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Health Agenda

for the Americas


2008–2017

Presented by the Ministers of Health


of the Americas in Panama City, June 2007
Contents
Declaration of the Ministers and
Secretaries of Health . . . . . . . . . . . . . . . . . . . . . . . . . .i

Health Agenda for the Americas


Statement of Intent . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1
Principles and Values . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3
Situation Analysis and Health Trends in the Americas
(a) Overview of Socioeconomic Trends in the Region . . . . . . .5
(b) Health Situation Trends in the Region . . . . . . . . . . . . . .7
(c) Trends in the Health System Response . . . . . . . . . . . . . .9

Areas of Action: A Health Agenda for the Americas


(a) Strengthening the National Health Authority . . . . . . .13
(b) Tackling Health Determinants . . . . . . . . . . . . . . . . . . .14
(c) Increasing Social Protection and Access to Quality
Health Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .15
(d) Diminishing Health Inequalities among Countries,
and Inequeties within Them . . . . . . . . . . . . . . . . . . . . .17
(e) Reducing the Risk and Burden of Disease . . . . . . . . . .18
(f) Strengthening the Management and Development
of Health Workers . . . . . . . . . . . . . . . . . . . . . . . . . . . . .19
(g) Harnessing Knowledge, Science, and Technology . . . .20
(h) Strengthening Health Security . . . . . . . . . . . . . . . . . . .21

Notes and References . . . . . . . . . . . . . . . . . . . . . . . . . . . .23


Health Agenda for the Americas i

Launching of the Health Agenda for the Americas 2008 – 2017

Declaration of the Ministers


and Secretaries of Health
W e, the undersigned Ministers and
Secretaries of Health of the
Americas, having assembled in
Panama City on the 3rd of June in the year
both within and beyond the mandates of the
National Health Authorities;

Our commitment to dialogue and joint


2007, for the purpose of presenting to the action among all stakeholders at the local,
international community the Health Agenda national, subregional and regional levels, in
for the Americas 2008–2017, which reflects order to promote and accomplish the regional
our countries’ intent to work together and in health objectives through the areas of action
solidarity towards the improvement of the identified in the Health Agenda for the
health and the development of our people, Americas;

Declare: and

Our renewed commitment to the principle Urge all Governments, civil society, and the
established in the Constitution of the World international community; which contribute
Health Organization, which recognizes that to technical cooperation and development
the enjoyment of the highest attainable stan- financing, to consider this Agenda as a guide
dard of health is one of the fundamental and inspiration when developing public poli-
rights of every human being without distinc- cies and implementing actions for health in
tion of race, religion, political belief, economic pursuit of the well–being of the population of
or social condition; the Americas.

Our commitment to intersectoral action,


acknowledging the role of the social determi-
nants of health in public policy making and Panama City,
that exclusion in health is the result of factors 3 June 2007
Health Agenda
for the Americas
Statement of Intent
1. The Governments of the Region of is conceived in alignment with the
the Americas jointly establish this goals of the Millennium Declaration.
Health Agenda to guide the collec-
tive action of national and interna- 5. In accordance with the documents
tional stakeholders who seek to cited in paragraph 4, this Agenda is
improve the health of the peoples of a high–level political instrument for
this Region over the next decade. health. It defines principal areas of
action in order to reiterate commit-
2. The Governments reiterate their ments made by countries in interna-
commitment to the vision of a region tional fora and strengthen the
that is healthier and more equitable response to effectively realize them.
with regard to health, addresses
health determinants, and shows 6. The Agenda will guide the prepara-
improved access to individual and tion of future national health plans,1
collective health goods and services as appropriate, and the strategic
– a region where each individual, plans of all organizations interested
family, and community has the in cooperating for health with the
opportunity to develop to its great- countries of the Americas, including
est potential. the Pan American Sanitary Bureau.
Assessment of progress in the areas
3. The Health Agenda for the Americas of action outlined in this Agenda
is a response to the health needs of will be done by evaluating the
our people. It reflects the commit- achievement of goals set in these
ment of each country to work plans.
together with a regional perspective
and with solidarity in support of the 7. The Governments of the Americas
development of health in the Region. emphasize the importance of ensur-
ing that stakeholders and institu-
4. The Agenda incorporates and com- tions working in health will benefit
plements the global agenda included from a concise, flexible, dynamic,
in the World Health Organization’s and high–level health agenda that
Eleventh General Program of Work, guides their actions, facilitates the
adopted by the Member States at mobilization of resources, and
the 59th World Health Assembly in influences health policies in the
May of 2006. Moreover, this Agenda Region.
Health Agenda for the Americas 3

Principles and Values


8. Acknowledging that the Region is countries of the Americas to advance
heterogeneous, and that our nations shared interests and responsibilities
and their populations have different in order to attain common targets, is
needs and sociocultural approaches an essential condition to overcome
to improving health, this Agenda the inequities with regard to health
respects and adheres to the follow- and to enhance Pan American health
ing principles and values: security during crises, emergencies,
and disasters.
9. Human rights, universality, access,
and inclusion. The constitution of the 11. Equity in health. The search for equi-
World Health Organization states ty in health is manifested in the
that: “enjoyment of the highest effort to eliminate all health inequal-
attainable standard of health is one ities that are avoidable, unjust, and
of the fundamental rights of every remediable among populations or
human being without distinction of groups. This search should empha-
race, religion, political belief, eco- size the essential need for promoting
nomic or social condition....” In order gender equity in health.2
to make this right a reality, the coun-
tries should work toward achieving 12. Social participation. The opportuni-
universality, access, integrity, qua- ty for all of society to participate in
lity and inclusion in health systems defining and carrying out public
that are available for individuals, health policies and assessing their
families, and communities. Health outcomes is an essential factor in
systems should be accountable to the implementation and success of
citizens for the achievement of these the Health Agenda.
conditions.

