The visionary nature of the Alma-Ata Declaration and the original PHC concepts still hold true, even as the world embraces a new call to action, the Sustainable Development Goals, which set out ambitious aims for the year 2030. SDG3, “Ensure healthy lives and promote wellbeing for all at all ages,” echoes the bold target of “Health for All by the Year 2000” established in 1978. The world may have missed that target, but much progress was made and lessons learned, and that accumulated knowledge, experience, and social capital propelled the PASB to rethink and reinvent its interventions during the period under review, with the aim of strengthening PHC as a critical strategy to advancing to UH in the twenty-first century.
Paragraph VI of the Declaration of Alma-Ata, 1978 – original PHC vision
“The Conference strongly reaffirms that health, which is a state of complete physical, mental and social wellbeing, and not merely the absence of disease or infirmity, is a fundamental human right and that the attainment of the highest possible level of health is a most important worldwide social goal whose realization requires the action of many other social and economic sectors in addition to the health sector.”
Making PHC a reality in the Region of the Americas in the twenty-first century means confronting those health inequities that delay progress to UH and sustainable development. The formulation of differentiated interventions that enable those in conditions of vulnerability to access quality, comprehensive health services and live healthy lives will be the cornerstone of PAHO’s work. A PHC approach in the twenty-first century, focused on addressing inequities and advancing towards UH, requires leadership, with renewed vision and political commitment. With this in mind, PASB coordinated the development of SHAA2030, which represents a call to action for health and well-being in the Americas on the basis of UH and the SDGs. SHAA2030 outlines the collective action needed for the countries and the Region to advance to equity and well-being for all people throughout the life course.
SHAA2030 - a regional blueprint for health
Developed through a broad consultative process coordinated by PASB, SHAA2030 is the highest-level strategic planning and policy document on health in the Americas. SHAA2030 represents the regional health response to the 2030 Agenda for Sustainable Development, together with unfinished business from the Millennium Development Goals and the Health Agenda for the Americas 2008-2017, as well as emerging regional public health challenges. It covers all health-related aspects of the SDGs, and provides vision and direction to health interventions for the period indicated. The agenda outlines the collective action needed for the countries and the Region as a whole to achieve, by 2030, the highest attainable standard of health, with universal access to health and universal health coverage, resilient health systems, and quality health services, advancing to equity and well-being for all people throughout the life course.
Goal 1 of the SHAA2030 is to “Expand equitable access to comprehensive, integrated, quality, people-, family-, and community-centered health services, with an emphasis on health promotion and illness prevention.” Included under Goal 1 is Target 1.5: “Increase resolution capacity of the first level of care as measured by a 15% reduction in hospitalization that can be prevented with quality ambulatory care.” Also under Goal 1 is Target 1.6: “Organize health services into integrated health services delivery networks with high resolution capacity at the first level of care.” SHAA2030 is made operational through PAHO’s strategic plans and biennial programs and budgets, as well as through subregional and national health plans.
Regional Forum on Universal Health in the 21st Century: 40 Years of Alma-Ata in Ecuador.
In December 2017, the Director of PAHO launched a regional movement for universal health at the high-level Regional Forum on Universal Health in the 21st Century: 40 Years of Alma-Ata in Ecuador. Over 200 political leaders, representatives of civil society and academia, and experts from approximately 30 countries and territories of the Americas participated, with the aim of identifying obstacles and generating alliances to help countries reach the goal of health for all by 2030. To complement the regional forum, in February 2018, the Director established the High-Level Commission on Universal Health in the 21st Century: 40 Years of Alma-Ata under the able leadership of Her Excellency, Dr. Michelle Bachelet, to examine the future of health systems in the Americas, review progress within the context of Alma-Ata, and determine how to promote greater social participation in health policy-making. The Commission brings together different perspectives, State and non-State actors, and experts working with different population groups, including indigenous people, Afro-descendants, LGBT persons, youth, persons with special needs, and migrants. The Forum and the High-Level Commission will continue work throughout 2018-2019 to advocate for this Region’s strong contribution to the UNGA high-level meeting on UHC in 2019.
During the reporting period, PASB worked collaboratively with Member States in the implementation of the regional Strategy for Universal Health in accordance with their respective national contexts and needs.
During the reporting period, PASB implemented several initiatives to respond to the differentiated needs of people, including persons living in conditions of vulnerability. In addition, 15 countries undertook reviews of inequities and inequalities in health, and developed country plans to address challenges identified.
The Commission on Equity and Health Inequalities in the Americas, established by the Director of PAHO in 2016 under the leadership of its Chair, Sir Michael Marmot, advanced in its mission to gather evidence about health inequities and inequalities in the Region, with a view to their reduction. The Commission’s first draft report was discussed in June 2018, and its final report, with recommendations to reduce or eliminate health equity gaps, is expected to be completed by the end of 2018. In 2017, the Commission convened several expert and advocacy meetings to discuss key issues affecting inequities, including in Colombia to examine ethnicity and its impacts on health, and in Costa Rica to focus on matters pertaining to gender and violence. In 2018, the Commission met in Trinidad and Tobago to address human rights issues, and in Atlanta, Georgia, United States of America, to discuss issues related to civil rights and minority populations in North America, under the auspices of the Morehouse School of Medicine.
Mais Médicos, Trocará, Pará, Brasil
A new PAHO Policy on Ethnicity and Health (CSP29/7, Rev. 1) was approved by the 29th PASC in 2017, following an extensive process of consultations with ministries of health; indigenous, Afro-descendant, and Roma peoples; and other key stakeholders. The policy seeks to ensure access to health for all ethnic groups by incorporating intercultural approaches into technical cooperation. The discussions surrounding the policy generated increased attention to ethnic disparities in health and fueled demand for technical cooperation and evidence on this issue. A number of PASB initiatives responded to this increased interest or reflected interprogrammatic collaboration resulting from ongoing efforts to mainstream gender and ethnicity concerns in all PAHO technical cooperation. For example, PASB collaborated with the Population Division (CELADE) of the Economic Commission for Latin America and the Caribbean (ECLAC) and the United Nations Population Fund (UNFPA) to produce a comprehensive Spanish-language report on the situation of Afro-descendants in Latin America and the Caribbean. The report is being used as a key source of data for analysis of Afro-descendants’ health in the Andean and other subregions. In addition, several reports analyzing the needs of indigenous and Afro-descendant populations in specific health issues were completed. PASB produced an analysis of human immunodeficiency virus (HIV), hepatitis, and sexually transmitted infections (STIs) among indigenous and Afro-descendant people, followed by the development of specific methodologies for addressing the identified issues.
The Bureau adapted WHO’s “Innov8,” an integrated programmatic tool focused on gender, equity, and rights, for use in The Americas. The tool, to which PASB added an ethnicity component, was used by the Dominican Republic and Jamaica in health program design and implementation, with the aim of ensuring inclusivity. PASB also intensified efforts to ensure the inclusion of gender and ethnicity perspectives in PAHO Country Cooperation Strategies (CCSs), particularly in Jamaica and Trinidad and Tobago.
PASB developed regional conceptual documents and technical webinars to support resolutions and facilitate new areas of technical cooperation in the areas of gender, masculinities, and health; gender identities; and access to health for LGBT persons. The Bureau made progress in the preparation of a report on the health situation and access to care of LGBT persons, the barriers they can face in accessing health care services, and the impact of reduced access for these persons. This report was mandated by the landmark PAHO resolution titled “Addressing the Causes of Disparities in Health Services Access and Utilization for Lesbian, Gay, Bisexual and Trans Persons” (CD52.R6), which was adopted by the 52nd PAHO Directing Council in 2013, based on data provided by 33 Member States and 28 nongovernmental organizations (NGOs) in the Americas. Following a peer review, the report will be finalized and presented to PAHO Member States by the end of 2018. Its findings on barriers, such as stigma and discrimination, lack of policies or comprehensive services, and inadequately trained personnel, will provide the basis for greater attention to the utilization of health services by LGBT persons and to targeted technical cooperation in this area.
PASB prepared a regional interprogrammatic report on gender, masculinities, and health, the findings of which will be discussed by key stakeholders at the subregional level and which will form the basis for spearheading new policy responses to address gaps related to masculinities and men’s health. Progress is being made by countries in advancing gender equality in health under the umbrella of universal health, including documentation of social protection in health, with attention to unpaid health care; commitments to women’s, children’s, and adolescents’ health for 2018-2030; and monitoring equity with specific gender indicators.
During this period, the PASB increased leadership and technical support to advance the health of women, children, and adolescents. The launch of Every Woman, Every Child – Latin America and the Caribbean (EWEC-LAC), and the Santiago Commitment to Action, with the sponsorship of the President of Chile, Her Excellency Michelle Bachelet, in 2017, gained interministerial-level political commitment for the implementation of the Global Strategy for Women’s, Children’s and Adolescents’ Health in the Region. EWEC-LAC is an interagency movement that supports country efforts to reduce inequities in access to health for women, children, and adolescents. PASB refocused technical cooperation for the implementation of the Strategy and made progress in the development of a plan of action that will be presented at the 56th PAHO Directing Council in September 2018.
Within this framework, during this period, implementation was accelerated on the Director’s “Zero Maternal Deaths by Hemorrhage” flagship initiative, which aims to reduce the equity gap in maternal mortality in 10 priority countries with at-risk maternal mortality indicators: Bolivia, Dominican Republic, Guatemala, Guyana, Haiti, Honduras, Nicaragua, Paraguay, Peru, and Suriname. PASB employed an interprogrammatic approach, building synergies across technical departments and country offices to improve efficiency in technical cooperation. Ten additional advisors on women’s health and maternal mortality reduction have been placed in these countries to increase technical cooperation for country-specific interventions, particularly innovative interventions to strengthen local capacity to reach women most at risk and in situations of vulnerability. These interventions consider the clear linkages between gender inequalities and high rates of maternal mortality among indigenous women in the Region. This modality of technical cooperation has proven to be effective. Four of the countries involved (Bolivia, the Dominican Republic, Guatemala, and Peru) reported that since the implementation of this initiative, there have been no maternal deaths due to hemorrhage. Paraguay reported reductions of 30% in the maternal mortality ratio and of 18.6% in the neonatal mortality rate, as of December 2017. PASB undertook technical cooperation with 32 countries in the Region. The regional Network for the Surveillance of Maternal and Neonatal Mortality was consolidated, with the implementation of two projects related to maternal mortality, Near Miss and the Assistance Network for Women in an Abortion Situation (MUSA). The Network for Surveillance aims to improve the analysis of data on maternal and neonatal health in the Region. The Region of the Americas is the only WHO region that has implemented this surveillance initiative.
Country-focused interprogrammatic work – maternal and perinatal health and environment
Nicaragua: An interprogrammatic project, “Healthy, Green and Sustainable Maternal Houses,” developed self-assessment instruments to evaluate environmental risks and identify priority mitigation interventions. This is part of a broader strategy to reduce maternal and perinatal mortality by improving maternal delivery care and creating environments that protect and promote health in the home. The project was supported by national and local authorities and institutions, including the Center for Health Research and Studies, and the Center for research in Workers’ Health and Environment. Funding is from the PASB-Canada Integrated Health Systems in Latin America and the Caribbean (IHSLAC) project.
In further targeting children’s health, the Bureau promoted integrated policies and services to accelerate progress on the health and development of children through sharing lessons learned from best practices in countries; updating countries on evidence-based approaches and strategies for multisectoral action; engaging health and social development ministries in current global efforts to improve the development of young children; and providing training on responsive caregiving. These efforts will contribute to increased access to, and coverage of, interventions that promote the health and development of children during the first years of life. All these activities were conducted as joint efforts with the UN Children’s Fund (UNICEF) and WHO, in collaboration with other partners, including the Bernard Van Leer Foundation, Plan International, the World Bank, and others. PASB facilitated the development of the Nurturing Care Framework, with the participation of more than 15 countries, and launched it at the 2018 World Health Assembly. The Bureau also established a network of experts and institutions on early childhood that includes UNICEF, the UN Educational, Scientific, and Cultural Organization (UNESCO), and research centers and universities from various countries. Political advocacy, partnership, and engagement of communities have been central to these efforts.
As part of its technical cooperation, PASB worked with 21 countries to review and update their adolescent health strategies, implement standards for adolescent health services, and build capacity for the implementation of Global Accelerated Action for the Health of Adolescents (AA-HA!) through subregional and country level workshops, the latter in Barbados, Brazil, Guyana, Haiti, Saint Vincent and the Grenadines, and Suriname. PASB also undertook technical cooperation in the development of health plans for indigenous and Afro-descendant youth, based on the priorities self-identified by these groups. The regional Accelerating Progress Toward the Reduction of Adolescent Pregnancy in Latin America and the Caribbean report has been completed, and a report on youth health is being prepared.
