Annual Report of the Director 2018 Part 1: Introduction

To the Member States:

Dr. Etienne official portrait

In accordance with the Constitution of the Pan American Health Organization, I have the honor of presenting the 2018 annual report on the work of the Pan American Sanitary Bureau, Regional Office for the Americas of the World Health Organization.

This report highlights the technical cooperation undertaken by the Bureau during the period August 2017 through June 2018, within the framework of the 2014-2019 Strategic Plan of the Pan American Health Organization, defined by its Governing Bodies and amended by the Pan American Sanitary Conference in 2017.

This report is complemented by the Financial Report of the Director and the Report of the External Auditor for the year 2017.

Carissa F. Etienne


Pan American Health Organization


August 2018

I had the honor of being elected Director of the Pan American Health Organization (PAHO) at the 28th Pan American Sanitary Conference in September 2012. At the start of my first term, in February 2013, I advocated strongly for four priorities: reducing inequities in health, strengthening health systems, addressing the social and environmental determinants of health, and achieving universal health coverage (UHC).

The overarching theme of my first term was “Championing health for sustainable development and equity: On the road to universal health.” It has become more evident than ever that PAHO’s Member States and the Pan American Sanitary Bureau (PASB, the Bureau), which is the secretariat of PAHO, must continue on that road, working to demonstrate the Organization’s values of equity, excellence, solidarity, respect, and integrity. During that term, Member States approved the forward-looking PAHO Strategic Plan 2014-2019 and the Strategy for Universal Access to Health and Universal Health Coverage—the Strategy for Universal Health—frameworks that provide strategic approaches to address health inequities within and between countries. The development of those frameworks was no accident.

I was gratified and humbled by the trust Member States placed in me and the PAHO team on my reelection for a second term as Director of PAHO during the 29th Pan American Sanitary Conference (PASC) in September 2017. In accepting the accolade, I noted that the Sustainable Health Agenda for the Americas 2018-2030, which was approved at the Conference, will guide our actions for the period stated. In keeping with that Agenda and the 2030 Sustainable Development Goals (SDGs), the overarching theme of my second term is “Advancing health and well-being, leaving no one behind.”

I indicated that the process to develop the next PAHO Strategic Plan would start in 2018, and pledged to continue the participatory process involving Member States that has become the hallmark of formulating the Organization’s guiding frameworks. I also stated that among my top 10 priorities for the next five years were advancing universal health (UH) through resilient health systems based on the primary health care (PHC) approach, and promoting renewed focus on equitable health for all, with particular emphasis on women, children, ethnic groups, indigenous populations, and persons living in conditions of vulnerability. These remain essential aspects of my commitment for this second term.

In this, the first year of my second term, we are celebrating the 40th anniversary of the Alma-Ata Declaration. The 1978 Alma-Ata Declaration was a milestone that reaffirmed the right to the highest attainable level of health, with equity, solidarity, and the right to health as its core values. This historic international conference 40 years ago provided a strategy for human and social development and gave the world PHC as an approach and a strategy for health and well-being, and for health systems development. The PHC approach espouses health systems that facilitate universal access to quality, comprehensive health services for all—especially those in conditions of vulnerability—with the full participation of individuals and families, at a cost that the community and country can afford to maintain, bringing the services as close as possible to where people live and work, and able to address barriers to access through community participation and intersectoral coordination.

The celebration of the 40th anniversary of the Alma-Ata Declaration inspired the theme for this report “Primary Health Care – The Time Is Now.” The theme reflects the efforts of the PASB leadership to take stock and analyze what has worked, what has not worked, and, more importantly, what we need to do differently. Leaving no one behind requires that we move expeditiously to strengthen the PHC approach: promoting and protecting health; removing the barriers to access; giving a voice to those who are not being heard; and enabling social participation, government action, intersectoral and multisectoral work, and advocacy. The convening of a regional forum and the establishment of the High-Level Commission on Universal Health in the 21st Century: 40 Years of Alma-Ata during this period represent concrete actions to facilitate a regional movement to accelerate the achievement of health for all.