10.Pan American solidarity. Solidarity,


defined as collaboration among the
Health Agenda for the Americas 5

Situation Analysis and Health


Trends in the Americas
(a) Overview of ancy tends to be longer in wealthier
Socioeconomic countries than in poorer countries.
Trends in the Region However, the differences in life ex-
pectancy are reduced when income
13. The Agenda is based on the health distribution is taken into account:
trends observed in the Region. Given countries that have a more equal
the significance of the social deter- distribution of income reach life
minants of health as variables that expectancy levels that are compa-
help to explain the range of health rable to, and sometimes better than,
conditions in a region or country,3 those of wealthier nations with a
it becomes essential to review the more unequal distribution of income.6
principal socioeconomic indicators
and trends in the health situation 15. Population growth has slowed in all
that have informed the Health countries of the Americas;7 mean-
Agenda for the Americas. In the while the proportion of people over
period 2001–2005, the per capita 60 years of age has progressively
gross domestic product of Latin increased.8 This calls for measures
America and the Caribbean grew by to respond to changes in the epi-
4.2%.4 The most recent estimates of demiological profile associated with
the Economic Commission for Latin an aging population.
America and the Caribbean (ECLAC)
indicate that in 2005, 39.8% of the 16. Urban areas have grown in all the
population in Latin America and the countries, often with little planning.
Caribbean lived in poverty (209 The growing phenomenon of urban-
million people) and 15.4% of the ization, despite allowing people to
population (81 million people) lived be closer to health services, may
in extreme poverty or indigence. also be associated with widespread
Projections, carried out by ECLAC, adoption of certain consumption
for the year 2006 indicated that the patterns and unhealthy lifestyles —
numbers of poor people and of poor diet, obesity, lack of physical
people in a state of extreme pover- activity, drug abuse— deterioration
ty were expected to diminish to of social support networks, and
205 and 79 million, respectively. increase in traumas and violence.
Although in recent years there has
been some improvement in the dis- 17. Literacy in the Region has increased
tribution of income, the Region from 88% of the population in 1980
continues to be the most inequit- to 93.7% in 2005, and there have
able in the world.5 been variable increases in school
attendance in most countries. Never-
14. Inequalities
in health bear a close theless, access to an education con-
relation to various socioeconomic tinues to be greater for men than for
determinants. In general, life expect- women, especially in rural areas, and
6 2008–2017

the quality of education is clearly America and the Caribbean were


differentiated by household income estimated at US$ 2.2 billion, demon-
levels. As a result of these dispari- strating their vulnerability and the
ties, some people have less opportu- need for prevention and mitigation
nity to develop healthy behaviors, plans and measures.
and have access to quality employ-
ment and improved living conditions. 20. Exclusion in health in the Region
appears to be closely linked with
18. The Region’s environment has poverty, marginalization, discrimina-
increasingly deteriorated as a result tion (cultural, racial, social, and
of air and water, and soil contami- gender), and the stigmatization suf-
nation. Environmental contamina- fered by people with mental illnesses
tion especially affects the infant and special needs. Language, infor-
population because they are still mal employment, unemployment
developing physiologically and and underemployment, geographic
neuro-psychologically. With regard isolation, low education levels, and
to water and sanitation coverage, insufficient information available to
94% of the population has access to potential health systems users are all
water in the household;9 sanitation important factors in exclusion in
(excreta and wastewater manage- health. In summary, 218 million
ment) coverage is 86%. The figures people are without protection against
are reduced to 91% and 77%, respec- the risk of disease because they lack
tively, when only the population of any form of health insurance cover-
Latin America and the Caribbean is age, and 100 million people lack
considered, where, moreover, even- access to health services due to
greater deficits persist in rural areas.10 geographic or economic barriers.12
At the same time, countries face the
need to control risks associated with 21. Latin America and the Caribbean
industrialization and unplanned received US$ 6.34 billion in official
development in large cities. development aid (ODA) in 2004,
only 8% of the worldwide total. At
19. Natural and manmade disasters the end of the 1990s the correspon-
affect the environment and the ding proportion was approximately
health status of the population in the 10% and has diminished due to
Region, and constitute a limiting financial reorientation towards other
factor in achieving health sector regions. Furthermore, some bilateral
goals, as well as in the normal partners have decided to suspend
functioning of health services. In support to health in our Region
2005 alone, for example, hurricanes during the coming years, or focus
left 4,598 people dead, seven mil- their assistance on a limited number
lion people affected, and caused of countries in Latin America and
losses valued at over US$ 205 bil- the Caribbean.13
lion.11 Economic damages in Central
Health Agenda for the Americas 7