The Bureau made progress in the implementation of the IHSLAC project, a collaborative effort between PASB and Global Affairs Canada (GAC). The project, which runs from 2016 to 2019, is being implemented in 11 countries: Bolivia, Colombia, Ecuador, Guatemala, Guyana, Haiti, Honduras, Nicaragua, Paraguay, Peru, and Suriname. The aim is to improve the health of children, young girls, and women (including mothers) in situations of vulnerability in Latin America and the Caribbean. Through this project, national health authorities have been able to reach out to underserved, hard-to-reach, and socioeconomically disadvantaged communities. The results reported during this period included: 100% exclusive breast-feeding of children (11,000+) born to mothers in maternity homes; provision of basic equipment, commodities, and other materials to support service delivery in 150 health facilities and two community networks in eight countries (Bolivia, Colombia, Ecuador, Guatemala, Haiti, Honduras, Nicaragua, and Peru); and community action, including support for implementation of telemedicine services, in Paraguay. Among other results reported during this period were: deworming treatment provided to approximately 305,214 people; screening of 1,457 children under 15 years of age for Chagas disease; screening of 1,500 women for cervical cancer; and building awareness on empowerment issues among 11,000+ women, including concerning entrepreneurship, leadership, participation, and the right to paid work. In addition, the project supported the development of policies, plans, standards, guidelines, and tools that are based on equity, human rights, ethnicity, and gender approaches. All 11 countries supported human resources capacity-building activities, and more than 11,000 health providers benefited from training and/or awareness activities.
PASB conducted advocacy and strategic interventions to support implementation of resolution CD55.R13, on the health of migrants, which was approved by the 55th PAHO Directing Council in 2016. At a side event at the 29th PASC in September 2017 that had been proposed by Mexico and other countries, panelists agreed that health should be at the center of any migration policy, and that PASB and PAHO Member States should jointly advocate for its inclusion in the Global Compact for Safe, Orderly and Regular Migration, currently in development. Such advocacy builds on the April 2017 Ministerial Declaration on Health and Migration, which was signed by 10 countries in Mesoamerica (Belize, Colombia, Costa Rica, Dominican Republic, El Salvador, Guatemala, Honduras, Mexico, Nicaragua, and Panama) and for which PASB provided political and technical support. The Ministerial Declaration established a series of joint working agreements to improve available information on the health situation of migrants and create partnerships to address their health needs in a comprehensive and timely manner.
Conscious of the need to strengthen the mainstreaming of PAHO’s crosscutting themes of human rights, gender, ethnicity, and equity in order to progress towards UH, during the reporting period the Director of PAHO undertook a reorganization of the Bureau that places the Office for Equity, Gender, and Cultural Diversity at the Executive Management level. This move aims to increase strategic and political actions to ensure that all PAHO programs and interventions take the crosscutting themes into consideration.
Selected PASB-supported interventions for groups in conditions of vulnerability
Argentina: The ministries of health and education collaborated to implement a comprehensive policy of care for children in the School Health Program (PROSANE), including dental, eye, and ear examinations, and immunization. In the framework of the Gran Chaco project, the preparatory phase of the implementation of Health Promoting Schools (HPS) in Salta Province was completed. HPS will foster intersectoral action for water, sanitation, hygiene, food and nutrition security, and disaster risk management. The preparation included workshops on ethnicity and intercultural health, with community participation in identifying actions for improving indigenous people’s access to quality health services.
El Salvador: A national policy on intercultural health was finalized in June 2018, under the leadership of the Ministry of Health and with full participation of indigenous groups, human rights associations, health sector institutions, and academia. The inclusion of indigenous groups represents an important step forward in reaching the unreached and leaving no one behind.
Guyana: Community awareness and sensitization sessions on gender-based violence and violence against women and children were conducted with law enforcement officers and health care providers in Regions 1, 7, and 8.
Jamaica: A comprehensive situation analysis of older persons was completed in December 2017 and a national framework for healthy aging drafted in January 2018, with ongoing identification of PHC best practices in this area.
Mexico: A community and gender approach to care of persons with diabetes was implemented in two states (Mexico and Campeche) in collaboration with local health authorities and the World Diabetes Foundation.
Panama: The UN Country Team contributed to advances in UH within the framework of the integrated health services delivery network (IHSDN) model. With special attention to indigenous people and border areas, PASB worked with UNICEF on healthy schools, with UNFPA on maternal health, and with the Food and Agriculture Organization of the United Nations (FAO) on family nutrition and community gardens.
Suriname: Ministry of Health programs for control of malaria, leishmaniasis, leprosy, and HIV/STIs collaborated to provide integrated PHC services to the mining population in the hinterland of Suriname.
South American subregion: In May 2018, meetings were convened in Paraguay and Brazil to discuss, respectively, border health in countries of the Southern Common Market (MERCOSUR) and indigenous people’s health in national health systems of the South American Chaco. The meeting in Paraguay aimed to promote South-South cooperation, while the event in Brazil addressed the incorporation of an intercultural focus in the respective national health systems.
United States of America: PASB collaborated with the United States National Council on Urban Indian Health (NCUIH) to adapt the Mental Health Gap Action Program (mhGAP) for indigenous communities, and to pilot an adapted guide with a group of Native American community health workers.
Promoting and accompanying health systems transformations based on PHC for UH
During this period, PASB advanced the implementation of a country-focused, comprehensive approach for technical cooperation with countries initiating or continuing major health systems transformation or strengthening initiatives. The technical cooperation modality, aiming at developing comprehensive road maps or national plans to advance towards UH, was tailored to the differing needs, realities, priorities, logic, and dynamics of country processes. Technical cooperation with an interdisciplinary approach was undertaken with a number of countries (The Bahamas, Belize, Bolivia, Chile, Dominican Republic, Ecuador, El Salvador, Guatemala, Guyana, Haiti, Jamaica, Panama, and Peru) to strengthen governance and stewardship, health financing, health legislation, and/or service delivery models consistent with a PHC approach and the Strategy for Universal Health. This technical cooperation modality involved direct technical support, capacity-building exercises, advocacy with high-level officials, facilitation of intersectoral national dialogues, and sharing of country experiences and evidence, according to needs.
Country-focused transformation of health systems towards UH
Dominica: A post-hurricane recovery action plan towards universal health is being developed, with close collaboration between PASB and Government authorities, to rebuild and transform the country’s health system towards greater resilience and effectiveness in the delivery of quality health care. The work included a first mission to reach agreements with the national authorities on the scope and areas of the technical cooperation, in accordance with the National Strategic Plan, and a rapid assessment of health services post-Hurricane Maria. Follow-up missions included assessment of first-level care facilities, governance and stewardship, and human resources for health. The action plan should be finalized by August 2018.
Haiti: In the context of the Government’s current initiative to develop a comprehensive transformation of the health system, members of the recently-created National Commission for the Reform of the Health System and Hospital Care were invited to a high-level discussion at PAHO Headquarters. PASB’s team facilitated the dialogue between the Reform Commission and Ministry of Health authorities, presenting case studies from other countries of the Region and facilitating discussion of feasible options for Haiti and a road map for increased collaboration. At the same time, a special mission to address important problems with the main public hospital in Port-au-Prince (Hôpital Universitaire de la Paix) was undertaken. During the mission, recommendations aiming to resolve urgent issues at the hospital, in order to make it an integral part of a network of care, were provided. Also, considering the importance of priority programs and development partner financing in Haiti, a joint mission to evaluate the country’s response to tuberculosis was undertaken, with a strong programmatic component and a health systems perspective.
Jamaica: Responding to a Government request to assess successes, challenges, and lessons learned from the implementation of a health sector reform program started in 1997, PASB conducted a comprehensive assessment of the public health care delivery services in Jamaica. The assessment concluded with specific recommendations on strengthening the PHC strategy, improving the stewardship capacity of the Ministry of Health, and increasing and improving health financing, among other areas. The findings were presented to a Cabinet meeting that included the Prime Minister. Concurrently, PASB undertook technical cooperation for the production of a national health insurance plan, supporting the supervisory national committee through virtual participation in meetings and provision of inputs to drafts of the plan.
Suriname: Following work started in 2017, PASB conducted an intensive two-week mission to Suriname to develop the outline of the Strategic Plan for Health and Well-being and a road map of activities to achieve the goals of the Plan. In a previous mission, technical cooperation involved discussion and development of a document on the model of care and organization of services for Suriname. In addition, PASB conducted a special study on fiscal space for health to provide Government authorities with specific feasible options for increased resources for the health sector, in the context of the delicate macroeconomic and fiscal situation that the country is experiencing. The presentation of the report will include the facilitation of necessary national dialogue between health and finance authorities.
PASB developed technical cooperation frameworks and tools geared towards strengthening stewardship and governance. The Monitoring Framework for Universal Health was finalized during this period and used to analyze progress being made by countries in increasing utilization of health services, eliminating barriers to access, and reducing health inequities. This included the analysis of access to health and equity using national health databases from seven countries in the Region (Canada, Chile, Colombia, Mexico, Peru, United States of America, and Uruguay) through robust methodologies standardized by the PASB. The results of this analysis provided information for the Regional Outlook on progress made in the last 5 to 10 years on health systems’ performance and impact on UH metrics across the Region of the Americas (“The Quest for Universal Health: Summary of Indicators on Health Systems Performance”) that is in the internet-based 2017 edition of PAHO’s flagship publication, Health in the Americas+, which provides health information and data for the Region. Progress was also made in the update of the Essential Public Health Functions Framework, through consultations with ministries of health, public health experts, and academia. The framework and tools will be critical for capacity-building on stewardship with national health authorities.
Technical cooperation in health financing addressed budgeting, financial resources and fiscal space, insurance, segmentation, and health accounts, among other issues. PASB experts met with representatives from 19 countries to discuss issues related to resource allocation and the challenges countries face in efforts to increase public expenditure in health with equity and efficiency. PASB’s technical cooperation supported dialogue and exchange of experiences to inform policy options for improving health financing, including payment systems and strategic purchasing in health services. During this period, PASB provided direct technical support to 17 countries for the improvement and regulation of financing systems that aim to enhance progress towards UH by prioritizing investment in PHC. Moreover, Chile, Colombia, Guyana, Haiti, and Peru now include social protection in health as a basic tenet of their health systems, and Mexico, Peru, and Uruguay have developed or updated their guaranteed health care benefit packages. Health financing studies were finalized in Barbados, Bolivia, Brazil, Chile, Colombia, Costa Rica, Ecuador, Guyana, Honduras, Jamaica, Nicaragua, Paraguay, and Peru, in order to provide them with concrete options for optimizing the efficiency of health system financing and for improving the fiscal space for health. A Spanish-language PAHO publication on fiscal space for health was premiered in April 2018 at the Cuba Salud 2018 convention.
Interprogrammatic collaboration has been recognized as improving the efficiency of health services, given the common concepts and platforms that characterize many public health interventions. This collaboration was consolidated, particularly with HIV prevention, to emphasize sustainability, especially in those countries graduating from Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund) support. There was also enhancement of joint work involving health systems strengthening; healthy life course and healthy aging; management and incorporation of vaccines, with Gavi; control and management of cancer and mental disorders; and control and management of Zika outbreaks. PASB supported full implementation of the interprogrammatic chronic kidney disease project (CSP29/INF/7, Item B) at regional and country levels during 2017.
PAHO’s CCHD framework for South-South and triangular cooperation continued to garner support from Member States and partners. Several new CCHD initiatives were launched in 2017-2018, including an intervention to improve maternal and child health along the border between the Dominican Republic and Haiti, and an intervention to improve the health of the populations of the South American Chaco, which spans Argentina, Bolivia, Brazil, and Paraguay.
Countries helping countries – PASB facilitating CCHD
Belize, Costa Rica, El Salvador, and Mexico: These four countries, on the road to elimination of malaria, undertook a comprehensive assessment of their programs in December 2017, aiming to strengthen their capacity for epidemiological and entomological surveillance, their information systems, the identification of foci of transmission, and the quality of their responses, in order to prevent endemic transmission.
Belize and Guyana: Key mental health personnel from Guyana participated in a one-week study tour to Belize that involved capacity-building activities and the development of an outline road map for a community-based mental health program in Guyana.
Canada and Cuba: An agreement between Canada and Cuba was signed in April 2018 for the strengthening of biosafety in the Cuban laboratory network, with a focus on the Pedro Kouri Institute of Tropical Medicine (IPK). Outputs include procurement of media for transfer of infectious substances to the national network, personal protection equipment, supplies and guidance from international experts for the establishment of a Biosafety Level 3 laboratory, and training in Canada for Cuban laboratory specialists.
CARICOM and Chile: CARICOM has long recognized NCD prevention and control as a priority issue for the subregion, as evidenced in the 2007 Port-of-Spain Declaration and the more recent Caribbean Cooperation in Health, Phase IV 2016-2025. Control of obesity has emerged as a key subregional strategy for NCD reduction, especially childhood obesity prevention, exemplified by the CARPHA Plan of Action for Promoting Healthy Weights in the Caribbean: Prevention and Control of Childhood Obesity 2014-2019. Chile has a history of efforts to establish a regulatory framework for addressing overweight and obesity, dating back to 2007. A law was approved by the Chilean Senate in 2012 and came into force in 2016, with provisions for front-of-package (FOP) nutritional labeling, restriction of the sale and promotion of unhealthy products in schools, and prohibition of the marketing of unhealthy products to children. Chile and CARICOM are implementing a project with the goal of learning from Chile’s knowledge and experience in order to develop and implement FOP labeling in the Caribbean. In addition to PASB, the cooperation team comprises the CARICOM Health Desk, UWI, HCC, CARPHA, Caribbean Law Institute Center (CLIC), CARICOM Regional Organization for Standards and Quality (CROSQ), CARICOM Office of Trade Negotiations, and the Government of Chile.
