualit y of lif e. Some count ries have assessed t heir policy, analysis, and development needs, and t his inf ormat ion, in t urn, has st rengt hened t he government s’ capacit y t o part icipat e in t he init iat ive.
In Chile, f or example, healt h promot ion has been est ablished as a St at e policy and is st rongly support ed by t he President and by most government sect ors. Led by t he M inist ry of Healt h and w it h support f rom PASB, 24 nat ional agencies w ork t oget her t hrough t he Nat ional Council f or Healt h Promot ion, know n as “ VIDA CHILE.” This in-t ersecin-t oral enin-t iin-t y sein-t s sin-t rain-t egic lines of w ork f or healin-t h promoin-t ion, and ensures in-t hain-t
PAHO’s Representative in Canada Speaks Out on Health Issues
As PAHO’s representative in Canada, the Canadian Society for International Health (CSIH) has vig-orously fought to focus attention on health issues. To publicize PASB’s work, CSIH organized a pres-entation on equity and health by Dr. George A.O. Alleyne, the Bureau’s Director. The prespres-entation was well covered by the media and also drew representatives from several NGOs. CSIH celebrated World Health Day with a special ceremony and a forum to discuss this year’s theme, “ Safe Blood Saves Lives.” The gathering provided an opportunity to distribute PAHO/ WHO information kits on the issue to public health clinics, blood clinics, hospitals, health care associations, and government officials throughout Canada. Finally, the Society sponsored study tours of Canada for high-level health sector officials from the ministries of health of Bolivia, Honduras, Mexico, and Peru.
In a press conference held in Ottawa, CSIH joined several other international organizations to plead for a quicker and more effective response to the growing worldwide crisis of children with HIV/ AIDS. The Society also organized a media breakfast at the National Press Club to further pub-licize the issue. Representatives from television stations, Radio Canada, the Medical Post, and the
t here is suff icient polit ical commit ment in t he count ry t o launch and sust ain healt h promot ion act ivit ies. Local int ersect oral councils also have been est ablished in t he count ry’s regions. The int ersect oral body relies on inf ormat ion disseminat ion, social communicat ion, and human resources t raining t o f ulf ill it s mandat e of st rengt hening healt h promot ion and enhancing qualit y-of -lif e eff ort s undert aken by each sect or. VIDA CHILE designed a communicat ion campaign t o promot e healt hy nut rit ion and underscore t he import ance t hat physical act ivit y has f or healt h. The privat e sect or, NGOs, scient if ic organizat ions, and universit ies have joined in t he campaign, w hich signif icant ly ext ends t he reach of t he message. In November, VIDA CHILE submit t ed t he nat ional goals f or healt h promot ion f or 2000–2006 t o Chile’s President ; PASB w as act ively involved in est ablishing t hese goals.
The f ocus on healt hy public policies is t imely, as most count ries are ref orming var-ious sect ors, part icularly healt h and educat ion, and are incorporat ing healt h promo-t ion in promo-t his process. During 2000, PASB’s promo-t echnical cooperapromo-t ion in healpromo-t h promopromo-t ion has support ed t he minist ries of healt h and ot her agencies at t he nat ional and regional levels in est ablishing healt hy public policies. The development of legislat ion f avoring healt hy public policies has been one w ay of addressing t he Region’s healt h priorit ies. Six count ries in t he Region have implement ed policies t o f acilit at e delivery of int e-grat ed adolescent care. In addit ion, t he Bureau act ively part icipat ed in t he discussion and f ormulat ion of law s t o prot ect t he sexual and reproduct ive healt h right s est ab-lished in t he const it ut ions of 14 count ries in t he Region, and many count ries have de-veloped law s t o guarant ee access t o sexual and reproduct ive healt h inf ormat ion and services. Venezuela has enact ed comprehensive law s t hat prot ect children and ado-lescent s and est ablish t heir right t o sexual and reproduct ive healt h educat ion. These law s aim t o increase access t o services and programs and ensure conf ident ialit y. In ad-dit ion, law s est ablishing nat ional int ersect oral yout h programs have been incorpo-rat ed int o t he f ramew ork of child and adolescent healt h and social policies, and a minimum age limit of 18 years w as est ablished f or t he purchase of cigaret t es. These law s require all cigaret t e packaging t o include a healt h w arning covering 20% of t he package’s surf ace area.
PASB, in collaborat ion w it h The George Washingt on Universit y’s Cent er f or Int er-nat ional Healt h, conduct ed case st udies of policies aff ect ing adolescent s and yout hs, w hich w ere published in Colombia, t he Dominican Republic, and Nicaragua. The Cen-t ral American counCen-t ries, as parCen-t of Cen-t he projecCen-t on adolescenCen-t sexual and reproducCen-t ive healt h conduct ed by PAHO and t he Sw edish Int ernat ional Development Cooperat ion Agency (SIDA), have f ormed an int ersect oral commit t ee on adolescence t o f ormulat e policies on adolescence and yout h. The Dominican Republic, w it h PASB’s support , passed t he Law of Yout h and allocat ed 1% of t he nat ional budget and 4% of munic-ipal budget s f or it s implement at ion. This process w as carried out w it h t he part icipa-t ion of various secicipa-t ors and of young people icipa-t hemselves. The Cenicipa-t ral American Semi-nar on Policy and Equit y w as also held w it h t he support of t he PAHO-SIDA project .
Wit h t he Bureau’s support , Ant igua, Bahamas, Barbados, Brit ish Virgin Islands, Do-minica, Grenada, Guyana, Jamaica, and Saint Lucia part icipat ed in t he survey of ado-lescent s published recent ly in A Port rait of Adolescent Healt h in t he Caribbean,w hich is being eff ect ively used as an advocacy t ool and a model f or t he use of research in policymaking and programming.
One of t he most signif icant public policy development s in healt h promot ion w as t he beginning of negot iat ions on t he Framew ork Convent ion on Tobacco Cont rol, t he f irst int ernat ional healt h t reat y of t his kind, w hich has been developed under t he aus-pices of WHO. Approximat ely 25 count ries in t he Region have part icipat ed in t his process. PASB provided t echnical cooperat ion and f unding t o help t he count ries pre-pare f or t he negot iat ions on t he Framew ork Convent ion on Tobacco Cont rol.
In 2000, signif icant t obacco policy development s in t he count ries included Brazil’s passage of w ide-ranging rest rict ions on t obacco advert ising, w hich are now t he most comprehensive in Lat in America. Canada int roduced new healt h messages t hat cover half t he surf ace area of t obacco packaging and provide advice t o smokers.
PASB support ed t he promot ion and monit oring of public policies f or iodine f ort if i-cat ion of salt t o ensure t he eliminat ion of iodine-def iciency-relat ed disorders in Bo-livia, Chile, t he Dominican Republic, and Panama. By improving t he monit oring and surveillance syst ems and ensuring t he qualit y of iodized salt , t his eff ort w ill help guar-ant ee t he sust ainabilit y of f ort if icat ion programs. At present , 97% of t he populat ion in Bolivia, over 95% in Chile, less t han 40% in t he Dominican Republic, and over 90% in Panama consume iodized salt .
