Health

1. First Summit of the Americas, Miami, U.S.A. (December 1994)

The Miami Summit, through Initiative 17, endorsed a strong commitment to basic health services. Noting that health inequities in the Hemisphere result in persistently high child and maternal mortality, particularly among the rural poor and indigenous groups, governments committed to the following actions:

• Endorsing the maternal and child health objectives of the 1990 World Summit for Children, the 1994 Cairo Accord and the 1994 International Conference on Population and Development, including the reduction of child mortality by one-third and maternal mortality by one-half from 1990 levels by the year 2000;
• Endorsing a package of clinical, preventive and public health services consistent with World Health Organization (WHO), Pan American Health Organization (PAHO) and World Bank recommendations and with the Program of Action agreed to at the 1994 International Conference on Population and Development. The package will address child, maternal and reproductive health interventions, including prenatal, delivery and postnatal care, family planning information and services, and HIV/AIDS prevention, as well as immunizations and programs combating the other major causes of infant mortality;
• Developing country action plans or programs for reforms to achieve child, maternal and reproductive health goals and ensure universal, non-discriminatory access to basic services, including health education and preventive health care programs. Reforms would include essential community-based services for the poor, the disabled, and indigenous groups; stronger public health infrastructure; alternative means of financing, managing and providing services; quality assurance; and greater use of non-governmental actors and organizations;
• Strengthening the existing Inter-American Network on Health Economics and Financing, which serves as an international forum for sharing technical expertise, information and experience, to focus on health reform efforts. The network gathers government officials, representatives of the private sector, non-governmental institutions and actors, donors and scholars for policy discussions, analysis, training and other activities to advance reform; strengthens national capabilities in this critical area; and fosters Hemisphere-wide cooperation;
• Convening a special meeting of hemispheric governments with interested donors and international technical agencies to be hosted by the IDB, the World Bank and PAHO to establish the framework for health reform mechanisms, to define PAHO's role in monitoring the regional implementation of country plans and programs, and to plan strengthening of the network, including the co-sponsors' contributions to it;
• Taking the opportunity of the annual PAHO Directing Council Meeting of Western Hemisphere Ministers of Health, with participation of the IDB and donors, to develop a program to combat endemic and communicable diseases as well as a program to prevent the spread of HIV/AIDS, and to identify sources of funding; and
• urging the gatherings of the World Summit for Social Development and Fourth World Conference on Women (which both took place subsequently in 1995) to address the issue of access to health services.

Much progress was made on the Miami commitments during the 4 year period between the Summits. Highlights of these advances included:

(a) Disease Control and Reduction:

PAHO�s Governing Council met in September 1995, and adopted a Regional Plan to combat the threat of new, emerging, and reemerging diseases reducing the incidence of communicable diseases in the Hemisphere. The Plan both targeted new diseases, and controlling the four major communicable diseases of the hemisphere, namely measles, malaria, dengue, and HIV/AIDS.

Measles: U.S. First Lady Hillary Rodham Clinton launched a Measles Elimination Program in 1995 at PAHO. Cases were reduced from 23,583 in 1994 to 2,109 in 1996, although the number of cases increased the following year to about 18,000, due to some 17,000 cases which occurred in Brazil due to a measles outbreak in Sao Paulo. The outbreak in Brazil, and the equally dramatic drop around the Hemisphere, showed the crucial importance of vaccination programs.

Malaria: Programs were instituted by PAHO to develop and disseminate national policies, prepare manuals for its clinical treatment, and organize specialized, and master's-level courses aimed at strengthening local health systems of countries most affected by the disease, namely Brazil, Colombia, Peru, and Venezuela.