This report covers the period August 2017 to June 2018, which is a relatively short period in which to achieve desired outcomes, but not too short to acknowledge real progress and achievements that are the result of team work, effective partnerships – including with non-State actors – and meaningful collaboration with nonhealth sectors.

PAHO’s core functions, related to leadership and partnerships; research, knowledge generation, and dissemination; norms and standards; ethical and evidence-based policy options; technical cooperation for change and sustainable institutional capacity; and health situation trends, continue to guide our work at national, subregional, and regional levels. The PASB aspires to continue to strengthen its performance in working with PAHO Member States, partners, and key stakeholders in managing the priority public health challenges that the countries and territories face.

I take this opportunity to express my sincere appreciation to PAHO’s Member States; Member States and staff in other World Health Organization (WHO) Regions; other United Nations (UN) agencies working in health; development partners; other key stakeholders in health, including those in civil society and the private sector; and all PASB personnel, in countries and in Washington, D.C., for their sterling efforts to continue strengthening primary health care and keep us all on the road to universal health.

Carissa F. Etienne


Pan American Health Organization


The Quinquennial Report of the Director of the Pan American Sanitary Bureau 2013-2017 (OD355, OD355, Corr.), presented to the 29th Pan American Sanitary Conference (PASC) in September 2017, summarized 10 main priorities for PAHO’s technical cooperation and institutional development over the next five years. One of the priorities is “advancing universal health through resilient health systems based on the primary health care approach, and ensuring universal access to quality and comprehensive services throughout the life course.”

Chajul Permanent Attention Center, Guatemala
Chajul Permanent Attention Center, Guatemala

In October 2014, at the 53rd PAHO Directing Council, PAHO Member States reaffirmed their commitment to improving equity, health, and development through their approval of the regional Strategy for Universal Access to Health and Universal Health Coverage (Strategy for Universal Health, CD53/5, Rev. 2). The goal of the Strategy, at both regional and country levels, is to ensure that “all people and communities have access, without any kind of discrimination, to comprehensive, appropriate, and timely quality health services determined at the national level according to needs, as well as access to safe, effective, and affordable quality medicines, while ensuring that the use of such services[1] does not expose users to financial difficulties, especially groups in conditions of vulnerability.” The Strategy also states that “universal access to health and universal health coverage require determining and implementing policies and actions with a multisectoral approach to address the social determinants of health and promote a society-wide commitment to fostering health and well-being.”

Once again, PAHO was at the forefront, well prepared for the adoption, in September 2015, of the UN 2030 Sustainable Development Agenda and its Sustainable Development Goals. The health goal, SDG 3, is to “Ensure healthy lives and promote wellbeing for all at all ages.” It includes Target 3.8, which asks countries to “achieve universal health coverage, including financial risk protection, access to quality essential health care services and access to safe, effective, quality, and affordable essential medicines and vaccines for all.” The importance of universal health coverage (UHC) as a means to provide access to health services for all has been underscored globally and has been addressed in several resolutions of the UN General Assembly (UNGA). In December 2017, UNGA resolution 72/138 agreed to proclaim 12 December as International UHC Day, and resolution 72/139 stated that a UN high-level meeting on UHC will be held in 2019. The 2019 one-day high-level meeting will be convened under the theme “Universal Health Coverage: Together for a Healthier World.”

The World Health Organization (WHO), for which PAHO is the Regional Office for the Americas, approved its Thirteenth General Program of Work (GPW 13) for 2019-2023 (A71/4) at the 71st World Health Assembly in May 2018. GPW 13 sets the strategic vision and direction for WHO for the next five years. GPW13 also defines three strategic priorities aimed at improving the health of three billion people: achieving universal health coverage, addressing health emergencies, and promoting healthier populations.

Universal Health poster

World Health Day in April 2018 promoted UHC under the theme of “Universal Health Coverage: Everyone, Everywhere.” In addition, WHO launched a campaign emphasizing that for SDG Target 3.8 to be achieved, one billion more people must have UHC by 2023. In October 2018, WHO will convene a Global Conference on Primary Health Care, aiming to renew the world’s commitment to strengthen primary health care (PHC) in order to advance towards achievement of UHC and the SDGs.