Technical cooperat ion w as provided t o several count ries t o implement vit amin A supplement at ion, signif icant ly increasing coverage of at least t he f irst dose (Figures 1 and 2). The implement at ion st at us of nat ional f ood and nut rit ion plans in t he Region w as review ed and inf ormat ion w as gat hered f rom 18 Spanish-speaking count ries. Eleven count ries’ plans have been approved and are being implement ed, f our coun-t ries have f ormulacoun-t ed plans, and coun-t hree councoun-t ries as yecoun-t have no plan.
pub-lic popub-licies t o address int ernal inequit ies. The Bureau also promot ed and support ed t he evaluat ion of Chile’s program t o f ort if y f lour w it h f olic acid in order t o demon-st rat e t his eff ort ’s cont ribut ion t o t he reduced incidence of neural t ube def ect s.
As a cont ribut ion t o t he development of healt hy public policies on breast f eeding, t he art icle “ Lengt h of Exclusive Breast f eeding: Linking Biology and Scient if ic Evidence t o a Public Healt h Recommendat ion” w as published in t he Journal of Nut rit ionand a chapt er w as produced f or a book on t he short - and long-t erm eff ect s of breast f
eed-100
80
60
40
20
0
Bolivia Brazil Dominican Republic
Ecuador Guat emala Honduras Nicaragua Panama Peru
(%
)
1998 1999 2000
FIGURE 1. V it am in A supplem ent at ion cover age of children 6 –11 m ont hs of age, 19 9 8 –20 0 0 .
100
80
60
40
20
0
Bolivia Brazil Dominican Republic
Ecuador Guat emala Honduras Nicaragua Panama Peru
(%
)
1998 1999 2000
ing on child healt h. In addit ion, PASB organized a t echnical consult at ion on t he rec-ommended lengt h of exclusive breast f eeding in August 2000, and invit ed expert s in t he f ield f rom t he Region.
To cont ribut e t o t he cost -eff ect ive purchase and consumpt ion of highly nut rit ious f oods, PASB published “ La M ejor Compra” (The Best Purchase) f or disseminat ion t hroughout t he Region. “ La M ejor Compra” cont ains a sof t w are package and guide-lines on how t o use t he media and ot her channels t o promot e t he best nut rit ional val-ues at t he low est cost in a specif ic region during specif ic t imes of year.
Wit h t echnical support f rom PASB, Ecuador’s M inist ry of Public Healt h f ormally launched it s nat ional f ood and nut rit ion program, w hich t arget s children under 2 years of age, as w ell as pregnant and breast f eeding w omen. The program, developed joint ly by PASB and t he M inist ry, cont ains component s t hat rely on healt h promot ion t o address public policy issues, communit y act ivit ies, t he development of lif e skills, and t he reorient at ion of healt h services t o ensure t hat appropriat e healt h messages are linked t o f ood provision.
Enlisting the Media to Promote Health
The Office of Caribbean Program Coordination (CPC) has been one of PAHO’s most active country offices in using strategic social communication to support its technical cooperation interventions. During 2000, the CPC continued to grant its Awards for Excellence in Journalism to journalists and other media workers in the English-speaking Caribbean who did outstanding work for health. Over the years, these awards have increased the reach of health messages among the people of the English-speaking Caribbean, and in doing so, have increased their capacity to make healthy lifestyle choices.
The awards, which have been handed out since 1992, are designed to increase awareness of health and environmental issues by encouraging the publication or broadcast of news items, fea-tures, documentaries, and other materials on these subjects; recognize the contribution of national and regional journalists in putting health and the environment on the public agenda; improve the coverage of health and environmental issues; and increase awareness of the importance of interna-tional cooperation in health in general and PASB’s contribution in particular.
Five count ries have implement ed healt hy public policies in t he area of nut rit ion, f ocusing on nat ional f ood securit y and micronut rient supplement at ion. Panama car-ried out nat ional surveys and ut ilized t he dat a collect ed t o review it s micronut rient supplement at ion st rat egies and t o w ork t ow ard cert if ying t he count ry as f ree of io-dine def iciency.
Also in 2000, PASB held a series of subregional f orums t o examine and promot e t echnical collaborat ion among count ries t o develop nat ional policies t o promot e t he healt h and w ell-being of t he elderly. The Cent ral American Forum on Healt h and Aging w as held in El Salvador in collaborat ion w it h t he M inist ry of Public Healt h, t he Nat ional Secret ariat of t he Family, t he Off ice of t he First Lady, and Spain’s Inst it ut e of M igrat ion and Social Services.
The Bahamas, Bolivia, Brazil, Chile, Cost a Rica, Dominica, El Salvador, M exico, and Peru developed policies t hat address qualit y of lif e issues f or older persons. These poli-cies use a mult isect oral approach t o promot e t he part icipat ion of nongovernment al organizat ions and ot her civil societ y act ors, and address healt h inequit ies and povert y as major risk f act ors f or poor healt h in t he elderly. Peru and Chile collaborat ed t ech-nically t o draf t Peru’s nat ional policy, w hich f ocuses on healt hy aging and on t he con-t ribucon-t ions con-t hacon-t various seccon-t ors of sociecon-t y make con-t ow ard a dignif ied old age. Technical collaborat ion bet w een Canada and M exico has signif icant ly advanced t he develop-ment of a model of healt hy public policy f or aging. This model w ill be t est ed in bot h count ries and used as part of an ongoing eff ort t o develop t he necessary building blocks f or est ablishing a public policy on healt hy aging. The Caribbean Chart er on Healt h and Aging has f ost ered t he adopt ion of nat ional policies orient ed t ow ard healt h promot ion in various count ries; Dominica’s and t he Bahamas’ nat ional policies are good examples.
To address t hese priorit ies, Brazil, Canada, Chile, Cost a Rica, Jamaica, M exico, Pan-ama, Suriname, Trinidad and Tobago, and t he Unit ed St at es have developed public policies f or ment al healt h and have empow ered communit ies t o care f or t he ment ally ill, sensit izing police and securit y f orces t o t he needs of t his group, and enact ing leg-islat ion t o prot ect t he human right s of t he ment ally ill.
Domest ic violence and violence against w omen have been increasing in t he Region, and f our count ries have responded w it h public policies t o address t hese concerns. St rat egies f or combat ing domest ic violence include put t ing t his problem on t he pub-lic agenda, st rengt hening mult isect oral coordinat ion bet w een government sect ors and nongovernment al act ors, and providing support t o w omen’s groups.
Acknow ledging t he link bet w een environment al condit ions and healt h out comes, in 2000, several count ries in t he Region f ormulat ed policies and st andards t o guide f u-t ure economic and developmenu-t al acu-t iviu-t ies in w ays u-t hau-t consider u-t he healu-t h impacu-t of environment al changes.
Healt h promot ion needs assessment s carried out in t he count ries ident if ied key issues f or int ersect oral collaborat ion. In Trinidad and Tobago, t raining needs in t he area of public policy analysis and development w ere assessed among senior st aff at t he M inist ry of Healt h. The object ive w as t o obt ain inf ormat ion about t raining needs and t o st rengt hen t he M inist ry’s capacit y t o lead healt hy public policy init iat ives and t o part ic-ipat e w it h ot her sect ors in joint eff ort s in t his regard. The result s highlight ed t he need f or negot iat ion skills t o build consensus among st akeholders and f or t he adopt ion of a mult isect oral approach. Based on t he assessment ’s f indings, t hree policy document s dealing w it h noncommunicable disease cont rol and prevent ion, t obacco consumpt ion cont rol and prevent ion, and sexual and reproduct ive healt h care w ere draf t ed w it h PASB’s support and are being submit t ed t o t he M inist ry of Healt h f or approval.
