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Quinquennial Report 2013 - 2017 of the Director of the Pan American Sanitary Bureau

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Executive Summary

Over the 2013-2017 period, the Pan American Health Organization, the Regional Office for the Americas of the World Health Organization, continued to undertake technical cooperation at the national, subregional, and regional levels in support of national health development. These efforts were led and coordinated by the Pan American Sanitary Bureau (PASB), PAHO’s secretariat, and involved key national and international stakeholders and partners. PAHO’s technical cooperation during this period, which began with Dr. Carissa Etienne assuming office as Director of PAHO, has been guided primarily by the PAHO Strategic Plan 2014-2019. The Strategic Plan was developed with significant involvement of Member States utilizing a bottom-up process that took into consideration priorities determined at the country level through the development of PAHO/WHO Country Cooperation Strategies together with a priority-setting methodology. It also aligned with the WHO General Programme of Work, the Millennium Development Goals, the Health Agenda for the Americas 2008-2017, and, in its forward-looking formulation, the 2030 Sustainable Development Goals, to ensure PAHO’s contribution to Member States’ fulfilment of these major health-related international agreements and frameworks.

During the period, guided by resolutions approved by its governing bodies, PASB emphasized a wide range of critical issues. These included health systems strengthening and resilience to advance toward universal access to health and universal health coverage; building national capacity to respond to health emergencies and disasters, and fulfill the requirements of the International Health Regulations (IHR) (2005); taking a life-course approach to health interventions, with emphasis on maternal, child, and adolescent health, as well as the health of older persons; reducing health inequities, with a focus on vulnerable groups, including ethnic and indigenous populations; reducing, and eliminating where possible, communicable diseases; preventing and controlling noncommunicable diseases (NCDs) and their risk factors; and addressing the social and environmental determinants of health through multisectoral and allof- society mechanisms. The Organization also sought to improve its own institutional capacity and systems for greater efficiency and effectiveness of its technical cooperation.

Notable successes in health system strengthening and building resilience occurred in expanding access to services, such as through the Mais Médicos Program in Brazil; developing or updating health-related legislation and regulations, as in the establishment of the Caribbean Regulatory System; advocating for improvements in health financing and use of the fiscal space; building the capacity of human resources for health to contribute to progress to universal health, including through online training using the PAHO Virtual Campus for Public Health; improving access to medical products and technologies, including safer radiation services; and strengthening health-related research, information systems, knowledge management, and communication.

PAHO’s Member States dealt with a myriad of emergencies, disasters, and disease outbreaks over the period, and there were significant improvements and innovations—both internally in the PASB and in technical cooperation with countries—in mechanisms to respond to these events, especially in the context of mass gatherings such as the Summer Olympics in Brazil in 2016. Hurricanes, earthquakes, fires, migrant flows, and viral disease outbreaks were among the varied causes of health emergencies that tested Member States’ capacities, partnerships, and solidarity, as well as the timeliness and scope of PASB’s response and resource mobilization capabilities. The threat of Ebola virus, the widespread circulation of chikungunya and Zika viruses, and the resurgence of cholera in Haiti led to assessments that identified gaps and challenges in the development of national core capacities for IHR implementation. However, they also allowed responses that included new approaches and innovations, such as implementation of the PASB’s Incident Management System and strengthening of its Emergency Operations Center; improved guidelines for deployment of national and international Emergency Medical Teams; strengthening of disease surveillance systems; technology transfer of water-quality monitoring systems; and development of new partnerships to address identified priorities.

In addressing life-course interventions, an important milestone was the creation in 2013 of the initiative “A Promise Renewed for the Americas,” the regional chapter of a global interagency movement for which the PASB serves as the secretariat.

The movement seeks to reduce inequities in reproductive, maternal, child, and adolescent health in Latin America and the Caribbean. Over the next 15 years, the regional chapter will help countries to develop and implement national operational plans to respond to equity concerns in these population groups, in the framework of the Global Strategy for Women’s, Children’s and Adolescents’ Health. Taking a holistic approach, the life-course interventions also included improvements in nutrition, with PAHO’s promotion of, and contribution to, the United Nations (UN) Decade of Action on Nutrition 2016-2025 and consideration of both under- and overnutrition. National interventions to prevent overweight and obesity included policy development and fiscal measures, the latter including taxation on sugar-sweetened beverages, as occurred in Barbados, Chile, Dominica, Ecuador, and Mexico.