(b)Health Situation those of the non–indigenous popu-


Trends in the Region lation.19 More than 45 million people
in the Region make up the indige-
22. The regional health panorama is nous population, but information
characterized by the coexistence systems do not sufficiently elaborate
of consequences of communicable the variables of race and culture,
diseases with those of chronic–de- complicating the development of
generative illnesses, violence, trau- appropriate strategies for health
ma, occupational diseases and interventions among this important
mental illness.14 The latter have population.
replaced communicable diseases as
leading causes of death and disease 25. Progress in reducing early and avoid-
in all of the countries.15 Among able mortality has largely been the
communicable diseases, traditional result of specific actions by the health
threats such as malaria persist, sector, mainly in primary care, such
threats from new agents (such as as increased vaccination coverage,
HIV/AIDS) have appeared, others family planning, and oral rehydra-
(such as tuberculosis) have re–e- tion therapy. Although maternal
merged, and changes have occurred mortality has declined, the Region
in the characteristics of agents whose still had a rate of 71.9 deaths per
variants could induce a severe pan- 100,000 live births in 2005. This
demic (such as influenza viruses). rate rises to 94.5 when only Latin
Meanwhile, a group of diseases that America and the Caribbean are
disproportionately affect develop- considered, with the highest rate of
ing countries persists, which are a 523 in Haiti and the lowest of 13.4
consequence of poverty and gener- in Chile.20 Pregnancies among ado-
ally result in stigma.16 Although lescents, for the most part unwanted,
these diseases are preventable and have reached 20% of total preg-
curable, with drugs that are easily nancies in many countries, a situa-
administered, controlling them tion posing evident challenges for
continues to be a challenge. these future mothers and fathers
and their children. The mortality by
23. Despite the fact that in recent years cervical cancer, breast cancer, sep-
there have been overall improve- ticemias, malnutrition, and acute
ments in most of the principal respiratory infections —all avoid-
health indicators,17 especially when able causes of death— can be reduced
considering national averages, the through greater primary health care
Region is characterized by large coverage and effectiveness.
differences among and within
countries. Inequalities in health are 26. In many cases, progress that can be
related to significant differences in achieved by specific actions of the
geography, age, gender, ethnicity, health system appears to be limited.
education level, and income distri- There is increasing recognition that
bution.18 the risk factors that require inter-
vention and are associated with the
24. The health conditions of indigenous principal causes of disease and death
peoples are consistently worse than are outside the direct control of the
8 2008–2017

health sector. For example, morta- tion of wealth, experience shows


lity from external causes and from that interventions that promote the
certain illnesses (such as cardiovas- maximum development of children’s
cular disease, diabetes, chronic ob- potential can improve access to
structive pulmonary disease, and productive employment and produce
HIV/AIDS) depends to a great extent future generations with greater social
on living conditions, lifestyles, and mobility, which continues to be
behavior. To make headway in re- severely limited in most countries of
ducing the burden of preventable the Region.21,22 The lack of opportu-
diseases, it is necessary to review nities is manifested early in child-
and act on the major determinants hood; for example, approximately
and risk factors of the principal 40% of the municipalities of Latin
health problems. This requires America and the Caribbean do not
analysis of evidence based on inter- reach the goal of vaccinating 95% of
national experience that can inform children under one year against
policy decisions as well as strategic polio, diphtheria, tetanus, and
partnerships, both intersectoral whooping cough, which means
and interinstitutional, to ensure the that at least 800,000 children have
effectiveness of interventions. not been adequately protected
against these diseases by that age.23
27. In terms of the contribution of
health to a more equitable distribu-
Health Agenda for the Americas 9

(c)Trends in the Health 30. Around the year 2005, national


System Response health expenditures in Latin America
and the Caribbean represented
28. Health systems have not been able approximately 6.8% of the Region’s
to overcome segmentation24 and gross domestic product; this amounts
severe deficiencies in health financ- to an annual per capita expenditure
ing policies. The situation is highly of US$ 500.25 About half of that
vulnerable, as some countries have amount was public health expen-
extremely low levels of health diture: expenditure for Ministry of
expenditure; others are excessively Health services and the services of
dependent on external resources, other units of central and local
and in most countries out–of–pocket government institutions, and health
expenditures continue to rise. All of service expenditure financed through
this predominantly affects the most compulsory premiums to privately
impoverished populations. In gen- administered health funds or social
eral, the allocation of resources security institutions. The remaining
continues to be disconnected from half corresponds to private expendi-
service performance and results. ture, which includes direct out–of
Often, allocation decisions are not –pocket expenditures to purchase
based on systematic analysis of the health goods and services, and
situation and of lessons learned, nor health services obtained through
do they take into account cultural private health insurance arrange-
diversity. Clinical management is ments or prepaid medical coverage.26
still insufficient and has not made
public health actions a priority. The 31. The scarce and poor distribution of
delivery of health services is charac- health personnel, along with the fail-
terized by the predominance of a ure to adapt personnel to actual
curative model centered in hospitals health needs, is exacerbated by the
and on individual care, relegating migration of professionals within
primary care and public health countries and by their emigration
services to a secondary role. This to wealthier nations. Most countries
model lacks mechanisms for coor- of the Americas are affected by
dinating a network of services and this phenomenon, which should be
does not adequately incorporate addressed at the national level as
health promotion. well as in the context of Inter–
American and international frame-
29. The health sector reform processes works, since a sizable number of
promoted in the 1990s in Latin countries in the Region do not have
America and the Caribbean focused the personnel necessary to provide
on financial and organizational minimum coverage (25 health work-
issues, marginalizing essential as- ers per 10,000 population),27 while
pects of public health. These pro- other countries have five times the
cesses undermined the role of the minimum personnel. The distribu-
State in key areas, resulting in a tion of health workers is extremely
steady decline in the ability of the uneven, illustrated by the fact that
Ministries of Health to exercise their urban areas have from 8 to 10 times
steering role and to develop essential more doctors than rural areas.
public health functions. Some countries have significant
10 2008–2017