The Bureau has act ively part icipat ed in monit oring t he f ulf illment of t he commit -ment s undert aken at t he 1990 World Summit f or Children and has cont ribut ed t o t he evaluat ion of t he achievement s and t o t he polit ical and st rat egic sit uat ion analysis of inf ant healt h in t he Region. An ongoing advocacy eff ort by UN agencies, NGOs, aca-demic inst it ut ions, and ot hers t o incorporat e healt h promot ion in public policies deal-ing w it h children and adolescent s is under w ay in t he count ries. These eff ort s have led t o t he signing of t he Kingst on Consensus and t o preparat ory meet ings f or t he Unit ed Nat ions Special Session on Children, w hich w ere held in January 2001, w here chil-dren’s healt h w as cent ral t o t he agenda of t he count ries in t he Region.
PASB made subst ant ive cont ribut ions t o t he const ruct ion of concept ual healt h pro-mot ion f ramew orks t hat highlight t he import ance of biological, psychological, and social det erminant s of healt h and qualit y of lif e of children and adolescent s. The role of support ive environment s (f amily, communit y, school, municipalit ies) f or compre-hensive childhood development w as clearly demonst rat ed, as w as t he need f or acces-sible, qualit y healt h services w it h a healt h promot ion approach.
M at ernal mort alit y cont inues t o be a major public healt h challenge in t he Region of t he Americas. A signif icant event in 2000 w as t he consolidat ion of t he Regional In-t eragency Task Force on M aIn-t ernal M orIn-t aliIn-t y ReducIn-t ion, w hich is a parIn-t nership among PAHO, t he World Bank, IDB, USAID, UNICEF, UNFPA, Family Care Int ernat ional, and t he Populat ion Council. This t ask f orce w as born of t he lessons learned f rom t he past decade, part icularly t hat part nerships can produce posit ive changes. As it s t echnical secret ariat , PASB played a key role in bringing t his t ask f orce t o act ion, building consensus on st rat egies and eff ect ive int ervent ions based on lessons learned, and creat -ing a common vision f or t he reorient at ion of public policies aimed at reduc-ing ma-t ernal morma-t alima-t y.
In conjunct ion w it h PASB and CDC, t he M ember St at es met t o assess epidemiolog-ical surveillance syst ems f or mat ernal mort alit y in 26 count ries of t he Region, and f ound t hat since 1995, most have improved t hese syst ems.
Health promoting schools hold the best promise for developing future citizens w ho w ill care for their health and that of their loved
PASB, in collaborat ion w it h t he count ries, is improving t he inf ormat ion and sur-veillance syst ems t hat w ill supply evidence on t obacco use and t obacco-relat ed deat hs t o be used in policy development . The Bureau cont inued t o collaborat e w it h WHO and CDC t o support implement at ion of t he Global Yout h Tobacco Survey in several Lat in American and English-speaking Caribbean count ries, w hich included t w o re-gional t raining sessions on conduct ing t he survey.
The Bureau published a st udy of t obacco use in Lat in America and Nort h America and began w ork on a st udy of t obacco use in t he Caribbean and on mort alit y caused by t obacco t hroughout t he Region. The lat t er t w o st udies w ill be published in 2001. Preliminary dat a f rom 1989 on t obacco-caused mort alit y in t he Americas show a f ar great er impact t han previously t hought , w it h an est imat ed 845,000 deat hs caused by t obacco every year. It is likely t hat t he current annual deat h t oll in t he Region f rom t obacco approaches one million.
Creating Supportive Environments
The Sundsvall St at ement on Support ive Environment s f or Healt h (Third Int ernat ional Conf erence on Healt h Promot ion, Sundsvall, Sw eden, June 1991) addresses t he cre-at ion of support ive environment s—t he physical and psychosocial aspect s of w here peo-ple live, w ork, and play. It also encompasses t he f ramew ork t hat det ermines access t o resources and opport unit ies f or empow erment . During 2000, PASB’s t echnical cooper-at ion enabled count ries t o crecooper-at e support ive environment s, considering t heir int erre-lat ed physical, social, spirit ual, economic, and polit ical dimensions. Coordinat ed act ions at local, regional, nat ional, and global levels w ere eff ect ive in achieving sust ainable so-lut ions. The Bureau collaborat ed w it h 17 count ries during 2000, mainly on t he init ia-t ives highlighia-t ed below.
Health Promoting Schools
t he incorporat ion of healt h promot ion in school curricula, part icularly w hen t raining t eachers in lif e skills educat ion. PASB also collaborat ed w it h UNICEF and UNESCO t o incorporat e lif e skills educat ion in t he Educat ion f or All Init iat ive, undert aken at t he World Conf erence on Educat ion f or All in Jomt ien, Thailand, in 1990.
M ost count ries have est ablished int ersect oral and int erinst it ut ional commit t ees in w hich all social sect ors act ively part icipat e t o discuss problems and suggest solut ions. As a result , domest ic violence and ot her problems t hat aff ect children and adolescent s are increasingly visible and are being addressed as priorit y issues.
Healthy Municipalities
In 2000, PASB collaborat ed w it h 13 count ries t o promot e healt hy municipalit ies. Figures 3 and 4 illust rat e t he evolut ion of healt hy municipalit ies f rom 1995 t o 2000 in select ed count ries. In M exico, t he healt hy municipalit y movement has developed dynamically and st eadily and is considered a key nat ional st rat egy t o promot e int er-sect oral collaborat ion, communit y part icipat ion, disseminat ion of healt h and public policy inf ormat ion, and creat ion of healt hy spaces. PASB provided t echnical coopera-t ion and mobilized nacoopera-t ional and incoopera-t ernacoopera-t ional resources f or coopera-t he consolidacoopera-t ion of coopera-t he healt hy communit y net w ork’s st rat egies and project s.
In Argent ina, several municipalit ies have w orked w it h NGOs, schools, government al and educat ional inst it ut ions, ecological groups, and t he Red Cross, t o implement st rat e-gies t o improve inf ant , adolescent , and mat ernal healt h; reduce malnut rit ion; creat e microent erprises and communit y gardens; and est ablish radio net w orks t o assist in t he disseminat ion of healt h promot ion and prot ect ion messages. PASB provided t echnical cooperat ion t o est ablish healt hier envi-ronment s in jails.
In Cuba, a model program for adolescents and young adults in the healthy municipality of Horquitas (Cienfuegos) involves com-munity members and young people in managing the program.
In Chile, healt h promot ion w as st rengt hened t hrough t he creat ion of int ersect oral healt h promot ion commit t ees in 60% of t he count ry’s municipalit ies. The mayors played a leading role in ensuring polit ical support and mobilizing resources.
In Jamaica, the creation of healthy spaces has been broad-ened to include the Inter-Church Association of Health, Healing, and Counseling Ministries, thereby expanding the churches’ health and healing programs to include health promotion in their services.