This global focus on UHC is timely, as 2018 marks the 40th anniversary of the Alma-Ata Declaration on PHC. The Region of the Americas played a critical role in the development and negotiation of the Declaration and the primary health care strategy. The values and principles of PHC have formed the basis of many PAHO mandates, and have guided health system strengthening initiatives and health reform processes. It is based on that accumulated experience that this Region is focused on universal health (UH), and not only on UHC; UH is the expression of the Alma-Ata Declaration in the twenty-first century.

The journey to UH has been a long one. The 1978 Alma-Ata Declaration clearly stated that it is a government’s responsibility to provide health services for its people, with comprehensive services that are not only curative, but that also addressed promotion, prevention, rehabilitation, and treatment of common conditions. The slogan of Alma-Ata, “Health for All by the Year 2000,” was the rallying call and the driver of this movement, which strives for culturally appropriate, accessible, affordable, and adaptable services. PHC is not merely the first level of care—it provides health care built on the first level of care as the basis for health system development.

After Alma-Ata, countries began the implementation of the PHC approach in the 1980s, but several factors, including the economic crisis and structural adjustment policies, led to the diminution of the Alma-Ata vision, with a consequent significant negative impact on the implementation of PHC. Some countries began to focus only on selective and minimum packages of services, while others returned to hospital-centric models of care. However, others persisted with the implementation of the vision of Health for All and achieved holistic national health development, with better health and empowerment of their people. The Ottawa Charter for Health Promotion, developed at the first International Conference on Health Promotion, which was convened by WHO in 1986, built on the Alma-Ata Declaration. The Charter revived intersectoral coordination, social participation, and a focus on social determinants of health, and called for the reorientation of health services, with an emphasis on improving promotion and prevention. This was a step in the right direction, but still fell short of the vision of Alma-Ata. In 2005, PAHO launched national and regional movements for the renewal of PHC and a wave of third-generation reforms aimed at the strengthening the first level of care and forming integrated networks of health services.


The countries of the Americas have reaffirmed their commitment to the vision of Alma-Ata through national and regional movements and actions, including with the approval of the Sustainable Health Agenda for the Americas 2018-2030 (SHAA2030) (CSP29/6, Rev. 3) at the 29th PASC in 2017 and the 2014 Strategy for Universal Health. This Region recognizes that PHC is a strategic approach to develop, organize, and finance health systems and services that are equitable and centered in people, their families, and their communities, and that a strong first level of care is needed to ensure universal health. However, the Region also understands that a strong first level of care without an equally strong integrated health services delivery network will not ensure universal health; that intersectoral coordination and social participation are critical for UH; and that the achievement of UH is only possible through strengthening of health systems based on a PHC approach.

Mais médicos

Despite progress and efforts, to date, significant inequities in health and barriers to access persist, and health systems are not responding effectively and efficiently to new challenges such as noncommunicable diseases (NCDs), climate change, and emerging communicable diseases. The Region of the Americas continues to be one of the most inequitable regions of the world. While there has been notable improvement in the health of peoples in the Americas in recent years, there are significant differences within and across countries, and the health and well-being of populations in conditions of vulnerability has not kept pace with overall gains. Poverty and extreme poverty have increased in the Region. In 2016, 30.7% of the population of Latin America was reported poor (186 million people), with 10.0% living in conditions of extreme poverty, compared with 28.5% (168 million people) and 8.2%, respectively, in 2014. Projections for 2017 were, respectively, 30.7% (186 million people) and 10.2% (48 million people).[2] There is much more to be done, as will be highlighted in the report of the Commission on Equity and Health Inequalities in the Americas, established by the Director of PAHO in 2016. The Commission’s report will be presented by the end of 2018.

The regional report on health systems performance in the PAHO publication Health in the Americas+ 2017 demonstrated that both barriers to access and socioeconomic inequalities persist across and within countries, even though insurance coverage and utilization of primary care services have improved in the Region. Health in the Americas+ 2017 also showed that the increase in public spending in health between 1990 and 2014 (by 25%, on average) and the decrease in out-of-pocket spending (by 15% on average) have not been sufficient. The majority of countries have not reached the agreed-upon benchmarks of 6% of gross domestic product (GDP) in public spending in health and the elimination of direct payment at the point of service, which are intrinsically related. Current assessments consistently emphasize that increased health financing is necessary, but not sufficient, to improve access to quality health care. Other critical factors include effective health system governance, efficient utilization of financial and health care resources, and the relative distribution of health system inputs across service areas and subnational locations. In summary, advancing towards UH requires a PHC approach.