imbalances in the capabilities of 33. The overview of the health determi-


available personnel, with very few nants, situation, and trends in the
nurses per physician and an absence Region of the Americas reveals the
of other indispensable professionals. need to develop strategies to reduce
Women occupy almost 70% of the inequalities among and inequities
health workforce, but they are the within countries. Those strategies
minority in management positions, should facilitate continued progress
tend to be paid less, and are the first in providing social protection to the
affected by unemployment. Human population through health systems
resource education continues through based on primary health care and on
traditional modalities that frequently public policies for good health
do not encourage the development developed with community partici-
of leadership and creativity. Planning pation and implemented by well–in-
for the required quantity and quality formed, respected health authorities.
of human resources is still lacking With that perspective, this Agenda
in the Region.28 identifies eight areas of action.
These areas are by definition broad,
32. In Latin America and the Caribbean, setting out principles and guidance
investment in science and technolo- for countries and the international
gy applied to health is characterized community without attempting to
by the absence of explicit agendas set priorities, since these will be
for needs–driven research that determined by each country in rela-
informs policy design, as well as by tion to its own problems and the
limited development of financing availability of resources.
mechanisms to meet these needs.29
Health Agenda for the Americas 13

Areas of Action:
A Health Agenda for the Americas
(a) Strengthening the 36. The National Health Authority should
National Health actively participate in the elabora-
Authority30 tion of policies aimed at addressing
social determinants. Dialogue, coor-
34. To improve the health situation, the dination, and collaboration between
National Health Authority should Ministries of Health and Ministries
strengthen its institutional capacity of Finance and Planning should
to exercise its steering role in health, center on forecasting, stability, and
as well as its intersectoral leadership continuity in the allocation of finan-
to bring together and guide partners cial resources to attain national
in promoting human development. human development goals.
The National Health Authority should
foster comprehensive social and com- 37. An essential part of the steering role
munity participation and strengthen of the National Health Authority is
primary health care to meet national to ensure that the health issues
health goals, involving all stake- adopted as regional and subregion-
holders including those in the private al mandates are incorporated in the
sector. At the same time, the National hemispheric development agenda.
Health Authority should have legal The National Health Authority, in
frameworks that support, and allow coordination with the sector for for-
for auditing of, its management. eign affairs and other relevant
areas, would thus ensure that
35. The exercise of governance, leader- health holds a predominant place in
ship, and accountability is a key ele- development and poverty reduction
ment that enables the National Health strategies which, within the global
Authority to obtain the commitment health framework, are discussed in
and political will, at the highest level, fora such as the Summit of the
needed to strengthen health develop- Americas and the Ibero–American
ment. Ministries of Health must fully Summit, among others.
carry out the essential public health
functions31 and efficiently perform 38. While encouraging greater invest-
their role in the guidance, regulation, ment in health, effective, efficient,
and management of health systems. and transparent accountability sys-
A major task is to clarify the respec- tems should be developed to support
tive responsibilities of government, the mobilization and proper man-
society, and individuals. Evidence agement of resources. Similarly,
–based decision–making strengthens National Health Authorities should
the National Health Authority. The strengthen their capacity to plan,
processes for allocating resources manage, and coordinate the use of
and designing policies would benefit national resources as well as inter-
from institutionalizing systems of national health cooperation.
information on expenditures and
financing for the health system.
14 2008–2017

(b)Tackling Health have an intercultural and gender-


Determinants sensitive approach, in which active
social participation is key. This
39. The National Health Authority should be supported by strengthen-
should advocate for health as a ing epidemiological surveillance
priority on the sustainable human systems through the inclusion of
development agenda. Recognition social, behavioral, and lifestyle
of the role of health determinants variables, enabling the evaluation
and their incorporation in national of health promotion interventions.
development plans that adopt lines Within the broader concept of hu-
of work and resources to address man security, concrete intersectoral
them will indicate that this mandate interventions should be promoted
has been fulfilled. to reduce social and interpersonal
violence as well as personal and
40. The determinants of health should community insecurity.
be tackled in order to effectively
protect poor, marginalized, and 43. Investment in social protection dur-
vulnerable populations. This refers ing childhood and in strengthening
to determinants that are related to families should be a priority among
(a) social exclusion, (b) exposure to the strategies directed toward tack-
risks, (c) unplanned urbanization, ling health determinants. Countries
and (d) the effects of climate change. should endeavor to guarantee effec-
This approach requires revision of tive protection for all girls and boys
legislative frameworks, which cur- from prenatal–care onward, employ-
rently provide adverse incentives ing technologies of proven effec-
for the improvement of health tiveness.34 Social management of
determinants.32 risk by all sectors responsible for
public policy is essential for
41. The actions required to tackle most achieving these results. In accor-
of these determinants are outside dance with the quest for equity, the
the mandate of Ministries of Health Health Authority should prioritize
and require the involvement of other and emphasize specific actions to
governmental entities. Consequently, reduce maternal, neonatal, and child
the National Health Authority mortality in all segments of society.
should expand the arena for public Breastfeeding should be promoted,
health activities by promoting and actions taken to prevent infec-
healthy public policies via interin- tions, dehydration, respiratory dis-
stitutional consensus–building and eases, and malnutrition and obesity
intersectoral collaboration. among children as part of the
problems of childhood nutrition.
42. Countries should invest more in Vaccination coverage should be
health promotion and have policy maintained or expanded, along with
frameworks that facilitate their the gradual introduction of new
development and the achievement vaccines and technology when
of measurable objectives.33 Health appropriate.
services delivery systems should
Health Agenda for the Americas 15