As part of t he Caribbean Tourism Healt h, Saf et y, and Re-source Conservat ion Project , w hich is a joint vent ure among 1995 2000
200
100
No
. m
u n ic ip al it ies ~670 ~1540 0 Bolivi a Brazi l Colo mbi a Chile Cuba
Dom inic
an
Rep ublicEcuad
or
El S alvad or Guat emal a Hond
uras Per u Mexi co Ven ezu ela
PAHO, CAREC, t he Caribbean Hot el Associat ion, and Caribbean Act ion f or Sust ainable Tourism, a number of w orkshops on t he need f or cont inued vigilance in preparing and serving healt hy f ood bot h t o t he local populat ion and t o f oreign visit ors w ere conduct ed f or hot el and rest aurant personnel and f or st reet f ood vendors. The w orkshops provided inf ormat ion t o man-agement and st aff on cost -eff ect ive st eps t o improve f ood and beverage preparat ion pract ices and t o eliminat e unsanit ary and unhygienic pract ices among cat ering indust ry personnel. Work w as done in collaborat ion w it h t he various nat ional min-ist ries and agencies, and privat e sect or groups, w hich result ed in t he st aging of several w orkshops on f ood saf et y in t he t our-ism indust ry.
In collaborat ion w it h t he minist ries of healt h of t he Bahamas and of Uruguay, PASB has been addressing t he challenge of im-proving physical and psychosocial condit ions in long-t erm care f acilit ies f or t he elderly. The Bureau has provided t echnical co-operat ion f or t he review of regulat ory and monit oring syst ems as w ell as f or t raining w orkshops f or caregivers. The lessons learned w ill be usef ul t o ot her count ries.
1995 2000 P ar ti ci p at in g m u n ic ip al it ies 30 ~46 ~64 20 10 0 Bolivi a Brazi l Colo mbi a
Chile Cuba Dom inican Repu blic Ecua dor El S
alva dor Guat emal a Peru Mexi co
FIGURE 4 . M unicipalit ies par t icipat ing in t he Healt hy M unicipalit y M ovem ent (%), select ed count r ies, 19 9 5 and 20 0 0 .
Mexico’s Healthy Municipalities Movement Soars
Beginning in the 1990s, PASB began to promote the creation of healthy municipalities in the Region, believing it to be a strategy that held great promise for improving health at the community level. In Mexico, healthy municipalities have burgeoned since the movement’s inception, and at this time, the country has close to 1,500 municipalities registered with the program coordinated by the Secretariat of Health. Many of the Mexican healthy municipalities fall along the perimeter of ancient Aztec set-tlements, which, in turn, were established according to sound ecological considerations.
Strengthening Community Action
The Bureau’s t echnical cooperat ion has f ocused on communit y leaders and individuals in an at t empt t o get communit ies t o accept great er social responsibilit y f or t heir healt h and t o t ranslat e t his int o act ivit ies t hat lead t o t he improvement of exist ing condit ions and t he adopt ion of healt hier choices and lif est yles by t he populat ion. PASB has collaborat ed w it h communit y leaders in t raining act ivit ies t hat have em-pow ered t hem, improved t heir relat ionship w it h healt h w orkers, and st rengt hened t he communit y development process. Communit y init iat ives have helped t o bridge gaps in healt h equit y in many count ries.
In recognit ion of t he role t hat cit y mayors play in decision-making and resource al-locat ion f or healt h, PASB developed advocacy t ools and audiovisual mat erials t o cre-at e aw areness of t he import ance of support ing saf e mot herhood programs cre-at t he local level. These mat erials w ere designed t o encourage communit y leaders t o mobi-lize eff ort s and increase access t o qualit y essent ial obst et ric care.
Healt h f airs are held f requent ly in t he Region. They st rengt hen t he relat ionship be-t w een be-t he communibe-t y and healbe-t h providers, including physicians, nurses, and phar-macist s. The communit y also benef it s f rom increased aw areness of t he import ance of healt h and a healt hy environment .
Jamaica’s f our Regional Healt h Aut horit ies conduct ed w orkshops t o st rengt hen t he leadership and healt h promot ion skills of 100 communit y leaders. For t he Int er-nat ional Day of Older Persons, 16 count ries in t he Region part icipat ed in t he WHO Global M ovement f or Act ive Aging, w hich advocat es great er recognit ion of t he role of healt hy lif est yles in maint aining healt h and f unct ion in old age. In M exico, t he day w as celebrat ed w it h 767 healt h w alks in 29 of t he count ry’s 32 st at es. Chile held an in-t ergenerain-t ional w alk and a healin-t h f air and disin-t ribuin-t ed healin-t h educain-t ion main-t erials. In Peru, PASB provided t echnical cooperat ion and sponsored a radio program on healt h and aging issues. PASB also collaborat ed w it h Peru’s M inist ry of Women and Devel-opment in sponsoring a number of self -care w orkshops f or older persons and in dis-seminat ing public inf ormat ion on import ant healt h t opics f or older persons.
The part icipat ion of members of t he clergy, beaut icians, and w omen’s associat ions is being proposed t o ident if y individuals suff ering f rom depression. An evaluat ion st udy conduct ed in Panama show ed t hat 89% of t he beaut icians surveyed w ere eager t o improve t heir know ledge of ment al healt h. Nearly 40% of a sample of 268 hair-dressers w ere able t o recognize depression in a case vignet t e, but only 14% of t hem said t hey w ould ref er t heir cust omers t o t he healt h services f or t reat ment .
plans, and programs. Young people have also part icipat ed in such int ernat ional event s as t he Fif t h M inist erial M eet ing on Children and Social Policy in t he Americas.
Paraguay’s Int erinst it ut ional Nat ional Commission on Tobacco Cont rol has collabo-rat ed w it h Argent ina, Bolivia, Brazil, Chile, Colombia, Peru, Uruguay, Venezuela, and on t obacco cont rol init iat ives. In some areas, t his init iat ive included alcohol abuse pre-vent ion t arget ed t o yout hs.
Wit h support f rom PASB, communit y leaders and healt h personnel w orked t o-get her t o develop programs in t he f ollow ing areas:
Domestic violence –
Several count ries in t he Region have f ocused t heir eff ort s on increasing t he visibilit y of t he issue of domest ic violence as a w ay t o def ine policies t o diminish or eradicat e t his kind of violence. In El Salvador, f or example, cit y leaders played an import ant role in est ablishing cooperat ion agreement s w it h t he M inist ry of Public Healt h, developing int ervent ions t o promot e and prot ect healt h, st rengt hening int ersect oral eff ort s, and seeking t he populat ion’s commit ment t o est ablish healt hy lif est yles and reduce violence. El Salvador’s comprehensive model f or domest ic violence prevent ion is support ed by nat ional development policies and a law against domest ic violence, w hich assist and prot ect such at -risk groups as w omen, children, girls, t he disabled, and t he elderly. Similarly, eff ort s have been init iat ed in Panama t hrough communit y net w orks in 14 regions t o inst it ut ionalize domest ic vio-lence prevent ion. The M inist ry of Healt h and several NGOs have st art ed sexual abuse prevent ion campaigns t o increase aw areness of child and adolescent abuse.Nutrition –
Int erinst it ut ional part icipat ion in t he prot ect ion and promot ion of inf ant healt h reached a high point in Ecuador in 2000 w it h t he adopt ion of t he Int egrat ed M anagement of Childhood Illness (IM CI) st rat egy in t he majorit y of public inst it ut ions. The IM CI st rat egy includes managing severe malnut rit ion and off ering breast f eeding and ot her nut rit ion counseling, as w ell as vit amin A and iron supple-ment at ion, at t he primary care level. Research and evaluat ion reveal t hat t he im-plement at ion of t he st rat egy yielded posit ive out comes. One of t he st rat egy’s ob-ject ives is t o empow er communit ies t o promot e and prot ect healt h. In 2000, t hese communit y-orient ed component s w ere expanded at t he nat ional level w it h t he sup-port of NGOs and communit y organizat ions, part icularly t hose w orking w it h indige-nous peoples.INCAP and El Salvador’s M inist ry of Public Healt h have ident if ied t he populat ion groups at great est risk of malnut rit ion. The mult isect oral w ork has result ed in t he signing of an agreement among INCAP, FAO, and WFP t o support nut rit ional and f ood securit y.