HIV/AIDS: The destructiveness of this disease was highlighted at the International Conference on AIDS (Vancouver, Canada, in July 1996). PAHO along with the Joint United Nations Program on AIDS (UNAIDS), instituted a regional plan which has resulted in many significant initiatives in this area, including:

• Surveillance reports from 40 countries and territories in the Americas in 1997;
• information dissemination on prevention, management and anti-retroviral treatments to all countries;
• studies commenced by many of the member nations;
• in-country training in planning and program management was conducted in Peru, Colombia, the Dominican Republic, Honduras, Panama, Guatemala, Argentina, Cuba, Ecuador, Grenada, and the Eastern Caribbean.
• Workshops on comprehensive HIV/AIDS care were conducted for Argentina, Chile, Uruguay, Peru, Ecuador, and Paraguay.
• Comprehensive care activities commenced in Brazil, Colombia, Costa Rica, Argentina, Ecuador, Chile, Bahamas, Trinidad and Tobago, and Mexico; and
• In 1995, women�s health projects begun in Costa Rica, Mexico, Nicaragua, and Brazil aimed at incorporating HIV/AIDS prevention.

PAHO has worked with countries to develop a package of basic health services and to devise mechanisms for monitoring the process of health care. The periodic meetings of the First Ladies of the Americas have given important impetus to progress on health problems. Summit governments have taken a wide range of national actions on health. Mexico has launched an ambitious five-year National Program of Action in Support of Infants and Children. Canada has developed innovative efforts, including an Aboriginal Head Start Program; and in the United States President Clinton announced the nation's first-ever program to protect children from the dangers of tobacco and nicotine addiction.

(b) Reduction of Mortality Rates

Child Mortality: Child mortality is a significant issue in the hemisphere. Infant mortality rates range from seven per 1,000 live births in Canada to 98 per 1,000 in Haiti. Most other Caribbean countries, as well as Argentina, Chile, Costa Rica, Panama, Puerto Rico, Uruguay and Venezuela, all have between 10 and 30 per 1000. Over 80% (on average) of infants under one year of are now immunized against diphtheria, tetanus, pertussis, polio, and measles.

Maternal Mortality: Only Canada and the United States have rates below 20 maternal deaths per 100,000 live births. Argentina, Costa Rica, Chile, Mexico and Uruguay all have levels ranging from 20 to 49 per 100,000 live births. Bolivia, Guatemala, Haiti, Honduras and Peru have above 150 maternal deaths per 100,000 live births. The remaining countries in the hemisphere show rates in the 50 to 149 range. Most of these deaths result from hemorrhaging, abortion, and hypertension.

Several efforts have been made to reduce these numbers. These include:

• PAHO�s Regional Plan for the Reduction of Maternal Mortality in the Americas.
• An agreement between USAID and PAHO for a new regional project to improve emergency obstetric care in eleven of the hemisphere�s countries most affected by this issue;
• The assistance of the IDB, World Bank, and various other institutions and donors in the areas of maternal health and maternal mortality, with respect to investment for projects in Peru, Haiti, the Dominican Republic, other Caribbean countries, Colombia, Mexico, Bolivia, Ecuador, El Salvador, Guatemala, Honduras, Paraguay, Venezuela and Nicaragua;
• Adoption of this subject as a priority at the meeting of Wives of Heads of States and Government of the Americas in Paraguay in 1995, and Bolivia in 1996.

Finally, a number of countries are developing a basic package of health care that includes access to family planning and that is to be guaranteed to all citizens. In the countries of the Hemisphere, the rate of contraceptive use is close to 70 percent among women who are in union with a partner and who use some method of family planning. Quality of care is an essential element of the delivery of reproductive health services, and several different initiatives are promoting quality care in the areas of family planning, safe motherhood, and prevention of HIV/AIDS and of cancer of the cervix. Close coordination among USAID, the Canadian International Development Agency, the Swedish International Development Agency, the German Society for Technical Cooperation, and other donors has led to increased efficiency in health care efforts.

PAHO, together with its co-sponsors, has fulfilled the Miami Summit mandate "to convene a special meeting of hemispheric governments with interested donors and international technical agencies ... to define PAHO's role in monitoring the regional implementation of country plans and programs". This meeting, the Conference on Health Sector Reform, was held in Washington, D.C. in September 1995 at PAHO Headquarters in cooperation with the IDB, the World Bank, the OAS, ECLAC, UNFPA, UNICEF, USAID, and the Canadian Government. The conference provided important information for countries to use in assessing their own heath sectors, and it assisted international agencies, including PAHO, in strengthening their roles in supporting and monitoring achievement of the Summit's health goals.