(c) Increasing Social 47. Countries should promote the effec-


tive extension of social protection
Protection and by strengthening: (a) access to serv-
Access to Quality ices; (b) financial security; (c) soli-
Health Services darity in financing; and (d) dignity
and respect for the rights of patients
44. Universality and improved social in health care, in accordance with
protection are important issues in national legislation.36
the political and academic dialogue
regarding sustainable human devel- 48. Access to drugs and health techno-
opment in Latin America and the logies is a requirement for effective
Caribbean35. Attempts are being made health interventions. To promote ac-
to address the uncertainty generated cess to drugs, countries should con-
by the labor market and its impact sider: (a) using to the full provisions
on family incomes, social security in trade agreements, including their
coverage, and health care. In this flexibilities; (b) strengthening the
context, public policies should pro- supply system; (c) strengthening
gressively increase the access, fi- regional and subregional procure-
nancing, and solidarity of social ment mechanisms; (d) promoting the
protection systems. rational use of drugs; and e) reducing
tariff barriers applied to drugs and
45. Although most countries in the health technologies.
Region have legislation that estab-
lishes the public’s right to universal 49. Emphasizing the primary health care
health, the reality is that, in many of strategy will be crucial to progress
them, effective coverage is still toward universal and equitable ac-
determined by the availability of cess to health care in marginalized
financing, without explicit criteria rural and peri–urban areas, where
for prioritization in most cases. services are practically nonexistent.
These services should be culturally
46. This reality highlights the need to acceptable and adequately incorpo-
develop insurance systems that rate local traditional practices, proven
reduce the financial burden on safe, and, to the extent possible,
families, protecting them from the effective. Health systems appropri-
risk of falling into poverty due to ate for indigenous peoples should
catastrophic out–of–pocket expen- be developed and included in na-
ditures, and to try to guarantee the tional health systems. Strengthening
population a set of health services. referral and cross–referral systems
Given the dilemma posed in prior- and improving health information
itizing one service over another, each systems at the national and local
country should carry out a national levels will facilitate the delivery of
dialogue with relevant stakeholders services in a comprehensive and
to enable informed decisions that timely fashion.
consider epidemiological, economic,
equity, financial, and social feasi- 50. Improving effective coverage of the
bility criteria. population will require more
16 2008–2017

effective and efficient service deli- cross–cutting requirement of all


very. This in turn will require the health systems and services.
use of evidence in the definition of
practices and better managerial 51. With regard to service delivery, the
capacity in services, while monitor- private sector — for–profit and
ing fulfillment of the commitment not–for–profit — plays an important
to reorient health services toward role, and should be regulated by the
models of care that encourage National Health Authority to help
health promotion and disease pre- achieve national goals for public
vention with a family and commu- health.
nity approach. Quality control is a
Health Agenda for the Americas 17

(d) Diminishing Health for this important aspect of human


development.
Inequalities among
Countries and Inequities 54. With respect to adolescents and
within Them young adults, their integrated
health care should be expanded,
52. In trying to achieve greater equity, including the promotion of youth
interventions to improve health development, the diagnosis and
should prioritize the poorest and treatment of mental illnesses, the
most marginalized and vulnerable prevention of risky behaviors, and
people. Indigenous peoples and the control of problems such as
tribal communities, as well as other smoking, alcoholism, drug addic-
groups,37 should be a priority. tion, suicide, unwanted pregnancy,
Countries should safeguard these violence, and sexually transmitted
groups’ inclusion, their access to infections, including HIV/AIDS.
culturally acceptable health services,
the collection and use of specific 5 5. Maintaining the quality of life of
data for appropriate decision- elderly people should be part of
–making, and the full exercise of health programs geared specifically
their rights as citizens. Health inter- to this age group. Combining eco-
ventions should respond to the spe- nomic and food subsidies to accom-
cific characteristics of each group. pany these health interventions is
key to ensuring that older adults
53. Sexual and reproductive health is a participate in health programs. Edu-
priority issue in the Region. It is cating health workers about elderly
imperative to provide women with care technologies should be a prior-
continuous care that starts prior to ity and the focus of specific primary
conception and continues during health care training programs.
pregnancy, childbirth, and puerperi-
um, including care of the newborn. 56 . The National Health Authority
Pregnant women infected with HIV should promote parity among the
must be provided with delivery con- sexes in the formulation and imple-
ditions in accordance with estab- mentation of health policies and
lished protocols to minimize the programs. Monitoring and evalua-
probability of transmission of the tion activities should make syste-
virus to the newborn, who should matic use of data disaggregated
also be guaranteed a breast–milk by sex.
substitute during the first six months
of life. Access to contraceptives is 57. The development assistance commu-
indispensable for reducing unwanted nity should consider aligning its
pregnancies and maternal morbidity funding with the specific areas of
and mortality; in addition, some of action in this Agenda and the priorities
them prevent sexually transmitted of countries in the Region. The objec-
infections, including HIV/AIDS. The tive is to increase the capacity of the
role of men in the promotion of sex- health sector to meet internationally
ual and reproductive health should agreed–upon targets and objectives,
be strengthened to avoid burdening as well as to reduce inequities which
women with exclusive responsibility national averages tend to hide.
18 2008–2017 June, 2007