PAHO and CFNI developed a posit ion paper on nut rit ion and healt hy aging, w hich is being review ed by a group of expert s and w ill be an import ant t ool f or t echnical cooperat ion in t he Caribbean.
Wit h support f rom PASB, communit y leaders and healt h personnel in Trinidad and Tobago are act ively part icipat ing in w ellness programs in f our healt h regions t o pro-mot e physical f it ness and appropriat e nut rit ional pract ices w it hin t he communit y. The eff ort f ocuses on developing healt hy lif est yles w it h emphasis on risk f act ors f or chronic diseases such as diabet es and hypert ension.
Indigenous rights –
The Wayuu communit y in Colombia has t aken t he lead in est ablishing microent erprises among indigenous communit ies t o st imulat e em-ployment and economic development in rural areas w hile improving basic sanit at ion. This project , init iat ed in Guajira St at e, has improved environment al healt h condit ions f or t he most vulnerable groups. In Brazil, t he Nat ional Healt h Foundat ion is develop-ing a syst em t o st rengt hen cult ural, ldevelop-inguist ic, and organizat ional pot ent ial t o en-hance t he qualit y of lif e and healt h of indigenous groups.Mental health –
In Uruguay, an init iat ive has been f ormulat ed t o address t he count ry’s high levels of depression and it s high suicide rat e, t he highest in t he Re-gion (12 t o 17 deat hs per 100,000 populat ion). “ El Club de los Cazabajones” (The De-pression Hunt ers) promot es self -help st rat egies f or people w ho suff er f rom deDe-pression and encourages t he involvement of t heir f amily and f riends in t reat ment . The club provides psychiat ric and psychological services, including diagnosis, psychot herapy, pharmacological t reat ment , and rehabilit at ion. An import ant f act or t aken int o con-siderat ion in t his init iat ive is t he economic sust ainabilit y of communit y act ivit ies.Developing Personal Skills
chil-dren and more t ime t eaching. M exico’s Healt h Promot ing Schools Net w ork sponsored a w orkshop f or t eachers and healt h sect or personnel in lif e skills educat ion.
The Elevent h World Conf erence on Tobacco or Healt h w as held in Chicago, USA, in August 2000. Draw ing nearly 4,000 part icipant s, t he conf erence provided a f orum f or PASB st aff and t obacco cont rol prof essionals f rom t he Americas t o highlight Regional achievement s and learn about t obacco cont rol experiences f rom around t he w orld.
In Goias St at e, Brazil, t he M inist ry of Healt h and t he M inist ry of Educat ion are im-plement ing a program f or t he promot ion of healt hy habit s, self -est eem, environmen-t al healenvironmen-t h, and prevenenvironmen-t ion of risk f acenvironmen-t ors w ienvironmen-t hin environmen-t he Healenvironmen-t h Promoenvironmen-t ing Schools Inienvironmen-t ia-t ive. Similarly, six counia-t ries in ia-t he Region paria-t icipaia-t ed in campaigns ia-t o raise aw areness about t he risks of t obacco and it s link t o several diseases, and t o encourage people t o quit smoking. In addit ion, PASB w orked w it h t he Int er-American Heart Foundat ion and M ember St at es t o implement counseling and t reat ment services at t he primary care level and assist ed in t he development of nat ional radio programs t o help smok-ers f rom Colombia, Peru, and ot her Andean count ries t o quit .
In Jamaica, PASB support ed “ Woman Inc.,” an NGO, t o help young w omen acquire skills needed in order t o develop self -est eem, access healt h inf ormat ion, and make healt hy choices. These skills empow ered t he w omen t o earn an income; make w ort h-w hile cont ribut ions t o societ y; develop t o t heir f ullest pot ent ial socially, economically, ment ally, and emot ionally; and t ake cont rol of f act ors t hat det ermine t heir healt h and ot her aspect s of t heir lives. Support w as also provided f or a summer program f or ado-lescent s, conduct ed by t he M inist ry of Healt h, t o empow er 50 adoado-lescent s t o make in-f ormed choices regarding t heir healt h, relat ionships, and sexualit y.
In Trinidad and Tobago, a subregional w orkshop w as held t o t rain healt h personnel, public relat ions off icers of t he Regional Healt h Aut horit ies, journalist s, and healt h
edu-Contest in Brazil Helps People Quit Smoking
A study on tobacco use conducted in Goias State, Brazil, revealed that 26% of the overall popula-tion and about 10% of the populapopula-tion aged 15 to 19 years used tobacco. Considering that tobacco advertising targets youths in this age group, the latter figure is particularly alarming. To counteract the influence of tobacco ads, the Secretariat of Health organized an international smoking-cessation contest—“ Quit and Win 2000” —in which contestants committed themselves to quit smoking for four weeks. This activity is part of an anti-tobacco effort supported by Finland’s National Institute of Public Health; in support, the Bureau provided specific technical cooperation to help launch the campaign.
cat ors t o develop quant it at ive and qualit at ive research project s t o assess healt h com-municat ion act ivit ies. As a result of t his eff ort , t he qualit y of healt h educat ion mat erials has improved and healt h educat ors at t he regional levels are conduct ing evaluat ions.
In Hait i, a nat ional commit t ee f or t obacco cont rol w as est ablished t o educat e t he populat ion about t he dangers of t obacco use and second-hand smoke.
In Cost a Rica, in collaborat ion w it h t he Cost a Rican Social Securit y Fund, and in M exico, in collaborat ion w it h t he M inist ry of Healt h, PASB f ield t est ed a t raining man-ual on healt h care f or older persons aimed at primary healt h care prof essionals. A t rain-ing w orkshop on agrain-ing w as held f or communit y caregivers in collaborat ion w it h t he PAHO/WHO Collaborat ing Cent er on Healt h and Aging at t he Universit y of West Indies in Kingst on, Jamaica. PASB also w orked w it h t he Cat holic Universit y of Chile t o conduct a w orkshop t o t each prof essionals w ho w ork w it h t he elderly about t he myt hs and re-alit ies of aging and st rat egies f or dealing w it h t hem.
Reorienting Health Services
PASB’s t echnical cooperat ion has cont ribut ed t o t he ident if icat ion and def init ion of new care models in Chile, Cost a Rica, and Jamaica by ut ilizing int egrat ed healt h care policies t hat aim t o st rengt hen primary healt h care, enhance t he problem-solving capacit y of t he healt h services, and emphasize healt h promot ion and prot ect ion ac-t ions ac-t haac-t involve civil socieac-t y. These policies also seek ac-t o make healac-t h promoac-t ion and prot ect ion an int egral part of t he healt h care delivery process, and t o incorporat e healt h promot ion principles int o healt h services management .
