Challenges and lessons learned

Annual Report of the Director 2018 Part 3: Challenges and lessons learned

Challenges and lessons learned

PAHO OAS scholarships
PAHO and OAS to offer scholarships to promote higher education and research

During the period under review, the achievements made have been tempered by challenges that the PASB will strive to overcome, in close collaboration with Member States and partners. Some of these challenges are chronic in nature, and the Bureau will undertake targeted technical cooperation and will develop, adjust, and refine relevant policies and strategies, based on the lessons learned.

The theme for this report, “Primary Health Care – The Time Is Now,” is a call to action that poses particular challenges for the PASB as it recaptures the vision of Health for All expressed by Alma-Ata within universal health and reaffirms PAHO’s commitment to the values and principles of that historic declaration, namely the right to health, equity, solidarity, social justice, community participation and engagement, government responsibility, and multisectoral action.


During the period under review, there have been notable changes in the political landscape in the Region. In several countries, new administrations were elected to office and brought a range of different philosophical positions, some of which could impact the health of the public. Additionally, we have seen the emergence of complex sociopolitical conditions, conflicts, and other crises. These circumstances have affected the public health goals of Member States and the health and well-being of their populations, and have also compromised health gains. Significant flows of migrant populations, with concomitant disease spread, have also occurred in our Region.

Though the economic situation of some of the larger countries in the Region has improved, others continue to face challenges. Even where there has been economic growth, concerns remain regarding the equitable distribution of benefits, including access to health. The people’s right to health is supported by the State’s responsibility to guarantee such a right. While in past decades there has been progress in recognizing the right to health in normative and legislative reforms, public institutions have been slow in acknowledging their responsibility to fulfill these rights. Without State action, there can be no progressive realization of the right to health, especially for people living in situations of social vulnerability, nor can there be progress toward social cohesion. Critical gaps in sexual and reproductive health and rights exist, and gender, sociocultural, economic, and structural barriers to access persist.

Vaccination campaing against diphtheria
Vaccination campaing against diphtheria

According to the IMF, economic growth in Latin America and the Caribbean during 2017 was only 1.3%, due to ongoing fiscal and external adjustments in some countries, and other country-specific factors. Over the medium term, the projections show that growth is likely to remain constrained at 2.6%, after expanding 1.6% in 2018. In this context, the Region cannot rely solely on growth to protect and sustain the enormous social gains and reductions in inequality that have been achieved over the past 15 years. Instead, the challenge will be to increase investment in people, particularly the poor, using countercyclical policy frameworks to ensure sustainable and equitable long-term growth.

Government leadership and political will are functions that need to be strengthened to guarantee intersectoral action for health that can address complex social determinants of health, including political, social, economic, environmental, and commercial factors that impact health equity and health outcomes. Effective articulation between health authorities and stakeholders involved in social development, agriculture, education, housing, environment, and commerce is essential. For that, there must be political and technical capacities within ministries of health and other sectoral entities, in addition to political will at the highest level. The HiAP approach, which is aimed at addressing these factors, faces obstacles. The voices of people, particularly those in conditions of vulnerability, are often not heard, and mechanisms for civil society’s participation in decision-making processes and social accountability are still weak.

Within the context of limited national capacity to spearhead sustainable efforts to address key equity issues, manage emerging priorities, promote accountability, and ensure effective approaches, a critical imperative is strengthening the stewardship role of the health authorities to formulate, organize, and direct national health policy. This enables transformation of health sector governance and improvements in the effectiveness, efficiency, and equity of the health system. The process of transforming a health system has both political and resource implications. The actors involved are responsible for making the process both feasible and viable, and also for regulating the health system’s critical resources, whether financial, human, or related to medicines and health technologies. Balancing the political and resource-related aspects for an adequate response is a central and strategic component within the framework of health system strengthening and transformation, to advance towards UH.

Health Center, San Antonio de Pichincha, Quito
Health Center, San Antonio de Pichincha, Quito

The capacity of health systems to deliver evidence- and rights-based policy and programming to remove access barriers to all, particularly populations in situations of vulnerability, is weak. Health care reforms in the Region have focused on expanding and transforming health systems to improve access and meet the health needs of the population, especially those in situations of vulnerability. However, in their efforts to meet the needs of different population groups, health systems have exacerbated the problem of segmentation. Vulnerable populations receiving basic packages of services through specific programs have been excluded from the broader packages of guaranteed services available to other segments of the population. This has become an obstacle to achieving equity in the context of explicit government efforts to fight poverty and reduce inequality. Furthermore, many countries have been unable to adress critical gaps in services and address the specific needs of women and girls (including for sexual and reproductive health services); migrants; LGBT, indigenous, and Afro-descendant people; adolescents; and older persons. Currently, the people most affected by lack of universal access to health and universal health coverage are those who live in conditions of greatest vulnerability.