(e)Reducing the Risk in behavior will only be sustained if


they are accompanied by environ-
and Burden of Disease mental, institutional, and policy
changes that truly allow people to
58. While efforts continue to control choose lifestyles that involve healthy
the transmission of infectious dis- eating habits, physical activity, and
eases, the countries of the Americas not smoking. Collaboration with
should emphasize the prevention industry, the media, and other
and control of non–communicable strategic partners is needed to pro-
diseases, which have become the duce and market healthier foods,
principal cause of morbidity and and with the education sector so
mortality in the Region. Specific that schools set an example of good
actions should be initiated or dietary practices and promote
strengthened to control diabetes, healthy habits.
cardiovascular and cerebrovascular
diseases, types of cancer with the 60. To combat the communicable dis-
greatest incidence, as well as hyper- eases that continue to affect the
tension, dyslipidemia, obesity, and populations of the Americas, cur-
physical inactivity. To cover the rent actions should be sustained,
growing gap in mental health care, favorable environments created
policies that include the extension and innovations introduced. A more
of programs and services need to intensive effort should be made to
be developed or updated. Each control those diseases that dispro-
country will have to target these portionally affect developing coun-
actions, aimed at reducing risks and tries, principally affect poor popu-
burden of disease, by age groups lations, and can be eradicated.38
and geographical criteria as needed.

59. The health authority should be high-


ly active in promoting healthy life-
styles and environments. Changes
Health Agenda for the Americas 19

(f)Strengthening the perspective, so that the health


workforce’s professional profile
Management and responds to each country’s reality.
Development of
Health Workers 63. In terms of knowledge and
learning, the following should
6 1 . Governments should collabora- be undertaken: develop shared
tively address these five critical technical frameworks; evaluate
challenges:39 (a) define and im- performance using systems of
plement long–term evidence–based measurement that are comparable
policies and plans to develop the between countries; finance re-
health workforce; (b) find solu- search; and share appropriate
tions to resolve inequities in the evidence–based practices. In pol-
distribution of health workers, icy aspects, it is necessary to:
assigning more personnel to promote ethical methods for the
populations most in need; (c) hiring and protection of migrant
promote national and interna- workers; monitor major migrant
tional initiatives for developing flows to safeguard equity and
countries to retain their health justice; and support fiscal sus-
workers and avoid personnel tainability.
deficits; (d) improve personnel
management capacity and work- 64. The proliferation and diversifi-
ing conditions in order to get cation of suppliers of services and
health workers more involved in of skilled human resources neces-
their institutions’ missions; and sitates emphasis on the develop-
(e) link training institutions with ment of accreditation systems
health services for joint planning and regulatory instruments that
to address the needs and profiles aim to guarantee quality. Coor-
of professionals in the future. dination of work between the
National Health Authority, educa-
62. The working conditions and the tional entities, service providers
health of workers themselves and professional associations
are relevant to retaining trained should be strengthened in order
staff and ensuring the quality of to adapt undergraduate and
services provided to the popula- graduate professional profiles to
tion. Emphasis is needed on the the needs of health systems.
training of public health per-
sonnel with a multidisciplinary
20 2008–2017

(g)Harnessing 69. All people should benefit from


Knowledge, Science, progress and have access to health
and Technology information and education. Countries
need to strengthen their capacity
65 . Countries should synthesize, sys- for, and the level of, scientific dis-
tematically assess, and use knowl- semination; public confidence in
edge in decision–making to select research; and the quality of know-
interventions that are relevant and ledge that supports health actions.
effective. To fulfill this function in The National Health Authority
Latin America and the Caribbean, should strengthen its capacity for
ongoing improvement in the devel- information and knowledge man-
opment of the necessary capacities agement, seek partnerships with
is needed. Moreover, cultivation of those who generate that know-
local capacity for research and its ledge, and promote as appropriate
utilization is necessary. financing mechanisms directed at
needs–driven research for policy
66. Research should be strengthened to design.
enable a better understanding of
the relationship between health 70. The National Health Authority, in
determinants and their conse- exercising its regulatory role, must
quences, to select interventions, and guarantee the quality, safety, and
to identify stakeholders that can be efficacy of drugs, technologies, and
partners or can be influenced medical supplies. More–over, it
through public policy. should promote rational use of these
products.
67. Research on traditional and com-
plementary medicines should be 7 1. Health surveillance should be
strengthened to identify those that strengthened at the local, national,
are relevant and effective and can regional, and global levels. The
therefore contribute to the popula- capacity of local health teams should
tion’s well–being. be strengthened to carry out analyti-
cal epidemiological processes that
68 . Bioethics should be better dissemi- generate scientific data for health
nated and applied in the countries planning and that enable the moni-
of the Americas to protect the toring and evaluation of interven-
quality of research, respect human tions. Health information should be
dignity, safeguard cultural diversi- standardized to facilitate comparison
ty, and assure the application of among and within countries, in order
knowledge in health, as well as in to monitor and evaluate progress in
public health decision–making. achieving health goals.
Health Agenda for the Americas 21

(h)Strengthening Health with the agricultural sector should be


Security strengthened for the prevention and
control of zoonotic diseases. Coun-
72 . The countries of the Americas tries should continue modernizing
should prepare for and take inter- and harmonizing legislation to
sectoral measures to address disas- strengthen the production and mar-
ters, pandemics, and diseases that keting of safe food.
affect national, regional, and global
health security. The latest iteration 74. In confronting circumstances that
of the International Health Regu- threaten health security, the countries
lations (IHR 2005) offer countries of the Americas and international
opportunities to strengthen public organizations should work together
health capacities and to collaborate with national authorities to respond
among themselves. The countries of rapidly and effectively on behalf of
the Americas should assume the the population.
new obligations established in the
IHR to prevent and control the 75 . The countries of the Americas should
spread of disease inside and beyond develop, as a collaborative public
their borders.40 health policy, an exercise in prepa-
ration to deal with the potential
7 3. Healthsecurity requires strategies pandemic influenza. This exercise
that are prepared in light of contin- ought to include every aspect related
gencies that exceed national borders, to the required preparation to con-
demanding effective and sustainable front these diseases at the national,
processes for subregional, regional, regional and global level.
and global integration. Joint efforts
Health Agenda for the Americas 23