In 2000, t he Bureau support ed M ember St at es’ eff ort s t o st rengt hen and reorient healt h service models. In Brazil, t he f amily healt h model w as st rengt hened and ex-panded, and t he inclusion of ment al healt h as an int egral part of t he model w as con-sidered. In Cuba, t he healt h promot ion component w as st rengt hened in t he f amily physician model, w hich includes a school healt h services component as w ell as primary healt h care f or f amilies at t he communit y level. In Chile, primary healt h care person-nel received int ensive t raining in healt h promot ion st rat egies and now f orm an int e-gral part of t he healt hy municipalit ies and “ comunas” init iat ive.
eff ort s t o have people-f riendly healt h services support t he w hole process of social mobilizat ion and communit y part icipat ion.
Brazil, Colombia, Cost a Rica, El Salvador, Guat emala, Honduras, Jamaica, and M ex-ico complet ed qualit at ive research on t he sexual and reproduct ive healt h of adoles-cent males in Lat in America and t he Caribbean t hat f acilit at ed t he incorporat ion of gender and healt h promot ion in healt h services f or adolescent s. In addit ion, healt h services personnel received t raining t hat incorporat ed t he new concept ual f ramew ork f or human development and healt h promot ion.
PASB support ed a Regional consult at ive group meet ing on primary healt h care and aging in Cost a Rica. As a result of t his meet ing, t he Bureau developed a kit t o enable healt h cent ers t o def ine t heir policies f or promot ing, prot ect ing, and caring f or t he healt h of older adult s. The kit t eaches healt h personnel how t o analyze t he social, economic, environment al, biological, and behavioral f act ors associat ed w it h t he au-t onomy and w ell-being of elderly persons in au-t heir communiau-t y. The au-t raining manual provides met hods and examples f or t he communit y healt h cent er t o w ork eff ect ively w it h t he local government in addressing t hese f act ors. The manual uses a part icipa-t ory meicipa-t hodology icipa-t o idenicipa-t if y resources, problems icipa-t haicipa-t older people f ace in accessing qualit y and appropriat e healt h care in t he communit y, and solut ions t o t hese prob-lems. The manual w ill be t est ed in a variet y of healt h cent ers bef ore it is made w idely available in t he Region.
The Bureau st rengt hened t he count ries’ capabilit ies t o est ablish adolescent healt h and development policies and programs and increased opport unit ies f or yout h in-volvement in reorient ing healt h services. In 10 of t he 11 count ries part icipat ing in t he Regional Init iat ive f or t he Reduct ion of M at ernal M ort alit y (Bolivia, Brazil, t he Domi-nican Republic, Ecuador, El Salvador, Hait i, Honduras, Guat emala, Nicaragua, Para-guay, and Peru), t he met hodologies used result ed in improved managerial capacit y and in t he incorporat ion and eff ect ive implement at ion of organizat ional policies and plans of act ion t o ensure qualit y essent ial obst et ric care at t he f irst ref erral level.
In t he Caribbean, t he healt h services’ capacit y in t he diet ary management of nut ri-t ion-relari-t ed chronic diseases w as sri-t rengri-t hened w iri-t h ri-t he supporri-t of CFNI and ri-t he min-ist ries of healt h. In t he Bahamas, nurses designed int ervent ion st rat egies in t he diet ary management of obesit y, diabet es, hypert ension, and coronary heart disease and de-veloped counseling skills f or use w hen int eract ing w it h pat ient s w it h chronic noncom-municable diseases. Nat ional diet ary guidelines t o promot e healt hy lif est yles w ere de-veloped w it h CFNI’s support , based on a survey on Bahamians’ diet ary habit s.
The Bureau support ed Argent ina, Bolivia, Cuba, Ecuador, Grenada, Saint Kit t s and Nevis, Saint Lucia, and Trinidad and Tobago in t raining and developing human re-sources w it hin t he healt h sect or t o promot e breast f eeding, including t he development of skills in breast f eeding counseling using t he WHO/UNICEF counseling met hodology.
The WHO/UNICEF/UNAIDS guidelines on HIV and inf ant f eeding w ere t ranslat ed int o Spanish and disseminat ed t o all count ries.
The decent ralizat ion of communit y healt h services has led t o t he incorporat ion of psychosocial services int o primary healt h care. In Brazil, El Salvador, Guat emala, and Trinidad and Tobago, a t echnical advisory group has been appoint ed t o guide t he re-orient at ion of ment al healt h services t ow ard a w ider primary-care-based program. In support of t his init iat ive, a t echnical cooperat ion among count ries (TCC) project w as undert aken w it h several Caribbean count ries t o develop and nurt ure ment al healt h care at t he primary care level. A main st rat egy has been t o encourage t he t raining of communit y healt h w orkers in ment al healt h issues. Several areas have been t arget ed in t he reorient at ion of communit y healt h care services, including large psychiat ric in-st it ut ions. A new ment al healt h care model int roduces f avorable condit ions and norms f or guarant eeing pat ient s’ right s and incorporat es new crisis management services and rehabilit at ion int ervent ions at t he communit y level.
Specialized ment al healt h services, including f amily and group t herapy modalit ies, are being int egrat ed int o primary healt h care in an eff ort t o provide ment al healt h care coverage t o more people. M ent al healt h services have also been t ailored t o meet t he needs of children, parent s, and t eachers as part of t he healt h promot ion and pro-t ecpro-t ion spro-t rapro-t egy pro-t o supporpro-t children’s psychosocial developmenpro-t .
In Barbados, t he Bureau is providing t echnical cooperat ion f or t he f ormulat ion of a nat ional ment al healt h plan t hat includes alt ernat ives t o t he care provided at psy-chiat ric hospit als. In El Salvador, a nat ional commit t ee on ment al healt h w as est ab-lished and a nat ional ment al healt h plan is being prepared; communit y ment al healt h services are being implement ed in San Salvador. In Brazil, t echnical support is being provided f or evaluat ing t he int egrat ion of chronically ill pat ient s discharged f rom t w o large ment al hospit als int o t he communit y. Colombia received support t o st rengt hen it s inst it ut ional capacit y t o implement communit y-based ment al healt h services. In Be-lize, a nat ional ment al healt h plan is being implement ed. Trinidad and Tobago ap-proved a nat ional ment al healt h plan and designed an act ion f or it s implement at ion. As part of t he Global Campaign Against Epilepsy and in collaborat ion w it h t he In-t ernaIn-t ional League AgainsIn-t Epilepsy and In-t he InIn-t ernaIn-t ional Bureau f or Epilepsy, PASB support ed t he development of a t raining module f or primary care doct ors and nurses t o det ect and manage epilepsy as w ell as t he development of quest ionnaires t o assess changes in know ledge, at t it udes, and pract ices af t er t raining. In preparat ion f or a demonst rat ion project t o be launched in 2001, t w o pilot st udies w ere conduct ed in Argent ina t o f ield t est bot h t he f easibilit y of t he module and t he provision of inf or-mat ional or-mat erials t o bot h t eachers and t he general public f or early det ect ion and re-f erral ore-f possible epilepsy cases. The creat ion ore-f selre-f -help groups re-f or epilept ics and t heir f amilies w as also promot ed.
PASB has w orked w ith ministries of health in the Americas to improve the physical and psychosocial conditions of older persons living in long-term care facilities. This approach is part of the Bureau’s many-pronged initiative
to promote the health and w ell-being of the Region’s elderly, bringing the hope of health, dignity, and
PASB supported the shift of family health and population programs from a birth-control orientation toward a more comprehensive sexual- and reproductive-health orien-tation. Action plans have been drawn up in the countries with the participation of NGOs, community-based organizations, and government agencies with special interest and ac-tivities in this area.