Central America and South America: The national cancer institutes of Argentina and Colombia collaborated with the ministries of health of El Salvador, Guatemala, Panama, Paraguay, and Peru to develop a CCHD project addressing population-based cancer registration. Also involved were the International Agency for Research on Cancer (IARC) and the Network of National Cancer Institutes of the Union of South American Nations (UNASUR). The project will reinforce the surveillance and information systems of the participating countries and facilitate decision-making and policy development for cancer prevention and control.
Cuba and Nicaragua: In the context of the transfer of manufacturing technology for influenza vaccine in Nicaragua, Cuba continued its tradition of South-South cooperation, using the Cuban National Regulatory Authority, CECMED, to work with Nicaragua to develop all functions recommended by WHO for medicines and biologicals, including licensing, postmarket surveillance, and regulatory oversight of locally manufactured products. Currently, CECMED is a National Regulatory Authority recognized by PAHO as a regional reference.
Gran Chaco project: A CCHD project called Towards Universal Health among the Population of the South American Chaco was initiated in 2017. It seeks to engage the Governments of Argentina, Bolivia, Brazil, and Paraguay in collaborative efforts to advance to UH in 20 municipalities in El Chaco. The project will benefit approximately 400,000 persons living in conditions of vulnerability, including indigenous people and rural populations.
Public health policies and intersectoral action
PASB continued to strengthen regional capacity on the Health in All Policies (HiAP) approach, and 30 experiences and good practices related to HiAP from 16 countries have been documented on PAHO’s online HiAP platform. Currently in development, a virtual course on HiAP for the Region of the Americas establishes a structured capacity-building program that can be rolled out across the Region, thereby supporting the sustainability of HiAP programming. By focusing on multisectoral approaches for addressing pressing health inequalities, the course will equip policymakers and other stakeholders to promote health equity across multiple dimensions, including interventions that target gaps in health outcomes according to the PAHO crosscutting themes of gender and ethnicity. This virtual course is the first example of an online adaptation of the WHO HiAP Training Manual to be rolled out, providing a unique opportunity for mainstreaming the crosscutting themes into intersectoral policy-making, and potentially serving as a model for other courses tailored for the Region.
The PHC approach requires revisiting health promotion and healthy cities interventions, and deciding, based on lessons learned, how to move forward with a comprehensive approach that is anchored in the twenty-first century, aligned with SHAA2030 and the SDGs, and enables progress towards UH. During the reporting period, PASB initiated the process for the development of a new strategy and plan of action on health promotion, including a review of experiences in the Region and informal consultations with health promotion networks and PAHO Member States. The strategy and plan of action on health promotion are expected to be completed in 2018.
As part of its efforts to reactivate the Network of the Americas for Healthy Municipalities, Cities, and Communities, PASB created the Healthy Cities Action Toolkit in 2017, which provides guidance to municipal leaders regarding planning health-promoting initiatives and policies. Piloting of the toolkit began in nine municipalities in El Salvador in January 2018 and is expected to start in municipalities in other countries in the Region by the end of 2018.
The Network of Health Promotion Managers of Latin America and the Caribbean (REDLACPROMSA) was instrumental in bringing health promotion to the local level. The groundwork to support the Network over the reporting period led to the ongoing development of a new network of mayors for healthy municipalities. It also contributed to the sustainability of initiatives and actions agreed upon among countries of the Network to advance the sustainable development and health promotion agendas, across different political administrations.
PASB fostered a better understanding of the economics of NCDs with two main goals: 1) to help health authorities advocate with heads of state and ministries of finance on the urgency of financing NCD prevention and control programs and 2) to demonstrate how economic policies that are outside the portfolio of ministries of health can help curb the NCD epidemic and have a positive economic impact. Toward these goals, PASB developed, and promoted the development of, evidence on the impact of NCDs on social and economic development at country and regional levels, as well as the costs and benefits of implementing prevention and control measures in country-specific contexts. PASB also promoted health and fiscal policy coherence, especially to mainstream taxation as a public health measure, and advocated for health and trade policy coherence. The Bureau highlighted the need to pursue the benefits of trade and investment agreements and economic integration, while also taking measures to prevent the negative impacts on health and well-being of increased accessibility and affordability of commodities such as tobacco, alcohol, and energy-dense, nutrient-poor, ultra-processed food.
The Bureau strengthened its unique role of facilitating intersectoral dialogue among finance, trade, and health officials by partnering with organizations that included WHO, United Nations Development Program (UNDP), World Bank (WB), International Development Research Center (IDRC), RTI Health Solutions, and the Public Health Agency of Canada (PHAC). In February 2018, PASB led a meeting on the economics of tobacco control, where the WB and International Monetary Fund (IMF) discussed their role in the use of tobacco taxes as a health measure. PASB also organized training on taxation of NCD risk factors, including tobacco, alcohol, and sugar-sweetened beverages.
In a related development, in 2017 the 29th PASC approved the new Strategy and Plan of Action to Strengthen Tobacco Control in the Region of the Americas 2018-2022 (CSP29/11), with the objective of accelerating implementation of the WHO Framework Convention on Tobacco Control (FCTC). The primary goals are to have a 100% smoke-free environment in all enclosed public and work spaces and to have graphic health warnings on the packaging of tobacco products in all Member States by 2022. The Strategy aims at reinvigorating the discussion on tobacco control in the public policy agenda, in light of SDG Target 3.a: “Strengthen the implementation of the WHO Framework Convention on Tobacco Control in all countries, as appropriate.”
The Bureau also addressed food labeling aimed at reducing consumption of unhealthy foods, which included support for 12 countries (Brazil, Canada, Colombia, Costa Rica, Dominican Republic, El Salvador, Guatemala, Honduras, Nicaragua, Panama, Paraguay, and Uruguay) and two integration mechanisms (the Caribbean Community (CARICOM) and the Central American Integration System (SICA)) in the design, formulation, revision, implementation, and/or monitoring and evaluation of front-of-package nutritional warnings. These warnings on packaged food and drink products will alert consumers to contents high in sugars, fats, and/or sodium. Such initiatives are key for addressing NCDs and protecting the right to health of all populations, but especially those in vulnerable situations, such as children and populations with low literacy.
In collaboration with regional and subregional integration entities, and civil society organizations, the Bureau played an important role in preparing Member States for participation in the Third UN High-level Meeting on NCD Prevention and Control (HLM3), scheduled for September 2018. PASB provided technical materials and undertook advocacy for countries to be represented at the highest political levels, calling on Member State capitals to ensure that their ministries of foreign affairs and permanent missions to the UN are well prepared to contribute to negotiations of the draft and final HLM3 outcome documents. As part of this advocacy, and given PAHO’s status as the specialized health agency of the inter-American system, PASB representatives participated in the Joint High-level Session of the Permanent Council of the Organization of American States (OAS) and the Inter-American Council for Integral Development that took place in March 2018. PASB was also represented at the Healthy Caribbean Coalition (HCC) Caribbean NCD Forum held in Jamaica in April 2018, and the Bureau’s contribution to the preparation of the Caribbean subregion for HLM3 was recognized in the Communique from the 39th Regular Meeting of the Conference of Heads of Government of CARICOM, held in July 2018.
PASB supported a number of subregional and country initiatives to address the high levels of violence against children and women in the Caribbean. This included workshops organized in collaboration with CARICOM, United Nations Entity for Gender Equality and the Empowerment of Women (UN Women), UNFPA, UNICEF, and the Johns Hopkins University School of Nursing, aimed at strengthening the capacity of health systems to prevent and respond to violence against women. Technical cooperation was also undertaken with countries to ensure that existing normative guidance (policies and protocols) informing the health service response to violence against women is based on the latest available evidence and on WHO recommendations. PASB’s alliance with Canada in this area has been instrumental in promoting the health of women and children survivors of intimate partner and sexual violence in the Americas, enabled by the that country’s Feminist International Assistance Policy, which was launched in June 2017. PASB worked with The Bahamas, Barbados, Guyana, and Trinidad and Tobago to review their existing guidance and partnered with UN Women and the Inter-American Development Bank (IDB) to carry out national surveys on violence against women in seven Caribbean countries (The Bahamas, Barbados, Guyana, Jamaica, Suriname, Trinidad and Tobago, and Turks and Caicos Islands).
Using a methodology developed by WHO, PASB undertook technical cooperation with the Dominican Republic to reduce road traffic injuries, based on evidence.
Addressing road safety in the Dominican Republic
Ranked as the country with the highest estimated road traffic mortality rate (41.7 per 100,000 population) in the 2015 Global Report on Road Safety, the Dominican Republic decided to make road safety a top priority in its 2016-2020 Government Plan and established a presidential commission on the issue. With PASB’s technical cooperation and the commission’s leadership, the country developed a National Road Safety Strategic Plan, promoted a new law (Law 63-17) on road safety, and established the National Institute of Traffic and Land Transportation (INTRANT). In parallel with these activities, the Strategic Plan for the Transformation of Urban Mobility (2017-2022) was developed, which complements the national plan to improve road safety.
PASB’s technical cooperation during the reporting period addressed environmental health issues and climate change adaptation. Household air pollution is a significant and avoidable public health risk in the Region, amenable to elimination or substantial reduction, in line with SDG Target 7.1.2 (“Proportion of population with primary reliance on clean fuels and technology”) and Target 3.9.1 (“Reduction of mortality due to air pollution”). A special initiative is being conducted in countries where solid fuels and kerosene are still in regular use for cooking, to accelerate the transition to clean energy and technologies, with a focus on urban settings. This represents a stepwise approach to clean energy for all by 2030, and presents an opportunity for numerous health-environment co-benefits, including climate change mitigation. Small island developing states (SIDS) are among the nations most vulnerable to climate change and health impacts, and the Caribbean region is not exempt from these impacts. PASB is implementing a special initiative on climate change and health in SIDS. The Bureau is developing, jointly with relevant Member States, a Caribbean action plan, to ensure that, by 2030, all health systems in Caribbean SIDS will be resilient to climate variability and change.
PASB continued to strengthen the role of health actors in the response to reduce the adverse health effects of air pollution, particularly among children, adults with cardiovascular and respiratory diseases, and older persons. To this end, the regional BreatheLife campaign was launched during the 29th PASC in 2017. The initiative increases awareness of the impact of household and ambient air pollution on health, and the co-benefits of reducing air pollution to mitigate the effects of climate change. Ten cities have joined the campaign, committing to reduce emissions to safe levels by 2030 and to measure related health outcomes. The launch was followed by a technical workshop for representatives from ministries of health and environment in 15 Member States, organized in collaboration with UN Environment, Climate and Clean Air Coalition (CCAC), and Clean Air Institute. Funding was provided by Norway for the CCAC.
As a broader initiative to mainstream climate change into national health policies and strategies, PASB organized capacity-building workshops for health representatives in the Caribbean, Central America, and South America, to develop chapters on health in national adaptation plans on climate change. The efforts were co-funded by the respective subregional integration mechanisms and subregional institutions, including the CARICOM Secretariat, CARPHA, Caribbean Community Climate Change Center (5C’s), Amazon Cooperation Treaty Organization (ACTO), and Andean Health Organization (ORAS).
Strategic focus on the first level of care within integrated health services delivery networks to address priority health problems
A PHC approach to the organization of service delivery requires people- and community- centered models of care to ensure access to comprehensive, quality health services that include promotion, prevention, cure, rehabilitation, and palliation, for common conditions. During this period, the PASB’s technical cooperation resulted in improvements in the organization of health services through the development of health care models that focus on the needs of people and communities, and on increasing response capacity at the primary level of care through integrated health services delivery networks to address a wide range of public health priorities, including maternal and child health, sexual and reproductive health, NCDs, mental health, injury prevention, communicable diseases, and health emergencies.
As part of the implementation of road maps for UH, PASB undertook technical cooperation for health services organization with Belize, Chile, Dominican Republic, Ecuador, Guatemala, Guyana, Jamaica, and Suriname in areas that included policies, legislation, hospital management, strengthening the first level of care, and integrated health services delivery networks. In order to facilitate countries’ development of IHSDNs, PASB developed a new tool for assessing progress in this regard, which was tested in five countries: Colombia, Cuba, Honduras, Panama, and Paraguay. The tool is designed to assess the level of integration of service delivery networks based on the IHSDN framework, to identify gaps, and to define interventions to strengthen management of the networks, including the primary level of care and specialized services. During the first semester of 2018, a virtual training course on IHSDNs was made available to all Member States via the Virtual Campus for Public Health (VCPH), to facilitate the development of such networks. By mid-2018, the course had drawn 290 participants from 16 countries. In addition, more than 200 managers received training on IHSDNs in Belize, Guyana, Panama, Peru, and Saint Lucia. Furthermore, a course on universal health was made available on the VCPH, drawing 1,200 participants by July 2018.
