HEALTH IN THE SUMMIT PROCESS

Pan-American Health Organization

June 2000

INTRODUCTION

SUMMITS OF THE AMERICAS

Miami Summit, 1994

• Initiative 17. Equitable Access to Basic Health Services
• Initiative 18. Strengthening the Role of Women in Society
• Initiative 23. Partnership for Pollution Prevention
• Role of the First Ladies of the Americas

Santa Cruz Summit on Sustainable Development, 1996

• Initiative 47. Bacteriological Quality of Drinking Water

Santiago Summit, 1998

• Access to Quality Vaccine and Drugs
• Immunization
• Essential Drugs
• Strengthening Health Information And Surveillance Systems
• Improvement in Access to and Quality of Water and Sanitation Infrastructure
• Technology Assessment
• Areas where PAHO can play a Supporting Role

lobal and hemispheric summits are important to set agendas and guide actions of countries and international organizations. Summits are an opportunity for the hemisphere�s leaders to come together and promote their collective belief that strong hemispheric partnerships encourage the advancement of mutual interests, including peace, democracy, economic integration, and social justice. The summit processes, by taking a multisectoral approach to dealing with a wide range of issues, bring all sectors of government together with international organizations, civil society, NGOs, and other stakeholders. Political, economic and social issues are viewed in a holistic manner. For example, the Santiago Summit helped raise awareness of the role that health plays in human rights and poverty alleviation and that access to health services is an integral part of preserving democracy. Solutions to health issues are an integral part of the poverty eradication effort and as such are extremely important to any dialogue concerning the Americas.

For an outward-looking international organization such as PAHO to realize the hemispheric health priorities, participation in the various inter-American and international fora is of great importance. Not only is the importance of health in the Region highlighted, but PAHO�s profile is also heightened through its participation in fora such as the summits of the Americas, increasing its effectiveness in achieving Member States� goals.

As Member States contributions to international organizations have decreased in recent years it becomes of increasing importance for international organizations, countries and NGOs to collaborate and enhance each other�s efforts and initiatives as well as to avoid the duplication of effort. In the spirit of Panamericanism, summits can help streamline and coordinate cooperation efforts by stimulating countries to work together. Based on the Summits� Plan of Action, PAHO mobilized financial resources for implementation in the order of $42 million from the United States Canada and European donors (Norway, Spain, Sweden, Denmark, The Netherlands).

There have been many changes in the hemisphere since the 1994 Miami Summit. Across the region the transition to democracy is almost complete, human rights abuses have declined and, economies have begun to recover from the 1980�s, as inflation declines and steps are taken towards free trade, promising new economic growth. However the problem of inequity in the region continues, threatening to undermine much of the progress made in the last decade. Inequity manifests itself in unequal access to quality education, avoidable health disparities, lack of economic opportunity and limited personal security. There is still much work to be done in all areas, particularly on the social agenda where health continues to play a pivotal role since it is a prerequisite for human development and the achievement of economic and political goals.

n December 1994, leaders of 34 hemispheric states met in Miami to participate in the Summit of the Americas. They released a Declaration of Principles which focused on four major themes: preserving and strengthening democracy, promoting economic integration and free trade, eradicating poverty and discrimination, and guaranteeing sustainable development. The aim was to channel the momentum created by the convergence of political and economic values in the region, into a concrete plan of action. The resulting plan is composed of 23 initiatives covering the four theme areas. PAHO became involved in initiatives Nos. 17, 18 and 23 as follows:

PAHO was given the role of responsible coordinator of Initiative 17, Equitable Access to Basic Health Services. Focus was placed on reduction of infant and child mortality, reduction of maternal mortality, eradication of measles by the year 2000, health sector reform, and programs to prevent the spread of communicable diseases with emphasis on AIDS. An independent evaluation of the Miami Summit process found that PAHO was the most effective of all responsible coordinators.

The Pan American Health Organization is convinced that the Integrated management of Childhood Illness (IMCI) strategy must be the principle primary health care intervention to reduce mortality from infectious diseases in children under five. IMCI will contribute in reaching the Healthy Children Goal 2002 using this intervention to prevent 100,000 deaths in children under five years of age in the Region of the Americas by the year 2002. This initiative, launched by the PAHO Director in December 1999, will prevent deaths by concentrating IMCI interventions in local areas with infant mortality rates greater than 10/1000 live births. This strategy has significance for all countries in the region including those with low child mortality rates, in view of the pervasive inequality that exists in access to an adequate quality of care.