Health in Human
Development
2
One of PA SB’s goals
is t o cooperat e w it h M ember St at es
in order t o produce healt h as a social good t hat result s f rom t he
collaborat ion of government s, public inst it ut ions, t he communit y,
Healt h promot ion is unquest ionably a key element f or bringing about equit y and sen-sit izing t he populat ion; it is also essent ial f or advocat ing policies t hat seek t o improve t he healt h sit uat ion by inf luencing it s socioeconomic det erminant s and modernizing healt h syst ems in t he Region.
The main challenge f acing t he healt h sect or is t hat of overcoming inequit ies in healt h st at us and in access t o healt h care. Because inequit ies in access t o healt h care are, in t urn, a ref lect ion of t he Region’s prevailing social inequit ies (economic, polit i-cal, et hnic, and gender), t he healt h and human development approach t arget s it s w ork t o t hose charged w it h f ormulat ing public policies t hat have an impact on living condit ions and human development , including t hose policies relat ed t o t he count ries’ healt h syst ems.
Povert y can only be f ully eliminat ed by increasing equit y. This is t he t hinking t hat drives t he current polit ical agenda f or development in t he Region of t he Americas. It is now w idely recognized t hat in order f or cert ain social groups t o overcome t heir de-velopment lag, inequalit ies in access t o educat ion and healt h services and in polit ical represent at ion must be redressed. This underst anding has sparked renew ed int erest in f ormulat ing public policies and programs t o combat povert y, especially t hose t hat w ill benef it t he most underserved groups in t he count ries of Lat in America.
PASB has embraced t he concern, as have t he government s of t he Americas, f or mit -igat ing povert y and is, t heref ore, direct ing eff ort s t ow ard reducing healt h inequit ies. A signif icant port ion of t he Bureau’s t echnical cooperat ion current ly cent ers around t he issue of equit y and healt h.
To t hat end, it must ident if y and combat t he f act ors t hat t hreat en t he populat ion’s overall healt h and st rengt hen t hose t hat f ost er it , promot e healt hy public policy, sup-port t he creat ion of healt hy environment s, and st rengt hen t he pow er of communit ies.
Building Healthy Public Policy
Healt h syst ems t he w orld over are being reexamined and, in many cases, ref ormed. These ref orm processes aim t o improve t he populat ion’s healt h and f ost er t he part ic-ipat ion of various sect ors in planning, implement ing, and evaluat ing public policies t hat benef it healt h.
One of t he Bureau’s st rat egies is t o support init iat ives emanat ing f rom legislat ive bodies, NGOs, and civil societ y t o promot e t he creat ion of healt hy public policies and environment s, in addit ion t o st rengt hening t he pow er of t he communit y and devel-oping t he personal skills of it s members. In at least t hree count ries—Brazil, Chile, and Venezuela—PASB has collaborat ed in incorporat ing st rat egies t o reduce inequit ies in healt h in sect or ref orms.
Wit h a view t o promot ing healt hy lif est yles and environment s and increasing t he know ledge and skills of individuals and communit ies t o care f or t heir healt h, t he Bu-reau f ormulat ed t he Plan on Healt h Promot ion f or 1998–2000, w hich has int ersect oral collaborat ion and social part icipat ion as it s st rat egic pillars.
In collaboration with the Ministry of Health of Chile, PASB designed a profile of health equity in that country, which included the development of equity indicators for environmental health. Under a collaboration agreement with the School of Social Sciences of the University of Chile, the Bureau also produced a series of reports on health inequities in the Region. Thus far, the situations in Panama and Chile have been ana-lyzed, and reports for another 10 countries will be published toward the end of 2001.
The Bureau support ed t he development of macro-legislat ion f or t he healt h sect or in Bolivia, Chile, Ecuador, El Salvador, Honduras, Nicaragua, Paraguay, and Venezuela. The last count ry’s new const it ut ion makes healt h promot ion a priorit y in w hich com-munit y part icipat ion is bot h a right and a civic dut y. It also prot ect s f amilies and t he right of couples t o decide t he number of children t hey w ish t o have, and guarant ees access t o t he inf ormat ion needed t o exercise t hat right .
Also in Venezuela, t he Bureau has support ed t he ref orm process launched by t he M inist ry of Healt h and Social Development . The ref orm seeks t o est ablish a concept of t ot al healt h and achieve t he act ive part icipat ion of t he various sect ors in t he f ormula-t ion of legal insormula-t rumenormula-t s ormula-t o puormula-t inormula-t o eff ecormula-t ormula-t he provisions of ormula-t he new consormula-t iormula-t uormula-t ion.
PASB assist ed t he M inist ry of Healt h of Cost a Rica in f ormulat ing it s Nat ional Healt h Policy, 1998–2002, and t he Nat ional Healt h Plan, 1999–2004. The f irst document de-f ines t he policies and st rat egies de-f or healt h promot ion and disease prevent ion t hat are t o guide t he comprehensive healt h care model, w hile t he second out lines t he model’s object ives, f inancing sources, t hose responsible f or carrying out act ivit ies.
In ot her count ries, PASB has promot ed t he st rengt hening of legislat ion relat ing t o issues such a blood banks and ment al healt h. Wit h WHO, t he Bureau has deepened it s collaborat ion in t he area of healt h and human right s.
In Bolivia, Brazil, Colombia, Nicaragua, and Peru, t he Bureau carried out a mult i-cent er research project on inequit ies in healt h, w hich is based on an analysis of result s of household surveys of living condit ions and on demographics and healt h. This pio-neering st udy in t he Region aims t o measure inequit ies in healt h, access t o and use of services, and f amily expendit ures on healt h, as w ell as t o compare t he result s w orld-w ide. The conclusions are expect ed t o make a valuable cont ribut ion t o t he measure-ment and surveillance of healt h inequit ies and t o t he f ormulat ion of policies aimed at reducing t hose inequit ies.
To guide PASB’s w ork on public policies t hat eff ect ively address healt h inequit ies linked t o race or et hnicit y, a st udy f ocusing on t he st at us of t he Lat in American pop-ulat ion of Af rican descent w as init iat ed. The result s of t his st udy w ill be submit t ed f or regional consult at ion by expert s, polit ical leaders, and communit y represent at ives.
Along the United States-M exico border, these substandard dw ellings offer little shelter and compromise the health of a community. Poorly constructed housing, often built on precarious terrain, is one
The PAHO/WHO count ry off ices w ork closely w it h t he legislat ures and w it h local and municipal inst it ut ions in t he Region t o promot e t he development of a holist ic model of healt h t hat incorporat es t he part icipat ion of all sect ors in t he f ormulat ion of policies on equit y and qualit y of lif e. Through it s t echnical cooperat ion, t he Bureau st imu-lat es legisimu-lat ive init iat ives t o promot e new healt h st rat egies t hroughout t he Americas, including legislat ion aimed at modernizing and int roducing innovat ions int o municipal ad-minist rat ion w it h t he object ive of est ablishing healt hy mu-nicipalit ies in t he Region.
In Brazil, Canada, Ecuador, El Salvador, M exico, and t he Unit ed St at es, support w as provided f or t raining t o measure and analyze inequit ies in healt h, as w ell as t o develop and analyze policies designed t o reduce t hose inequit ies.