Seven countries implemented the updated Productive Management Methodology for Health Services (PMMHS) developed by the PASB: Brazil, Chile, Dominican Republic, Ecuador, El Salvador, Honduras, and Panama. New tools, including the PERC (Production, Efficiency, Resources and Cost), for the analysis of productivity, efficiency, and cost of health services, and the Assessment of Essential Conditions (AEC), to analyze the quality of health services, were made available to countries. With the AEC tools, technical cooperation was undertaken with 32 hospitals in five countries (Brazil, Colombia, Dominican Republic, Honduras, and Panama), for the analysis of essential conditions.
PASB’s technical cooperation to develop people-centered models of care also addressed the promotion of intercultural approaches, including traditional, complementary, and integrative medicine (TCIM). During this period, the interprogrammatic action plan that had been developed collectively with countries in a June 2017 regional meeting on traditional and complementary medicine for advancing toward universal health was implemented. Efforts are focused on technical cooperation with Member States to strengthen their capacity to integrate TCIM into national health systems. The Bureau facilitated the development of an expert network in this area, and in March 2018 the Director of PAHO launched the Virtual Health Library on Traditional, Complementary, and Integrative Medicine, (VHL TCIM), which aims to improve information access and foster research capacity and collaboration in this area, with the goal of supporting informed decision-making.
In May 2018, the PASB hosted a webinar on the contributions of TCIM to PHC that described the Brazilian experience, the perspective of indigenous peoples, and the initiatives of the United States National Center for Integrative Primary Healthcare (NCIPH). The Bureau also facilitated the participation of delegates from Brazil, Cuba, and Curaҫao in a WHO interregional training workshop on appropriate integration of traditional and complementary medicine in health systems and health care services, as well as the participation of delegates from Chile and Peru in a WHO interregional training workshop on the quality of traditional and complementary medicine services. Both those events were in the Macau Special Administrative Region of China. PASB supported other WHO-led initiatives, such as an update to the Second Global Survey on National Policies and Regulations on Traditional and Complementary Medicine, to which 25 PAHO Member States responded, and the participation of regional experts in working meetings for the development of TCIM training and practice benchmarks.
The functionality and well-being of older persons living with a chronic condition were improved through the implementation of evidence-based chronic disease self-management programs in 13 countries: Anguilla, Antigua and Barbuda, Argentina, Barbados, Chile, Dominica, Grenada, Martinique, Mexico (Mexico City and Guadalajara), Peru, Saint Kitts and Nevis, Saint Lucia, and Saint Vincent and the Grenadines.
PASB supported the implementation of the Global Hearts Initiative in primary care clinics in Barbados, Colombia, Chile, and Cuba, to reduce cardiovascular risk through hypertension control and secondary prevention. Demonstration sites were established in Bridgetown, Barbados; Santiago, Chile; Cali, Colombia; and Matanzas, Cuba. The interventions comprise implementation of standardized hypertension treatment control guidelines, training of providers, establishment of a core set of medications, and use of a registry for patient follow-up. A network of 12 municipalities and states was established in the four implementing countries with partner organizations that included the Latin American Society of Hypertension, the InterAmerican Heart Foundation, and the Inter-American Society of Cardiology. Early results show that these interventions can lead to increased coverage and access to hypertension control services, and improved hypertension control in the populations served. The activities were carried out in collaboration with the countries’ ministries of health and with support from the United States Centers for Disease Control and Prevention (U.S. CDC), the World Hypertension League, and several leading international experts in hypertension control.
Via its technical cooperation work, the Bureau increased access to, and the quality of, services for cervical cancer prevention and control, focusing on the promotion of human papillomavirus (HPV) testing for cervical cancer screening and the diagnosis and treatment of precancerous lesions in primary care. This work included disseminating new evidence and PAHO guidelines on the effectiveness of HPV testing throughout the Region; updating national cervical cancer guidelines in the Dominican Republic, Peru, and Suriname; training primary care providers in El Salvador and Guyana on screening; conducting refresher training to improve the competencies and skills of gynecologists from Bolivia, Colombia, Honduras, Paraguay, and Peru in colposcopy, biopsy, and treatment of precancerous lesions; equipping clinics in Bolivia and Honduras with new colposcopy units; and conducting a cervical cancer program needs assessment in Bolivia, in collaboration with the United Nations Joint Global Program on Cervical Cancer Prevention and Control.
PASB also launched a Web-based training course on comprehensive cervical cancer control through the PAHO VCPH, in which, as of mid-2018, over 3,000 primary care providers had participated. Partners in these activities included ministries of health, the U.S. CDC, and the International Agency for Research on Cancer (IARC). Financial support was received from the Government of Canada, the U.S. CDC, and the OPEC Fund for International Development (OFID).
PASB supported efforts to integrate interventions for ocular health in primary care, with notable initiatives in four countries during the reporting period: Argentina, Chile, Colombia, and Trinidad and Tobago. In Argentina, the Bureau supported a policy and legislative advocacy effort by national professionals that achieved increased coverage for the control of visual loss from retinopathy of prematurity. In Chile, the National Board of School Aid and Scholarships documented best practices and barriers to coverage of services for refractive errors associated with visual impairment, as well as increased the percentage of children wearing glasses. In Colombia, ocular health among indigenous people in the department of Vaupés was improved through the training of PHC personnel in the detection of visual deficiencies in adults, and of surgeons in cataract removal techniques, as well as through the use of a public-private partnership to offer care to indigenous people in remote rural environments. In Trinidad and Tobago, a “health system dynamics” framework was used to synthesize data and identify health system barriers, in order to prioritize actions for strengthening primary care for the early detection of eye disease.
Country-focused strengthening of integrated health services delivery networks
Chile: PASB supported the implementation of the PERC tool in the 25 reference hospitals and the development of cost and expenditure models that account for the complexity of the health services offered. These models are used by the Ministry of Finance and the Ministry of Health to map out equitable payment mechanisms based on efficiency and quality of health services.
El Salvador: In the framework of the health reform program 2017-18, PASB supported the Ministry of Health in the implementation of the PERC system, generating updated information on production, efficiency, and costs of all primary care services and the hospitals in 17 basic integrated health systems (SIBASIs) and five health regions. This process involved PAHO's transfer of appropriate technology and the development of institutional capacities in the country. Currently, in addition to the Ministry of Health, the PERC tool is installed and operating in all the facilities of the Salvadoran Institute for Comprehensive Rehabilitation (ISRI) and the Solidarity Fund for Health (FOSALUD).
Honduras: The implementation of the Evaluation of Essential Conditions (VCE) in national hospitals as part of the PMMHS facilitated the development of continuous improvement plans aimed at guaranteeing access to health services and quality care. These processes have produced transformations in the organizational culture that are evident to patients, and the transfer of knowledge to the work teams of the hospitals has allowed continuity in the processes.
Nicaragua: PASB supported the integration of complementary medicine practitioners who were located in health centers and primary level hospitals as part of the Family and Community Health Model (MOSAFC), and facilitated training for the incorporation of new protocols in 11 clinics of the Ministry of Health’s Institute of Natural Medicine and Complementary Treatment.
Peru: Studies on the use of medicinal plants have been conducted, and the process is proceeding for the Center for Complementary Medicine of EsSalud, the national social security program, to become a WHO Collaborating Center.
Venezuela: The progressive loss of operational capacity in the national health system over the past five years intensified during 2017. Since April 2017, PASB and the Ministry of Health (MPPS) have cooperated to strengthen services in 11 high-priority hospitals of high complexity in main cities, including Caracas. Staff were trained in hospital safety and prevention of health care–associated infections, and on evaluations of essential capabilities within these hospitals. In addition, basic and complementary units of the Interagency Emergency Health Kit, which provides medicines and medical devices for 10,000 people for approximately three months, were distributed to the 11 hospitals, with more to be procured for those institutions. The Bureau is working with the MPPS to strengthen the national primary health care network, where Cuban medical cooperation has been provided for 16 years. With PASB support, professionals from 24 states were trained in essential methodologies to improve obstetric and other medical services.
The integration of mental health into primary care services has proven essential for the development of equitable service delivery, bridging the mental health treatment gap, and enhancing UH. PASB provided technical cooperation in this area through the Mental Health Gap Action Program Intervention Guide (mhGAP-IG). In coordination with ministries of health, local universities, and PAHO/WHO Collaborating Centers, PASB assisted in mhGAP training in 12 countries and in one regional training-of-trainers event during the reporting period. Additionally, mhGAP was implemented using the PAHO VCPH to train PHC providers in constrained-resource settings, and a pilot virtual clinic was set up to ensure supervision and follow-up for those PHC professionals trained online in mhGAP. In addition, work was initiated on a study funded by the IDB to examine the association between alcohol and/or drug use and traffic-related injuries in selected emergency departments in four countries of the Region (Chile, Dominican Republic, Jamaica, and Peru). The study will provide evidence to inform brief interventions at the primary care level for injured patients, with the aim of preventing subsequent episodes.
Country-focused improvements in mental health services in primary care - mhGAP
Argentina: Training of trainers from the Ministry of Health in the Mental Health Gap Action Program (mhGAP) was undertaken and followed by training in three provinces, representing the start of countrywide capacity-building and implementation in different localities. In Jamaica, in March 2018, two trainers were trained in the updated version of mhGAP, to facilitate their instruction of PHC providers on the integration of mental health care into primary care services. In Trinidad and Tobago, two mhGAP training-of-trainers sessions were held and then rolled out to the various regional health authorities to strengthen the capacity of front-line primary care physicians and nurses for screening, initial management, and referral of persons with mental health disorders.
Brazil: Technical cooperation to implement the Portuguese-language translation of the mhGAP guide facilitated the training of approximately 300 primary care and mental health professionals in the states of Rio Grande do Sul, Minas Gerais, Goiás, Tocantins, Ceará, and in the Federal District. In Mexico, PHC teams in six border states received mhGAP training, in partnership with the United States-Mexico Border Health Commission. In Venezuela, PHC workers were trained in the detection and treatment of mental health problems.
Human resources for universal health
The Region’s health leaders approved the PAHO Strategy on Human Resources for Universal Access to Health and Universal Health Coverage (CSP29/10) through resolution CSP29.R15 at the 29th PASC in September 2017. Subsequently, PASB led the development of the Plan of Action on Human Resources for Universal Access to Health and Universal Health Coverage 2018-2023 (CE162/16) through a process of extensive consultation with countries and key stakeholders. The Plan of Action will be presented to the 56th PAHO Directing Council in September 2018, and, like the Strategy, focuses on the importance of human resources as a fundamental component for the achievement of UH, particularly utilizing a PHC approach for the expansion of access to quality comprehensive services for populations in conditions of vulnerability in underserved areas. Both frameworks highlight the need for intersectoral action, between health, education, labor, and finance, among others; long-term human resources planning and forecasting; increased public investment in human resources; widening of access to interprofessional teams in primary care settings; and reorienting education for the health professions toward PHC.
PASB developed a diagnostic instrument called the Indicators for Social Accountability Tool (ISAT) to help educational institutions dedicated to the health professions assess their progress towards social accountability. A product of the PASB-supported Consortium of Social Accountability in Health Professions Education in the Region of the Americas, the tool measures the extent to which education programs have curricula that are aligned with social needs; select students in targeted ways to guarantee diversity and gender equity; include training in the primary care context in which graduates are expected to serve; include regional postgraduate training and career pathways in underserved regions; offer interprofessional education and practice; and engage in meaningful partnerships with communities and other stakeholders. The ISAT will be available in Spanish, English, and Portuguese and will be tested in Argentina, Barbados, Brazil, Canada, Chile, Cuba, Guyana, Jamaica, Mexico, Nicaragua, Panama, Suriname, Trinidad and Tobago, and the United States of America during 2018.
In order to strengthen health workforce planning, PASB conducted workshops for over 50 ministry of health staff, PAHO/WHO technical officers, and other stakeholders in Costa Rica and Guatemala. The workshops were a first step in introducing an innovative model for workforce strengthening that focuses on futures thinking and horizon scanning, an analysis of workforce characteristics, and generating and quantifying scenarios. As follow-up, the PAHO VCPH will provide virtual resources and deliver workshop-related webinars. Additional workshops are planned for 2018 in Belize, Dominica, El Salvador, Guyana, Paraguay, and Suriname. PASB is also collaborating with WHO Headquarters, the WHO European Regional Office, and academic institutions to develop a network for health workforce planning, to complement the training.
PASB supported a subregional study on the migration of health workers in the Caribbean. The results will be used to inform implementation of the Caribbean Plan of Action on Human Resources for Universal Health (HRUH) 2019-2023, the output of a subregional workshop held in April 2018. The Caribbean Plan of Action on HRUH is aligned with the regional Plan of Action for Human Resources for Universal Access to Health and Universal Health Coverage 2018-2023, which was discussed at the 162nd Session of the Executive Committee in June 2018 (CE162/16) and which will be presented to the 56th PAHO Directing Council in September 2018 for approval. The Caribbean Plan of Action also aligns with the CARICOM health agenda (the Caribbean Cooperation in Health (CCH)), which is now in its fourth phase, CCH IV 2016-2025.