The majority of countries are challenged to implement a comprehensive approach to NCDs. This is despite the demographic, epidemiological, and socioeconomic changes that have resulted in an increasing burden of these diseases in the Region and the imperative to accelerate interventions for their effective prevention and control. Health services are still organized to respond to acute conditions, and they lack resolution capacity at the first level of care to provide comprehensive quality care for NCDs and mental health disorders. The implementation of public policies to influence risk factors is limited, and industry interference remains a significant obstacle to the implementation of policies at country level to reduce the harmful use of alcohol, encourage healthy nutrition, and impose tobacco control. This interference with population-based preventive policies will result in continued high health care costs and non-achievement of health for all. The tobacco industry has attempted to deter officials from making progress with effective tobacco control measures that comply with the mandates of the WHO Framework Convention on Tobacco Control (FCTC), and from ratifying the Protocol to Eliminate Illicit Trade in Tobacco Products. However, with its ratification by the United Kingdom of Great Britain and Northern Ireland in June 2018, this Protocol is poised to enter into force in September 2018. A comprehensive approach to prevention, promotion, and integrated care, as fostered in PHC-based approaches to advance to UH, is paramount in reducing the epidemic of NCDs, which threatens to reverse many of the hard-earned achievements in health and development in the Region of the Americas.

Important challenges also occur in sustaining the gains in the prevention and control of communicable diseases. Despite improvements in epidemiological surveillance and vaccination coverage in all the countries in the Region, during this period there was a setback in measles elimination. Further, a number of zoonotic diseases persist, including rabies, leishmaniasis, yellow fever, equine encephalitis, avian influenza, and brucellosis. There are limited effective intersectoral strategies for their surveillance, control, and prevention at the human-animal interface that are consistent with the One Health approach. This approach is critical to addressing food safety and controlling zoonoses, as well as mitigating the rising threat of antimicrobial resistance (AMR). Despite collaboration among the participating international agencies—FAO, World Organization for Animal Health (OIE), International Regional Organization for Plant and Animal Health (OIRSA), and Inter-American Institute for Cooperation in Agriculture (IICA)—multisectoral engagement at the country level poses challenges for the implementation of AMR national action plans. 

Neighborhood doctors visit homes in Quito
Neighborhood doctors visit homes in Quito

Segmentation and fragmentation of health services exist in the majority of the countries of the Region, which exacerbates difficulties in access to comprehensive, quality services and results in inefficiencies and low response capacity at the first level of care. Planning processes that lead to further centralization of health services are evident in some countries. Health care reforms that focus on expanding health coverage through basic health services packages—with limited initiatives to strengthen the model of care and organization of health services—have resulted in inadequate improvements in access to care. This is particularly true for the poorest people and populations in situations of greatest vulnerability. Data on economic inequalities in access conditions for the Region of the Americas show that the percentage of the population facing access barriers in the Region differs greatly among countries. They range from 6.8% to as much as 66%, and they are highest in the poorest households. In many instances, investments in health continue to prioritize specialized and hospital-based services, in an ad hoc manner and without appropriate investment plans. The development of new facilities takes place in the absence of appropriate considerations of human resources needs, financing, management of service delivery, and specific interventions to strengthen the primary level of care. Issues of sustainability and resilience are not taken into consideration, and plans often favor the organization of health services in developed urban centers, leaving the needs of poorer peri-urban and rural areas unmet.

 Furthermore, inequities persist in the availability, distribution, and quality of the health workforce within and between countries, as well as between different levels of care, and the public and private sectors. Funding for HRUH continues to be highly inconsistent within the Region, and in many countries it is insufficient to ensure the delivery of quality health services, particularly at the first level of care, and to meet the needs of underserved populations. Poor retention rates in rural and neglected areas, precarious working conditions, low productivity, and poor performance constitute some of the challenges that countries are facing. All these factors hinder the progressive expansion of services, particularly at the first level of care. Even when human resources for universal health are in place, they often lack appropriate profiles and competencies, consequently affecting the health of the communities they serve.

There has been exponential growth in health sciences education within the Region over the past few decades. Despite this, the regulation of these processes remain insufficient, and there are concerns about the quality of training, the relevance of many academic programs, and the standards of professional practice. Many countries are having difficulty in moving toward skills-based training, establishing interprofessional learning programs, designing flexible curricula, strengthening teaching capacity, and extending training to all levels of the care network.