As of January, 2000, IMCI has been introduced and activities begun in seventeen countries in the Region, thirteen countries have adapted IMCI as a national strategy, eleven have prepared national and local plans of action, and twelve countries have held training workshops. Extensive clinical training and follow-up after training and work at the household and community level has begun. Expansion activities are underway in eight countries.

The goal to reduce maternal mortality rates by 50% from 1990 rates by the year 2000 has not been fully achieved yet. The majority of countries have revised their national plans for the reduction of maternal mortality. PAHO has strengthened ongoing regional projects for adolescent reproductive health in 14 countries and is working with USAID to implement a project to improve emergency obstetrical care in 11 countries. To spearhead these activities, an interagency taskforce with the participation of the World Bank, UNFPA, UNICEF, USAID, and UNICEF has focussed its activities on Nicaragua, Peru, and Haiti.

In 1994, the Ministers of Health of the Americas adopted a resolution, calling for the elimination of measles transmission from the Americas by the year 2000. Countries that have followed PAHO�s recommended three-step vaccination strategy are effectively protecting children in the 1 through 14-year age range and the Region has seen a marked reduction in the annual number of reported cases with the PAHO recommended strategy.. For 1998, the total number of confirmed cases was 14,504, which represents a 73% reduction from 1997. In 1999, a provisional total of 2,803 cases has been confirmed.

In health sector reform (HSR), PAHO, with the collaboration of the IDB, the World Bank and the Canadian Government organized a Special Meeting on HSR, aimed to provide quality health care to the populations, meet their cumulated and emerging health needs and achieve greater equity. In 1996 a first report on monitoring and evaluation of HSR was prepared, and in 1997 a document to serve as a conceptual framework to facilitate the work in the countries and the efforts of technical cooperation was released. Since 1997, the PAHO/USAID Regional Health Sector Reform Initiative in Latin America and the Caribbean" (LAC Initiative), provided regional support for developing tools and methodologies, gathering and disseminating information, networking and exchanging experiences which will support the activities and processes at the country level. A specific methodology to monitor health sector reform process and evaluate health sector reform outcomes has been developed and applied to 22 countries; an important effort to support countries in order to elaborate National Health Accounts is currently underway; and a specific tool to monitor equitable access to basic health services is now in preparation. PAHO�s Directing Council of 1999 approved a resolution in which member countries: recognized the Methodology for Monitoring and Evaluating Health Sector Reform in LAC, and, urged Member States to institutionalize the monitoring and evaluation of their health sector reform processes.

Also, research projects and studies such as the Regional Study on the Health Sector of the Caribbean, conducted by PAHO with support from the Inter-American Development Bank (IDB), the World Bank (WB), and the Caribbean Development Bank (CDB), were undertaken. Five projects were selected in a research competition on financial and organizational aspects of health sector reform, and PAHO supported eight countries in formulating national plans. In addition, PAHO, alone and in collaboration with other multilateral and/or bilateral cooperation agencies is supporting health sector reform efforts in most of the countries in the region. Areas that are targeted include fostering the steering role of national health authorities (for instance, promoting a tool to monitor essential public health functions (in collaboration with the Center for Disease Control) or extending social protection in health (in collaboration with ILO).

In the prevention of HIV/AIDS, several international agencies including PAHO, USAID, the Canadian International Development Agency (CIDA), IDB, Gesellschaft fuer Technische Zusammen Arbeit (GTZ), the Department for International Development (DFID), the Spanish International Cooperation Agency (AECI) and other European donors, have established and consolidated inter-institutional and intersectoral mechanisms for cooperation in the operation of national AIDS prevention and control programs. In connection with the United Nations Joint Program on AIDS (UNAIDS), PAHO has prepared a regional plan for HIV/AIDS control which is being implemented by the countries of the hemisphere. Priorities include behavioral surveillance, which will help clarify which populations are at risk and why; new methods of prevention and care; and assistance to countries to increase access to new expensive anti-retroviral drugs from PAHO�s Strategic Fund at a lower cost.