The Bureau organized a regional initiative with the PAHO/WHO Collaborating Center in Primary Health Care and Health Human Resources at McMaster University (Canada) that was centered on advanced practice nursing (APN). A six-part webinar series was offered in English and Spanish, with the goal of increasing interest in, and awareness of, the APN role for nurses and key stakeholders in Latin America. The initiative also produced regionally focused publications on nursing education for UH, doctoral training in nursing, and strategic direction to nursing. In addition, a new publication titled “Expanding the Roles of Nurses in Primary Health Care” was launched during the celebration of International Nurses Day 2018.
The Regional Network for Interprofessional Education in the Americas was established with the support of the ministries of health of Argentina, Brazil, and Chile during a regional technical meeting on interprofessional education (IPE) held in Brasilia in December 2017. Approximately 120 participants from 23 countries of the Americas were present at the event, which resulted in the presentation of national IPE plans prepared by 18 countries and a regional plan of activities and publications for 2018-2019. PASB is monitoring the activities and providing technical cooperation for development of the network.
PAHO’s VCPH continued to grow as a learning platform based on people, institutions, and organizations that share courses, resources, services, and activities for education, information, and knowledge management. A new node was established for the English-speaking Caribbean in collaboration with the Caribbean Public Health Agency (CARPHA), and a node in Central America was updated in collaboration with the Council of Ministers of Health of Central America (COMISCA). The number of VCPH users increased from 174,568 in 2016 to 568,037 by mid-2018. In 2017, 13 tutored courses were offered and were completed by 525 professionals, while more than 200,000 additional professionals per year took self-learning courses. The VCPH’s most popular course, as of mid-2018, was on the correct completion of death certificates. The course is available in English, Spanish, and French, and has attracted more than 80,000 certified participants, to date.
The Region has numerous successful initiatives for strengthening HRUH, several implemented at subnational level, focused on expanding access to quality comprehensive services.
Country-focused HRUH strengthening for improved access to quality services
Argentina: In the framework of the Gran Chaco project, and in collaboration with the Garrahan Foundation, capacity-building of health workers, health promoters, nurses, doctors, and obstetricians took place in the province of Salta, aiming to strengthen services in areas with the highest levels of poverty and infant and maternal mortality. In the province of Santiago de Estero, 1,015 community health workers and 31 doctors were trained in the management and implementation of the Integrated Management of Childhood Illnesses (IMCI) strategy, to improve the care given to children and pregnant women at the primary level. The capacity-building also aimed to validate the role of community health workers, empower them, and contribute to their career development.
Brazil: The Mais Médicos program was started in 2013 and has now been extended until 2023. The program has deployed over 17,281 Brazilian and foreign health care professionals to more than 3,819 municipalities, most of them socioeconomically vulnerable areas in remote zones, on the outskirts of cities, or in Brazil’s 34 special indigenous health districts. As of June 2018, the program was serving an estimated 59 million people in historically underserved communities. The participation of foreign health care professionals, many from Cuba, provides a demonstration of triangular cooperation in support of UH. PASB continued to undertake technical cooperation with the Mais Médicos program for the development and implementation of a monitoring and evaluation framework, as well as documentation of best practices and lessons learned. A systematic analysis focusing on the effectiveness of the program was done, with results showing a decrease in hospitalizations due to conditions sensitive to primary care of up to 20%; a reduction of hospital costs of up to 32%; and improvements in trends of indicators for exclusive breast-feeding, among other effects.
Caribbean: In September 2017, the CARICOM Council for Human and Social Development (COHSOD) agreed on seven priority areas for the Caribbean Roadmap 2018-2022 to strengthen HRUH in the subregion, in line with the PAHO Strategy on Human Resources for Universal Access to Health and Universal Health Coverage. Ten Caribbean countries now have finalized (or are in the process of finalizing) HRUH plans, aligned with the strategic objectives in the PAHO Strategy and with PHC. The implementation of these plans will be facilitated by the subregion’s strengthened and expanded partnerships for HRUH development; partners now include CARICOM; Organization of Eastern Caribbean States (OECS); University of the West Indies (UWI); universities of Belize, Guyana, and Suriname; IDB; Caribbean Development Bank (CDB); European Union (EU); NextGenU, the World’s first free, online accredited university; Humber River Hospital; Axon Medical Technologies; and International Business Machines (IBM).
Chile: PASB successfully conducted an evaluation of the National Single Examination of Medical Knowledge (EUNACOM) in Chile, the first country where PASB has conducted such an assessment. The EUNACOM is applicable to all graduates of medical schools in Chile and to doctors who qualify abroad and wish to practice in the country. The purpose of the examination is to ensure that these health professionals have the appropriate profile and performance for Chile’s needs, and provide quality care at all levels. The PASB evaluation aimed to contribute to strengthening HRUH in Chile, especially at the primary care level.
Nicaragua: With PASB’s technical cooperation, the School of Medical Sciences at the National Autonomous University of Nicaragua (UNAN) in Léon incorporated a course titled “Community Practices Based on Primary Health Care” into its core training curriculum. The course will allow students to undertake rotations of six to nine weeks each year in Years 2 through 6, located in various settings, including the classroom, laboratories, health centers, and hospitals. The aim is to improve coverage in areas where students are located, including in more remote communities.
Peru: PASB partnered with national and local health authorities, and academia, to reduce illness and death due to diabetes in nine regions of the country with high prevalence of the disorder, with financing from the World Diabetes Foundation. The capacity of 979 health professionals was strengthened through their participation in the course “University Diploma in Comprehensive Management of Diabetes Mellitus Type 2” implemented by the Cayetano Heredia Peruvian University. Related activities included provision of supplies to PHC facilities and implementation of a communication strategy.
Trinidad and Tobago: PASB supported a Cabinet-approved training of caregivers and parents of children living with autism and other developmental disorders, in partnership with the Office of the Prime Minister; the Gender and Child Affairs Unit, which provided funding; WHO; and Autism Speaks.
Access to medicines and health technologies
The selection, incorporation, and use of medicines and other health technologies significantly affect the efficiency of health systems and are critical determinants of health outcomes. PASB’s technical cooperation helped countries to advance in strengthening and institutionalizing health technology assessments (HTAs), as called for by the 28th PASC in 2012 (CSP28.R9). As of mid-2018, 13 countries had established HTA units, commissions, or institutes, and 33 institutions from 16 Member States were members of the Health Technology Assessment Network of the Americas (RedETSA). The first regional HTA database (BRISA) was launched in November 2017, initially with 600 reports, and approximately 450 health professionals were trained in the assessment and management of health technologies through PASB and RedETSA capacity-building activities.
An integrated approach to the assessment and rational use of health technologies was implemented and a first road map developed with the English-speaking Caribbean countries. This road map presents proposals for the evaluation, selection, incorporation, prescription, dispensing, use, and monitoring of medicines and other health technologies for the Caribbean countries, as well as the implementation of relevant guidelines. The road map is being considered by the CARICOM COHSOD, and is coordinated by a subregional working group. PASB’s technical cooperation also addressed strengthening the essential medicines lists in Guatemala, Guyana, Haiti, Honduras, and Jamaica.
PASB continued its technical cooperation in improving drug regulatory oversight by strengthening national regulatory authorities (NRAs). This initiative aims to build capacities, promote transparency and good regulatory practices, avoid duplication of effort, and foster a cooperative environment where NRAs can share information and work together to ensure the quality, effectiveness, and safety of medicines and other health technologies. As of mid-2018, 16 PAHO Member States were actively reporting to, and exchanging information through, WHO’s global rapid alert system for substandard and falsified products, while 17 countries were exchanging pharmacovigilance alerts through the PASB-supported focal points’ regional network.
In related work, PASB is managing the development of a regulatory exchange platform (REP), a Web-based tool that allows the exchange of nonpublic/confidential regulatory information on medical devices and on the results of regulatory inspections. The Bureau is collaborating with Australia, Brazil, Canada, Japan, and the United States of America in the development and implementation of the tool.
PASB also continued its collaboration with CARPHA for the further development and implementation of the Caribbean Regulatory System (CRS). The CRS has helped to reveal existing regulatory challenges and has provided a platform for updating knowledge and introducing international best practices, spurring countries (including The Bahamas, Belize, Guyana, Haiti, Jamaica, and Trinidad and Tobago) to initiate reforms aimed at modernizing their regulatory systems. The CRS itself has brought the same high-quality medicines that are approved by strong regulatory authorities (including by WHO prequalification) to the Caribbean. It has recommended 18 WHO prequalified essential medicines, some of which have been registered through in-country, fast-track processes and purchased by national procurers. The CRS also launched a new regional platform for reporting adverse reactions and substandard and falsified medicines. In addition, the CARPHA drug testing laboratory is now focused on postmarket surveillance testing of medicines in a proactive and risk-based manner.
PASB worked closely with five countries (Ecuador, El Salvador, Honduras, Nicaragua, and Paraguay) to strengthen public health supply chains. This program is aimed at improving national capacities by identifying gaps in forecasting, warehousing, and supply and demand management processes. Over the period of July 2015 to August 2017, the activities were partly supported through an agreement with the Global Fund aimed at improving logistical management information systems and access to HIV, tuberculosis, and malaria treatments in target countries in Latin America and the Caribbean.
The Bureau, through a grant from the United States Agency for International Development (USAID), undertook technical cooperation with Guyana and Paraguay to increase access to maternal health–related technologies for vulnerable populations of the hinterlands in Guyana and the Paraguayan Chaco. This project supported an assessment of over 65 health centers in both of these Key Countries, and the current phase of the project involves the implementation of corrective actions.
PASB provided recommendations to all countries for improving the quality and safety of, as well as access to, radiological services, and assessed these services in The Bahamas, Bermuda, and Trinidad and Tobago. More than 150 radiotherapy photon beams in more than 25 countries and territories were evaluated through the International Atomic Energy Agency (IAEA)/PAHO postal dose quality program, which seeks to assure proper calibration of radiotherapy beams to avoid mistreatment of cancer patients and prevent radiation accidents. In addition, the Bureau organized national courses, workshops, and educational activities on diagnostic imaging in Guatemala, Guyana, Suriname, and Trinidad and Tobago, as well as regional webinars and online courses on pediatric imaging and ultrasound, and on the role of radiology in tuberculosis.
During 2017, the PAHO Strategic Fund for Public Health Supplies (commonly called the PAHO Strategic Fund) continued to ensure timely access to medicines and other health technologies through forecasting-related assistance, proactive management of the stock levels, and technical cooperation. The Strategic Fund received requests for more than 200 products from the 33 signatory countries, with total procurement of US$ 90.4 million. Member States utilized US$ 14.9 million from the Strategic Fund Capital Account. The PAHO Strategic Fund provides a mechanism for pooled procurement of essential medicines and strategic health supplies, and ensures that affordable quality medicines are available at all times in a country, in the required presentation and quantities needed.
During this period, PASB established multiyear long-term agreements (LTAs) with suppliers for essential medicines and strategic health supplies, particularly for drugs to treat HIV, tuberculosis, and malaria. The LTAs ensure that affordable, quality medicines are available to PAHO Member States in the required presentation and quantities needed, with increased savings. The Bureau also engaged in direct negotiations with suppliers to reduce current vaccine prices and to increase the availability of yellow fever, inactivated polio, and measles vaccines, the last-mentioned for use in controlling the outbreak in Venezuela.
Health information and knowledge management
Achieving UH requires information from national, subnational, and local levels to enable decisionmakers to prioritize issues, allocate resources, and formulate policies that ensure that no one is left behind. In response to identified challenges and capacity gaps concerning Information Systems for Health (IS4H), and building on achievements within countries and prior subregional strategies, PASB, in conjunction with WHO, developed an innovative framework for IS4H. Using a strategic approach based on UH, the framework aims to improve countries’ decision- and policy-making mechanisms by strengthening IS4H to ensure universal, free, and timely access to quality and open data and strategic information. The framework uses the most cost-effective information and communication tools, and provides a comprehensive road map to adopt and implement standards for interoperable and interconnected systems. It also enables information communication technology (ICT) solutions and identification of best practices in vital and health statistics and in data and information management, all to facilitate improved decision-making.
As at mid-2018, PASB had undertaken targeted technical cooperation with seven countries and territories—Anguilla, Belize, British Virgin Islands, Ecuador, Guyana, Jamaica, and Sint Maarten—to implement the new IS4H approach, including comprehensive IS4H assessments, provision of model governance frameworks, and guidance in establishing national IS4H committees and working groups. PASB continued its work with the Caribbean IS4H Technical Working Group, following up on the High-level Meeting on IS4H held in that subregion in 2016, and convened a meeting with IS4H national focal points from Central America at PAHO Headquarters in 2017 to generate a subregional consensus on the IS4H framework. The Bureau is planning a similar meeting with South American IS4H personnel during 2018. Partners in this initiative include WHO, the Federal University of Santa Catarina, Brazil; the University of Illinois, United States of America; and the Buenos Aires Italian Hospital, Argentina.
