OEA/Ser.G CE/GCI-52/96
15 March 1996
Original: English

REPORT ON THE ACTIVITIES OF THE PAN AMERICAN HEALTH ORGANIZATION (PAHO) IN FOLLOW-UP TO THE MANDATES OF THE SUMMIT OF THE AMERICA'S PLAN OF ACTION TO THE SPECIAL COMMITTEE ON INTER-AMERICAN SUMMITS MANAGEMENT
(Second Report)

PAN AMERICAN HEALTH ORGANIZATION
Pan American Sanitary Bureau, Regional Office of the

WORLD HEALTH ORGANIZATION
525 TWENTY-THIRD STREET, N.W., WASHINGTON. D.C. 20037-2696, USA

Dear Ms. Ambassador:

In follow-up to your letter of 9 February 1996, please find enclosed the report, prepared by our Office of External Relations, on the activities of the Pan American Health Organization (PAHO) in follow-up to the mandates of the Summit of the Americas' Plan of Action.

Sincerely yours,

George A. 0. Alleyne
Director

Her Excellency Harriet C. Babbitt, Ambassador, Permanent Representative of the United States to the OAS Department of State, 2201 C Street N.W. Washington, DC 20520-6494

The Pan American Health Organization is privileged to act as the "responsible coordinator" for Item 17 of the Plan of Action of the Summit of the Americas, Equitable Access to Basic Health Services.

PAHO is the specialized intergovernmental health agency of the Inter-American system and also serves as the Regional Office of the Americas for the World health Organization. PAHO was honored to participate in preparations for the Summit of the Americas meeting held in Miami in December 1994 and is pleased to be playing an active role in supporting the countries of the region in implementing the Plan of Action approved at the summit.

OVERVIEW

The Pan American Health Organization (PAHO) is pleased to report to you on the specific activities PAHO has undertaken together with member countries to implement Item 17 and as "responsible coordinator" to report to you on activities undertaken by member countries. In addition, we will briefly share with you an indication of actions undertaken by PAHO regarding two other important areas: the agenda of the First Ladies and Item 23, the Partnership for Pollution Prevention.

As "responsible coordinator" for Item 17, in late November, the Director of PAHO wrote to governments requesting summary reports of health activities by each country related to the Summit of the Americas. To date, we have received a number of such reports -which detail efforts related to the implementation of the Plan of Action. All of the countries whose reports we have received demonstrate a very deep commitment to achieving the goals of the summit.

Information on health activities over the last year, the first since the Miami Summit, is only now being gathered and analyzed. Additional information on specific progress in the health sector will also be found in the Annual Report of the Director of PAHO for 1995 which will be published later this year. And, of course, much data will become available throughout the Americas as annual reviews are made of progress in each country.

It is startling to realize that the Miami Summit was held only thirteen months ago. From PAHO's perspective the pace of summit related activities has been rapid, indicating the seriousness of purpose -with which governments are working to achieve the goals set forth both in the Declaration of Principles and in the Plan of Action. At the same time, thirteen months is a very short time to, measure meaningful progress across two continents of nations, enormously diverse in size, culture and resources. It was part of the genius of the Hemisphere's leaders that they included in their Plan of Action not only general and lofty goals but also specific measurable actions that could be taken. This report necessarily must focus on what can be readily measured.

All of the important specific steps urged in Item 17 have been achieved with the energetic and constructive involvement of all countries This clearly indicates that the commitments made in Miami are not simply words on a piece of paper but reflect a deeper and sustainable desire to work together to better the health of all the peoples of the Americas. We all can and should take pride in the speed with which many of the goals have been achieved. At a series of important meetings, the countries of our region have laid out new detailed policies for improving the health and environment of the region.

There is a danger, however, in reporting only on what we can see at this point, so dose in time to the Miami Summit. We must take great care to not be overly optimistic about progress thus far made on Item 17. The real work of actually reducing child and maternal mortality by 2000, of achieving child, maternal and reproductive health goals of assuring universal, non-discriminatory access to basic services, of combating infectious and communicable diseases and HIV/AIDS, and of providing essential community-based services for the poor, the disabled and indigenous groups - all goals of Item 17- will take many, many years of sustained effort both at the country and regional levels. At the same time, the scope of the task the Hemisphere has set for itself should never discourage us. For those of us in the health field we can look back at a long history of steady improvement of health indicators in our Region. Over a comparatively short period of time many of our countries have made dramatic improvements in the length of lives of out citizens and, in the quality of life for most people. In recent years, we have eliminated smallpox and polio from, our Region and measles is fast yielding to the determined efforts of our governments.