Notes and References


1
In countries that have a federal government system, this Agenda will guide the preparation of subnational health plans.
2
Gender equity is understood to mean the provision of appropriate responses to the particular health needs of men
and women.
3
World Health Organization Commission on Social Determinants of Health. Action on the Social Determinants of Health:
Learning from Previous Experiences. WHO, Geneva, 2005.
4
Economic Commission for Latin America and the Caribbean. Statistical Yearbook for Latin America and the Caribbean.
ECLAC, Santiago, 2005.
5
Economic Commission for Latin America and the Caribbean. Social Panorama of Latin America 2006
LC/G.2326–P/E. December 2006.
6
At the end of 1990, the gap in life expectancy at birth between the richest and poorest populations was declining, with
a difference of 9.8 years (75.6 and 65.8, respectively). In 2000, it was calculated that life expectancy at birth in the
countries of the Region ranged from 79.2 to 54.1 years between countries with the longest and shortest life
expectancies at birth. Between 1950–55 and 1995–2000, the difference in life expectancy between men and women
increased from 3.3 to 5.7 years in Latin America, from 2.7 to 5.2 years in the Caribbean, and from 5.7 to 6.6 years
in North America.
7
Population growth ranges from 0.4% in the non–Latin Caribbean to 2.1% in Central America.
8
UN Population Division, Department of Economic and Social Affairs. World Population Ageing 1950–2050. United
Nations, New York, 2002.
9
This availability, however, does not guarantee certainty of potability, since monitoring of quality varies in the coun-
tries of Latin America and the Caribbean.
10
Joint Monitoring Program (PAHO/UNICEF). Information updated to 2004 for MDG target #10 monitoring “Halve, by
2015, the proportion of people without sustainable access to safe drinking water and basic sanitation.”
11
Economic Commission for Latin America and the Caribbean. Preliminary overview of the economies of Latin
America and the Caribbean 2005. LC/G.2292–P/I December 2005. The figures include the United States.
12
International Labor Organization/Pan American Health Organization. Overview of the Exclusion of Social Protection
in Health in Latin America and the Caribbean. Report presented at the ILO Tripartite Regional Meeting with the
collaboration of PAHO on “Extension of Social Protection in Health to Excluded Groups in Latin America and the
Caribbean” (Mexico, 29 November–1 December 1999).
13
German Technical Cooperation Agency (GTZ) and the Norwegian Agency for Development Cooperation (NORAD)
have indicated that they will either suspend their assistance to health in the Region in the next few years or that
their cooperation will focus on a small number of countries in Latin America and the Caribbean. The Canadian
International Development Agency (CIDA) will focus on only five countries in the Region. Other organizations, like
United States Agency of International Development (USAID), face increasing difficulties in obtaining financing for
health programs in the Region.
14
Kohn R, Levav I, Caldas de Almeida JM, Vicente B, Andrade L, Caraveo–Anduaga JJ, Saxena S, Saraceno B. Mental
disorders in Latin America and the Caribbean: a public health priority. Pan American Health Journal of Public Health
2005; 18 (4/5):229–40: indicates that “the current gap in treatment of mental illnesses in Latin America and
the Caribbean continues to be overwhelming and is estimated that the number of people with these illnesses in the
Region of the Americas will increase from 114 million in 1990 to 176 million in 2010.”
15
Some authors have coined the term “epidemiological polarization” to refer to this profile of morbidity and mortality.
24 2008–2017