The Bureau continued its coordination of the Metrics and Monitoring Working Group (MMWG) of EWEC-LAC. The MMWG is dedicated to ensuring that the measurement and monitoring of social inequalities in health are included in countries’ systematic health analyses, and it facilitates the use of disaggregated data at subnational levels to identify the most vulnerable social groups. The MMWG has catalyzed regional and country efforts that have led to the development of 14 country teams responsible for health inequality measurement and monitoring; a toolkit to measure and respond to health inequities; and the creation of guides and action items for reducing inequality and improving health.
PASB supported the implementation of the iPIER (Improving Program Implementation through Embedded Research) initiative in 10 countries: Argentina, Bolivia, Brazil, Colombia, Chile, Dominican Republic, Mexico, Panama, Peru, and Saint Lucia. iPIER emphasizes the benefits of embedded implementation research to support health policy, programs, and systems. Key results of the initiative to date include the establishment of national research priorities in Brazil, Dominican Republic, Ecuador, Guatemala, Honduras, Mexico, Panama, Paraguay, and Peru; the creation of mechanisms for evidence-informed, rapid-response decision-making in Argentina, Brazil, Colombia, Chile, and Mexico; and strengthening of evidence-for-policy mechanisms (EVIPnet) to support decision-making in Brazil, Colombia, and Chile. Partners in this work include the Alliance for Health Policy and Systems Research (AHPSR), WHO’s Special Program for Research and Training in Tropical Diseases (TDR), and the National Institute of Public Health of Mexico (INSP).
PAHO’s information products continued to serve as trusted sources of authoritative, scientific, technical information on public health in the Americas. During the reporting period, PASB published 19 new ISBN titles and 10 translations.
Documenting health in the Americas – a selection
PAHO’s publications during the period under review included the 15th edition of its flagship report, Health in the Americas. Health in the Americas+ 2017 examined the Region’s public health developments between 2012 and 2017, focusing on advances in expanding health care coverage to the subnational level of each country and territory. The report’s country chapters present unique information at the country level, analyzing key health indicators for population groups such as children, the elderly, and people with disabilities, among others, as well as key achievements of, and challenges to, each country’s health system. The report discusses the role of civil society, the reform of health systems towards UH, and the application of new information technologies to improve health. The report was presented during the 29th PASC in September 2017 and is available in print and electronic format.
PASB coordinated the preparation of a special issue of the Pan American Journal of Public Health on the Cuban health system, published in April 2018. The Bureau collaborated with the Cuban National School of Public Health (ENSAP) to identify topics for the articles and to conduct 16 studies pertaining to advances made in the system.
PASB continued to foster national capacity-building for knowledge management and promoted access to, and sharing of, knowledge related to public health. This included maintaining the Institutional Repository for Information Sharing (IRIS), PASB’s online institutional memory library, which, as at June 2018, consists of more than 40,000 full-text documents. During the reporting period, PASB organized 40 on-site training exercises on information access and scientific communication in partnership with ministries of health, and disseminated methodologies and tools to support countries’ implementation of policies and programs on knowledge management.
During the reporting period, 17 new PAHO/WHO Collaborating Centers were designated in the Americas, bringing the number of active centers in the Region to 192. These centers make an important contribution to PASB’s technical cooperation by generating knowledge and evidence related to the Organization’s programmatic areas.
Between January 2017 and April 2018, seven countries and territories of the Americas reported confirmed cases of yellow fever: Bolivia, Brazil, Colombia, Ecuador, French Guiana, Peru, and Suriname. The number of human cases and epizootics collectively reported in this period in the Americas was the highest observed in decades.
In response to the largest outbreak of yellow fever in Brazil since the 1940s, PASB activated its Emergency Operations Center (EOC) and Incident Management System (IMS) at the Headquarters and the country levels to support coordination of the health response, health information management, capacity-building, and monitoring of vaccination activities. Specialized technical experts, including epidemiologists and data managers, were deployed to assist the health secretariats of each of the five affected states (Minas Gerais, Espírito Santo, Rio de Janeiro, Bahia, and São Paulo) in data collection, analysis, and reporting.
PASB also provided interprogrammatic support for the Ministry of Health in Brazil to update the emergency response plan for yellow fever, which included introducing the use of fractional doses of yellow fever vaccine, as recommended by the WHO Strategic Advisory Group of Experts on Immunization (SAGE) in special situations. The team supported implementation planning for fractional vaccination to protect populations in urban areas and the design of action plans to actively find unvaccinated pockets in selected municipalities. Yellow fever vaccines were procured through PAHO’s Revolving Fund for Vaccine Procurement (commonly referred to as the PAHO Revolving Fund): 20 million 0.1 ml syringes arrived in the country between January and April 2018, enabling national authorities to undertake vaccination activities on a schedule that will allow them to protect all 77.5 million inhabitants of the country by 2019. The PAHO Revolving Fund provides countries and territories with guarantees of quality, safe, adequate supplies of vaccines, as well as lower prices. Through the Revolving Fund, Member States pool their national resources to procure high-quality, life-saving vaccines and related products at the lowest price. PASB also assisted national authorities in Brazil to strengthen surveillance of adverse events following immunization (AEFIs) and to develop a comprehensive and updated vaccination plan that includes vaccine production and risk communication.
For the 2017-2018 monitoring period, up to 8 May 2018, Brazil recorded 1,261 laboratory-confirmed cases of yellow fever, including 409 deaths, and 738 confirmed epizootics among nonhuman primates. Most of the cases and epizootics were reported in the country’s southeast, in areas not previously considered at risk, bordering large urban centers.
PASB represented the Americas in the global Scientific and Technical Advisory Group on Geographical Yellow Fever Risk Mapping and the revision of tools and processes for updating requirements related to the International Certificate of Vaccination or Prophylaxis. Between January 2017 and April 2018, six revisions and updates to the risk map were made.
Funding for the yellow fever response came primarily from PASB’s own resources, including through the PAHO Epidemic Emergency Fund, and Brazil’s national voluntary contributions.
As of 7 April 2018, four countries in the Region—Brazil, Colombia, Haiti, and Venezuela—had reported suspected and confirmed diphtheria cases.
Addressing diphtheria in Haiti
Haiti has reported 515 cumulative probable cases of diphtheria from the onset of the outbreak in Epidemiological Week (EW) 51 of 2014 to EW 18 of 2018. In support of the emergency response, PASB activated the IMS at the country level and undertook key activities with support from the PAHO Epidemic Emergency Fund, the U.S. CDC, and the WB. These included:
Development of a PAHO/WHO internal alert system to strengthen diphtheria surveillance and response activities.
Revision of national diphtheria guidelines; training in infection control and prevention, clinical management of the disease, and epidemiology; and data management support.
Mobilization of epidemiologists to be stationed in the Ministry of Health in eight departments (Artibonite, Centre, Grand’Anse, Ouest, Sud, Nord-Est, Nord-Ouest, Sud-Est) to strengthen department-level surveillance and data management, and continued support from the central level in case of outbreaks in Haiti’s two other departments (Nippes and Nord).
Procurement of 2,000 vials of diphtheria antitoxin (DAT) serum, adequate treatment for the expected number of severe cases for one year, given the epidemiological conditions. Personal protective equipment for infection control and prevention was also procured, for appropriate clinical management.
Evaluation of 55 health care facilities across the 10 departments to assess their preparedness and capacity to treat diphtheria cases.
Distribution of erythromycin treatments (95,500 tablets and 1,780 vials of suspension) and 50 diphtheria infection control and prevention kits to health care facilities and health directorates across nine departments.
Support to the Ministry of Health in planning and implementing the first round of a mass vaccination campaign in March 2018, which covered 2,251,581 of the total 2.3 million persons targeted (estimated average coverage of 98%) in nine departments (at the time of the vaccination campaign, Grand’Anse department did not have any reported diphtheria cases). PAHO was able to mobilize the diphtheria-containing vaccines used in the campaign through its Revolving Fund.
Infectious diseases in Venezuela and neighboring countries
In Venezuela, there has been an increase in the number of outbreaks of infectious diseases, particularly of measles, diphtheria, and malaria. The situation is being aggravated by population movement both within the country and to neighboring countries.
Country-focused management of disease outbreaks – Venezuela and neighboring countries
Venezuela: PASB’s technical cooperation is contributing to the Venezuelan Ministry of Health’s implementation of its rapid response plan to halt the outbreak of measles and to control diphtheria in the country. The plan includes vaccination, extensive contact tracing, and associated laboratory work. The Bureau continues to collaborate closely with other members of the UN System, including UNICEF, FAO, UNDP, and UNFPA. Venezuela is a signatory to the PAHO Strategic Fund and acquires a significant number of medicines and supplies through the Fund, including antiretroviral agents (ARVs), diagnostics, and reagents. It has also obtained mosquito bed nets and medicines for malaria, leishmaniasis, leprosy, and other communicable diseases.
Since the first reported case of measles in Venezuela in July 2017, there have been 1,631 confirmed cases, including two deaths, as at May 2018. About 67% of the confirmed cases were reported in the state of Bolívar, with cases also occurring in the states of Apure, Anzoátegui, Delta Amacuro, the Capital District, Miranda, Monagas, and Vargas. Children under 5 years of age have been the most affected age group among the confirmed cases, followed by those aged 6-15 years. The spread of the virus to other areas is in part due to the high levels of population movement associated with mining and commerce, among other factors.
PASB’s technical cooperation included support for a national rapid response plan designed to interrupt transmission of the virus, through the mobilization of national, regional, and municipal rapid response teams. On 6 April 2018, Venezuelan health authorities launched a vaccination campaign to immunize 4 million children between the ages of 6 months and 15 years against measles. The campaign has been initiated in nine states with the greatest number of the measles and diphtheria cases (Anzoátegui, Apure, Bolívar, Delta Amacuro, the Capital District, Miranda, Monagas, Vargas, and Zulia). There are plans to extend the campaign to the rest of the country, aiming to deliver an additional 11 million vaccine doses.
In Venezuela, since the beginning of the diphtheria outbreak in July 2016 up to May 2018 (EW 16), a total of 1,716 suspected diphtheria cases have been reported, including 324 in 2016, 1,040 in 2017, and 352 in 2018, of which 1,086 were confirmed by laboratory or clinical diagnosis. There have been 160 confirmed deaths (17 in 2016, 103 in 2017, and 40 in 2018). The state of Bolívar, which borders Brazil and Guyana, has been the epicenter of this outbreak. In 2017, confirmed cases were reported in 22 states and the Capital District. Most of the cases are occurring in states with low vaccination rates, and the mobile mining population has been instrumental in the spread of the disease. However, the risk of diphtheria spreading to other countries in the Region has been assessed as moderate.
Vaccination activities are being implemented in states with confirmed cases and 2.3 million children are expected to receive the vaccine against diphtheria. In addition, 90,000 pregnant women are expected to be immunized against neonatal tetanus, and more than a million adults are expected to be vaccinated against tetanus and diphtheria.
Epidemiological surveillance is being strengthened with active case finding and contact tracing, while health education initiatives are ongoing. The training of local health personnel is constantly being updated, while laboratory capacity for diagnosis is also being strengthened.
Malaria cases increased 69% between 2016 and 2017 in Venezuela. The total 406,000 malaria cases reported in 2017 was higher than the annual average since 1988. More than 50% of those cases were reported from the state of Bolívar, followed by the states of Amazonas and Sucre. This increase is linked to more frequent migration of illegal miners and indigenous populations into areas with favorable ecosystems for malaria, an overburdened health system with shortages of antimalarial drugs, and weakened vector control programs.
The Government of Venezuela has enhanced its support for the detection and treatment of malaria cases, focusing on the five most affected states. PASB has been supporting the purchase of malaria medicines and rapid tests, providing training for health care workers, and supplying communication material to promote patient adherence to prescribed treatment. In 2017, the Bureau donated 130,000 treatments for Plasmodium vivax, 800 complete treatments for P. falciparum, 300 treatments for severe malaria cases, and 300,000 quick diagnostic tests. As of April 2018, PASB had given 52 kits to treat severe malaria cases and 25 kits to treat nonsevere malaria, for nearly 10,000 treatments, plus 20,000 quick diagnostic tests. More than 450 health workers have received training in case management, in the states of Bolívar, Sucre, Anzoátegui, and Aragua.
Access to vaccines, medicines, and supplies
PASB is collaborating with national and local immunization programs in Venezuela and facilitating the purchase of vaccines through the PAHO Revolving Fund. In 2017, Venezuela purchased the following supplies and vaccines through the Revolving Fund: 1.15 million doses of pentavalent vaccine, 8 million doses of diphtheria and tetanus (DT) vaccine for the immunization campaign, and 1,000 vials of diphtheria antitoxin. PASB also assisted with the purchase of laboratory supplies for diphtheria and measles diagnosis.