A recent report of the Fundacion Mexicana para la Salud, Health and the Economy: Proposals for Progress in the Mexican Health System, dramatically reflects the march of progress in health, briefly describing the lives of three generations of women in a Mexican family. The report begins by describing a girl born in 1943 when there was a 20% chance she would. not survive the first year and Mexico had only 4,300 physicians. By 1968, when that girl's daughter was born, the death rate for the first year of life had been cut in half and Mexico had 22,000 doctors. By the time a granddaughter became seven, in 1993, her life expectancy was 30 years more than her grandmother at a comparable age, most children were fully vaccinated, and Mexico had 175,000 doctors. And the story of this Mexican family can be repeated from examples of progress in many other countries of the Region. We have a long way to go but we have come a very long way already.

ITEM 17: EQUITABLE ACCESS TO BASIC HEALTH SERVICES

In addition to setting broad goals, as briefly summarized above, Item 17 described a number of quite specific activities to be undertaken by governments and international institutions.

Progress on Maternal and Child Health Goals

The first commitment under Item 17 represents a commitment to endorse the maternal and child health objectives of the 1990 World Summit for Children, the 1994 Narino Accord and the 1994 International Conference on Population and Development and to reaffirm the governments' commitment to reducing child mortality by one-third and maternal mortality by one-half from 1990 levels by the year 2000. Governments of this region played a leadership role in crafting the various international policies for maternal and child health objectives. Through programs in member countries it is clear that all are striving to achieve the year 2000 objectives. Colombia, for example, has formulated the PAMI program aimed at strengthening the delivery and accessibility of maternal and child health services, with an aim of resolving 70% of routine and emergency problems through a network of centers. El Salvador has increased its efforts aimed at lessening child mortality by assuring proper child nutrition through distribution of Vitamin A, fortification of various foods, formation of 1,700 voluntary nutrition advisers at the communal level and strengthening of its nutrition education program.

In 1990 the countries of the Americas adopted a Plan of Action for the Reduction of Maternal Mortality. The goal of that plan was to reduce maternal mortality by 30% by 1995. The Summit of the Americas built on that commitment, setting a goal of reducing maternal mortality by one-half by the year 2000. PAHO will soon issue a landmark study -which evaluates progress toward our goal in the period 1990-1994. The report will demonstrate that there has been significant progress in reporting. With respect to maternal mortality itself, there has been substantial progress in some countries but inadequate progress elsewhere so that the reporting does not yet fully show the necessary pattern of decrease in mortality. The PAHO evaluation report is based on comprehensive reports from each country which are available to those interested in receiving a particular report. These reports, and particularly that of the United States, are very thorough and provided an excellent basis for PAHO's own evaluation of progress in the region. PAHO's report reflects an enormous effort on the part of governments to carry out a multisectoral program aimed at a sharp reduction in maternal mortality. The new data included in the report and the insights it offers will provide a clearer diagnosis of maternal mortality and better guide our efforts to achieve our goal for the year 2000.

PAHO is undertaking a number, of other, actions aimed at maternal mortality reduction. Included is a new series of specific publications aimed at establishing guidelines for risk reduction. PAHO, in cooperation with the United States Centers for Disease Control and Prevention (CDC) will soon publish a second edition of its book on maternal death surveillance which is aimed at further strengthening the surveillance system and the data which guide our actions to reduce mortality. PAHO is also working with USAID on a joint project to improve systems for primary referral. at the community level. In the second quarter of this year, PAHO is convening a technical advisory group on the prevention of maternal death in Jamaica which has made rapid progress in this area in recent years. PAHO is also working on preparations for a meeting in Bolivia on reproductive health and maternal mortality which is a follow-up to the Paraguay meeting of the First Ladies last year.

PAHO remains convinced that the goals of Item 17 are achievable. The rapid progress toward measles eradication and continued progress to reduce infant and neonatal mortality are important positive indicators. But violence, substance abuse and accidents remain problems in need of more effective solutions.