PAHO took on a supporting role in incorporating gender equity in PAHO�s and country programs, by providing financial and technical assistance in formulating projects against domestic violence in 10 countries and in addressing gender equity in health sector reform policies and processes. These projects target women living in poverty and focus on community-based networks linking health, education, legislation and women�s organizations. In providing gender training to health services personnel, PAHO worked on including a gender perspective in health sector reform; and, in the area of quality of care, PAHO developed a qualitative methodology capable of identifying problems of gender equity in health care. To date, the method has been tested in six countries using three different medical conditions as examples: hypertension, diabetes, and tuberculosis. Results have not only been applied locally in the context of quality improvement programs, but also promise to form part of a new body of knowledge on the gender experience of specific diseases. Major partners in these efforts have been the governments of Canada, Norway, Spain, Sweden and The Netherlands.

The following actions have been undertaken as mandated by the Plan of Action:

• Continuing joint efforts to phase lead out of gasoline; with the World Bank, PAHO, US Environmental Protection Agency (EPA), and others.

• PAHO support to countries in establishing mechanisms for surveillance of blood lead levels.

• Together with the EPA, efforts to make an assessment in Brazil of the environmental exposure to lead from sources other than gasoline.

• Continuing efforts in managing the six country projects (PLAGSALUD) in Central America with financial resources from the Danish Cooperation Agency (DANIDA).

• Organization and support to the Latin American network for safe management of pesticides. The nucleuses for the network are the Chilean network and PLAGSALUD, which are providing technical guidance and sharing experiences.

The meetings of First Ladies continue to play an important role in achieving the goals of the Summit of the Americas Plan of Action in health and other social agenda matters. At the 1994 meeting, which took place on the fringes of the Miami Summit, and at subsequent meetings, the First Ladies took steps that have led to progress in their countries on issues such as maternal and child mortality, violence against women, eradication of measles by the year 2000, health education. and the reduction of childhood illnesses. This forum heightens the profile of health issues and highlights the work of governmental, non-governmental and international organizations that work in health. In addition, the First Ladies have proven themselves adept at both human and financial resource mobilization.

his Summit was held in Santa Cruz, Bolivia, in December 1996. Sustainable development has been discussed for more than two decades, but it is only since the 1992 Earth Summit in Rio de Janeiro that the topic has met international consensus. At the Miami Summit of the Americas, in 1994, the participants approved a Declaration and a Plan of Action, which made provision for the Santa Cruz Summit on Sustainable Development, where the participants discussed regional actions on a wide range of related topics. Health, particularly environmental health, played a significant role at this conference. Governments agreed to undertake the following:

• Development of a public awareness of economic, social, and environmental concerns, in order to open pathways for the transition of societies to sustainable development.

• Equitable access to health services and improvement of their quality in accordance with the principles and priorities laid down in the Pan American charter, Health and Environment in Sustainable Human Development, taking into account diseases related to environmental deterioration.

• Reduction of negative environmental effects on health, particularly those relating to mortality and morbidity among the most vulnerable groups, such as women and children.

• Establishment and/or strengthening of disease outbreak response and disaster preparedness, as well as disaster management institutions and their policies and response capabilities.

The Organization of American States (OAS) convened an interagency committee which assigned to PAHO the coordination of the activities of the Regional Plan for Drinking Water Quality. Participating agencies included the EPA, USAID, OAS, NSF International, Inter-American Association of Sanitary Engineers (AIDIS), UNICEF, and eight WHO Collaborating Centers. This Plan of Action has proposed activities on water policies, legislation and standards; water quality surveillance and control; increase in access to safe water and promotion of disinfection; community participation and education; and establishment of a partnership.

eaders from the 34 countries of the hemisphere met at the Second Summit of the Americas in Santiago, Chile, on 18-19 April, 1998 to discuss the key issues affecting the Region. The agenda included education, democracy and human rights, economic integration and free trade, and eradication of poverty and discrimination. In the spirit of panamericanism, countries pledged to work jointly to further equity by bringing health to the most vulnerable groups. Emphasis was placed on the development and implementation of effective low-cost health technologies as a means towards poverty eradication. Leaders recognized and committed themselves to use new technologies to improve the health conditions of every family in the Americas, with the technical support of PAHO in achieving greater levels of equity and sustainable development.