16
The international community has coined the expression “neglected diseases” to refer to these diseases. In the
Americas, these diseases are grouped as follows: (a) in poor neighborhoods: elephantiasis, leprosy, and leptospirosis;
(b) in rural areas: snail fever (shistosomiasis), fasciolasis, kala–azar, and cutaneous leishmaniasis, Chagas' disease,
cysticercosis, trichinosis, and plague; (c) in some indigenous communities: river blindness (onchocerciasis) and para-
sitic diseases of the skin (scabies, sand fleas, and fungus); and (d) in the majority of poor populations: ascariasis,
hookworm disease, and tricurosis (helminth infections transmitted through contact with the soil).
17
In Latin America and the Caribbean, infant mortality in the period from 1980 to 2005 went from 56.6 to 24.8 per
1,000 live births.
18
Economic Commission for Latin America and the Caribbean. The Millennium Development Goals: A Latin
American and Caribbean Perspective. ECLAC, Santiago, 2005.
19
Pan American Health Organization. Health of the Indigenous Population in the Americas. 138th Session of the
Executive Committee, Document CE138/13. PAHO, Washington, D.C., 12 June 2006.
20
Pan American Health Organization. Gender, Health and Development in the Americas – Basic Indicators 2005. PAHO,
Washington, D.C., 2005.
21
World Bank Office for Argentina, Chile, Paraguay, and Uruguay. International Evidence on Policies on Early Infancy
that Stimulate Child Development and Facilitate Female Integration into the Workforce. World Bank Working
Document 01/06, May 2006.
22
P. Bedregal, P. Margozzini, and H. Molina. Systematic review on the effectiveness and intervention costs of bio–psychoso-
cial childhood development. PAHO, Washington, D.C., 2002.
23
Annual country reports to the immunization unit in the Pan American Sanitary Bureau via EPI tables/ joint reporting
forms for PAHO/WHO–UNICEF in the Americas (2005 data).
24
Segmentation is the coexistence of subsystems with different mechanisms for financing, affiliation, and provision—
“specialized” in accordance with different segments of the population—that are determined by income and economic
position. Segmentation occurs, both in terms of provision as well as insurance, in a public subsystem oriented
toward the poor —under the social security subsystem, specialized for formal workers and their dependents, and under
the private for— profit subsystem, concentrated on the wealthiest segments of the population.
25
Dollars adjusted for purchasing power parity (PPP).
26
Pan American Health Organization. Health expenditure database, 2006.
27
The World Health Organization and the Joint Learning Initiative have proposed using a measure called the “density of
human resources in health” comprised of the sum of the indicator available for all the countries: physicians and
nurses per 10,000 population. The measurement of density through this method is imperfect, since it does not take
into account all other health workers, but it is the only viable measure for global comparisons.
28
Public Health in the Americas (PAHO/WHO, Washington, D.C., 2002). Analysis of essential public health function
number 8 (development and training of human resources in public health) in the measurement exercise developed
by PAHO and the CDC in 2000 and 2001 reveals a lack of coordination among Ministries of Health and human
resource training centers for planning the number and professional profiles of the people necessary for serving at
different levels and structures of health systems in the Region. At the same time, the conclusions of various regional
meetings of training centers have pointed out the need to develop the conditions for leadership and capacities to face
new problems and solve conflicts among the people who will work in health services. Education methodologies
to achieve these capacities should focus on problem solving, rather than the traditional methods based on theoretical
teachings that consider students to be passive recipients in the teaching–learning process.
29
In accordance with studies sponsored by the Council for Health Research and Development (COHRED), in the Region
only three countries showed development of research funds aimed at financing essential health research projects,
defined as those intended to provide an evidence base for decisions with regard to health policy.
30
In countries that have a federal government system, this includes health authorities at all levels that have policy
and programmatic functions and responsibilities.
Health Agenda for the Americas 25

31
Public Health in the Americas (PAHO/WHO, Washington, D.C., 2002) identifies 11 essential public health functions:
(1) monitoring, evaluation, and analysis of health conditions; (2) public health surveillance, research and control of
public health risks and harms; (3) health promotion; (4) citizen participation in health; (5) development of public health
policies and the institutional capacity for planning and management; (6) strengthening institutional capacity in public
health regulation and enforcement; (7) assessment and promotion of equitable access to necessary health services;
(8) development and training of human resources in public health; (9) guaranteeing and improving the quality of
individual and collective health services; (10) public health research; and (11) reducing the impact of emergencies
and disasters on health.
32
The variables included in this grouping are the following: (a) social exclusion: income, gender, education, ethnic ori-
gin, and disability; (b) exposure to risks: poor living and working conditions, unhealthy lifestyles, lack of informa-
tion, difficulty in accessing food and water, soil, water and air pollution, and contaminated food; (c) unplanned
urbanization exacerbates the inadequate water services, sanitation, and housing; and (d) among the consequences
of climate change are floods, droughts, and vector–borne diseases, which affect poor population with higher intensity.
33
Jakarta Declaration on Leading Health Promotion into the 21st Century. The Fourth International Conference on
Health Promotion: New Players for a New Era – Leading Health Promotion into the 21st Century (Jakarta,21–25 July 1997).
http://www.who.int/healthpromotion/conferences/previous/jakarta/declaration/en/
34
Various initiatives carried out in Canada, the United States, Mexico, and other countries of the Region have shown
the effectiveness of programs to support families at psychosocial risk through: home visits by health personnel; early
developmental stimulation; personal sensitivity in delivery care and other services; development of effective
parent–child attachments; resilience; and the prevention of domestic and social violence, substance dependence and
early school dropouts.
35
Economic Commission for Latin America and the Caribbean: Shaping the Future of Social Protection: Access,
Financing and Solidarity LC/G.2294(SES.31/3)/I. February 2006.
36
In this Agenda, these conditions are understood to be: (a) access to services: services necessary for providing health
care exist, and people have physical and economic access to them; (b) financial security: health expenditures do not
threaten the economic stability of households or the development of family members; (c) solidarity in financing: sub-
sidies exist between generations, groups of different levels of risk, and groups with different income levels; and
(d) dignity and respect for the rights of patients in health care: this refers to the quality and provision of care in
an environment where the rights and the culture, racial, and socioeconomic characteristics of the patient are respected.
37
Among the groups that deserve special attention are immigrants, displaced peoples, inmates, ethnic minorities and
people with physical and mental disabilities.
38
These diseases are elaborated in note 16.
39
Pan American Health Organization and Health Canada. Toronto Call for Action.
www.observatoriorh.org/Toronto/CallAction_eng1.pdf
40
In view of the International Health Regulations (IHR) entering into effect, WHO member countries are assuming the
following oblitions: (1) to designate or to establish a national center for the IHR; (2) to strengthen and maintain the
ability to detect, notify, and respond rapidly to public health events; (3) To respond to requests for verification of
information regarding hazards to public health; (4) to evaluate public health events using decision tools, and notify
WHO within 24 hours of all events that constitute a public health emergency of national importance; (5) to pro-
vide systemic inspection and control activities in international airports, ports, and designated terrestrial borders to
prevent the international spread of diseases; (6) to do everything possible in order to implement measures recom-
mended by WHO; and (7) to collaborate among themselves and with WHO to implement the IHR (2005).