Basic Package of Clinical Preventive and Basic Public Health Services

Item 17 committed member countries to endorse a basic package of health services consistent with WHO, PAHO, and the World Bank recommendations and the Program of Action of the 1994 International Conference on Population and Development. The package of services is intended to address child, maternal and reproductive health interventions, including prenatal, delivery and postnatal care, family planning information and services, HIV/AIDS prevention, immunization and other programs combating other causes of infant mortality Item 17 specifically says that these plans will be developed by each country.

Through its network of country representatives, PAHO maintains a regular and detailed dialogue with its member governments and a wide cross section of organizations and individuals in each country. For a number of years PAHO has worked with member countries to develop just such packages of basic services. While each country has a different pattern of health delivery services, and different mixes of private and public systems, there is general support for the concept of such clinical, preventive and public health services packages. Such packages of health services are part of the general debate about health sector reform being conducted in almost every country. Much information concerning the package of basic health services -was incorporated in reports made by countries in preparation for the Conference on Health Sector Reform held at PAHO last year. PAHO hopes to be able to report more fully on progress on this aspect of progress under Item 17 at an early date.

Country Action Plans to Achieve Health Goals and Ensure Access to Services

Individual countries are committed by Item 17 "to develop or update country programs for reforms to achieve child, maternal and reproductive health goals and ensure universal, nondiscriminatory access to basic health services, including health education and preventive health care programs." These plans are to be developed by countries and such reforms should cover essential community-based services for the poor, disabled and indigenous groups. They should also encompass a stronger health infrastructure, alternative means of financing, managing and providing services; quality assurance; and greater use of nongovernmental organizations.

This part of Item 17 addresses a number of important issues. Member governments are generally strongly committed to these goals and many had made considerable progress in various areas prior to the summit. It is clear, however, that the summit and the United States own debate on internal health refor4i has generated great interest on all of the issues covered in this topic.

Since the Summit this topic continues to receive active attention in every country. The Mexican foundation report, mentioned above, is only one indicator of the constructive debate on health policy. Jamaica's report to PAHO describes its own package of services for delivering child and maternal health services to communities and also sets forth its own steps toward implementing "a major health reform thrust to decentralize the management of service delivery, involving the private sector and nongovernmental organizations to a greater extent, and to introduce new methods of financing health services."

At the subregional level, Caricom health ministers met in November to review health reform from a joint perspective.

Attention to the issue of access is addressed strongly by Peru in its report which describes the emphasis that Peru's President gave to the need for women to receive the benefits of development on an equitable basis in his address to the Beijing Women's Conference.

Non-governmental organizations, it is now recognized, can and do play an important role in achieving many of the goals of hem 17. PAHO is working actively with governments and NGO's to strengthen their mutual aims for more effective delivery of health services. To this end, PAHO will convene a meeting of NGO's in March at our headquarters.

PAHO itself has been actively working with governments on all of the issues described under this topic. Details on many of these activities will be found in the report of the PAHO Director for 1995 to be published later in the year, as earlier indicated.

Health Economics and Financing Network and Health Sector Reform

Item 17 called on PAHO, the Inter-American Development Bank, and the World Bank to meet with governments, interested donors, and international technical agencies "to establish the framework for health reform mechanisms, to define PAHO's role in implementation of country plans and programs," and to plan strengthening of the Inter-American Network on Health Economics and Financing. This meeting, The Conference on Health Sector Reform, was held at PAHO's headquarters September 29-30 1995 with participation of Ministers of Health, Finance and other appropriate agencies. Cosponsors included PAHO, IDB, the World Bank, the OAS, ECLAC, UNFPA, UNICEF, USAID and the Canadian Government. The conference afforded all participants to share their own perceptions regarding health sector reform and generated ideas and principles to be taken into account by member governments regarding health financing and the organization of health services.

Health Sector Reform has been a prominent feature of PAHO's technical cooperation with over 25 governments in the Region. Both the IDB and the World Bank have often been partners in this endeavor. PAHO's own role ordinarily concentrates on alternative mechanisms for financing and/or organization of the health sector to increase efficiency and equality of access in the delivery of health services. PAHO has also promoted and actively participated in intercountry seminars and workshops on health sector reform. One such seminar, jointly sponsored with the IDB and the World Bank, was held in Costa Rica with representatives from all the Central American countries.