PAHO also organized, on the occasion of II Summit of the Americas, a round table on the Challenges of Health for the 21^st Century, with the participation of the First Lady of the United States as keynote speaker. This successful initiative served to promote the importance of health issues in the context of the political dialogue and sustainable democracy in the hemisphere.

As responsible coordinator, PAHO was given the mandate to develop and implement the initiative Health Technologies Linking the Americas, which comprises three elements: access to quality drugs and vaccines, strengthening of information and surveillance systems, and improvement in access to and quality of water and sanitation infrastructure. The first and third of these are continuations of the Miami Summit objectives. Enhancing basic access to drugs and vaccines is the continuation to Initiative 17. Equitable Access to Basic Health Services. Water and sanitation infrastructure is also related to Initiative 23. Partnership for Pollution Prevention, and, to the Santa Cruz Summit.

Governments will seek, through public and private efforts, or partnerships between them, to enhance the availability, access to, and quality of drugs and vaccines, especially for the most needy, by promoting efforts to safeguard the quality, rational selection and use, safety and efficacy of pharmaceutical products, with special emphasis on vital and essential drugs; and by supporting regional initiatives that by the year 2002 will facilitate research, development, production and utilization of vaccines, which will reduce the incidence of diseases, such as pneumonia, meningitis, measles, rubella and mumps. /1

Immunization

PAHO developed a Regional Vaccine Initiative to: support countries in building national capabilities in the area of vaccine-preventable diseases; conduct surveillance; strengthen laboratories and immunization activities; ensure the sustainable introduction of vaccines into routine programs; and foster inter-country and inter-institutional cooperation in vaccine development allowing countries to participate and incorporate new technologies of vaccine production against diseases of public health importance. The priorities and actions under this Initiative are:

• The full implementation of PAHO's recommended vaccination strategy for measles eradication in all countries.

• Continued advocacy of the critical importance of immunization and surveillance programs.

• Support Member States in the introduction of other and new vaccines in the basic immunization schedule of every country in the Region.

• Support for Member States in defining and/or strengthening the role of local and central health authorities to assure the equitable vaccination of the population.

• Fostering of inter-country collaboration in the area of vaccine production and elaboration of a strategy for regional technical cooperation, aimed at the joint development of conjugated vaccines.

• Strengthening of national control authorities to assure that quality vaccines are used in national immunization programs and to guarantee that local vaccine production follows international standards.

Actions Taken

• In the final stages of the regional goal of measles eradication by the year 2000, all countries in the Americas are making unprecedented efforts to fully implement and finance the recommended vaccination and surveillance strategies.

• Since 1998, PAHO has been collaborating with the World Bank in Bolivia and Peru, and more recently in Paraguay, to strengthen their national immunization programs. This partnership seeks to establish a specific budget line to cover vaccine and syringe costs of immunization programs, introduce new vaccines in the routine immunization schedule (hepatitis b, Haemophilus influenzae type B (Hib), measles, mumps and rubella, and yellow fever), and improve in the immunization program�s management and data gathering aspects. In April of 1999, the Centers for Disease Prevention and Control (CDC) joined PAHO in the effort to eradicate measles by improving regional measles surveillance and diagnostic capabilities.

• In response to the processes of health reform and decentralization, PAHO is working with Ministries of Health in defining the new roles of the central government on immunization and surveillance. At the same time, the Organization is collaborating with local health authorities in identifying technical and managerial gaps, to ensure the delivery of quality immunization and surveillance activities.

• Progress has been made in the introduction of Haemophilus influenzae type b in the Americas. By early 2000, over 95% of the children born in the Americas will have Hib vaccine in the regular vaccination schedule. The PAHO Revolving Fund for Vaccine Procurement is playing a mayor role in accelerating the incorporation of this and other vaccines, by allowing countries to acquire high quality vaccines at affordable prices. The availability of a new combination vaccine that includes five antigens named pentavalent (DTP vaccine, Hib and hepatitis B) has further facilitated the uptake of these new vaccines in the national immunization programs.