In addition to the rapid response plan, Venezuela is also implementing a national plan to increase vaccination coverage in indigenous communities, border areas, municipalities with low coverage, and difficult-to-reach areas. However, the economic constraints and, in some cases, lack of availability of medicines at the national level, are negatively impacting the continuous and timely supply of health products necessary to meet the country’s public health needs.
PASB, in coordination with the Ministry of Health of Venezuela, has expanded its support for procurement of high-priority medicines such as immunosuppressant drugs, medicines for maternal and child health care, and for high-prevalence chronic diseases. The Bureau is also supporting the country with the purchase of ARVs and tuberculosis medicines. Along with other UN agencies and civil society groups, PASB has been exploring alternative support mechanisms to ensure continuity in access to ARVs and other essential medicines in Venezuela. Efforts are being made to acquire more than 20 oncological drugs with the Venezuelan Institute of Social Security (IVSS).
Neighboring countries: PASB is working with Brazil, Colombia, and Guyana to strengthen their health system responses in border areas and epidemiological surveillance at local and national levels, in order to detect and respond effectively to the needs of Venezuelan migrants and the host population. The Bureau has established field offices in, or deployed additional personnel to, border areas.
Brazil: There is an ongoing measles outbreak, with 995 reported cases (611 in Amazonas state and 384 in Roraima state). Of these cases, 114 have been laboratory confirmed (30 in Amazonas and 84 in Roraima), and there have been two deaths. The PAHO/WHO Country Office in Brazil is working with national and local authorities to contain the measles outbreak in these states, aiming to have residents and Venezuelan migrants aged 6 months to 49 years vaccinated against measles. At the request of the Brazilian Ministry of Health, PASB is assisting with the establishment of a vaccination post in Pacaraima, in the state of Roraima, on the border with Venezuela. PASB is also assisting the Brazilian federal Government in procuring syringes, purchasing supplies to maintain the vaccine cold chain, hiring professionals to administer vaccines and other health interventions, and providing specialists to support national and local authorities in training health care workers in case management and intensified epidemiological surveillance.
Colombia: Between EW 11 and EW 21 of 2018, 26 confirmed measles cases were reported in individuals ages 10 months to 26 years; 17 of these cases were imported from Venezuela, 7 were of secondary transmission (in people from Venezuela who have resided in Colombia for more than 4 months), and 2 cases were related to importation. No deaths have been reported. The cases were reported in the departments of Antioquia, Bolívar, Cauca, Cesar, Norte de Santander, Risaralda, and Sucre, and the districts of Cartagena and Santa Marta. Colombian health authorities are undertaking detection and follow-up of contacts, active case finding in institutions and communities, and vaccination of susceptible persons, while PASB is supporting national and local authorities through field offices with staff, including epidemiologists, and vehicles in border areas of the departments of Arauca, La Guajira, Vichada, and Norte de Santander.
In Guyana, the PAHO/WHO Country Office is working closely with the Ministry of Public Health to monitor the condition of migrants and to strengthen the detection, verification, and risk assessment of events related to epidemic-prone diseases. Work is also being done to assess immunization coverage and laboratory capacities, and identify potential health needs in areas with migrants.
Response to Hurricanes Irma and Maria
Hurricanes Irma and Maria were back-to-back, record-breaking, destructive events that impacted several Caribbean islands in September 2017. The most severely affected islands were Antigua and Barbuda, British Virgin Islands, Cuba, Dominica, Puerto Rico, Saint Martin, Sint Maarten, Turks and Caicos Islands, and the United States Virgin Islands. Thirty-nine fatalities were directly linked to the two hurricanes, 31 of them in Dominica, where 34 persons were also reported missing. Some islands lost over 80% of their housing stock and faced serious challenges in restoring access to electricity and clean water. Over two million people were estimated to be living in areas that were exposed to intense rainfall and winds in excess of 120 kilometers/hour.
PASB mobilized more than US$ 5 million through its humanitarian appeal to support local and national authorities in their response and recovery efforts. In most of the affected islands, PAHO/WHO was the first international organization on the ground, providing immediate support to promote and protect the health of all affected people. PASB focused on four main lines of action: 1) restoring health care delivery capacity and access to health services, including mental health care; 2) increasing epidemiological surveillance to support early detection and timely management of disease outbreaks; 3) ensuring access to safe water, emergency sanitation measures, and vector control; and 4) ensuring efficient coordination and management of information to effectively address the most urgent humanitarian needs.
The Bureau activated an IMS in Barbados for the multicountry response to both disasters and sent over 50 expert missions to 11 countries and territories: Anguilla, Antigua and Barbuda, The Bahamas, Barbados, British Virgin Islands, Cuba, Dominica, Haiti, Saint Martin, Sint Maarten, and Turks and Caicos Islands. PASB’s support included joint damage and needs assessments in Anguilla, British Virgin Islands, Sint Maarten, and Turks and Caicos Islands, and provision of medicines, vaccines, other medical supplies, equipment, and insecticides, sent from PAHO’s strategic warehouse in Panama or procured from local and regional suppliers. The goods were transported with support from the International Medical Corps, Direct Relief, the Royal Netherlands Navy, Americares, and other partners.
In response to urgent requests from the British Virgin Islands and Dominica, PAHO coordinated emergency donations of vaccines and medical supplies from Barbados, Haiti, Jamaica, and Trinidad and Tobago and also made vaccine purchases through the PAHO Revolving Fund for Vaccines. PASB’s work and impact on the ground was strengthened through the intensification and rationalization of the activities of various networks and partnerships, exemplified by coordination with the Royal Netherlands Army to repair the water plant at Dominica’s hospital. The Medical Information and Coordination Cell (CICOM) was also activated for the coordination and monitoring of emergency medical teams (EMTs). Twelve EMTs were coordinated, and reported on their activities to the CICOM during their deployment in Dominica.
Hurricanes Irma and Maria convincingly demonstrated the importance of disaster preparedness. The health sector’s efforts facilitated an improved response, reflected in the relatively low number of deaths and affected health facilities, despite the destructive capacity of both events. Continued support from the international community will be vital for the islands’ recovery. Financial support for the response to both disasters was provided by GAC; USAID/Office of United States Foreign Disaster Assistance (OFDA); European Commission/European Civil Protection and Humanitarian Aid Operations (ECHO), United Nations Central Emergency Response Fund (CERF); and United Kingdom Department for International Development (DFID).
Response to the eruption of Guatemala’s Fuego volcano
On Sunday, 3 June 2018, Guatemala’s Fuego volcano, located about 16 kilometers west of Antigua, erupted. It produced columns of ash of up to 10,000 meters above sea level, constant pyroclastic flows, lava, mud, ballistic (small rocks) emissions, and fiery clouds with temperatures of up to 700 degrees Celsius. Ash particles and lahars affected communities located near the volcanic dome in the departments of Escuintla, Chimaltenango, and Sacatepéquez. In the first hours following the eruption, ash reached all the way to Guatemala City, affecting air operations and resulting in the closure of La Aurora International Airport for almost 24 hours. The eruptions continued intermittently, generating lahars, pyroclastic flows, and columns of ash for many days. An estimated 1,702,130 people were affected, with 110 persons reported dead, 58 injured, and 197 missing. In addition, over 12,800 individuals were evacuated, including some 4,175 persons relocated to shelters.
PAHO’s support focused on strengthening the response capacity of the health sector under the leadership of the Ministry of Public Health and Social Assistance. PAHO immediately deployed response experts to assist national and local health authorities in conducting damage assessments, coordinating information management and health response operations on the ground, and facilitating health care delivery in shelters, including mental health assistance. PAHO distributed personal protection equipment, hygiene kits, water quality monitoring kits, and sterile materials for burn patients, to hospitals and shelters in the department of Escuintla. The Bureau also provided departmental health authorities with technical guidance on the management of dead bodies, and procured supplies and equipment for the establishment of field emergency operations centers and situation rooms in the department of Escuintla. Public health messages and educational materials on good practices and psychosocial support were also developed to be disseminated within the affected communities through health promotion and prevention campaigns.
PAHO mobilized over US$ 310,000 from the Central Emergency Response Fund (CERF) to support the health emergency response and prevent the further degradation of the health status of the communities impacted by the El Fuego volcano eruption, focusing on four main lines of action: 1) strengthening public health and epidemiological surveillance and disease prevention in shelters and affected communities; 2) improving access to mental health services and psychosocial support for the victims of the disaster; 3) increasing access to safe water and intensifying vector control interventions to prevent water- and vector-borne disease outbreaks; and 4) raising awareness about health risks and promoting healthy environments and good practices through risk communication and health information campaigns.
Emergency preparedness and disaster risk reduction in the health sector
During the review period, PASB’s technical cooperation contributed to strengthening of Member States’ health response capacity in emergencies. Twelve countries—Anguilla, Antigua and Barbuda, Cayman Islands, El Salvador, Grenada, Guyana, Honduras, Montserrat, Panama, Saint Kitts and Nevis, Sint Maarten, and Trinidad and Tobago—updated their health disaster plans, and El Salvador completed its national health risk management plan.
Anguilla, Bermuda, Dominica, Montserrat, and Saint Vincent and the Grenadines trained responders in emergency care and treatment; Anguilla, Cayman Islands, Dominica, Jamaica, Guyana, Saint Lucia, Saint Vincent and the Grenadines, Suriname, and Trinidad and Tobago trained responders in mass casualty management; The Bahamas, Dominica, Guyana, Jamaica, Montserrat, and Trinidad and Tobago received training in the Incident Command System; and Ecuador and El Salvador carried out workshops to strengthen their national disaster response teams.
Based on the experiences with Hurricane Maria, Dominica improved its early warning and rapid response systems for epidemics; Antigua and Barbuda enhanced its EOC infrastructure; and Dominica, Jamaica, and Venezuela strengthened the technical capacity of their EOCs.
International Health Regulations
To foster countries’ sense of ownership of the International Health Regulations (2005) (IHR), PASB actively promoted the engagement and participation of States Parties in PAHO and WHO Governing Bodies’ processes related to the IHR Monitoring and Evaluation framework and the development of a draft five-year global strategic plan to improve public health preparedness and response. States Parties from the Americas provided significant contributions during face-to-face and virtual consultations, including a regional consultation held in Brazil in July 2017. Throughout the formal consultative processes from 2015 to 2018, PAHO’s Member States have increasingly highlighted the need to frame the application and implementation of the IHR within the context of health system strengthening.
Thirty-one of the Region’s 35 States Parties reported on their IHR status to the 71st World Health Assembly in 2018. The countries’ annual IHR reports to the World Health Assembly between 2011 and 2018 showed steady improvements in, or plateauing of, the scores in all core capacities. However, the status of core capacities differs among the subregions, with the lowest scores reported in the Caribbean, particularly in relation to the capacities to respond to chemical and radiation-related hazards. Accordingly, PASB joined forces with the IAEA and the WHO Collaborating Center for the Public Health Management of Chemical Exposures (which is hosted by Public Health England) to support two of its main initiatives: “Establishing and Strengthening Sustainable National Regulatory Infrastructure” and "Strengthening Cradle-to-Grave Control of Radioactive Sources." Of the 14 States Parties in the Caribbean, 12 of them now have IAEA membership (Antigua and Barbuda, Bahamas, Barbados, Belize, Dominica, Grenada, Guyana, Haiti, Jamaica, Saint Lucia, Saint Vincent and the Grenadines, Trinidad and Tobago). The IAEA-PAHO collaboration is recognized as a model worldwide.
PASB and the WHO Regional Office for the Western Pacific joined efforts to adapt the IHR Joint External Evaluation Tool to the context of small island developing states (SIDS). This work is closely related to the collaboration between PASB and the authorities of France, the Netherlands, and the United Kingdom to support capacity-building activities in their overseas territories in the Americas. By mid-2018, proposals on the implementation of after-action reviews and simulation exercises in SIDS had been shared with WHO Headquarters, to be formalized at the global level.
Easter Island – simulation for Public Health Emergency of International Concern
Easter Island (native name Rapa Nui), with a population of approximately 6,000 people and a majority of indigenous people, is a remote, volcanic island territory of Chile, located some 4,000 kilometers from the South American coast, in the middle of the Pacific Ocean. It is a major tourist destination due to its archeological sites and the renowned moai, but its geography and endemic vector-borne diseases make residents and visitors alike vulnerable to public health emergencies.
In collaboration with the Ministry of Health of Chile and the population of Rapa Nui, in December 2017 PASB spearheaded a simulation of a Public Health Emergency of International Concern (PHEIC) in the framework of the IHR (2005). The simulation exercise was conducted at the Mataveri International Airport in Hanga Roa, with the participation of all the sectors involved in the emergency response and with the aim of testing current protocols for the management of a probable PHEIC on the island. The results of the simulation gave rise to a project involving the Ministry of Health, PAHO/WHO, and IDB, to strengthen preparation and response systems in Rapa Nui, including control and elimination of the Aedes aegypti mosquito vector, management of dengue infection, and capacity strengthening of local teams.