PAHO is also working closely with the Economic Development Institute of the World Bank to strengthen the Inter-American Network of Health Economics and Finance in accordance with Item 17.  The network involves national associations or groups of health economists from a dozen countries and plays an important role in the dissemination of technical expertise in the Region.

PAHO is working actively with a large array of national institutions and organizations important to health sector reform. These include all relevant government ministries, national social security institutions and their regional counterparts, and national parliaments.

Communicable Diseases and HIV/AIDS

Included in Item 17 is a mandate for governments to use the 1995 PAHO Directing Council meeting "to develop a program to combat endemic and communicable diseases as well as a program to prevent the spread of HIV/AIDS…"

At the meeting of PAHO's Governing Council in September 1995 a new regional plan was adopted for countering the threat of new, emerging and re-emerging diseases. This plan was based on earlier extensive consultations with technical experts at PAHO which identified a number of actions needed to assure appropriate ability to identify and respond to outbreaks of new diseases as well as to monitor the re-emergence of older diseases and to monitor problems of drug resistance. Recent PAHO activities have related to recent outbreaks of dengue, Venezuelan equine encephalitis, and leptospirosis.

The 1995 meeting of PAHO's Governing Council was also the site of calls for intensified attention to the problem of dengue fever and dengue hemorrhagic fever. PAHO is reviewing steps which could be taken, within the constraints of available resources, to confront this disease.

Disease prevention through vaccinations remains an extremely effective tool. The elimination of smallpox globally and polio in the Americas demonstrates the potential for enormous savings in finances and in human suffering from vaccinations. PAHO is pleased to report the universal support for vaccination programs throughout the region and a very high level of cooperation demonstrated nationally and internationally to achieve the full benefits from this technology. As indicated elsewhere, rapid progress is being made toward the elimination of measles. PAHO is working actively with both governments and the private sector to provide a larger arsenal of vaccines against infectious diseases affecting the health of our region.

HIV/AIDS continues to be a major health problem throughout the Region. The Pan American Health Organization in connection with the establishment of the new Joint United Nations Program on AIDS (UNAIDS) has prepared a regional plan for HIV/AIDS control. This plan has been discussed with governments and other regional and UN agencies, the multilateral financial institutions and bilateral donors.

PAHO's Regional Plan of Action would provide technical cooperation to countries within the framework of the strategy of UNAIDS. PAHO's plan seeks to maintain a culturally specific, multinational and multi sectional response to HIV/AIDS and other Sexually Transmitted Diseases (STDs) in the Americas. The plan is designed to provide a solid structure and comprehensive framework to the national AIDS programs. PAHO is concerned that difficulties associated with the transition from WHO's Global AIDS Program to the jointly sponsored UN AIDS program is having an adverse impact on efforts to control this disease.

Summits: Social Development and Women

The final item under Item 17 called on member governments to address the issue of access to health services at the March 1995 World Summit for Social Development and at the Fourth World Conference on Women.

PAHO was privileged to participate in both summit meetings and is pleased both to report on the active participation of governments of the region in both meetings and to note the active role of many governments in raising the issue of access to health services at both meetings. The remarks of Peru's President on this subject were mentioned earlier. The United States, Canada, Chile and many other member states played active, and important roles in the successful outcome of both meetings.

OTHER ACTIVITIES

There are many, many more areas of action discussed under other Plan of Action Items which have an important bearing, on. health issues from the strengthening of democracy to combating drugs, science and technology cooperation and education. It is obvious that all of the goals of the entire Plan of Action, are important, one to the other and mutually self supporting progress cannot be made in any one area, in isolation from the others. But there are two other items which deserve special mention: first, Item 23 of the Plan of Action, the Partnership for Pollution Prevention, and, second, the activities of the First Ladies of the Americas.

Partnership for Pollution Prevention

The Pan American Health Organization, in close cooperation with other institutions and governments, has undertaken a number of activities important to health and described under Item 23 of the Plan of Action of the summit.