The Region has accumulated experience, expertise, and knowledge to take stock 40 years after Alma-Ata and to influence the course over the next 40 years. The vision of Health for All originally expressed in the Alma-Ata Declaration has been recaptured, within the context of health and development in the twenty-first century and the achievement of UH. The right of everyone, everywhere, to have access to health that allows full, productive, and dignified lives has been reaffirmed.


The Region of the Americas joined the global campaign for World Health Day in April 2018 under the theme “Universal health: everyone, everywhere,” emphasizing the need to remove persistent barriers to health and health care services. These barriers are varied in nature, and removing them requires a whole-of-society movement, with people’s participation and spaces for the voices of all to be heard, particularly the voices of those living in extremely difficult circumstances due to social inequalities: indigenous people, Afro-descendants, and other ethnic groups; women; lesbian, gay, bisexual, and trans (LGBT) people; and migrants. This Region is playing an active role in the lead-up to the Global Conference on Primary Health Care, to be held in Kazakhstan in October 2018, and will showcase to the world its commitment to strengthening PHC as means to progress towards achievement of UH and the SDGs.

The SDG agenda calls for the eradication of poverty by fighting inequities; focuses on people’s development, greater social participation, and intersectoral coordination; and includes a goal on ensuring healthy lives and the promotion of well-being for all at all ages (SDG 3). These elements are central to the vision of Alma-Ata and Health for All, and this vision can be realized in the Region of the Americas through intensified efforts to transform health systems in the quest for UH, firmly based on the PHC approach. Therefore, the time for PAHO Member States to implement or strengthen the PHC approach is now.

The “whole-of-society” approach encourages public participation and creates spaces for all voices to be heard.

The PHC approach implies a whole-of-society commitment to the development of people-centered models of care, where the right to health is fully expressed; responding to the health needs of the population within the communities they serve; increasing the capacity of the first level of care within integrated networks of services; addressing the social determinants of health; working together; being accountable for commitments made; listening to and heeding the voices of persons in conditions of exclusion and vulnerability; including people and communities in the design, implementation, and oversight of health policies and plans; and ensuring mechanisms for the participation of government, civil society, and key stakeholders in defining the path towards UH. The PHC approach requires governance and political will; well-trained, motivated, and equitably distributed human resources for health (HRH); financing mechanisms that are fair, equitable, and solidarity-based; information systems for health; access to safe, appropriate, affordable, and effective medicines and technologies; and effective social participation. It is the foundation of resilient health systems that can deliver adequate, quality care for the population and that have the flexibility to scale up actions to respond to the demands caused by disasters and infectious disease outbreaks, while continuing to provide regular services.

PHC constitutes the most effective and efficient strategy through which Member States can build resilient and sustainable health systems to support the achievement of UH and the goals adopted within SHAA2030 and the SDGs. The evidence, mandates, and knob-how to make it happen exist. What is needed now is prioritization, commitment, and effective implementation.

This report summarizes PASB’s technical cooperation with Member States, collaboration with key partners and stakeholders in advancing towards UH—with special focus on the use of the PHC approach—and progress in the internal administrative processes and systems that support the Organization’s work, during the period under review.

As in all of PAHO’s technical cooperation, special attention was given to the Organization’s eight Key Countries: Bolivia, Guatemala, Guyana, Haiti, Honduras, Nicaragua, Paraguay, and Suriname. PASB emphasized technical cooperation at both subnational and subregional levels, and, wherever feasible, interprogrammatic collaboration was an integral aspect of the interventions.

[1] Including services and interventions to promote health, prevent disease, provide care for illness (diagnosis, treatment, palliative care, and rehabilitation), and offer the necessary short-, medium-, and long-term care.

[2] Economic Commission for Latin America and the Caribbean (ECLAC). Social Panorama of Latin America 2017.

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