• The majority of countries in the Region have introduced measles/mumps/rubella (MMR) vaccine in their routine immunization schedule. With the Caribbean Community goal of rubella elimination by the year 2000, PAHO has collaborated with that region in reviewing guidelines for rubella surveillance, to accurately define disease burden and identify appropriate vaccination strategies.

• Surveillance of vaccine preventable diseases has been strengthened with PAHO�s establishment and coordination of a network of sentinel hospitals, public health laboratories and epidemiology groups responsible for the epidemiological surveillance of bacterial meningitis and pneumonia in the Americas.

• Critical for the effective implementation of national immunization programs is the utilization of vaccines of proven quality, according to international standards of safety, efficacy and stability. PAHO is supporting National Regulatory Authorities in vaccine-producing countries to comply with the basic six functions of: licensing, clinical evaluation, Good Manufacturing Practices inspections, lot release, laboratory testing and post-marketing surveillance. PAHO has also initiated a network of NRA for non-producing countries, to facilitate through technical cooperation and exchange of information, the harmonization of regulatory procedures.

The obstacles which are noted in the Initiative are:

• Countries need to prioritize the establishment and/or strengthening of national epidemiological surveillance systems for vaccine-preventable diseases, in order to ensure that immunization programs reach the entire population in all areas of a country.

• Heightened attention is needed to meet the technical, financial, and logistical requirements of introducing other vaccines of public health importance, such as Haemophilus influenzae type B (Hib), yellow fever and measles, mumps and rubella (MMR) in routine immunization schedules.

• Governments in the Region recognize that vaccine and immunization are key in the control, elimination and eradication of vaccine-preventable diseases, however, still lacking are concrete steps towards the promotion and support R&D. Some of the public vaccine manufacturers have received resources and have upgraded their facilities, but no major input is seen in the area of research and development or in updating production methodologies. This places these manufacturers at a disadvantageous position to promptly incorporate new technologies that will allow national production of new vaccines that can meet indigenous demands. Human resources and technical capabilities for vaccine research and development although present in the Region are limited, a major problem being their failure to coordinate their work objectives nationally and internationally.

Essential Drugs

Four events to further the access to quality, inexpensive drugs have taken place in The Region this year:

• Expert Consultation on Bioequivalence of Pharmaceutical Products, 13-15 January 1999.

• Expert consultation on Good Clinical Practices, May, 1999.

• Consultation on the Establishment of a Steering Committee for the Pan American Conferences on Drug Regulatory Harmonization, 14-15 January 1999.

• The II Pan American Conference on Drug Regulatory Harmonization. November 1999

PAHO's project for the Joint Procurement of Critical Drugs for Central America will support countries to strengthen and make legal frameworks more flexible so that the joint Central American Negotiation Commission can conduct negotiations on behalf of the states that it represents. This project has been discussed with the Central American Bank for Economic Integration (CABEI), and has been integrated as part of a comprehensive project on drug, which was approved by the Ministers of Health in their annual meeting RESSCA 1999.

A revolving fund for drug procurement has been established in PAHO to assist countries to improve availability of priority drugs of selected treatments: malaria, tuberculosis, antiretrovirals and leishmaniasis.

Strengthen and improve existing national and regional networks of health information and surveillance systems, so that stakeholders have access to data to address critical health issues in the Region, in order to make appropriate clinical and managerial decisions. They will address the development, implementation and evaluation of needs-based health information systems and technology, including telecommunications, to support epidemiological surveillance, the operation and management of health services and programs, health education and promotion, tele-medicine, computer networks and investment in new health technologies. /2

(a) Publications:

• Setting Up Health Care Services Information Systems: A Guide for Requirement Analysis, Application Specification, and Procurement.

• Cyberspace Law and Ethics: A Health Sector Perspective,

• Nursing Informatics.

2. Development and Research Projects:

• Education and Training in health informatics for the English-speaking Caribbean �funded by a grant of the W.K.Kellogg Foundation

• Palmtop computers (P/PC) in community health � [1] to test applicability of P/PCs by community workers in a house visit application in a poor-area community health project in Recife (Brazil).

• Evidence-based practice and information systems � conducted an extensive review on the topic.