At the Summit of the Americas, PAHO signed a Memorandum of Understanding with the U.S. Environmental Protection Agency (EPA) calling for closer collaboration of the two organizations and the development of joint projects. As a result of this agreement PAHO and EPA have jointly sponsored a number of workshops and conferences to promote environmental health in the region. PAHO is also grateful to EPA for making available to us two of its employees who are working on projects regarding air quality and environmental health information. EPA is also working with Central American countries regarding, a network for the exchange of information on legislative and regulatory developments and on a variety of other regional initiatives. In addition, EPA has initiated a cooperative work program with Chile -and entered into a Memorandum of Understanding with the Organization of American States regarding a wide array of environmental areas, including the PPP.

In connection with Item 23's call for a meeting of technical experts on the impacts of lead contamination, PAHO was the cosponsor of two conferences, the International Workshop on Phasing Lead Out of Gasoline in March, 1995, and a subsequent workshop on the health effects of lead in Mexico in May 1995., These workshops facilitated discussion and an exchange of technical information necessary to begin the process of achieving the Partnership for Pollution Prevention (PPP) goal of elimination of lead from gasoline in the Americas.

PAHO has worked closely with the Inter-American Development Bank to develop for country use prototype funding proposals for the IDB's Multi-Lateral Investment Fund (MIF.) These project prototypes are designed to assist countries or regions in seeking financing to implement various objectives of the Partnership for Pollution Prevention.

PAHO is also working actively with the International Program for Chemical Safety (IPCS) to develop plans for chemical safety. PAHO joined with IPCS and EPA to sponsor a hemisphere-wide meeting on this subject in Puerto Rico in November 1995. PAHO is also proud to have been active in preparations for the first Partnership for Pollution Prevention meeting, also in November of which it was honored to be a cosponsor.

PAHO has also coordinated four training courses on risk assessment and management for environmental decision-making. PAHO is also actively -working to design work plans to address a variety of key environmental health issues. Regional plans for chemical safety and hazardous waste control are complete. Plans for workers health, air quality and risk assessment and management are close to completion. A framework for environmental health data collection and reporting is also under development.

sFrom October first through the third, PAHO hosted the Pan American Conference on Health and Environment in Sustainable Development at its headquarters. This meeting was held with the cosponsorship of the OAS, the IDB, the World Bank, UNDP, and LNEP. This meeting achieved important results including:

--the consensus adoption of the Pan American Charter on Health and Environment which, with its associated Regional Plan of Action, will serve as a frame of reference to assist countries in fulfillment of their international commitments, agreements and priorities in these areas; and
--a strengthened focus on environment and health among the countries of the Americas.

First Ladies

Since the meeting of the Summit of the Americas in December 1994, where the Spouses of the Heads of State and Government of the Americas, conducted their own meeting, the spouses have played an important role in stimulating activity throughout the Americas on a number of issues related to Item 17 of the summit's Plan of Action. Because of their positions of direct influence and the visibility they have within their countries, the spouses have become extraordinarily effective advocates for, important health initiatives. PAHO has been privileged to work closely with many the spouses and has worked with the Office of the First Lady of the United States and the First Ladies Offices, of the hemisphere in developing plans for measles elimination and maternal mortality reduction programs and for discussions related to violence against women.

The spouses held a summit meeting in Asuncion, Paraguay, October 16 - 20, 1995. The meeting was a follow-up to the Miami Summit Symposium on the Children of the Americas and a subsequent meeting in St. Lucia. The theme of the meeting was the health and education of women and children. PAHO was privileged to play a major role in the conference, especially with respect to its major themes of measles eradication, violence against women and the reduction of maternal mortality. All of the First Ladies present played an active and important role in the discussions. The meeting produced an important initiative, the Declaration of Paraguay, in which the spouses committed themselves to work within their own countries to:

- work for the health and education of women and children;

- promote the implementation of, the goals of the Children's Summit;

- contribute to the reduction of maternal and child mortality;

- work toward the elimination of measles;

- promote access to education of children to education, formal and informal; and

- work for the prevention and elimination of all forms of violence against women and children.

CONCLUSION

Promises are easily made and too easily broken One year is -almost no time at all when it comes to reaching conclusions about success o ' r failure in our pursuit of the noble objectives inherent in Item 17 of the Plan of Action. But, one has to admit it has been quite a year, filled with activities that dearly demonstrate a sincerity of purpose and a deep commitment to action. For the health sector, it is a fair statement of which we should be proud: We have made an excellent beginning; we are headed in the right direction.

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