PAHO’s commitment to reducing inequities in health remained one of the strong pillars of its technical cooperation, and the Organization worked assiduously to integrate the cross-cutting themes of gender, equity, human rights, and ethnicity into all its work. Actions included the creation by the Director of PAHO of an interprogrammatic group to facilitate such integration; the groundbreaking approval by the 53rd Directing Council in 2014 of a resolution to address disparities in access to, and use of, health services by lesbian, gay, bisexual, and transgender people; development of a core set of indicators for gender and health; identification of priorities for the health of indigenous peoples and Afro-descendants; and PASB’s adoption of a new set of metrics for measuring changes in health inequality. In 2016, PAHO launched the Commission on Equity and Health Inequalities in the Region of the Americas in partnership with the Institute of Health Equity at University College London.

Despite continuing challenges in reducing communicable diseases, with PASB’s technical cooperation, including the use of the PAHO Revolving Fund (for vaccine procurement) and the PAHO Strategic Fund (for public health supplies), several Member States succeeded in eliminating some of these diseases at the national or subnational levels. The eliminated diseases include onchocerciasis (Colombia, Ecuador, Guatemala, and Mexico), and trachoma (Mexico). Vector transmission of Chagas’ disease was interrupted in Brasil, Chile, and most of Paraguay. In June 2015, Cuba became the first country in the world to receive validation of the elimination of mother-to-child transmission of human immunodeficiency virus (HIV) and syphilis. In April 2015, the International Expert Committee for Documenting and Verifying Measles, Rubella, and Congenital Rubella Syndrome Elimination determined that the Region of the Americas had eliminated endemic transmission of rubella and congenital rubella syndrome. At the 55th PAHO Directing Council in September 2016, the Committee announced the elimination of endemic measles from the Region, a historic milestone that capped a 22-year effort involving mass vaccination against measles, mumps, and rubella throughout the Americas. These diseases were the third, fourth, and fifth to be eliminated from the Americas, following smallpox in 1971 and polio in 1994, and all five represent first-in-the-world regional achievements.

PAHO has now set its sights on the elimination of malaria in the Region’s 21 endemic countries, cholera in Hispaniola, and HIV transmission regionwide; strengthening the “One Health” approach to addressing health issues at the human-animal-environment interface; and responding to increasing antimicrobial resistance.

The increasing burden of NCDs, recognized at the national, subregional, regional, and global levels, generated a host of declarations, recommendations, guidelines, strategies, and action plans. PAHO developed regional plans of action for the prevention and control of both NCDs and childhood obesity, and fostered the formulation of national multisectoral NCD action plans, advocating for inclusion of nonhealth sectors, civil society, and the private sector. The Organization worked to strengthen Member States’ development and implementation of legislation, regulations, and policies aimed at reducing the four main NCD risk factors: tobacco use (acting within the context of the WHO Framework Convention on Tobacco Control), unhealthy diet, physical inactivity, and harmful use of alcohol. PAHO also promoted the chronic care model for improved quality of care at the primary level, focusing on the four main NCDs: cardiovascular disease, diabetes, cancer, and chronic respiratory disease. In addition, PAHO included NCD medications for procurement through the PAHO Strategic Fund. In collaboration with partners, PASB spearheaded interventions to strengthen NCD risk factor surveillance, conduct research on the occurrence of chronic kidney disease from nontraditional or unknown causes in Central America, and address violence and injuries, particularly road traffic injuries and violence against women. The Organization continued its focus on mental health, working with countries to implement WHO’s Mental Health Gap Action Program, which promotes scaling up of services for mental, neurological, and substance abuse disorders, especially in primary health care.