A PHC approach to health financing is far from a reality. Health financing in the Region is far from meeting the objectives set by PAHO Member States in 2014, when they adopted the Strategy for Universal Health. Economic recovery from previous global downturns has been slow in some countries, resulting in insufficient allocation to the national health budget, which puts health gains at risk and delays progress in priority areas. Although collaboration between ministries of health and ministries of finance has increased during the reporting period, only five countries—Canada, Costa Rica, Cuba, United States of America, and Uruguay—have achieved public health expenditures of 6% of GDP. This situation is compounded in many countries by limited capacity to introduce changes in the health system due to the rigidities of the public financial management systems and line item budgets. Competing national priorities and inefficient health financing often result in failure to ensure access to comprehensive services for priority health programs. Limited priority is given to NCDs and NCD-related policies and regulations, at times resulting in inadequate domestic investment in the implementation of these policies. The failure of investment aggravates the adverse effects of the direct and indirect costs of NCDs and their risk factors, mental health disorders, and injury and violence, which significantly impact national health systems, individual and population health, productivity, and overall national development.

Complete health care to TB patients
Complete health care to TB patients

An efficient investment in health needs to sustain and expand gains in other priority health issues such as HIV, tuberculosis, immunization, and sexual and reproductive health. It should be possible to build resilience in health systems by ensuring adequate financing for essential public health functions, including capacities for IHR implementation and for preparedness and response to health emergencies. Neither national budgets nor new sources of funding have fully succeeded in filling the gaps created by the withdrawal or reduction of external funding from some international development partners for national immunization and HIV prevention and control programs. Other communicable diseases, such as neglected infectious diseases and hepatitis, remain underprioritized and underfunded. The response to hepatitis lacks resources from international development partners and is entirely dependent on domestic financial commitments. This challenge is exacerbated by inadequate recognition of the disease as a priority for action, as compared with other pressing public health issues in the Region; the high cost of hepatitis medicines to individuals and health systems; and the higher costs of those medicines in the Region of the Americas as compared with other regions.

Ongoing work to strengthen preparedness and response for health emergencies is critical for building resilience in health systems and the community. Implementation of the IHR is a key part of this work. It requires the constant efforts of States Parties and the PASB to manage public health events of potential international concern, as well as to comply with recurrent, discrete, and long-term obligations such as the establishment and maintenance of core capacities for surveillance and response, including at designated points of entry as detailed in Annex 1 of the IHR. Among the challenges that hinder progress in implementation is a lack of full and harmonized understanding of IHR concepts. Additionally, the four components of the IHR Monitoring and Evaluation framework—which is designed to ensure mutual accountability—are not tailored to the needs of all States Parties in the Region, such as small island developing states.

With respect to disasters, most Latin American and Caribbean countries have the capacity to respond to minor and moderate events that affect the health of their populations, by applying a single-hazard approach and without needing international support. The challenge arises when responding to large and/or multi-hazard emergencies when there is overwhelming external cooperation, as well as when there is politicization or “verticalization” of the response.

Climate change and natural disasters

Disasters and emergencies often result in the suspension or reduction of many priority health programs. This can occur during those events and for long periods afterwards. These disruptions may involve critical services for persons with chronic conditions and others in positions of vulnerability.

Forty years after the Alma-Ata Declaration, many countries in the Region are still lagging in ensuring equitable access to the environmental determinants of health. Adequate water quantity and quality, basic sanitation of acceptable quality, and adequate, safe living conditions in the home, school, workplace, and community are requirements for progress to UH. The projected negative impact of climate change on the environment, health, and other critical developmental issues has been recognized, but there are delays in the development and implementation of national climate change adaptation plans. Stronger engagement, political commitment, and multisectoral approaches are needed to meet ambitious SDG targets related to environmental health and to tackle challenges in climate change, particularly in Key Countries. Enhanced capacity-building, awareness, and human resources, as well as the allocation of specific country resources for environmental health agendas, are needed to fully integrate environmental health topics into the programs, policies, and interventions of ministries of health, other sectoral agencies, civil society, and the private sector.

Quality data and epidemiological analyses using disaggregated data are very limited in the Region, particularly in PAHO’s Key Countries and the Caribbean, which hinders efforts to monitor progress on UH. Despite Member States’ efforts to collect information to systematically monitor and evaluate progress in health equity, most countries still need to strengthen national monitoring systems. Even in countries that collect information disaggregated by socioeconomic variables, health equity analysis and use of evidence for policy-making are often limited.