• Evaluation methodology for health telecommunication projects � in collaboration with the Polytechnic University of Madrid, Spain, initiated research to developed framework for evaluation of health telecommunication initiatives.

• Telehealth application projects � three projects were developed in collaboration with the Federal University of S�o Paulo, Brazil.

[1] "Internet-based Continuing Education for Health Community Workers"- with the objective of developing multimedia didactical material for the training of community health workers.

[2] "Telemedicine Support to Health Care of Deprived Populations" � objective is the integration of the community health care services ensuring increased access to quality health care, continuing care, and preventive programs.

[3] "Computer-based Decision Support System for the Diagnosis and Treatment of Tuberculosis".

(c) Support to national initiatives:

• Conclusion of the implementation of Drug Registration System (SIAMED), at the Sanitary Surveillance Center, Health Secretariat, and design and detailed specification for the development and implementation of a Food Registration System, to be initiated in early 2000. State of S�o Paulo (Brazil).
• Technical support to the first phase of a US$100,000,000 project for the Ministry of Health of Brazil with the objective of implementing a national health card and care management system (user requirements analysis, design, and preparation of Request for Proposal documentation).
• Preparation of projects in distance education to the Inter American Development prepared by the Center for Health Informatics, UNIFESP (Brazil).

(d) Partnerships and International Collaboration:

• PAHO continued collaboration with multilateral funding agencies (World Bank and Inter American Development Bank) and other agencies (Department of Commerce, NASA).
• Two proposals for PAHO/WHO Collaborating Centers in the area of Health Informatics completed (Johns Hopkins Department of Nursing in the US and the CEDISAP/INFOMED/CECAM consortium in Cuba).
• Participation at the 4^th Annual Interactive Discussion Forum and the Future of Health Technology Summit 1999, at the Massachusetts Institute of Technology Media Laboratory (Boston).
• Participation at International Expert Consultation Meeting on Telehealth and Telemedicine Geneva November 1999.
• Participation at consultation meeting organized by WHO and WTO to discuss international issues related to Telemedicine, Seattle (USA) November 1999.

(e) Conferences:

• Nursing data standards �. Washington December 1999.
• Ethics in the Internet �Washington February 2000.

Develop initiatives designed to reduce deficits in access to and quality of drinking water, basic sanitation and solid waste management, with special emphasis on rural and poor urban areas, by applying existing technologies or developing new, appropriate and effective low-cost technologies. /3

PAHO's focus is on the development of low cost technology for water and sanitation for the urban poor and rural environments. This effort is being lead by the Pan American Center for Sanitary Engineering and Environmental Sciences (CEPIS). The following activities are being undertaken:

• Establishment of a regional network of institutions that are developing low-cost water and sanitation technologies to exchange experiences and provide support. Peru, Bolivia, Nicaragua, Honduras and Cuba will initially form this network. CEPIS will be the coordinator and it will be extended gradually.

• Organization of a system for the classification of technologies for water and sanitation.

• Cataloging of technologies developed and tested by CEPIS, for example, in situ generators of water disinfectants, simplified water treatment units, school sanitation, healthy schools, manual drilling of wells, etc.

• Preparation of a "Technology Manual" for water and sanitation in print and electronically. This consists of a catalogue of available technologies, including descriptions of conditions necessary for implementation.

• Coordination of a regional meeting between countries and international agencies including both the producers and the consumers of technologies, for the preparation of a plan for capturing and disseminating low cost technologies.

• Negotiation of a major project for basic sanitation activities in Central America.

Alone or with other partners, PAHO is serving as facilitator (at both sub-regional and national levels) by cooperating with countries in establishing suitable policies and mechanisms for promoting health technology assessment, including identifying relevant groups and national institutions in this field. PAHO is also: supporting situation analysis and the identification of needs; encouraging the organization of national coordinating agencies and/or specific units; facilitating coordination with international agencies, groups and networks; organizing workshops and seminars on health technology methodology, setting of priorities and practice; establishing and/or reinforcing the mechanisms for disseminating results and sharing experiences; and supporting the evaluation of the impact of the recommendations of the assessment reports in terms of fostering the health sector authorities' regulatory capacities.

At the moment, the two main constraints in this field are the lack of a proper understanding on the part of many policymakers about the importance of health technology assessment for health services and health sector and the absence of a critical mass of trained personnel.