An IHR Joint External Evaluation (JEE) was hosted by Canada in June 2018, and five other countries have included JEEs in their 2018-2019 PAHO Work Plans: Antigua and Barbuda, Dominica, Grenada, Saint Kitts and Nevis, and Saint Vincent and the Grenadines. Additionally, Argentina, Colombia, and Mexico have expressed the intent to host JEEs during the 2018-2019 biennium, and Haiti has requested a follow-up to the JEE it conducted in 2016.
Argentina’s presidency of the G20 during 2018 offers a valuable opportunity for PASB to advocate for sustainable investments to prevent and mitigate the impact of health emergencies, including the organization of high-level simulation exercises.
PASB’s work under the IHR umbrella during the period was implemented with support from the U.S. CDC, PHAC, and Brazil’s national voluntary contributions.
Emergency Medical Teams
In September 2017, Ecuador became the second country in the Region, after Costa Rica, to receive WHO certification for its own EMTs that meet international quality standards for clinical care. The country received certification for two Type 2 EMTs and one specialized surgical cell. Like Type 1 EMTs, Type 2 EMTs are able to serve at least 100 people per day on an outpatient basis and stabilize patients who need to be transferred to higher-level services. However, in addition, Type 2 EMTs and specialized surgical cells have in-patient capacity of at least 20 beds and are able to provide 24-hour emergency care, perform general and emergency surgeries (including obstetrics), and treat fractures and trauma injuries.
With support from PASB, four other countries—Chile, Colombia, Costa Rica, and Peru—initiated national procedures to request and deploy EMTs, and began implementation of CICOMs, which are designed to facilitate handling of information and coordination of EMTs during emergencies and disasters.
As at mid-2018, the regional EMT coordinators roster listed 78 experts from 23 countries who have been trained with PASB’s support and deemed competent to be deployed during an emergency to assist national authorities in coordinating requests for, and reception of, external medical assistance.
Financial support for the work on the EMT initiative during the period came primarily from the Spanish Agency for International Development Cooperation (AECID), the United States Department of Health and Human Services (HHS), WHO’s Health Emergencies Program (WHE), and PAHO’s flexible resources.
Strengthening laboratory capacity to respond to emerging and reemerging viral pathogens
PASB, with support from the U.S. CDC and the IDB, worked to strengthen the Region’s laboratory networks and improve responses to the increased regional threat posed by emerging and reemerging viral and bacterial pathogens. These efforts produced the following outcomes during the reporting period:
Access by 35 national laboratories in 27 Member States (including 23 National Influenza Centers) to standardized protocols for the safe, accurate, and timely detection of the chikungunya, Zika, yellow fever, and influenza viruses.
At least one laboratory professional certified for the safe shipment of infectious substances, including Category A pathogens, in all Member States.
At least one laboratory professional certified for the detection of V. cholera O:1 and other enteric pathogens, in 11 countries.
Update of SIREVA II standard operating procedures for the diagnosis of meningococcal disease.
Complete laboratory assessments in priority countries of Latin America and the Caribbean, using tools to evaluate installed capacities, general laboratory management, quality assurance policies, and availability of equipment and reagents in national reference laboratories. These assessments identified areas requiring strengthening, particularly in terms of training and laboratory supplies.
In order to address the gaps identified in the laboratory assessments, PASB trained laboratory professionals from 17 countries. In the English-speaking Caribbean countries, the training aimed to enhance detection capacities, with hands-on training focused on molecular detection of yellow fever and Mayaro viruses, and distribution of critical laboratory reagents and materials. Additionally, the U.S. CDC trained personnel from four countries—Brazil, Colombia, Paraguay, and Peru—in the use of new serology detection kits for yellow fever diagnosis. With the support of these personnel, PASB expects to replicate the workshop for other countries during the second half of 2018.
The diagnosis of emerging viral diseases using tissue samples has been critical to characterize fatal cases, in the context of the recent yellow fever outbreak in Brazil. However, related protocols and capacity are not well established in many laboratories. With PASB’s technical cooperation, 14 personnel from different laboratories in Brazil were trained in histopathological diagnosis and immunohistochemistry protocols to diagnose and differentiate emerging arboviral diseases. The training courses were conducted at the Pathology Laboratory of Colombia’s National Institute of Health.
Quality improvement is a critical aspect of effective laboratory services. The results of an external quality assessment panel (EQAP), conducted during the first semester of 2018 with 26 laboratories in 16 countries in the Region, rated the laboratories’ performance positively, including in the molecular detection of yellow fever. To further enhance capacity-building and continuous quality improvement, PASB convened an expert advisory meeting in Washington, D.C., in June 2018 to review, update, and validate the current diagnostic algorithms, protocols, and regional guidelines for yellow fever.
Smart Hospitals Initiative
Phase II of the Smart Hospitals project, funded by the United Kingdom Department for International Development (DFID), entered its third year of implementation in the 7 targeted countries: Belize, Dominica, Grenada, Guyana, Jamaica, Saint Lucia, and Saint Vincent and the Grenadines. Three showcase health facilities were retrofitted to improve their resilience to disasters and reduce their impact on the environment: Princess Alice Hospital in Grenada, La Plaine Health Center in Dominica, and Chateaubelair Hospital in Saint Vincent and Grenadines. Additionally, 362 health facilities in 12 countries and territories were assessed, using the Smart Hospitals Toolkit. Training in the use of the toolkit was also provided for evaluators.
PASB continued to support Member States in the elimination of mother-to-child transmission (EMTCT) of HIV and syphilis, within the framework of the Plan of Action for the Prevention and Control of HIV and Sexually Transmitted Infections 2016-2021 (CD55/14). Between mid-2017 and 2018, in-country technical cooperation was undertaken with El Salvador, Haiti, Honduras, and Nicaragua through joint integrated missions; with Colombia and Uruguay for the rollout of the EMTCT Plus framework; and with countries applying to WHO for validation of the achievement of dual elimination targets.
In the second half of 2017, Antigua and Barbuda, Bermuda, and Saint Kitts and Nevis were recognized by WHO as having achieved EMTCT of HIV and syphilis. Those three, along with Anguilla, Cayman Islands, and Montserrat, received their certificates in December 2017. In addition, Cuba was recertified by WHO for a further two years for having maintained the validation targets achieved in 2015, a unique global accomplishment, to date. Partners in the EMTCT validation process include the Joint United Nations Program on HIV/AIDS (UNAIDS), UNICEF, and the U.S. CDC, with guidance in the Americas provided by an expert regional validation committee. Most of the supporting financial resources were derived from PAHO’s regular budget.
In a related decision, the PAHO Office of Eastern Caribbean Countries prioritized improvements in the quality of services and data collection to allow for timely and informed decision-making and to strengthen those countries’ maternal and perinatal services at the first level of care, which will also support the strengthening and sustainability of the EMTCT strategy. The Perinatal Information System (SIP), developed by PAHO’s Latin American Center for Perinatology, Women, and Reproductive Health (CLAP/WR), has been identified as a key tool for timely, reliable perinatal data. Full utilization of the SIP is being rolled out in Anguilla, Antigua and Barbuda, Saint Lucia, Saint Kitts and Nevis, and Trinidad and Tobago, with plans for its rollout in the near future in the British Virgin Islands, Grenada, Montserrat, and Saint Vincent and the Grenadines.
To foster HIV prevention and advance toward ending the HIV epidemic in the Region, PASB produced a report titled “HIV Prevention in the Spotlight: An Analysis from the Perspective of the Health Sector in Latin America and the Caribbean, 2017,” prepared in close collaboration with UNAIDS and with important contributions from civil society from more than a dozen countries. This first regional report on HIV prevention focused on population groups that are highly vulnerable and have a higher burden of HIV infection. The report examines progress, gaps, and challenges to improve HIV prevention, and outlines the need for expanded access to health services for these population groups.
PASB also mobilized interprogrammatic technical missions to review the national health system response to HIV and STIs in four countries—El Salvador, Honduras, Nicaragua, and Suriname—and to promote dialogue among all actors involved in the response at the national level. The interactions generated recommendations and operational plans to expand, innovate, and improve the effectiveness, efficiency, and sustainability of the national response.
The Region of the Americas – a leader in disease elimination
Maternal and Neonatal Tetanus (MNT)
The regional elimination of the disease, which used to be responsible for the deaths of more than 10,000 newborns every year, was achieved in 2017 after Haiti declared its elimination.
Key partners involved in the elimination effort included the ministries of health of the PAHO/WHO Member States, the U.S. CDC, and the Government of Brazil. For MNT elimination efforts in Haiti, UNICEF collaborated with the Government of Canada, UNFPA, WHO, UNICEF National Committees, and the private sector.
In June 2018, WHO certified Paraguay as having eliminated malaria, the first country in the Americas to be granted this status since Cuba in 1973. From 1950 to 2011, Paraguay systematically developed policies and programs to control and eliminate malaria, a significant public health challenge for a country that had reported more than 80,000 cases of the disease in the 1940s. As a result, Paraguay registered its last case of P. falciparum malaria in 1995, and of P. vivax malaria in 2011. A five-year plan to consolidate the gains, prevent reestablishment of transmission, and prepare for elimination certification was launched in 2011, with activities focused on robust case management, engagement with communities, and education to make people more aware of ways to prevent malaria transmission and options for diagnosis and treatment.
The independent Malaria Elimination Certification Panel, in recommending that the WHO Director-General certify the country malaria-free, highlighted such success factors as the quality and coverage of health services (including malaria awareness among front-line health workers), the universal availability of free medical treatment, and a strong malaria surveillance system.
PASB’s technical cooperation, including procurement of treatment and collaboration with other partners, such as the Global Fund, has accompanied Haiti’s and Paraguay’s achievements, and these two PAHO Key Countries are to be particularly congratulated for reaching these milestones.
 EWEC-LAC’s members are the IDB, PAHO/WHO, UNICEF, UNFPA, the United Nations Entity for Gender Equality and the Empowerment of Women (UN Women), UNAIDS, USAID, and the World Bank.
 The 17 countries were: Antigua and Barbuda, The Bahamas, Belize, Bolivia, Chile, Costa Rica, Cuba, Dominica, Dominican Republic, Ecuador, El Salvador, Guatemala, Haiti, Honduras, Jamaica, Peru, and Suriname.
 The 12 countries were Argentina, Bolivia, Brazil, Chile, Colombia, Guyana, Mexico, Peru, Suriname, Trinidad and Tobago, Turks and Caicos Islands, and Venezuela.
 The 23 countries were The Bahamas, Bolivia, Brazil, Canada, Chile, Colombia, Costa Rica, Cuba, Dominican Republic, Ecuador, El Salvador, Guatemala, Guyana, Haiti, Honduras, Jamaica, Nicaragua, Panama, Paraguay, Peru, Suriname, United States of America, and Uruguay.
 The 16 were Argentina, Barbados, Brazil, Chile, Colombia, Costa Rica, Cuba, Ecuador, El Salvador, Guatemala, Guyana, Nicaragua, Paraguay, Peru, Uruguay, and Venezuela
 The 17 countries were Argentina, Barbados, Brazil, Chile, Colombia, Costa Rica, Cuba, Ecuador, El Salvador, Guatemala, Guyana, Honduras, Nicaragua, Paraguay, Peru, Uruguay, and Venezuela.
 Among them were Antigua and Barbuda, The Bahamas, Barbados, Bermuda, Bolivia, Chile, Colombia, Costa Rica, Cuba, Dominican Republic, Ecuador, El Salvador, Guatemala, Guyana, Honduras, Jamaica, Mexico, Nicaragua, Panama, Paraguay, Peru, Suriname, Trinidad and Tobago, Uruguay, and Venezuela.
 The 14 country teams were in Belize, Bolivia, Chile, Colombia, Costa Rica, Dominican Republic, Ecuador, El Salvador, Guatemala, Honduras, Nicaragua, Panama, Paraguay, and Peru.
 ISBN = International Standard Book Number.
 Argentina, Belize, Bolivia, Brazil, Cayman Islands, Chile, Colombia, Costa Rica, Cuba, Dominican Republic, Ecuador, El Salvador, Guatemala, Guyana, Haiti, Honduras, Jamaica, Mexico, Nicaragua, Panama, Paraguay, Peru, Saint Lucia, Suriname, Trinidad and Tobago, Uruguay, and Venezuela.
 Costa Rica, Cuba, Dominican Republic, El Salvador, Guatemala, Haiti, Honduras, Mexico, Nicaragua, Panama, and Peru.
 The Bahamas, Barbados, Belize, Bolivia, Cayman Islands, Colombia, Costa Rica, Cuba, Ecuador, Guatemala, Guyana, Haiti, Jamaica, Nicaragua, Peru, Suriname, and Venezuela.
 The Bahamas, Barbados, Belize, Bolivia, Cayman Islands, Colombia, Costa Rica, Cuba, Ecuador, Guatemala, Guyana, Haiti, Jamaica, Nicaragua, Peru, and Suriname.
 Antigua, The Bahamas, Belize, British Virgin Islands, Dominica, Grenada, Guyana, Jamaica, Saint Kitts, Saint Lucia, Saint Vincent and the Grenadines, and Suriname.