Lessons learned

The commitment to leave no one behind, as specified in the 2030 Sustainable Development Agenda, requires Member States to set specific, attainable targets for reducing health inequities and to establish functional health inequality monitoring systems. Member States must commit to investing in their national and subnational planning, reporting, monitoring, and evaluation systems to attain UH. Information systems for health must be conceived as an integrated mechanism of interconnected and interoperable systems and processes that ensure the convergence of data, information, knowledge, standards, people, and institutions. Various measures are key to the maintenance and sustainability of interventions, including during political transitions and changes of government. Among these vital processes are the evidence-based definition of a national health agenda for the medium and long term; development of PASB’s medium-term strategic agenda for technical cooperation with the country (the CCS); and formal agreements for technical cooperation. The activities to develop these frameworks should be participatory, with involvement of a wide range of stakeholders, including parliamentarians, health workers, local leaders, and civil society, during the planning, implementation, monitoring, and evaluation phases, in order to obtain “buy-in” and commitment to action.

Complete health care to TB patients
The delegations of the Americas met with Carissa F. Etienne, PAHO/WHO Director, to discuss the topics that will be discussed in the plenary.

Addressing governance in a comprehensive and integrated manner, as well as creating interconnected regulation mechanisms (including financial resources, human resources, and health technologies and services), are linchpins in institutional transformations to achieve equitable improvements in health service access. Research on the most effective role of the ministry of health, in relation to other ministries that also have impact on population health, and rethinking the purpose and functions of relevant civil service structures, would be useful for enhanced efficiency and effectiveness on the road to UH. Greater social participation in health policy planning, implementation, and oversight is to be fostered, in order to promote more responsive policies, and to ensure transparency and sustainability. Enhanced awareness of the various priority health issues and of strategies to overcome cultural and psychosocial barriers at community level must be included in efforts to improve the accessibility, availability, affordability, and quality of integrated health services. Intensification of the promotion of, and technical cooperation in, HiAP, with reinforcement of messages concerning equity, can further advance progress in HiAP even as political changes occur. This is particularly relevant for political support and financing.  In this regard, the establishment and strengthening of networks and strategic alliances would be critical for success.

Even during difficult times and economic stagnation, it is possible to increase public investment in health. Countries can identify and utilize existing fiscal space for health, and increased public resources can come from a wide range of sources. These can include improved tax collection (by reducing evasion and elusion), new or increased public health taxes, reduced waste and corruption, the prioritization of expenditure in health over other sectors, and social contributions. Every country can do something, according to its national context. However, promoting greater fiscal space requires a broader social dialogue among all stakeholders. Related decisions, which involve States, tend to be political and are based primarily on technical arguments, often to the detriment of input from key social partners, including civil society and the private sector. An important consideration is increased efficiency. This can be achieved by investing in the first level of care so as to provide comprehensive, quality health services within integrated health services delivery networks; by giving attention to priority health problems; and by providing adequate financing for human resources, medicines, and other health technologies.

The collection, documentation, and dissemination of good practices are critical for showcasing opportunities for the introduction and sustainability of strategic interventions for UH. PAHO’s technical modality of cooperation among countries for health development (CCHD) (including cross-border cooperation that focuses on migration and other issues with first and direct impact on communities and PHC) can strengthen work at the subnational level, contribute to improved local capacities, and help mitigate potential challenges that may arise due to changes in national policy directions.

Complete health care to TB patients
Clínica da Família Estácio de Sá., Rio de Janeiro, Brazil

Given challenges with sustainability, countries may benefit from strengthening the subregional approach. This will facilitate the adoption of standards, technologies, solutions, and methodologies. It will also help manage data, information, and knowledge, as well as encourage collective decision-making, evidence-based policy development, and pooling of resources. The production of subregional public goods is also valued as a cost-effective strategy to reach small island developing states, which often have limited capacity to develop complex programs. Identification of priorities within and across subregions, and PASB’s greater interaction with its counterparts in other WHO regions, will facilitate the Bureau’s effective technical cooperation with PAHO Member States in their various and varied political integration groupings.

As an integral component of public health systems, dedicated supply chain management (SCM) is aimed at holistically managing the complete health system and at leveraging the results achieved with vertical health programs. SCM can contribute significantly to long-term sustainability in access to medicines and technologies. SCM impacts all areas of a public health system directly or indirectly, and an interprogrammatic approach to SCM involving all PASB technical units can make many contributions. They include enhanced access to medicines across all levels of national health systems; introduction of new health technologies; migration of patients as part of an effort to align clinical practices with WHO recommendations; and supply chain economic studies that review and highlight opportunities to maximize the use of government funds. The Caribbean Regulatory System has the potential to be one of CARICOM’s major successes on the promise of a common market, by providing harmonized regulation and a single point of entry for medicines and other health technologies to the Caribbean subregion. There should also be advocacy for greater use of the PAHO Strategic Fund.