Given the constraints mentioned, PAHO has taken the following steps:

• Organization of several subregional workshops for stakeholders and policy makers in Mexico DF, Mexico (1997), Santiago, Chile (1997), Bogot�, Colombia (1998), Panama, Panama (1998), Havana, Cuba (1999) and Quito, Ecuador (1999). In the majority of cases, this has been done in close partnership with the International Society for Technology Assessment in Health Care (ISTAHC), the International Network of Agencies for Health Technology Assessment, the WHO collaborating centers on health technology assessment, and in some European institutions.

• Strengthening technical cooperation with the countries in the management and evaluation of a number of relevant health technologies, particularly those related to clinical engineering, laboratory and blood safety, radiology and radiotherapy, oral health, clinical rehabilitation, and ocular health.

• Organization of several subregional workshops for stakeholders and policy makers in Mexico DF, Mexico (1997), Santiago, Chile (1997), Bogot�, Colombia (1998), Panama, Panama (1998), Havana, Cuba (1999) and Quito, Ecuador (1999), Bariloche, Argentina (2000), Mexico DF, Mexico (2000). Partners include: the International Society for Technology Assessment in Health Care (ISTAHC), the International Network of Agencies for Health Technology Assessment, the WHO collaborating centers on health technology assessment.

• Dissemination of publications:

• Health Technology Assessment in Latin America and the Caribbean: a collection of cases.
• Developing Health Technology Assessment in Latin America and the Caribbean

• Websites

• Creation and design of a specific Web site on health technology assessment;
• Provision of accessibility through the PAHO Web page to full-text Spanish version of the Monitor, the most credited information and alert system on medical devices.

• Support for efforts of the recently created health technology assessment groups or units in Chile, Colombia, Cuba, Panama, Mexico, Argentina, Ecuador, Brazil and Uruguay.

• Financing participation of professionals and policy makers in the ISTAHC annual conferences and other international scientific meetings on health technology and health technology assessment.

Cooperation with the countries in the management and evaluation of a number of relevant health technologies, particularly those related to clinical engineering, laboratory and blood safety, radiology and radiotherapy, oral health, clinical rehabilitation, ocular health.

In addition to assuming the responsible coordinator role for Health Technologies Linking the Americas, it was agreed at the XV Summit Implementation Review Group that PAHO would play a supporting role or act as a resource in the following topics of the Plan for Action:

Education (Mexico-Regional Coordinator): The Plan of Action states: Intersectoral programs in education, health and nutrition as well as early childhood educational strategies will be priorities, inasmuch as they contribute more directly to plans to combat poverty. At the meeting of Education Ministers in Brasilia, PAHO proposed to play a supporting role or serve as resource in the area of education, on the basis of its expertise in the areas of health education, particularly in the health promotion school initiative, and nutrition. The Interagency Group agreed to the proposal.

The Health Promoting Schools Initiative is supported by the PAHO/World Bank Partnership for School Health and Nutrition, which was endorsed by the First Ladies at the 1997 Summit in Panama. The Initiative supports the following areas:

• Policy: Review and up-date of joint health and education policy to strengthen health promotion in schools and to activate the national commissions that facilitate intersectorial collaboration.
• Curriculum reform: Review health education topics and materials and up-date with life skills education.
• Teacher training: Strengthen teacher training institutions to increase competency in health promotion in schools, including training in life skills education methods.
• Healthy and supporting environments: Review the physical and psychosocial environments in schools to improve their potential to promote health.
• Health services: Reorient health services to assure quality and access to school children and youth.
• Monitoring and Evaluation: Strengthen country capacity to carry out the needs assessment using rapid assessment tools; introduce the surveillance of priority health risk behaviors and conditions for youth; monitor and evaluate the Initiative.