As a result of the special meeting, the Directing Council of PAHO adopted a resolution requesting that the member states give priority to health sector reform as a mechanism for guaranteeing equitable access to basic health services and achieving greater efficiency and effectiveness in health sector activities. The Directing Council also requested that the cooperation agencies increase their support for health sector reform. In addition, it was decided that PAHO, together with the countries and cooperation agencies, should develop (a) national evaluation mechanisms for monitoring the process of health reform and its results; and (b) an inter-American network to support the reform.

Currently, PAHO is fulfilling this mandate. The network that is being created for the exchange of experiences in health reform includes national authorities, cooperation agencies, universities, NGOs, and health care providers and users. To support the effort to monitor health care reform and to promote consensus-building, sub-regional seminars have been held in the following countries: Costa Rica (with the collaboration of the IDB and the World Bank); Jamaica (with the involvement of the Caribbean Community, CARICOM); and Guatemala (cosponsored by the Central American Council of Social Security Institutions). Similar events at the national level took place in Uruguay, Chile, and Peru.

Several research projects and studies on reform processes have been carried out as well. For example, a "Regional Study on the Health Sector of the Caribbean" was conducted by the IDB and PAHO with support from national authorities, the Caribbean Development Bank, and the World Bank. In 1996, a research competition on Financial and Organizational aspects of Health Sector Reform was organized by PAHO; five projects (in Brazil, Uruguay, Peru, Colombia and Costa Rica) were selected from more than 90 proposals. In addition, major efforts have been devoted to health sector reform processes. PAHO has assisted the following eight countries in the development of national plans: Barbados, Bolivia, Chile, Dominican Republic, Ecuador, Guatemala, Paraguay and Peru. These same countries have established national commissions for health sector reform. The commissions serve as consensus building mechanisms among various interest groups, facilitating the preparation of proposals and the formulation of proposed legislation.

Special attention has also been paid to the management of human resources in the health sector. Several workshops have been held in different countries in the fields of integral management, personnel administration, performance evaluation, and training.

In 1994, the Economic Development Institute of the World Bank, PAHO, and the Inter-American Center for Social Security Studies established the Inter-American Network on Health Economics and Financing (REDEFS) to promote training, research and information activities in health economics and finance. The three founding organizations pooled their resources to develop a program to strengthen national capabilities in health economics and finance.

Since the Summit, REDEFS has conducted the following activities:

In 1995, a seminar-workshop on "Modalities of Health Provider Contracting" in Argentina; seminars on health economics in Peru and Uruguay; a seminar on "Health Services Financing" in Paraguay, and a seminar on "Financial Data and Hospital Costs for the Caribbean" in Trinidad and Tobago.

In 1996, an international seminar on "Methodological And Conceptual Topics in Health Economics" in Brazil; a course on "Health Systems Research Methodology, Focus on Health Economics" in Mexico; a number of high-level technical seminars involving seven countries and 1,000 participants; support for the Fourth International Conference on Health Economics entitled "Equity, Efficiency and Quality: The Challenge of Health Models" in Argentina; organization of a regional seminar on research in health economics in Chile; and the creation of a REDEFS home page on the Internet.

In 1997, a seminar on health economics in Ecuador and Paraguay; sub-regional meetings for preparing work programs and implementation strategy in Central America (Honduras) and the Southern Cone (Uruguay); a seminar entitled "Critical Aspects of the Health Reform Process: Are Integrated Health Services Possible for All?" in Chile; and support for the Fifth International Conference on Health Economics in Argentina.

The First Ladies of the Americas have played an important role in achieving the goals of the Miami Summit Initiative on Equitable Access to Basic Health Care. At their symposium at the Miami Summit and in subsequent hemispheric meetings of First Ladies, they took steps that have led to progress in their countries on such issues as infant mortality, maternal and child mortality, violence against women, and sexually transmitted diseases. At their meeting in Paraguay, the First Ladies adopted the Declaration of Paraguay, which recognized the important links between health and education of both mother and child and listed eight specific activities the First Ladies would pursue with respect to maternal and child health.