Evidence has shown that investing in HRUH improves employment rates and enhances economic development. Strong political will is essential for translating commitments into effective budget allocations for HRUH. In addition, effective governance and regulation are critical for developing HRUH-related strategic policies and for designing, funding, and implementing a national HRUH plan. Effective intersectoral coordination, high-level involvement, and strategic positioning of HRUH issues are needed to spearhead a public-sector commitment to HRUH reform. This should include greater efforts to develop HRUH information systems and institutional frameworks that enable shared accountability for the analysis and use of the information. The decentralization of training institutions and the recruitment of students from underserved communities can increase the production, deployment, and retention of health workers in underserved health services settings.

Complete health care to TB patients
EMTCT-plus - Elimination of mother to child transmission of HIV, congenital syphilis, congenital Chagas and hepatitis B.

Evidence has also shown that a strong first level of care, with capacities to respond to priority health programs and supported by an integrated network of services, leads to better health outcomes, equity, and efficiencies. Obtaining high-level political commitment to ensure mobilization and efficient allocation of needed human, financial, and technical resources facilitates an adequate response in order to maintain and advance disease elimination (including EMTCT, hepatitis B, Chagas disease, and cervical cancer); to prevent the reestablishment of endemic diseases such as malaria; and to achieve homogenous vaccination coverage at the national and subnational levels. PASB’s ongoing advocacy to integrate the various interventions required to advance towards equitable access to quality health services is crucial. Also essential is increased capacity of the first level of care to provide appropriate services related to such issues as NCDs, mental health, and sexual and reproductive health, so as to enable people to optimize their functioning and well-being throughout the life course.

Innovative solutions and approaches that look beyond traditional models of service delivery and that involve communities and multisectoral stakeholders are required to address the complex interplay of different factors affecting the health of the population in the Region. Participatory action that includes local community leaders, health workers, scientific societies, government, civil society organizations, and other key stakeholders is critical to responding in a comprehensive manner to multiple health challenges. Multisectoral environmental health programs and initiatives are advancing across the Region, due in part to the inclusion of other sectors in capacity-building activities to which countries have committed.

There is a need for more extended dialogue at the country level with interested groups and various stakeholders, including the private sector, in implementing the One Health approach and in developing and executing AMR national action plans. In addition, increased awareness, capacity-building, task-shifting, human resources, and national budgets for environmental health agendas are necessary for effective action in communicable disease control. Finally, demonstrations of the central role of water, sanitation, and hygiene measures in the context of public health emergencies and disasters are key.

With more than half of the island’s power still out, thousands of residents are left without access to clean drinking water.

Comprehensive multisectoral engagement, including with the private sector as appropriate and with due regard for possible conflicts of interest, is critical to address NCDs and their risk factors, and requires sustained political commitment. In working with the private sector, collaboration with other UN agencies to promote the Framework of Engagement with Non-State Actors and resolution E/2017/L.21 (on tobacco industry interference, adopted by the UN Economic and Social Council (ECOSOC) in June 2017) can facilitate mutually beneficial cooperation and resistance to industry tactics. There is a need to expand awareness among high-level officials in health and nonhealth sectors of the solid evidence on which the FCTC is based and of the value of effective tobacco control policies. Strengthened intersectoral work, including in law and trade, is important for a common understanding and negotiation of outcomes that are consistent across government sectors. Nonetheless, the health sector has an essential role to play, given its remit to address all major causes of morbidity and mortality. Promoting country ownership through strong political leadership is vital for the successful implementation of any initiative, particularly regarding NCDs, which are by nature chronic and multifactorial. NCD prevention and control and UH are mutually reinforcing.

In order to have long-term impact on making health systems more resilient, PASB’s IHR-related technical cooperation requires ongoing advocacy at different levels, focused on establishing communication bridges between technical and decision-making levels in-country. While the IHR provides for mechanisms to ensure mutual accountability, along with requirements for monitoring implementation and compliance by the States Parties, application of the four components of the IHR Monitoring and Evaluation framework should be tailored to the needs of States Parties in the Region, such as for small island developing states.

Public health emergencies during 2017-2018 highlighted the need to strengthen surveillance, including data collection mechanisms, in the Americas in four areas: sylvatic epidemics, intensive animal production, human mobility, and social media. There is also a need to strengthen interprogrammatic approaches and mechanisms to integrate critical interventions for persons with priority conditions or vulnerabilities into the disaster or emergency response, and to enable more holistic efforts.

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