Drugs (United States-Regional Coordinator): Under the topic Prevention and Control of Illicit Consumption of and Traffic in Drugs and Psychotropic Substances and Other Related Crimes, various references are made to the prevention of drug consumption and drug use being a public health problem as well as an enforcement issue. The hemispheric dialogue on drugs must take into account that the most frequent substances of abuse and dependence are tobacco and alcohol and ensuring that the health issue, which is universal, is addressed. PAHO continues to collaborate with CICAD (Inter-American Drug Abuse Control Commission) to put forward the agenda of the Substance Strategy for the Hemisphere, which addresses standards of care, education programs, epidemiological surveillance and social communication. Increased leadership on tobacco control in the Americas by PAHO has brought about, through the approval of an Action Plan by the Ministers of Health, the design of a strategic plan. This plan includes building countries' support for the Framework Convention on Tobacco Control, now being developed by countries under the auspices the World Health Organization (WHO). Formal negotiations on the Convention will begin in October 2000. It is anticipated that the Convention will be adopted by the World Health Assembly no later than 2003.

Women (Nicaragua-Regional Coordinator): Under the Miami Summit�s Item 18, Strengthening Women in Society, PAHO played a supporting role primarily by acting as a resource in projects against domestic violence and in gender training of health services personnel. The Santiago Summit Plan of Action calls to eliminate all forms of discrimination and violence against women as well as to promote policies designed to improve women�s health conditions and the quality of health services at every stage of their lives. Projects addressing violence against women continue to be a priority area for PAHO, which is organizing an intergovernmental conference on this issue in Toronto, Canada, later this year. PAHO is preparing a research, training and lobbying project to show, document and correct gender inequities in public health policies, and continues to work in the area of quality of care in further applying the qualitative methodology capable of identifying problems of gender equity in health care.

Hunger and Malnutrition (Argentina-Regional Coordinator): The Plan of Action states: Give the highest priority to reducing infant malnutrition, concentrating efforts on health, nutrition and education programs for the nutrition of infants�to that end emphasis shall be given to adequate nutrition and correction of specific nutritional deficiencies specifically with vitamin and mineral supplements.

PAHO�s program in the prevention of micronutrient deficiency is active in the following areas:

• Iodine: To ensure that countries guarantee universal consumption of iodized salt and to implement quality assurance and monitoring and surveillance systems in order to ensure that all salt for human consumption is adequately iodized and to detect the population at risk of iodine deficiency (IDD);

• Vitamin A: To assist at-risk countries in the formulation of national plans to eliminate vitamin A deficiency, to design and execute vitamin A supplementation (for young children and postpartum mothers) and national fortification programs;

• Iron: To assist countries in the development of national programs to control iron deficiency and anemia through a comprehensive strategy that includes iron supplementation for pregnant women, process complementary foods for small children, and national and focalized fortification programs;

he Summit processes have offered tremendous opportunities to enhance hemispheric health objectives in the context of global political agendas. Hemispheric health ministers have been able to convey their priorities and convince other sectors in government and society that attaining health goals is crucial to ensuring socioeconomic development and political stability in the Region. PAHO�s Governing Bodies have offered an excellent platform for Pan American sectoral discussions resulting in mandates that have been introduced and later adopted in higher political fora, such as the various summits of presidents and heads of state and government.

The clear mandates that have come out of the different summits have facilitated the joint work of countries and institutions like PAHO who has responded to the specific priorities with technical cooperation and resource mobilization efforts. They have not represented additional initiatives and responsibilities for PAHO, as they have been very much at the core of its work since they emanate from its own Governing Bodies.

The next Summit of the Americas to take place in Quebec 2001, offers further opportunities to move the health agenda forward in both general and specific terms. Generally, the profile of health must be raised by highlighting the integral association between health, human rights and democracy which goes beyond health simply having a place in the Plan of Action under the Social Agenda heading. It should be recognized that equity in health is in fact an integral link, if not a prerequisite, for much of the Plan of Action, such as education, rights of women, rights of workers, indigenous populations, illicit drugs as well as human rights and democracy. In specific terms, the upcoming Quebec Summit will be an opportunity to reiterate PAHO�s commitment to mandates that arose as a result of both the 1994 and 1998 Summits, as well as to include new health priorities in the new Plan of Action. This can be undertaken by adding to the 1994 theme of equitable access and to the 1998 theme of health technologies, a new effort to reduce avoidable disparities in health conditions both within and among countries, and by doing so contributing to the hemispheric goals of equity and human security. 

Endnotes:

1/  Santiago Summit Plan of Action, 1998

2/  Op. cit.

3/  Op. cit.