Recognizing the critical importance of addressing the social determinants of health and ensuring healthy and safe environments, PASB not only advocated for wholeof- government, whole-of-society, and Health in All Policies (HiAP) approaches, but also developed a regional Plan of Action for Health in All Policies, which was approved by the 53rd Directing Council in 2014. PASB partnered with the Government of Suriname and others to hold the first regional HiAP workshop in Suriname in 2015 and established a partnership with institutions in Brazil, Chile, and Mexico to build capacity in HiAP. Prior to the 2016 Global Conference on Health Promotion in Shanghai, China, PAHO collaborated with the Ministry of Health in Chile and other partners to hold a Mayors’ Pre-Forum. The Declaration of Santiago that resulted from the Pre-Forum called on the Region and the global community to promote health through local networks and develop policies and actions that address the determinants of health, human rights, and inequities, through HiAP and intersectoral action, in the framework of the SDGs.

In further efforts to secure safe, healthy environments, several of PAHO’s Member States contributed to the final text of the Minamata Convention on Mercury; the Organization advocated for and contributed to interventions for workers’ and consumers’ health, including establishment of a regional CARcinogen EXposure (CAREX) database; and selected Member States participated in the Consumer Health and Safety Network coordinated by PAHO and the Organization of American States. Work continued to improve water and sanitation, with strengthening of countries’ capacity to develop and use water safety plans and sanitation safety plans, as well as promotion of country involvement in the UN Global Analysis and Assessment of Sanitation and Drinking Water. PASB also addressed health-related aspects of climate change, advocating for inclusion of relevant text at the 20th and 21st Conferences of the Parties to the UN Framework Convention on Climate Change in 2014 and 2015, respectively, and contributing to the preparation of Member States for implementation of the WHO air quality guidelines, which address air pollution and its impact on climate change and health.

Internally, PASB’s measures to improve its efficiency and effectiveness included governance, programmatic, management, and administrative innovations. Selected Member States, with support from PASB, formulated a new high-level framework for health development in the Region—the Sustainable Health Agenda for the Americas 2018-2030—to succeed the Health Agenda for the Americas 2008-2017. The Organization experienced deeper participation of Member States in its strategic planning and priority-setting processes, as well as in the monitoring and evaluation of programs and plans. PASB responded to adjustments in WHO’s health emergency programs with adjustments of its own to maintain alignment and take advantage of lessons learned globally and regionally in responses to emergencies, disasters, and outbreaks.

PAHO continued to tailor its technical cooperation to address country and subregional health priorities, with the strengthening of mechanisms for country focus and updating of the Organization’s Key Countries Strategy. PASB revamped PAHO’s signature Technical Cooperation among Countries program to become the more strategic and inclusive cooperation among countries for health development program, which makes operational the policy on cooperation for health development in the Americas approved by the 52nd Directing Council in 2013, and strengthened the structure, development, and coordination of subregional technical programs.

Internally, substantial benefits have come from the introduction of the new PAHO Management Information System (PMIS); enhancement of the Integrity and Conflict Management System; development of the new PAHO People Strategy for strengthening the PASB’s own human resources; a new information technology strategy; continued development of the Organization’s enterprise risk management structures and processes; and the establishment of mechanisms for learning from audit and evaluation findings. The positive results have included increased efficiency (despite the steep learning curve for the implementation of the PMIS), a working environment more conducive to quality performance, improved identification and mitigation of risks, and enhanced institutional learning.

Over the next five-year period, PAHO’s functions and actions at the national, subregional, and regional levels— within the frameworks of the respective health policies, strategies, and plans; country and subregional cooperation strategies; and global health and development goals—will address selected priorities based on needs and gaps, while also building on successes and lessons learned. The priorities include universal health; IHR and emergency and disaster response capacity; antimicrobial resistance; equitable health for vulnerable groups (including women and children, ethnic groups, and indigenous populations), with continued mainstreaming of the cross-cutting themes of gender, equity, human rights, and ethnicity; elimination of communicable diseases where feasible; prevention and control of the main NCDs and their risk factors; determinants of health and multisectoral approaches (including response to climate change); access to essential medicines and health technologies; health and health-related SDG targets; and continued institutional strengthening. Partnerships, alliances, and collaborations with key stakeholders across sectors will continue to play major roles in the Organization’s work and progress made by Member States in sustainable health development.

Carissa F. Etienne Director Pan American Health Organization