In collaborat ion w it h WHO, PASB init iat ed a st udy on healt h and povert y reduct ion policies in 19 low -income count ries in t he Region; t he st udy w as designed t o det ect and analyze t he synergy and complement arit y bet w een t hese
t w o t ypes of policies. It is part of t he Bureau’s eff ort s t o place healt h at t he f oref ront of povert y reduct ion policies and incorporat e povert y reduct ion int o healt h policies. At t he same t ime, t his st udy w ill serve as t he basis f or t he povert y reduct ion st rat egies t hat M ember St at es w ill adopt in t he coming years, especially t hose t hat are included in t he Debt Init iat ive f or Heavily Indebt ed Poor Count ries.
Inequit y manif est s it self in various w ays. Diff erent ial access t o pot able w at er, f or ex-ample, is w idespread t hroughout t he Region. As Figure 1 illust rat es, t he poorest peo-ple have t he least access t o pot able w at er. In Peru in 1997, in t he poorest decile—as measured by household income—only around 40% of t he populat ion had adequat e access t o pot able w at er t hrough house connect ions, versus 90% of t he populat ion in t he highest -income decile. The sit uat ion w it h regard t o availabilit y of adequat e of ex-cret a and solid w ast e disposal syst ems, as w ell as housing condit ions among t he poor (dirt floors, substandard walls and roofs, and other conditions not conducive to a healthy lif e), is similar.
Health Accounts, Regional Integration,
and Health Legislation
Wit hin t he f ramew ork of t he PAHO/IDB/World Bank Shared Agenda f or Healt h in t he Americas and w it h t he collaborat ion of WHO, t he OECD, USAID, and SIDA, PASB sup-port ed t he count ries of t he Region t hat are t aking part in t he second phase of t he
100 80 60 40 20 0 1 Poorest
2 3 4 5
Income deciles
Homes w it h household connect ion
Homes w it hout household connect ion
Wit hout service
6 7 8 9 10
Wealt hiest P o p u lat io n (% )
FIGURE 1. P opulat ion (%) w it h access t o w at er, by annual household incom e, P er u, 19 9 7.
healt h account s init iat ive. The init iat ive, w hich w ill provide a basis f or analyzing and conduct ing int ernat ional comparisons of public and privat e expendit ure and f inanc-ing in t he healt h sect or, is a t ool of t remendous import ance f or t he equit able alloca-t ion and macro-managemenalloca-t of public and privaalloca-t e f inancial resources. The goal f or 2002 is f or all t he count ries of t he Region t o have at least an init ial est imat e of t heir respect ive healt h account s. The result s w ill serve as input f or t he dat abases of t he co-operat ion organizat ions involved.
As part of t his eff ort , st udies on spending and f inancing f or healt h care services f or w omen w ere undert aken in collaborat ion w it h IDB and t he World Bank. Wit h t he ISALUD Foundat ion of Argent ina, a met hodology w as developed f or est imat ing na-t ional expendina-t ure on and f inancing f or drugs.
In collaborat ion w it h WHO, IDB, t he World Bank, and t he M exican Healt h Founda-t ion (FUNSALUD), supporFounda-t w as provided f or Founda-t he Founda-t raining of naFounda-t ional Founda-t echnical person-nel f rom most of t he Lat in American count ries on t he OECD met hodology f or est i-mat ing healt h account s, w hich has been adopt ed by PASB. In addit ion t o several t echnical report s on household healt h surveys, t he Bureau published t he OECD man-ual on healt h account s.
PASB disseminat ed, via it s w ebsit e, t he dat abase on nat ional healt h expendit ure and f inancing, w hich cont ains det ailed inf ormat ion on public and privat e spending on healt h since 1980 in all count ries of t he Region. This dat abase w ill also be made avail-able elect ronically on t he w eb page of t he Shared Agenda.
Bearing in mind t he healt h implicat ions of regional int egrat ion and t rade liberaliza-t ion movemenliberaliza-t s, PASB conliberaliza-t inued liberaliza-t o assisliberaliza-t liberaliza-t he Region’s counliberaliza-t ries in incorporaliberaliza-t ing liberaliza-t heir healt h priorit ies int o agreement negot iat ions relat ed t o t he t w o processes. This support w as off ered in conjunct ion w it h WHO and t he Unit ed Nat ions Conf erence on Trade and Development in t he f ramew ork of t he World Trade Organizat ion, M ERCOSUR, t he An-dean Communit y, SICA, t he Caribbean Communit y, t he Lat in American Int egrat ion As-sociat ion, and t he Free Trade Area of t he Americas.
This issue w as t he subject of t he Sevent h Course/Workshop on Healt h Legislat ion, conduct ed in M exico joint ly w it h t he Int er-American Cent er f or Social Securit y St ud-ies. Part icipant s f rom most Lat in American count ries at t ended t he w orkshop. In addi-t ion, addi-t he book Acceso a los servicios de salud en el marco del t rat ado de libre comer-cio de América del Nort e (TLC) [Access t o Healt h Services in t he Framew ork of t he Nort h American Free Trade Agreement (NAFTA)] w as published. The book analyzes, f rom a legal st andpoint , NAFTA’s implicat ions f or t he reduct ion of inequit ies in access t o healt h services f or t he most vulnerable populat ions.
In cooperat ion w it h several PAHO regional cent ers and t he Regional Healt h Legis-lat ion Net w ork, t he Bureau cont inues t o updat e t he LEYES dat abase of healt h legis-lat ion in Lat in America and t he Caribbean on PAHO’s w ebsit e. The dat abase current ly
cont ains more t han 10,000 records of healt h legislat ion f rom t he Lat in American and Caribbean count ries.
Bioethics
PASB has conduct ed st udies on bioet hical aspect s of healt h legislat ion and is cont inu-ing t o st udy bioet hical component s of Lat in American biomedical publicat ions. Among t he act ivit ies undert aken f or t he promot ion of bioet hics, one of t he most not ew ort hy is t he publicat ion of t he f irst issue of t he series Act a Bioet hica, f ollow ing a lengt hy and complex process of def ining object ives and obt aining art icles. In addit ion, t hree inf ormat ion bullet ins, a book, and various w orking document s w ere produced.
The Bureau, t oget her w it h several ot her int ernat ional agencies, made an import ant cont ribut ion t o t he revision and disseminat ion of t he Spanish version of t he operat ing guidelines f or et hics commit t ees t hat review biomedical research, developed by t he UNDP/World Bank/WHO Special Program f or Research and Training in Tropical Dis-eases, and t he draf t ing of guidelines f or t he Council f or Int ernat ional Organizat ions of M edical Sciences f or t he regulat ion of research involving human subject s. It also cont inued t o conduct t he series of w orkshops on bioet hics inst ruct ion, w hich w ere off ered in nine count ries (Argent ina, Bolivia, Colombia, Cuba, Dominican Republic, Ecuador, El Salvador, Guat emala, and M exico) during 2000, in collaborat ion w it h t he respect ive PAHO/WHO count ry off ices.
Creating Supportive Environments
The monit oring of healt h int ervent ions is an import ant component of t he creat ion of healt hy environment s. In collaborat ion w it h t he M inist ry of Healt h in Chile, t he Bu-reau w orked t o develop social indicat ors and ident if y risk f act ors and healt h impair-ment s t hat w ill f acilit at e assessimpair-ment of t he progress of healt h int ervent ions aimed at achieving t he count ry’s healt h goals.
